Every finding on record at NYS Veterans Home in NYC

Based on record review and interview conducted during an abbreviated survey (# 2623262), the facility did not ensure they reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident. This was evident for one (1) of three (3) residents (Resident #1) reviewed. Specifically, the results of the investigation for Resident #1 was not submitted to the New York State Department of Health within five working days of the incident.The findings are: The facility policies titled 'Prevention of Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property' dated 01/2025 and 'Resident's Accidents Investigation and Reporting dated 8/25 did not document a report of the result of the investigation should be submitted to the Department of Health within five (5) working days of the incident. Resident #1 had diagnoses which included Dementia, Alzheimer's Disease, and Parkinson Disease. The Accident Investigation Report dated 09/20/25 documented on 9/20/25 at 2:30 PM, while the two assigned Certified Nurse Assistants were transferring resident #1 via Hoyer Lift to the shower chair for his scheduled shower, the Hoyer Lift tilted to the left and staff were unable to prevent the resident from falling. Resident #1 fell and sustained laceration to forehead. The resident was transferred to the hospital at 3:35 PM for further evaluation and treatment.Review of the New York State Department of Health Nursing Home Facility Incident Report for intake #2623262 revealed the facility was first made aware of the incident on 09/20/2025 at 2:30 PM, and the incident was submitted to the New York State Department of Health on 09/20/2025 at 8:28 PM. There was no documented evidence the results of investigation for incident #262326 was reported to the New York State Department of Health within five days working days.On 11/10/2025 at 01:11 PM, an interview was conducted with the Assistant Director of Nursing who stated that they, along with the Director of Nursing and some other Registered Nurse Supervisors are responsible for reporting incidents. The Assistant Director of Nursing also stated all alleged violations involving abuse, neglect, including injuries of unknown source are reportable to the New York State Department of Health within 2 hours, and there should be a five day follow up report thereafter. The Assistant Director of Nursing concluded they reported the incident when it was brought to them and could not explain the reason why the five day follow up report was not submitted. On 11/10/2025 at 03:07 PM, an interview was conducted with the Director of Nursing who stated the five day follow up report is submitted after a full investigation is conducted, and they thought the facility had submitted the report. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during abbreviated Survey (NY00361611, NY00363114), the facility did not protect a resident's right to be free from physical abuse by nursing home staff. This was evident in two out of seven residents sampled (Resident #1 and #4). Specifically, on 12/04/2024 at 10:37 AM, the facility's surveillance camera recording was reviewed and showed on 11/23/2024 at 3:00 PM, there was a physical altercation between Resident #1 and Security Guard #1. The facility's investigative notes dated 11/27/2024, documented on 11/23/2024, Registered Nurse Supervisor #1 and Registered Nurse #1 observed Security Guard #1 grabbed Resident #1 by the collar of Resident #1's clothes and held Resident #1 against the wall. There were no injuries to Resident #1. Specifically, on 12/03/2024 at 9:30 PM, the Facility's Incident Report documented Certified Nursing Assistant #3 reported to Registered Nurse #3 that Resident #4 was combative and refused personal care. Registered Nurse #3 accompanied Certified Nursing Assistant #3 to provide personal care to Resident #4. Resident #4 agreed to receive personal care but while attempting to take Resident #4's pants off, Resident #4 kicked at Certified Nursing Assistant #3. Certified Nursing Assistant #3 used their hand to block Resident #4 from kicking Certified Nursing Assistant #3 in the face. Registered Nurse #3 reported they saw Certified Nurse Assistant #3 hit Resident #4 with the back on their right hand. The findings are: The Facility's Policy on Abuse Prohibition revised 04/2022, assured all residents and families that the facility will take steps within its control to prevent Abuse, Mistreatment, Adverse Events, Neglect, Exploitation, and Misappropriation of Resident Property. Resident #1 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Adjustment Disorder, and Depression. A Minimum Data Set, dated dated dated [DATE], documented that Resident #1's cognition was intact and Resident #1 was at risk for wandering. The facility's surveillance camera was reviewed on 12/04/2024 at 10:37 AM, with the Acting Administrator, Director of Nursing and Security Guard #2. The surveillance video recording showed: No date recorded for incident that occurred on 11/23/2024 at 3:00 PM. At 00:18 seconds to 00:31 seconds, Resident #1 was seen walking down the hallway of a locked nursing unit. Certified Nursing Assistant #1 and Certified Nursing Assistant #2 (who is providing 1:1 supervision of Resident #1) were talking to Resident #1. Resident #1 stopped in the middle of the hallway. At 00:32 seconds to 00:37 seconds, Registered Nurse #1 was walking down the hallway to meet Resident #1. Registered Nurse Supervisor #1 was standing in the hallway with Certified Nursing Assistant #1 and #2. At 00:39 seconds to 00:43 seconds, Certified Nursing Assistant #1 was trying to redirect Resident #1. Resident #1 continued to walk and make hand movements toward Registered Nurse #1. Certified Nursing Assistant #2 and Registered Nurse Supervisor #1 continued to follow Resident #1. At 00:46 seconds to 00:56 seconds, Registered Nurse #1, Certified Nursing Assistant #2, and Registered Nurse Supervisor walked behind Resident #1 who is proceeding to the emergency exit door. At 00:56 seconds, Security Guard #1 walking towards the emergency exit door. At 01:19 seconds to 01:23 seconds, Security Guard #1 approached Resident #1 and stood on left side of Resident #1. Registered Nurse #1, Certified Nursing Assistant #2, and Registered Nurse Supervisor #1 were standing close to Resident #1. At 01:35 seconds to 01:42 seconds, a physical altercation taking place between Resident #1 and Security Guard #1 (unable to view clearly what was going on in the video). The video did not capture clearly what was happening. At 01:43 seconds to 01:49 seconds, the three staff went to Resident #1 and Security Guard #1. At 01:51 seconds to 01:53 seconds two more nursing staff ran to assist them. At 01:56 seconds, Resident #1 and Security Guard #1 were separated. At 01:07 seconds, Security Guard #2 approached the hallway. At 02:49 seconds to 02:59 seconds, Security Guard #1 and Security Guard #2 walked down the hallway and passed through an exit door to the main lobby. At 03:11 seconds, (video was too blurry to view) the emergency exit door opened, and staff followed. (As per interview with staff, Resident #1 opened and exited through the emergency exit door). They (staff) were able to encourage Resident #1 to return to unit. The Facility's Investigation dated 11/27/2024 documented on 11/23/2024 at 3:00 PM, there was an employee to resident altercation resulting in grabbing of Resident #1's collar. The Security Guard #1 (the perpetrator) was removed from duty immediately and reported to their Contract Agency. Resident #1 was transferred to hospital for evaluation of uncontrollable agitative behavior. Based on investigation there was reasonable cause to believe alleged physical abuse occurred. The 911(Emergency number) was called and four Police Officers and Emergency Medical Service responded. The New York City Police Officers did not arrest Security Guard #1 or make any report. During an interview on 12/04/2024 at 10:30 AM, Resident #1 stated they do not remember any incident that happened to them. During an interview 12/04/2024 at 11:55 AM, Security Guard #1 stated they heard the locked unit exit door alarm sounded and saw the staff running in the hallway. Security Guard #1 stated they responded immediately and observed Resident #1 going to the emergency exit door. Security Guard #1 stated they approached Resident #1 and told them that they cannot leave. Resident #1 told Security Guard #1 to leave them alone or else they will punch them (Security Guard #1). Security Guard #1 stated Resident #1 suddenly punched them in their face. Security Guard #1 stated they reacted and grabbed the neck of Resident #1's clothes and held Resident #1 against the wall. Security Guard #1 stated they did not have any intention of hurting Resident #1. Security Guard #1 stated they were aware that they were not supposed to grab Resident #1 and believed that it was considered abuse. During an interview on 12/04/2024 at 12:22 PM, Registered Nurse Supervisor #1 stated they responded to the alarm and saw Resident #1 walking down the hallway towards the emergency exit door. Registered Nurse Supervisor #1 stated there were three staff members trying to redirect Resident #1. Registered Nurse Supervisor #1 stated while Security Guard #1 was talking to Resident #1, they (Registered Nurse Supervisor #1) heard Resident #1 saying to Security Guard #1, if you touch me, I will kill you. Registered Nurse Supervisor #1 stated they did not witness Resident #1 punch Security Guard #1 but observed Security Guard #1 grab Resident #1 by the collar of Resident #1's clothes and held Resident #1 against the wall. Registered Nurse Supervisor #1 stated they immediately separated Security Guard #1 and Resident #1. Registered Nurse Supervisor #1 stated Resident #1 breached the emergency exit door and proceeded to go outside and they and two other staff members followed Resident #1, and they were able to redirect Resident #1 back on the nursing unit. Registered Nurse Supervisor #1 stated they called Emergency Medical Services and Law Enforcement who responded. No reports was made. Registered Nurse Supervisor #1 stated Resident #1 refused body check, but there were no visible injuries observed and Resident #1 did not complain of pain. Resident #1 was transferred to the hospital for evaluation by the Emergency Medical Services. Resident #1 was discharged from the emergency room and returned to the facility on [DATE]. During an interview on 12/04/2024 at 3:30 PM, Registered Nurse #1 stated the Security Guard #1 tried to control Resident #1 but Resident #1 was too strong. Registered Nurse #1 stated they saw Resident #1 raised their right hand but did not observe if they (Resident #1) punch Security Guard #1. Registered Nurse #1 stated they saw Security Guard #1 holding Resident #1 by the collar against the wall. Registered Nurse #1 stated they intervene and separate them. During an interview on 12/05/2024 at 12:55 PM, Director of Nursing stated Resident #1 had a history of elopement attempt from other nursing homes. The Director of Nursing stated Resident #1 was placed on one to one since Resident #1 was admitted to facility on 09/18/2024. Director of Nursing stated Resident #1 tried to elope by pushing the locked nursing unit door and was unable to be redirect by staff despite encouragement. Director of Nursing stated the video and staff statements were reviewed and concluded that physical abuse occurred. The Director of Nursing stated, Security Guard #1 was removed from the schedule immediately and reported to their Contract Agency not to returned to the facility. Resident #4 was admitted to the facility on [DATE], with diagnoses of Hemiplegia, Depression, Cerebrovascular Accident, and history of Post Traumatic Stress Disorder. A Minimum Data Set, dated dated dated [DATE] documented that Resident #1's cognition was intact. There were no mood or behavioral symptoms documented. The Facility's Incident Report dated 12/03/2024 at 9:30 PM, documented Certified Nursing Assistant #3 reported to Registered Nurse #3, Resident #4 was combative and refused care. Registered Nurse #3 accompanied Certified Nursing Assistant #3 to provide care to Resident #4. Resident #4 agreed to receive the care but while attempting to take Resident #4's pants off, Resident #4 kicked at Certified Nursing Assistant #3. Certified Nursing Assistant #3 used their hand to block Resident #4 from kicking Certified Nursing Assistant #3 in the face. Registered Nurse #3 reported observed Certified Nurse Assistant #3 hit Resident #4 with the back on the right hand. The Registered Nurse Supervisor #2 Nursing Note dated 12/04/2024 at 1:23 AM, documented Resident #4 was assessed and there were no visible injuries bruises or discoloration. Resident #4 denied any pain or discomfort. Certified Nursing Assistant #3 was immediately removed from the unit pending the investigation. Resident #4's family member was notified. Reviewed of behavioral notes dated 10/28/2024, 11/01/2024, and 11/10/2024, documented Resident #4 refused personal care and was aggressive towards staff. During an interview with Resident #4 on 12/04/2024 at 12:30 PM, Resident #4 said they do not recall any incident. During a telephone interview on 12/04/2024 at 12:58 PM, Certified Nursing Assistant #3 stated Resident #4 has aggressive behavior during care and required two persons to be in the room while providing personal care. Certified Nursing Assistant #3 stated Resident #4 asked to be put in bed, so Certified Nursing Assistant #3 called Certified Nursing Assistant #4 to assist. Certified Nursing Assistant #3 and Certified Nursing Assistant #4 transferred Resident #4 to the bed. Resident #4 then refused to remove their clothes and said they are cold. Certified Nursing Assistant #3 stated they informed Registered Nurse #3 that Resident #4 refused to take their clothes off for personal care because Resident #4 said they are cold. Certified Nursing Assistant #3 stated they served Resident #4 dinner included a hot drink and covered Resident #4 with an extra blanket. Certified Nursing Assistant #3 stated around 9:00 PM, they went to Resident #4's room with the Registered Nurse #3, and Registered Nurse #3 informed Resident #4 that Certified Nursing Assistant #3 was going to provide personal care. Resident #4 agreed and did not want their top to be removed. Certified Nursing Assistant #3 stood at foot of the bed to take off Resident #4's pants, Resident #4 attempted to kick Certified Nursing Assistant #3 on the face. Certified Nursing Assistant #3 stated they blocked Resident #4 with their hand to stop Resident #4 from kicking them (Certified Nursing Assistant #3) on the face. Registered Nurse #3 was standing at the head of the bed and told Resident #4 they are not supposed to hit the staff. Certified Nursing Assistant #3 stated Registered Nurse #3 told them (Certified Nursing Assistant #3) they are not supposed to hit Resident #4. Certified Nursing Assistant #3 stated they told Registered Nurse #3 they did not hit Resident #4, but they were protecting themselves from Resident #4 kicking their face. Certified Nursing Assistant #3 stated they have been working at the facility for eight years and they would never do such a thing. Certified Nursing Assistant #3 stated they have worked on the dementia unit for four years and they were trained on how to care for residents with behavior. Certified Nursing Assistant #3 stated they were suspended after giving their statement. During an interview on 12/04/2024 at 4:08 PM, Registered Nurse #3 stated Certified Nursing Assistant #3 reported to them that they will not give Resident #4 care because Resident #4 hit them. Registered Nurse #3 stated they told Certified Nursing Assistant #3 they will come and observed when Certified Nursing Assistant #3 is providing personal care to Resident #4. Registered Nurse #3 stated Certified Nursing Assistant #3 called them at approximately 9:30 PM, to provide personal care to Resident #4. Registered Nurse #3 stated they went with Certified Nursing Assistant #3 into Resident #4's room to observe Certified Nursing Assistant #3 given care. Registered Nurse #3 stated Certified Nursing Assistant #3 stood by Resident 4#'s right side of the bed across from Registered Nurse #3 on the left side of the middle of the bed. Registered Nurse #3 stated before Certified Nursing Assistant #3 starting to provide personal case, Resident #4 said do not take off my sweater, Certified Nursing assistant #3 started to remove Resident #4's sweatpants, Resident #4 suddenly used their right hand to hit Certified Nursing Assistant #3 's left arm. Certified Nursing Assistant #3 hit Resident #4 back on the right hand. Registered Nurse #3 stated they told Certified Nursing Assistant #3 they cannot hit Resident #4 and to stop providing care and leave Resident #1's room. Registered Nurse #3 stated Certified Nursing Assistant #3 immediately stopped and left the room and they called the Registered Nurse Supervisor #2 to the Nursing unit. On 12/03/2024, The temperature of Resident's #4's room was 77.6 degrees Fahrenheit. During an interview on 12/09/24 at 3:30 PM, the Director of Nursing stated they interviewed Certified Nursing Assistant #3, who denied hitting Resident #4. The Director of Nursing stated according to Certified Nursing Assistant #3, Resident #4 attempted to kick them while they (Certified Nursing Assistant #3) were assisting Resident #4, and they used their hands to block the attempt. The Director of Nursing stated Certified Nursing Assistant #3 demonstrated this action to them (Director of Nursing). The Director of Nursing stated they interviewed Registered Nurse #3 who said Certified Nursing Assistant #3 hit Resident #4 on their right hand appropriately three times in rapid succession. The Director of Nursing stated Registered Nurse #3 said they instructed Certified Nursing Assistant #3 to leave Resident #4's bedside and called the Registered Nursing Supervisor #1 to report the incident. The Director of Nursing stated they conducted their investigation based on staff 's statements, and interviews, and concluded a physical altercation did occur between Resident #4 and Certified Nursing Assistant #3. This was physical abuse of Resident #4. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure food was stored, prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during kitchen observation. Specifically, milk was stored above 41 degrees Fahrenheit and expired food was observed in the dry storage room in the kitchen. The findings are: The facility policy titled Food Service Sanitation Guidelines dated ,d+[DATE] documented if potentially hazardous food exceeded 41 degrees Fahrenheit for more than 2 hours, discard the food. On [DATE] at 09:50 AM, the kitchen was observed with the Dining Services Director. Refrigerator #3 was observed with milk and eggs on the shelf and the refrigerator thermometer read 51 degrees Fahrenheit. The dry storage room was observed with 6 5-pound bags of instant mashed potatoes with a expiration date of [DATE]. During an interview on [DATE] at 12:58 PM, Food Service Worker #1 stated they forgot to label the instant mashed potatoes with an expiration date. It is very important to put date and they forgot. 10 NYCRR 415.14 (h)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00334937) survey from 5/9/2024 to 5/16/2024, the facility did not ensure services provided met professional standards. This was evident for 1 (Resident #24) of 38 total sampled residents. Specifically, Licensed Practical Nurse #5 did not inform the Registered Nurse and Medical Doctor when Resident #24 had a fall incident. The findings are: The facility's policy titled Standards of Nursing Practice and Nursing Care dated 1/22/2022 documented standards of care employed by the nurse includes implementing nursing actions and interventions that promote, maintain, and or restore physical and mental health, prevent illness, and effect rehabilitation and recovery and/or enhance quality of life. Resident #24 had diagnoses of cerebral infarction and atrial fibrillation. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #24 had severely impaired cognition. A Nursing Note dated 3/1/2024 documented Registered Nurse #3 received a report from Resident #24 and their roommate that Resident #24 fell on [DATE] at night while attempting to transfer to their wheelchair. The residents reported that a male staff member responded to the roommate's call bell and assisted Resident #24 back to bed. The facility Investigation Report dated 3/5/2024 documented Licensed Practical Nurse #5 and Certified Nursing Assistant #10 failed to follow facility policy and did not inform a nursing supervisor when Resident #24 sustained a fall, delaying the resident's care. There was no documented evidence Licensed Practical Nurse #5 informed the Registered Nurse supervisor and the Medical Doctor when Resident #24 sustained a fall on 2/29/2024, delaying evaluation and assessment necessary to determine Resident #24's condition. On 05/14/2024 at 3:44 PM, Certified Nursing Assistant #10 was interviewed and stated Licensed Practical Nurse #5 called them to Resident #24's room on 2/29/2024 and Certified Nursing Assistant #10 observed Resident #24 sitting on the floor. Licensed Practical Nurse #5 instructed Certified Nursing Assistant #10 to assist with getting Resident #24 back into bed. Certified Nursing Assistant stated they did not know Licensed Practical Nurse #5 did not report the incident to the nursing supervisor. On 05/14/2024 at 10:18 AM, Registered Nurse #3 was interviewed and stated they were the nurse manager on 3/1/2024 when Resident #24 and their roommate reported that Resident #24 fell on the floor on 2/29/2024. Certified Nursing Assistant #10 and Licensed Practical Nurse #5 transferred Resident #24 back to bed without informing the Registered Nurse supervisor so that Resident #24 received the necessary assessment of their condition. Upon inquiry, Certified Nursing Assistant #10 admitted they assisted in transferring Resident #24 back to bed following their fall in 2/29/2024. Licensed Practical Nurse #5 initially denied that Resident #24 fell but eventually admitted they did not inform the Registered Nurse supervisor when the resident fell . On 05/15/2024 at 10:20 AM, the Director of Nursing was interviewed and stated staff were responsible for reporting resident falls to the Registered Nurse and Medical Doctor to ensure the resident receives an assessment. Licensed Practical Nurse #5 and Certified Nursing Assistant #10 did not follow the facility's policy and placed Resident #24 back into bed without informing a Registered Nurse. Licensed Practical Nurse #5 was placed on administrative leave and has not returned to work. 10 NYCRR 415.11(C)(3)(i)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00334937) survey from 5/9/2024 to 5/16/2024, the facility did not ensure a resident received quality of care. This was evident for 1 (Resident #24) of 38 total sampled residents. Specifically, Licensed Practical Nurse #5 did not inform the Registered Nurse when Resident #24 sustained a fall, delaying an assessment of the resident's condition and potential injuries. The findings are: The facility's policy titled Standards of Nursing Practice and Nursing Care dated 1/22/2022 documented standards of care employed by the nurse includes implementing nursing actions and interventions that promote, maintain, and or restore physical and mental health, prevent illness, and effect rehabilitation and recovery and/or enhance quality of life. Resident #24 had diagnoses of cerebral infarction and atrial fibrillation. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #24 had severely impaired cognition. A Nursing Note dated 3/1/2024 documented Registered Nurse #3 received a report from Resident #24 and their roommate that Resident #24 fell on [DATE] at night while attempting to transfer to their wheelchair. The residents reported that a male staff member responded to the roommate's call bell and assisted Resident #24 back to bed. The facility Investigation Report dated 3/5/2024 documented Licensed Practical Nurse #5 and Certified Nursing Assistant #10 failed to follow facility policy and did not inform a nursing supervisor when Resident #24 sustained a fall, delaying the resident's care. There was no documented evidence Licensed Practical Nurse #5 informed their Registered Nurse supervisor when Resident #24 sustained a fall on 2/29/2024, delaying evaluation and assessment necessary to determine Resident #24's condition and potential injuries. On 05/14/2024 at 3:44 PM, Certified Nursing Assistant #10 was interviewed and stated Licensed Practical Nurse #5 called them to Resident #24's room on 2/29/2024 and Certified Nursing Assistant #10 observed Resident #24 sitting on the floor. Licensed Practical Nurse #5 instructed Certified Nursing Assistant #10 to assist with getting Resident #24 back into bed. Certified Nursing Assistant stated they did not know Licensed Practical Nurse #5 did not report the incident to the nursing supervisor. On 05/14/2024 at 10:18 AM, Registered Nurse #3 was interviewed and stated they were the nurse manager on 3/1/2024 when Resident #24 and their roommate reported that Resident #24 fell on the floor on 2/29/2024. Certified Nursing Assistant #10 and Licensed Practical Nurse #5 transferred Resident #24 back to bed without informing the Registered Nurse supervisor so that Resident #24 received the necessary assessment of their condition. Upon inquiry, Certified Nursing Assistant #10 admitted they assisted in transferring Resident #24 back to bed following their fall in 2/29/2024. Licensed Practical Nurse #5 initially denied that Resident #24 fell but eventually admitted they did not inform the Registered Nurse supervisor when the resident fell . On 05/15/2024 at 10:20 AM, the Director of Nursing was interviewed and stated staff were responsible for reporting resident falls to the Registered Nurse and Medical Doctor to ensure the resident receives an assessment. Licensed Practical Nurse #5 and Certified Nursing Assistant #10 did not follow the facility's policy and placed Resident #24 back into bed without informing a Registered Nurse. Licensed Practical Nurse #5 was placed on administrative leave and has not returned to work. 10 NYCRR 415.12

Based on observations, record reviews, and interviews, conducted during the Recertification survey from 05/09//2024 to 05/16/2024, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent infection and promote healing. This was evident for 1 (Resident #139) reviewed for Pressure Ulcer Injury out of 38 sampled residents. Specifically, during wound care observation, Resident #139 did not receive the physician ordered pressure ulcer treatment. The findings are: The facility policy titled Pressure Ulcer Injury and Wound Prevention dated 4/2022 documented that the residents of the facility will have a pressure injury prevention and intervention program to identify risk factors, prevent pressure ulcer formation, when possible, and promote skin integrity, as well as implement interventions to heal existing pressure ulcer injury, prevent infection, and prevent new ulcer/ injuries from developing. Resident #139 had diagnoses of unhealed pressure ulcers and dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented that Resident #139 was severely cognitively impaired and at risk of developing pressure ulcers. A Physician's Order initiated 04/27/24 documented cleanse Resident #139's left and right great toes with Normal saline, pat dry, paint with Betadine 10% solution, and cover with non-woven gauze and secure with tape On 05/14/24 at 11:40 AM, Registered Nurse #8 was observed performing wound treatment for Resident #139 on Deep Tissue Pressure Ulcer injuries to both heels. NS, Betadine, Dry Gauze, foam and Keflex dressings were applied to the left and right heels. Registered Nurse #8 did not perform the physician ordered treatment to the left and right great toes. On 05/15/24 at 10:44 AM, Registered Nurse #8 was interviewed and, after reviewing the Physician's Order for Resident #139, stated that they forgot to perform the treatment ordered for the left and right great toes. On 05/15/24 at 10:11 AM The Director of Nursing was interviewed and stated they spoke with Registered Nurse #8 regarding not following physician wound treatment orders for Resident #139 and informed them that they should have reviewed the orders prior to performing the treatment. 10 NYCRR 415.12 (c)(1)

Based on observation, record review and interviews conducted during the Recertification and Complaint Survey ( NY00336934 & NY0032139 ) from 5/9/2024 through 5/16/2024, the facility did not ensure that the resident environment remains as free of accident hazards. This was evident for 2 (Resident #72 and #33) of 38 total sampled residents. Specifically, 1) Certified Nursing Assistant #5 transferred Resident #72 without assistance and the resident required 2 person assistance for transfer, and 2) Resident #33 was not adequately supervised to prevent them from being found outside the building unsupervised on 8/2/2023 and from being missing for over an hour on 3/5/2024. The findings are: The Facility's Policy and Procedure titled Wandering and Elopement: Risk Assessment and Interventions dated last reviewed 5/2024, documented it is the policy of the home to ensure that the resident environment remains free as free from accident hazards as is possible and that each resident receives adequate supervision and assistance to prevent accidents. The policy further documented it is the responsibility of the Home to supervise all residents to ensure their safety and know their whereabouts. The Facility's policy and Procedure titled Policy for Safe patient Handing last revised 12/2016 documented all lifting and transferring of residents shall be performed utilizing the approved lift/transfer devices and methods to prevent resident and employee injury. the lift transfer shall be performed as determined by lift/transfer assessment as documented on comprehensive care plan, resident profile and Certified Nursing Assistant Accountability Record. There must be two caregivers present when using the total mechanical lift. Resident #72 was initially admitted to the facility on [DATE]. The Quarterly Minimum Data Set MDS dated [DATE] documented the resident's cognitive level is severely impaired. The resident needs total dependence and two assist for bed mobility, toilet use and transfer. The resident's diagnoses include dementia, PVD, hyperlipidemia and medically complex condition. Fall assessment dated [DATE] documented the resident is high risk for falls. Fall care plan initiated on 9/22/23 documented the resident needs two persons assist for Hoyer lift transfer. Care plan for Activities for Daily Living initiated on 9/22/23 and last updated on 03/23/24 documented two persons assist is needed for Hoyer lift transfer to reclining chair. The intervention as documented in the CCP was that nursing staff were to ensure two persons in application of Hoyer pad and removal. A Total of two staff for safety. Approach staff in a calm manner. Resident is confused and can be agitated and physically aggressive. If a resident is agitated during care, leave resident, monitor closely and reapproach him when he is calm. Nursing note dated 3/23/24 at 01:50 PM stated that the assigned Certified Nursing Assistant reported that the resident fell from the reclining chair to the floor while Certified Nursing Assistant was attempting to remove the Hoyer lift pad underneath the resident. Skin assessment reveled blanchable redness and closed blister noted to right upper back. Certified Nursing Assistant # 5 stated on 3/23/24 at 10:50 AM, He transferred resident #72 by himself to the reclining chair. The resident was seating down in the chair, and I proceeded to take the Hoyer lift pad from under him. I pulled him towards me and was able to get most of the pad away from him. Unfortunately, I attempted to remove the pad under his buttocks, the resident slipped off the chair onto the pillow placed under him. The facility's Investigation revealed that the Assigned Certified Nursing Assistant transferred the resident alone using Hoyer lift without assistance, failed to request additional assistance from nursing staff on the unit to assist him to provide care for resident. The resident is dependent on staff and two persons assist for activities of daily living. The plan of care was not followed. To conclude, the CNA failed to follow facility's policy on safe patient handing and failure to follow plan of care. There is reason to believe that evidence of neglect has occurred in the case. The New York Police department was informed of the incident. The facility's in-service records revealed Certified Nursing Assistant #5 received training on safe patient handling on 12/15/23. On 05/14/24 at 03:37 PM, Certified Nursing Assistant #3 stated that Certified Nursing Assistant #5 did not ask for help. The resident needs two persons assist for Hoyer lift transfer. The Hoyer lift the pad should stay on the chair. It should not be removed unless it is causing discomfort for the resident. Certified Nursing Assistant #3 stated that two CNAs have to be with the resident from the beginning of transfer until the resident is safely positioned on the recliner chair. We need two Certified Nursing Assistant #3 to assist the resident for safety reasons. The plan of care call for two persons assists for Hoyer lift transfer. On 05/14/24 at 11:57 AM, Certified Nursing Assistant #5 stated that it is unknown to why the resident was transferred without assistance. Certified Nursing Assistant #5 stated that the resident is a long-term resident. Certified Nursing Assistant #5 stated that the protocol was not followed when the resident was transferred via Hoyer lift without help. Certified Nursing Assistant #5 stated that the resident was transferred safely to the reclining chair safely. When an attempt was made to remove the Hoyer lift pad under the resident buttocks, the resident slipped from the reclining chair to the floor. The charge nurse was informed of the resident being on the floor. Certified Nursing Assistant #5 further stated that the resident needs two people assist for Hoyer lift transfer from beginning to end of the transfer. Certified Nursing Assistant #5 further stated that the resident should have never been transferred without assistance from another nursing staff. Certified Nursing Assistant #5 stated that education on safe patient transfer was provided to all staff prior to the incident. Certified Nursing Assistant #5 apologized for the occurrence. On 05/14/24 03:43 PM, Registered Nurse #6 stated while passing out medications, Certified Nursing Assistant #5 reported the resident fell out of recliner chair when Certified Nursing Assistant #5 was attempting to remove the Hoyer lift pad under the resident. Registered Nurse #6 stated the resident was assessed along with RN # 4. Redness and closed blister we reobserved on right side of resident back. No discomfort noted. we transferred the resident to bed. The resident requires two persons assist for Hoyer lift transfer. Registered Nurse #6 further stated the assigned CNA was trained on safe transfers. The Certified Nursing Assistant did not follow the facility's protocol. The resident's care plan call for two persons assists. It is also reflected on the Activities of Daily living care plan and the Certified Nursing Assistant Accountability record. The CNA did not follow the plan of care for the resident. On 05/14/24 at 04:04 PM, Registered Nurse #4 stated that the RN Supervisor is responsible for supervising all nursing staff on the unit. Registered Nurse #4 stated that several rounds were made on the day of the incident. During rounds, Registered Nurse #4 overheard Certified Nursing Assistant #5 telling Registered Nurse #6 that the resident was on the floor. The resident was observed seating on the floor in front of the wheelchair. Certified Nursing Assistant #5 stated that he just finished transferring resident without help. When Certified Nursing Assistant # 5 attempted to remove the Hoyer lift pad under resident #72 and he slid off the chair. Registered Nurse # 4 further stated there were five other nursing staff on the unit to assist. The protocol is there should be two people from beginning of transfer to the end of transfer. Two staff members must always remain at patient side. Certified Nursing Assistant # 5 failed to follow the facility's policy for safe transfer. the resident sustained redness and a blister on his right back. Resident #72 had redness and blister from the friction. The resident had no other skin abnormalities prior to the incident. We concluded that the resident plan of care was not followed. Registered Nurse#4 also stated that the resident # 72 plan of care requires two persons assist for transfer. On 05/15/24 at 11:51 AM, the Director of Nursing Services stated that our policy is that all equipment used for transfer requires two persons assist. We always need two staff for transfer. The Director of Nursing Services stated when an aide must transfer a resident; the Aide has to get assistance from a second staff member for safety reasons. We do annual trainings on safe transfer. Certified Nursing Assistant # 5 was trained prior to the incident. We want the staff to remove the Hoyer lift pad after transfer with assistance because it may cause skin impairments. The staff still need another staff to remove the pad. It is always supposed to be two people. Everyone was trained on safety protocol. The Director of Nursing Services further stated that there were four other Certified nursing Assistants plus three nurses on the floor around that time. There is no good reason why Certified Nursing Assistant # 5 transfer the resident without help. 415.12 (h) (2) 41709 Resident #33 Accidents 2. The Policy and Procedure titled Wandering and Elopement: Risk Assessment and Interventions dated last reviewed 5/2024, documented it is the policy of the home to ensure that the resident environment remains free as free from accident hazards as is possible and that each resident receives adequate supervision and assistance to prevent accidents. The policy further documented it is the responsibility of the Home to supervise all residents to ensure their safety and know their whereabouts. Resident #33 was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder, Hypertension, Malignant Neoplasm of the Prostate, Wanderer, Diabetes, Non-Alzheimer's Dementia, and Insomnia. The Annual Minimum Data Set assessment tool dated 6/10/2023 and Quarterly Minimum Data Set assessment tool dated 2/3/2024 documented Resident #33 had severely impaired cognition. The resident required limited assistance of one person for bed mobility and transfers, supervision of eating and extensive assistance of one person from dressing, toilet use and personal hygiene. Both Minimum Data Set assessment tool documented the resident uses wheelchair for ambulation. The resident was observed on two occasions throughout this survey: On 05/09/24 at 12:51 PM, resident observed sitting in the dining area sitting in wheelchair eating in dining area. Resident able to wheelchair independently. 05/10/24 at 11:52 AM, Resident wheeling self-up and down the unit, wheeling towards the elevator pressing buttons, but not entering the elevator. Appropriately dressed in no distress. On 05/14/24 at 09:32 AM, and 05/16/24 at 11:04 AM, Resident not on the unit. Staff reporting resident fell and transfer to the hospital for evaluation and remains in the hospital. The resident annual elopement assessment dated [DATE] documented the resident was not at risk for elopement. Subsequent elopement assessments dated 8/2/2023 documented a score of 9 (8 or higher is considered high risk for elopement), and further documented the resident tends to wander thru out the building, requires wheelchair but can propel self, resident able to walk short distances, tends aimless seeking the social security office to collect resident check, has history taking the elevator to the basement. Fall risk assessment dated [DATE] documented score of 17 ( score of 10 or higher considered high risk for falls) Nursing progress notes dated 8/2/2024 documented Fall with injury, at 8:00 pm recreation personnel reported the resident is on the floor. Upon response resident observed outside the main front door on resident knees attempting to climb to the wheelchair with security guard and recreation staff standing by resident, ensuring resident will not fall again. Injuries to face observed upon approach, superficial abrasion above right eyebrow, right cheek and nose noted. According to recreation staff observed resident on the floor an as approach resident tried to get up and fell on face on the ground. Resident was agitated, refusing assistance, and attempting to stand and come out of the wheelchair while being assisted back to the unit. Body assessment done abrasion to right knee noted, skin injuries cleansed Bacitracin applied. Complain of knee pain Tylenol given. Neuro check done, no deviation. Doctor informed. Telephone order to transfer to emergency room for evaluation. Resident niece informed of Medical Doctor order to transfer to the hospital, resident left facility in stable condition, alert and responsive at 9:25 pm. Nursing progress notes dated 8/3/2023 at 3:31 pm documented approximately 10:00 am resident returned from [NAME] Hospital. Resident observed with abrasions/scabs' formation to right elbow, right cheek and nose and right knee abrasion. Resident received daily medications, administer by nurse. According to discharge notes: Computed Tomography scan of head, sinus maxilla facial bones without contrast, and x-ray of right and lateral head, medication administered Haldol and midazolam. Nurse Practioner informed. Resident placed on every 15 minutes monitoring and code alert placed to left ankle. A facility investigation dated 08/02/24 documented that on Wednesday August 2nd at 8:02 pm, staff heard a loud scream heard coming from the outside. On arrival outside observed the two-recreation staff (Activity staff #1 and #2) yelling about something. When arrived they saw resident #33 on the ground. The investigation further stated resident #33 was last seen by staff at 6:30 pm in the hallway, after given evening care. The investigation further documented the rounding monitoring was incorrect and the resident was not on the unit at 8:00pm. The investigation concluded the resident left by the main entrance and not any other entrance and was not redirected by the security guard. The report concluded the resident did not leave buy any other door because in the walk through the resident was unable to navigate through two doors, the door saddle and ramp. Residents sustain abrasion to face, elbow, and knees. Resident was transfer to the hospital with all negative results. The facility provided no documented evidence that the other exit out of the facility was monitored, and the alarm at the door was working on 8/2/2023. The facility provided monitoring logs dated 8/1/2023 and 8/3/2023 and stated unable to find any monitoring logs for 8/2/2023. There was no documented evidence that resident was monitored hourly before being found outside the facility. Physician order last recertified dated 3/1/2024 documented order for visual monitoring every 15 minutes Nursing progress notes dated 3/5/2024 documented received report resident was noted asleep in unoccupied bed on [NAME] unit overnight. Resident skin was assessed for abnormalities, no visible injuries noted. Resident had no recall due to cognitive impairment to what occurred and stated, I don't know what happened. Resident continues to wander on/off unit and redirected by staff as needed, on every 15 minutes monitoring. Resident niece was notified by writer. Facility Investigative summary dated 3/5/2024 documented resident was last seen by staff at 11:50 pm and reported missing by staff at 12:05 AM when assigned Certified Nursing Assistance was looking for resident to change. Resident was later found at 1:05 am sleeping on a closed unit. The investigation further documented the Certified Nursing Assistant did not document every 15 minutes monitoring as ordered and last documented at 11:30 am. Facility documented titled observation 15 min documented the resident was last seen at 11:30 am and was in room. There were no signatures on the documented from 11:45 PM to 7:15 AM. There was no documented evidence that resident #33 was adequately monitored hourly on 8/2/2023 and no documented evidence resident #33 was monitored every 15 minutes as ordered on 3/5/2024. On 05/14/24 at 10:12 AM, an interview was conducted with Nursing Supervisor Register Nurse #4. Nursing Supervisor Register Nurse #4 stated completed the investigation for the incident on 3/5/2024, when staff reported the resident was missing, and or not on the unit. Nursing Supervisor Register Nurse #4 stated the staff on unit reported the resident was reported missing at 12: 05 AM, and staff looked all over the building for the resident and eventually looked on the empty unit and the resident was found sleeping in an empty be in room [ROOM NUMBER] A. Nursing supervisor stated the resident who was on every 15 minutes monitoring was found at 1: 05 am. Nursing Supervisor Register Nurse #4 sated the resident wanders and is free to go on and off the unit, free to get on the elevators and go anywhere in the facility. Nursing Supervisor Register Nurse #4 stated the resident have a code alert attached to the resident wheelchair and if the resident goes to the basement security will get and alert, if the resident attempted to go through the doors on 1st floor the security will get an alert as well. Nursing Supervisor Register Nurse #4 has Post traumatic Stress Disorder, Impulse behaviors and cannot stay a constant place, always wants to go and get check about Social Security, and it staff attempts to restrain or stop the resident, the resident will get agitated, yells scream, attempt to roll over staff with the wheel chair, use profanity so staff have to back away, and allow the resident to go on the elevator and staff monitor. Nursing Supervisor Register Nurse #4 stated the resident is currently in the hospital secondary to two falls this weekend. Nursing Supervisor #4 stated when the resident was sleeping in another closed unit the Certified Nursing Assistant assigned did not do every 15 minutes monitoring as ordered. Nursing Supervisor Register Nurse #4 stated the last round was done at 11: 30 pm and the facility started looking for the resident at 12:05 AM. Nursing Supervisor Register Nurse #4 stated the Certified Nursing Assistant did not give an answer as to why the rounds were not completed during interview. Nursing Supervisor Register Nurse #4 stated was inserviced on elopement and stated knows the protocol for if a resident is missing and to communicate and inform all units right away so they can help locate the resident. On 05/14/24 at 02:55 PM, an interview was completed with Nursing Home Activity Assistant #1. Nursing Home Activity Assistant #1 stated was leaving the facility with colleague at 8:00 pm. Nursing Home Activity Assistant #1 stated saw an empty wheelchair was standing empty, and resident was on the ground right in front the building. Nursing Home Activity Assistant #1 immediately inform security and alert nursing. Nursing Home Activity Assistant #1 stated resident able to wheel self independently and when on the ground saw little blood on the resident face and stated told the resident to wait, called security and security came out and stay with the resident. Nursing Home Activity Assistant #1 stated the resident was on the ground and saw no one was around the area. Nursing Home Activity Assistant Nursing #1 stated nursing came and help the resident and check resident and was informed to write a statement and wrote the statement. Nursing Home Activity Assistant#1 stated the resident is known to staff and the resident can go on and off the unit independently, redirect as needed. Nursing Home Activity Assistant #1 stated was inserviced on elopement and missing resident. On 05/14/24 at 04:20 PM, a telephone interview was completed with Certified Nursing Assistant #4. Certified Nursing Assistant #4 stated was assigned to the resident on 3/5/2024. Certified Nursing Assistant #4 stated the night of 3/5/2024 the resident was on the unit at the time coming into the unit. Certified Nursing Assistant #4 stated took care of another resident and come back around to get the resident and resident was not there. Certified Nursing Assistant #4 started look around with coworkers to look for the resident. Certified Nursing Assistant #4 stated thought the resident was in the dining room but once was not there went to look on the other units. Certified Nursing Assistant #4 stated did go onto the empty and did see the wheelchair but did not see the resident in the wheelchair. Certified Nursing Assistant #4 stated was so used to seeing the resident in the wheelchair did not think to go into the room and investigate the bed to look for the resident. Certified Nursing Assistant #4 stated after looking for a while another coworker went and look on the same unit and found the resident sleeping in the bed with wheelchair at bedside. Certified Nursing Assistant #4 stated miss the resident and if would of gone into the room would of seen the resident sleeping in the bed. Certified Nursing Assistant #4 stated the resident was found after 1:00 am. Certified Nursing Assistant #4 stated the resident on 15 minutes watch and made a mistake of not documenting the 15 minutes watch on the resident, and stated this was just a mistake. Certified Nursing Assistant #4 stated was in-service on 15 minutes documentation, as well as for protocol regarding elopement. On 05/14/24 at 03:06 PM, an interview was completed with Nursing Home Activity Assistant #2. Nursing Home Activity Assistant #2 stated was going home a little after 8:00 pm on 8/2/2023 and saw a wheelchair upwards and there was no one in the chair. Nursing Home Activity Assistant #2 stated when look to the side of the wheelchair and saw the resident lying on the ground right outside the building. Nursing Home Activity Assistant #2 stated left colleague with the resident and alerted security and Nursing. Nursing Home Activity Assistant #2 stated security reported right away, and Nursing also came to assist the resident, and escorted the resident back to the unit. Nursing Home Activity Assistant #2 stated the resident is known throughout the facility because the resident goes up and down on the unit, in the lobby, basement. Nursing Home Activity Assistant #2 stated the resident was sent to the hospital. Nursing Home Activity Assistant #2 started was in-service on elopement and not aware of this resident ever trying to leave the facility before this incident. On 05/15/24 at 11:59 AM, an interview was completed with Register Nurse #5 on unit. Register Nurse #5 stated the resident have a diagnosis of Dementia with behaviors of wandering on and off the unit as well as other behaviors. Register Nurse #5 stated the resident have code alert in the wheelchair because the resident keeps cutting it off the Code alert. Register Nurse #5 stated the resident is allowed to go on and off unit, and the resident is not restricted form freedom. Register Nurse #5 stated the resident is allowed to go on and off the unit, and the Code alert works on the two exit doors on the first floor, as well as the basement area. Register Nurse #5 stated was aware when the resident fell outside in August 2023 and when resident was found sleeping on the bed in the closed unit. Register Nurse #5 stated the resident was on the closed unit before it was empty. Register Nurse #5 stated the staff supervise the resident and the resident is on every 15 minutes monitoring, and the closed unit now have an alarm , and if resident or staff entering the unit the alarm will sound. Register Nurse #5 stated resident remains on every 15 minutes monitoring. Register Nurse #5 stated that the resident goes on and off the unit independently by wheeling in the wheelchair, and all staff is aware of the resident and redirects the resident as needed. Register Nurse #5 stated if staff attempts to redirect the resident, the resident will roll the wheelchair over the staff feet, yell screams, exposes self. On 05/15/24 at 12:24 PM, an interview was conducted with The Director of Nursing Services. Director of Nursing Services stated the incident of 8/2/2023, according to report two recreation staff saw the resident outside the door and called the security and Nursing staff to assist. Director of Nursing Services stated the resident was in an unsupervised area and reporting is part of the elopement process. Director of Nursing Services stated the supervisor assessed the resident and after the investigation concluded the resident was able to wheel self-past security and get outside the building. Director of Nursing Services stated the resident did fall outside the front door and passed security, so it was an elopement. Director of Nursing Services stated the resident have a wandering behavior of going on and off the unit, visits all the offices here on the 1st floor, and ask everyone for Social Security checks. Director of Nursing Services stated all the staff is familiar with this resident, and the resident had never made any attempt to elope or leave the facility. Director of Nursing Services stated the second incident is when the resident was found on a closed unit unharmed. Director of Nursing Services stated the staff did not do the monitoring in both incident and staff was disciplined and inserviced. On 05/16/24 at 08:53 AM, a Telephone interview was conducted with Security Guard #1 on duty at time of incident on 8/2/2023. Security Guard #1 stated is responsible for sitting on the front desk on the evening shift on 8/2/2023. Security Guard #1 stated while sitting at the desk at some point in the evening heard a faint noise of someone yelling and followed the noise coming from outside. Security Guard #1 stated went outside and saw two staff from recreation yelling telling the security guard to look. Security Guard #1 stated when turn around notice resident lying on the ground in front of the building next to a car that was packed outside the door. Security Guard #1 stated the resident wheelchair was in the regular position and the resident on the ground. Security Guard #1 stated it looked like the resident fell out of the chair. Security Guard #1 stated the resident was saying was hurt and in pain. Security Guard #1 stated there are two exits, the main entrance where and the second exit over by the volunteer office. Security Guard #1 stated multiple people exit at the main entrance door on 8/2/2023 and the resident #33 was not one of them. Security Guard #1 stated every door has an alarm box and if the resident exit at the side entrance, the alarm will sound at the security front desk. Security Guard #1 stated the side entrance alarm for the door was not working on 8/2/2023, and the resident is able to go through the door and no one will know. Security Guard #1 stated there was no camera. Security Guard #1 stated this is a resident who was known to the facility and is known to use feet to move the wheelchair, and it was possible for the resident to use the wheelchair and go down the ramp, and along the path and end up in front of the building. Security Guard #1 stated the security Guard is responsible for walking and checking all the doors. Security Guard #1 stated Security is responsible for checking exit doors and writes in a log when the door is checked. Security Guard #1 stated check door by ensuring the alarm box is on and this is done by pushing on the door and the alarm will go off. Security Guard #1 stated if the door is pushed there is a red dot on the alarm box. Security Guard #1 stated did a walk through the next day with Nursing and proved the door was not working at the time Security Guard #1 stated did not get an alarm alert on that evening of 8/2/2023. Security stated did demonstrate that the door was not working at the times. Security Guard #1 stated was asked questions and stated was inserviced and receive no disciplined for this. On 05/16/24 at 11:59 AM, an interview was conducted with the Administrator for the facility regarding incident on 8/2/2023. The administrator stated aware that two recreation staff was leaving for the evening, and they observed the resident outside on the walkway and resident was unable to state how get outside. The Administrator stated the next day did a return demonstration, as well as a walk through with the resident, and the resident was not able to get through the double doors, over the door saddle and down the ramp. The Administrator stated the second exit was alarmed and working during the walk through. The Administrator stated based on the return demonstration it was not possible for the resident to go through any door than the front door. The Administrator stated the front door is not alarmed, and staff, visitors go freely with no alarm. The Administrator stated most likely this resident went through the front door. The Administrator stated the Code alert or alarm system on the door was working on 8/2/2023, and when the walk through was done the door was working. The Administrator stated if the resident went through any other door than the front door, the alarm would have sounded. The Administrator stated the resident is allowed to go freely on and off unit and was not at risk at the time was found outside. The Administrator stated based on the investigation, the concluded was the only way the resident left the facility was the front door. The Administrator stated the doors are checked and not sure about the logs for monitoring on 8/2/2023 for the doors. 10 NYCRR 415.12(h)(1)(2)

Based on record reviews and interviews conducted during the recertification and complaint survey (NY00336988) from 05/09/2024 to 05/16/2024, the facility did not ensure that all residents were free of significant medication errors. Specifically, Resident #109 did not receive antianxiety medication in accordance with Physician's Orders. The findings are: The facility policy titled Medication Administration General Procedure dated 04/2022 documented medications are to be charted as soon as they are given. Resident #109 had diagnoses of schizoaffective disorder and anxiety. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident @109 was cognitively intact. The facility Investigation Report documented Resident #109 was ordered to receive Ativan, an antianxiety medication, at 10 PM on 3/24/2024. The blister pack count at the beginning and end of the evening shift (3PM to 11PM) was 9 pills of Ativan, indicating that the 10PM dose of Ativan was not administered. The facility investigation concluded that Licensed Practical Nurse # 2 failed to follow facility's policy on preventing medication errors. On 05/14/2024 at 03:50 PM, Licensed Practical Nurse #2 was interviewed and stated they signed the Medication Administration Record on 3/24/24 confirming they provided Resident #109 with Ativan which was an error. Resident #109 did not receive their prescribed Ativan on 3/24/24. On 05/15/24 at 11:51 AM, the Director of Nursing Services stated that nurses fill out the Medication Administration Record after medication has been administered. Resident #109 reported they did not receive their Ativan on 3/24/24. The facility investigation concluded Resident #109 did not receive their Ativan. All the nurses were re-trained on medication administration and policy for control substances. 10 NYCRR 415.12(m)(2)

Based on observations, record review, and interviews conducted during the Recertification Survey from 05/09/2024 to 05/16/2024, the facility did not ensure infection control practices were maintained. This was evident for 2 (Pine Unit and Maple Unit) of 6 floors. Specifically, 1) Certified Nursing Assistant #6 did not perform hand hygiene and did not sanitize the blood pressure cuff in between each resident use and 2) Certified Nursing Assistant #7 did not sanitize the blood pressure cuff in between resident use. The findings are: 1) On 05/09/2024 at 11:26 AM and 11:36 AM, Certified Nursing Assistant #6 was observed rolling the blood pressure machine to Resident #90 in the Pine Unit floor dayroom. Certified Nursing Assistant #6 did not perform hand hygiene and did not sanitize the blood pressure cuff before applying the cuff to Resident #90's right arm. After obtaining Resident #90's blood pressure reading, Certified Nursing Assistant #6 removed the cuff, did not perform hand hygiene, did not sanitize the cuff, and applied the blood pressure cuff to Resident #49's left arm. After obtaining Resident #49's blood pressure reading,Certified Nursing Assistant #6 did not perform hand hygiene, did not sanitize the blood pressure cuff, and proceeded to place the cuff on Resident #94's left arm. During an interview on 05/09/2024 at 2:38 PM, Certified Nursing Assistant #6 stated they were supposed to sanitize their hands and blood pressure cuff in between each resident use in accordance with infection control standards. During an interview on 05/09/2024 at 02:46 PM, Licensed Practical Nurse #3 was stated they reminded the Certified Nursing Assistants to sanitize the blood pressure cuff in between each resident use. Sanitizer wipes were available on the unit. 2) On 05/13/2024 at 04:23 PM, Certified Nursing Assistant #7 was observed rolling the blood pressure machine into Resident #139's room on the Maple Unit. Certified Nursing Assistant #7 did not perform hand hygiene, placed the blood pressure cuff on Resident #139's arm, obtained a blood pressure reading, removed the cuff, and rolled the blood pressure machine into Resident #164's room. Certified Nursing Assistant #7 did not sanitize the blood pressure cuff, did not perform hand hygiene, and placed the cuff on Resident #164's right arm to obtain a blood pressure reading. On 05/13/2024 at 04:39 PM, Certified Nursing Assistant #7 was interviewed and stated equipment shared between residents should be sanitized in between each resident use to promote infection control. Certified Nursing Assistant #7 stated they forgot to sanitize the blood pressure cuff in between use with Resident #139 and #164. On 05/13/2024 at 04:52 PM, Registered Nurse #2 was interviewed and stated they perform rounds every shift to observe staff interaction with residents. Equipment should be sanitized before and after resident use. During an interview on 05/15/2024 at 10:01 AM, the Infection Control Preventionist they monitor that staff by arriving on the unit and watching the staff as they provide care. The Registered Nurse supervisor also monitors staff to ensure they are following infection control protocols. 10 NYCRR 415.19(b)(4)

Based on observation, record review, and interview, the facility did not ensure the Minimum Data Set 3.0 (MDS) assessment accurately reflected the resident's status. This was evident for 1 of 5 residents reviewed out of a total 32 sampled residents (Resident #99). Specifically, Resident #99's evaluation for Gradual Dose Reduction (GDR) of [CONDITION(S)] drugs was documented in the MDS. The findings are: The facility policy titled MDS, and Care Area Assessment (CAA) Process dated revised 09/2016 documented that MDS and CAA must be completed prior to the care plan meeting. Resident #99 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] and 03/15/2022 documented Resident #99 was severely cognitively impaired, GDR was not attempted, and the GDR was not documented by a physician as clinically contraindicated. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/19/2021, MDO documented [MEDICATION(S)] was decreased from 5 mg twice daily to 5mg once daily. Medical Doctor note dated 02/23/2022 documented gradual dose reduction was done by reducing Resident #99's [MEDICATION(S)]. On 04/19/22 at 10:28 AM, Registered Nurse (RN) #3/Unit Manager was interviewed and stated RN #3 reviewed medical records and assessed Resident #99 prior to filling out the MDS. Resident #99 is evaluated regularly for [CONDITION(S)] drug review and has received GDRs. RN #3 stated the MDS is reviewed by the MDS department prior to submission and the GDR information must have been missed. On 04/19/22 at 02:15 PM, the MDS Coordinator (MDSC) was interviewed and stated MDS assessments are completed by Interdisciplinary Team (IDT) related to their department and the MDSC checks for completion and then submits the MDS. The RN who completed Resident #99's MDS should have documented GDR for Resident #99, but it was omitted. 415.11(b) 415.11(b)

Based on record review and interviews conducted during the Recertification/Complaint survey (NY 684), the facility did not ensure suspected cases of abuse, including injuries of unknown origin, were reported to the New York State Department of Health (NYSDOH) within 2 hours after the allegation was made. This was evident for 1 of 1 residents reviewed out of a sample of 35 (Resident #300). Specifically, Resident #300 was observed with a skin discoloration to the right side of their forehead and the facility reported the injury of unknown origin to the NYSDOH more than 2 hours after the injury was discovered. The findings include: The facility policy titled Abuse Prohibition revised 04/2022 documented the facility will identify and investigate injury of unknown origin, submit incident reports via the Health Commerce System (HCS) immediately once the reasonable cause threshold for abuse is met. Resident #300 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had severely impaired cognition and was totally dependent of assistance of others to complete activities of daily living. The Comprehensive Care Plan (CCP) related to skin integrity dated 1/2/2020 documented Resident #300 had fragile skin that bruises and tears easily. Documented with measurable goals and interventions. Nursing note dated 09/22/2020 documented Resident #300 was observed with a small dark area on the right side of the forehead. Medical Doctor assessed, ordered bloodwork, and was referred to Physical Therapy to evaluate for siderail enabler and padding. The Health Electronic Response Data System (HERDS) report dated 9/23/2020 at 03:06 PM documented the mark to Resident #300's forehead was discovered on 09/22/2020 at 1:15 PM, more than 2 hours before the report was made. The Summary of Investigation dated 09/24/2020 documented the date of incident as 09/22/2020 at 01:15 PM and the time reported to the NYSDOH as 09/23/2020 at 3:06 PM. On 04/19/22 at 11:48 AM, Certified Nursing Assistant (CNA #1) was interviewed and stated Resident #300 was given morning care and transferred out of bed on 09/22/2020. CNA #1 went to the resident's room to bring them a supplement and observed the skin discoloration on the resident's forehead and immediately reported it to the charge nurse. On 04/19/22 at 12:07 PM, the Registered Nurse (RN) #1/Charge Nurse was interviewed and stated Resident #300 was observed with a discoloration the right forehead and was assessed by the RN #1 on 09/22/2020. An investigation was initiated by collecting staff statements. RN #1 is unaware of when the incident was reported to the NYSDOH. On 04/19/22 at 12:51 PM, the Assistant director of Nursing (ADON) was interviewed and stated a resident's injury of unknown origin is repotted to the NYSDOH within 2 hours of being discovered. The ADON was unable to provide a reason Resident #300's skin discoloration was not reported to the NYSDOH within 24 hours. 415.4(b)(1)(i).

Based on interviews and record review conducted during an abbreviated survey (NY 127), the facility did not ensure that a resident's representative was provided with a copy of the resident's medical records within 2 working days upon request. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, the Law Firm/Attorney (representing Resident #1's Appointed Surrogate/Primary Next of Kin) and Resident #1's next of kin requested Resident #1's medical record, but the facility did not provide the medical record to the Law Firm/Attorney or to Resident #1's NOK. The findings are: Review of the facility's policy and procedure entitled Confidentiality of Medical Records and Request last revised in ,d+[DATE], documented: All requests for release of information and/or access to residents' medical records of the facility shall be coordinated by Medical Records. The release of residents' medical information shall be consistent with federal and state laws and regulations that contain provisions relating to release of information for residents' medical records. Resident request for access to own record done within 24 hours, subpoenas and depositions done within 48 hours and all other requests done within five (5) working days. Requests for Attorneys: Review for potential liability and check the record for completion, notify the Associate Director of Medical Records, and Administrator and wait for their clearance for release, count the number of pages and number each page, photocopy the record as requested and mail copy of record to appropriate party. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] identified Resident #1 with a Brief Interview for Mental Status (BIMS) sore of ,d+[DATE], associated with severely impaired cognition. Resident #1 expired in facility on [DATE]. Review of Resident #1's medical record revealed a Surrogate Notification of Surrogate Appointment form dated [DATE]. The documentation on the form showed that Resident #1's NOK was authorized as the designated representative for Resident #1 due to Resident #1's lack of capacity. The name on the Surrogate Notification of Surrogate Appointment document was the same named person listed on Resident #1's Face Sheet as Resident #1's emergency contact and number one NOK. Review of several letters from the Law Firm/Attorney, (complainant) for Resident #1's Appointed Surrogate/NOK, and a letter from the facility, revealed that the Law Firm/Attorney requested Resident #1's medical record on behalf of Resident #1's Appointed Surrogate. The facility requested several documents from the Law Firm/Attorney and the requested documents were provided to the facility. Additionally, the facility sent the Law Firm/Attorney a bill for the copied medical records and the Law Firm/Attorney remitted payment to the facility. A few days later, the Law Firm/Attorney received a letter from the facility stating that the facility would not release Resident #1's medical record and that the payment was remitted to the Law Firm/Attorney. Although, the Law Firm/Attorney provided the facility with all the required documents, to date, the Law Firm/Attorney and Resident #1's NOK did not receive Resident #1's medical records that had been requested since [DATE]. A letter dated [DATE], from the Law Firm/Attorney to the facility, revealed that the Law Firm/Attorney requested Resident #1's medical record. Review of the letter from the Law Firm/Attorney, revealed that the name mentioned in the letter was not on Resident #1's Face Sheet or on Resident #1's Appointed Surrogate Notification document. Review of a letter signed and dated [DATE], from Resident #1's Appointed Surrogate/NOK, to the facility, revealed that Resident #1's NOK requested Resident #1's medical records and that the medical records be mailed to the Law Firm/Attorney (address enclosed). An undated letter from the facility to the Law Firm/Attorney, revealed that the facility notified the Law Firm/Attorney that the name of the person mentioned in the letter (from Law Firm/Attorney) requesting Resident #1's medical record, was not authorized to act on Resident #1's behalf. The letter from the facility also mentioned that the person who was authorized to act on Resident #1's behalf had signed the letter. The facility requested several documents from the Law Firm/Attorney. Review of several documents that were provided by the Law Firm/Attorney, revealed that the facility received the required documents as requested. A Death Transcript/ Certificate of Death (Resident #1's Death Certificate) document, from the Law Firm/Attorney, was submitted to the facility. A Durable Power of Attorney document dated [DATE] documented that Resident #1's Appointed Surrogate/primary NOK, via the Durable Power of Attorney, appointed the Law Firm/Attorney (complainant) to execute a written request for patient information regarding Resident #1. The qualified person indicated on the Durable Power of Attorney document was the same name listed on Resident #1's Face Sheet. This document was provided to the facility from the Law Firm/Attorney. An Authorization for Release of Health Information Pursuant to HIPAA (Health Insurance Portability and Accountability Act), Form 960 dated [DATE], documented that the Law Firm/ Attorney was authorized to sign on behalf of Resident #1. The Power of Attorney document was attached to the HIPAA release document and was submitted to the facility. A facsimile cover sheet dated [DATE] documented that a total of 6 pages of documents including cover sheet was sent from the Law Firm/Attorney to the facility. A letter dated [DATE], from the Law Firm/Attorney to the facility, stated that the Law Firm/Attorney was following up on the prior request dated [DATE]st, 2020 which was mailed and then subsequently faxed to the facility on [DATE]th, 2020. The letter also stated that the Power of Attorney document was now enclosed. A Notarized Distributee Certification Form Public Health Law Section 18, dated [DATE], from the Law Firm/Attorney to the facility, documented that Resident #1's Appointed Surrogate/NOK was the child of Resident #1. The form was signed by Resident #1's NOK. This form was submitted to the facility. A letter dated [DATE], from the Law Firm/Attorney to the facility, stated that the Law Firm/Attorney did not receive the medical records to date and was requesting the medical record again. A letter dated [DATE], from the Law Firm/Attorney to the facility, stated that the Law Firm/Attorney was enclosing a copy of Resident #1's death certificate, copy of the facility's invoice dated [DATE] and a check in the amount of $223.06. During an interview on [DATE] at 4:50 PM, the complainant (Law Firm/Attorney) stated that they did not receive any of the requested documents for Resident #1 from the facility. The complainant (Law Firm/Attorney) further stated that they sent multiple requests to the facility for Resident #1's medical records. The complainant (Law Firm/Attorney) also stated that Resident #1's primary NOK/Surrogate provided via Power of Attorney authorization for the complainant (Law Firm/Attorney) to request Resident #1's medical records. The complainant (Law Firm/Attorney) added that they provided all the documents that the facility requested and paid the required fee for Resident #1's medical records. The complainant (Law Firm/Attorney) added that in February 2021, the complainant (Law Firm/Attorney) was told that the medical records would not be provided to the complainant (Law Firm/Attorney) because the records were placed on hold by the facility ' s legal counsel. During an interview on [DATE] at 11:45 AM, the Medical Records Representative stated that the facility received Resident #1's Law Firm/Attorney's request and payment for Resident #1's medical records. The Medical Records Representative further stated that the facility did not send Resident #1's medical records to the Law Firm/Attorney because the facility requested Resident #1's death certificate in early 2021 and the Law Firm/Attorney did not provide Resident #1's death certificate. During an interview on [DATE] at 1:00 PM, the Administrator stated that the Administrator was aware that the complainant (Law Firm/Attorney) made several requests for Resident #1's medical records. The Administrator stated that the facility could not comply with the complainant (Law Firm/Attorney) request because Resident #1's primary NOK was not the resident Health Care Proxy (HCP) or Resident #1 legal representative. The Administrator also stated that the complainant (Law Firm/Attorney) did not send the requested official proof of HCP or legal representative for Resident #1. The Administrator added that the facility could not comment further due to a pending lawsuit related to the case. 415.3 (c) (1) (iv)

Based on observations and staff interviews during the recertification and abbreviated survey, the facility did not ensure the garbage compactor area was kept clean and free of debris, specifically the surrounding area of the garbage compactor including the loading dock had empty soda can and milk carton, used disposable gloves, used plastic cups, loose slices of bread and sheet of plastic. This was evident during the Kitchen Task - Garbage and refuse was disposed of properly. The findings are: On 01/26/18 10:31 AM, the area surrounding the garbage compactor was observed to be littered with debris and not kept clean, specifically, the ground on both sides of the compactor (the front side of the compactor close to the loading dock and back side of the garbage compactor), and the extension ramp or the metal flapper (the metal plate attached to the loading dock that opens and serves as the bridge from the loading dock to the compactor). The ground on the front sides of the compactor have puddles of brown water on both sides. On the left of the front side of the compactor (viewing the compactor from the loading dock), an empty 8 oz milk carton and sheet of plastic were on the brown water. The ground on the right side of the garbage compactor (the right side when standing on the loading dock) has a puddle of brown water. There is a drainage situated on the ground next to the back of the compactor (left side). The drainage was covered with dried leaves. Pieces of compressed black cardboard were strewn next to the drainage. The metal flapper is broken on top, leaving about 2 feet gap between the loading dock and the garbage compactor. The broken metal flapper is on top of its base, leaving the metal base that holds the metal flapper, open. The base of the flapper is filled with empty can of soda, used disposable gloves, used plastic cups, loose slices of bread. There was an empty 8 oz carton of milk and a sheet of plastic on the brown water (a puddle of brown water (accumulated dust and water mixed together) There is a drain by the front which is fully covered with dried leaves and there are pieces of compressed black cardboard. On 01/26/18 03:40 PM, the garbage compactor area was being cleaned by Housekeeper #1. Housekeeper #1 was sweeping the front left side of the area where the brown water with litter was. On 01/26/18 10:33 AM, Housekeeper #1 was interviewed: Housekeeper #1 said that the metal flapper is broken about 2-3 months ago. The driver took the dumpster and when he was backing off to put the compactor back, he backed up all the way to the extension metal flap and it broke open. The compactor is washed when they take it on Monday or Tuesday. On 01/26/18 10:59 AM, Food Service Worker 1(FSW 1) #1 was interviewed. FSW1 #1 was interviewed and said when he throws out the garbage he tries to tie the bag well avoiding the gap between the garbage compactor and the loading dock. And every time the compactor is full, a Staff from Housekeeping, Dietary and the Big Storeroom can compress the items thrown in. The metal plate between the compactor has been noticed to be broken about 3 weeks ago. On 01/26/18 11:22 AM, Food Service Director (not a RD or CDN) was interviewed. Cleaning of the garbage compactor area is Housekeeping's responsibility. Maintenance/Engineering does the repair of the garbage compactor extension(metal flapper), or any repairs needed in the kitchen like a leaking faucet, a paint job, etc., including the kitchens on the floors. Dietary did not put in any repair to Engineering regarding the broken compactor extension or metal flapper. On 01/26/18 11:32 AM Assistant to the Acting Housekeeping Director was interviewed. Housekeeping is responsible for cleaning the compactor. The top of the loading dock and the area around the compactor is cleaned daily every morning and afternoon, around AM and PM. The Director of Engineering was informed about the broken metal plate. On 01/26/18 11:38 AM Acting Director of Housekeeping was interviewed. Cleaning the compactor area is supposedly a shared cleaning responsibility between Housekeeping and Dietary. Nobody cleaned the inside of the gap (the base of the metal flapper) because they don't want the cover to fall. The ground around the compactor is cleaned daily as needed. There is a ditch closer to the dock that holds water. There was no work order given to Engineering for the broken metal flapper. The flapper was broken since September 2017. The Director of Engineering was notified when it happened in September 2017. The piece that covered the metal flapper was on the ground at one point. On 01/26/18 11:51 AM Food Service Worker 1(FSW1) #2 was interviewed. FSW1 #2 said that the Porter cleans the kitchen, empties the garbage, sweeps the floors, wipes down the counters and mops the spills in the kitchen, throws the garbage at least 3 times daily between meals. About 3 months ago, he noticed the plate was broken. Porters from dietary never cleans the area. They clean what spills and falls out of the garbage. On 01/26/18 03:40 PM, the Director of Engineering was interviewed and said that Environmental rounds are done weekly. Director said he did not know that the metal flapper is broken not until today. 415.14(h)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure proper hand hygiene practices were performed during [MEDICAL CONDITION] care. Specifically, a Licensed Practical Nurse (LPN) was observed handling sterile supplies with soiled gloves. This was evident for 1 resident reviewed for [MEDICAL CONDITION] care out of 35 sampled (Resident #183). The finding is. The facility policy and procedure titled Hand Hygiene (Dated 9/16) documented the following. .the following is a list of some situations that require hand hygiene .after contact with a resident's mucous membranes and body fluids or excretions, after handling soiled or used catheters, after removing gloves .change gloves during resident care if moving from a contaminated body site to a clean body site. Resident #183 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 dated 12/19/17 documented resident needing total dependence for activities of daily living. Resident was also receiving daily suctioning and [MEDICAL CONDITION] care. The Comprehensive Care Plan (CCP) titled Suction last updated 1/26/18 documented the following. .[MEDICAL CONDITION] as ordered using sterile technique . The CCP titled Infection last updated 1/7/18 documented the following. .Use good hand washing technique . On 1/26/18 at 9:49 AM, the resident was observed sitting up in bed with white secretions collected inside [MEDICAL CONDITION]. On 1/26/18 at 10:37 AM, the LPN was observed performing [MEDICAL CONDITION] care. Next to resident's bed was a cart that had a suction machine and supply boxes of gauze,[MEDICAL CONDITION], inner cannula, gloves, foley, normal saline, and ambu bag. The LPN had on gloves and placed a sterile drape over the resident's chest and underneath [MEDICAL CONDITION]. The LPN than proceeded to move the resident's room garbage can, holding it with her gloved hands from the left side of bed, to the right side for it to be closer to her. She then took off gloves and put on new gloves without washing her hands or using an Alcohol Based Hand Rub (ABHR). The LPN retrieved a [MEDICAL CONDITION] from the cart, opened it, held it with her gloved hands, disconnected the old collar and connected the new one wearing the same gloves. She then removed her gloves and put on new ones without washing her hands or using as ABHR. The LPN proceeded to unwrap a soft red rubber foley and held it with one hand, opened a bottle of Normal Saline (NS), than dipped the red rubber foley inside bottle of NS, and proceeded to insert the red rubber foley in the resident's [MEDICAL CONDITION] suctioning it three to four times. The secretions were observed to be clear to white in color. The LPN held the soiled red rubber foley with her left gloved hand contaminating her glove and proceeded to retrieve a packaged gauze pad with her right hand from the cart, opened it, and held the gauze with her soiled left gloved hand. She poured NS over the gauze pad and used it to wipe down the red rubber foley and then disposed it in the garbage. The LPN then retrieved a packaged inner cannula, opened it, disconnected the old one and connected the new one while wearing the same soiled gloves. The LPN removed the sterile drape that was over the residents chest and disposed it in the garbage with the same soiled gloves. She then proceeded to move the garbage can back to the original location with the same soiled gloves. The LPN was observed washing hands with soap and water upon completion. On 1/26/18 at 11:20 AM, the LPN was interviewed. She stated she was supposed to set up supplies over the table but she grabbed, used, and discarded supplies along the way instead. The LPN stated she only washes her hands before and after completing treatment. She puts on new gloves before suctioning and changes gloves after suctioning and wiping off tube. She stated she would've changed gloves if there was mucous on it because you don't want to do dirty and clean. The LPN stated she was supposed to change gloves but didn't and stated her hands did not get soiled so she didn't wash her hands. The LPN stated she has not been in-serviced on how often she should wash or use ABHR when performing [MEDICAL CONDITION] care. However, she stated she was in-serviced on infection control and hand washing every six months and as needed. On 1/29/18 at 2:21 PM, the Assistant Director of Nursing (ADON) who is also the Infection Control Nurse was interviewed. She stated the nurses are expected to remove gloves and wash hands with soap and water if gloves get soiled during suctioning. The ADON further stated the nurses are not to touch any part of [MEDICAL CONDITION] retrieve sterile supplies when gloves are soiled. All Registered Nurses (RN) and LPN are in-serviced twice yearly regarding infection control and [MEDICAL CONDITION] care and competency on hand hygiene are performed biannually and as needed. 415.19(b)(4)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure a Significant Change (MDS) Minimum Data Set assessment was completed for a resident who experienced a major improvement in multiple care areas. Specifically, Resident #182 experienced major improvement in their functional status, and improved bowel and bladder continence and the facility staff did not conduct a significant change assessment to reflect the resident's status. This was evident for 1 out 35 sampled residents. Findings are Resident #182 is [AGE] years old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical records also documented that the resident had a history of [REDACTED]. The initial Physical therapy assessment dated [DATE] documented the that the resident had a poor balance, ambulates up to 15 feet distance, static is fair, resident like to lean forward with his head, severe [MEDICATION NAME] Kyphosis. The admission MDS (Minimum Data Set 3.0 assessment) dated 5/02/17 documented that resident was not able to perform in room, or floor ambulation. The admission MDS further documented that the resident is total dependent on staff for bathing, and frequently incontinent in bowel and bladder. A comparative review of the resident's status as documented on the comprehensive assessment with the most recent (Quarterly MDS assessment) was conducted. It revealed that the resident consistently improved in ambulation, bathing, bowel and bladder status. The last two quarterly MDS assessments dated 10/01/17 and 12/18/17 both documented that the resident requires limited assistance for mobility status, bowel and bladder is always continent. The PT (physical therapy) discharge summary dated 6/27/17 documented that the resident was seen in restorative PT 5 times per week for at least 175 minutes for therapeutic exercise, transfer training, neuromuscular facilitation and safety education. Resident is gradually making progress in bed mobility, balance, transfer, and ambulation. The resident ambulates without using any assistive device. The comprehensive care plan dated 4/20/17 was revised on 10/18/17 and documented that the resident is highly involved in activity; staff provide guided assistance with one person in mobility/transfer, bowel and bladder is always continent There was no evidence that a significant change assessment was done to accurately reflect the improvement in the resident's condition. On 01/29/18 at 10:28 AM the resident was observed in the room alert and awake. The resident was lying in bed, appeared to be confused, the resident did not speak. On 01/29/18 at 11:00 AM, the resident was also observed walking in the hallway independently without an assistive device, gait and balance were steady. The resident was not standing straight while walking. On 01/29/18 at 11:20 AM, an interview was conducted with the assigned Certified Nursing Assistant (CNA#1) who stated that he has been providing care for the resident for over 6 months. He stated that the resident had improved in ADSL, compared to when the resident was just admitted . CNA #1 further stated that the resident requires assistance with toileting but sometimes the resident goes to the bathroom, able to clean himself up and pull up his pant at times. CNA #1 also stated that the resident uses a wheel chair when going long distances, because he gets tired. On 01/29/17 at 11:35 AM, an interview was conducted with CNA #2. CNA #2 alternates a schedule with CNA #1. CNA #2 stated the she has been working on Unit 1 for the past 2 years. CNA #2 stated that the resident has been walking independently for a few months with little assistance. She also stated that the resident needs assistance sometimes for toileting, and sometimes goes to the toilet without calling staff. The resident is confused the CNA #2 stated. The CNA records dated from 01/2017 to 1/28/18 documented that the resident requires limited assistance with ADLs, and the resident is always continent of bowel and bladder. On 01/29/18 at 11:45 AM an interview was conducted with the charge nurse, a License Practical Nurse (LPN). She stated that she has been working in Unit 1 for about 3 years. She also stated that the resident had been walking with no assistive device, has a wheel chair if he gets tired while walking out the door. The LPN further stated that the resident sometimes bends down as if he's reaching to pick something from the floor, and this was believed to be the cause of his most recent accident. On 01/29/18 11:58 AM, an interview was conducted with MDS coordinator, who stated that she and the MDS nurses are responsible for the accuracy of the MDS assessment. She also stated that she makes sure that each discipline completed the assessment accurately. She further stated that they have interdisciplinary communication form that should be completed if there is any change in resident status, for example if there were improvement or decline. The staff who noticed a change will notified the MDS staff also . In addition to that, we also have verbal morning report and if there is any issues , it will be discussed. At the 7 days look back periods, we have the notes that document the ADLs, we also collect the ADLS status of the CNA records. The MDS assessors don't routinely do a physical assessment of resident unless there is an issues that will warrant the MDS nurse to look at the resident . This particular one was missed. The MDS coordinator could not explained why a significant change assessment was not done. She stated that a significant change was supposed to have done. It was an oversight. The MDS continues to explain that the resident was admitted in April 2017, the resident improved significantly from the admission MDS which the walking in the room and corridor were (Activity not occur) meaning that the resident is non ambulatory at that time. The resident consistently improved. There were no documented evidence that a significant change MDS assessment was completed within 14 days after a determination was made that the resident improved in ADLS status. The improvement was permanent. 01/29/18 12:25 PM, the resident was also observed walking to the dining room, no assistive device, gait was observed steady. 01/29/18 02:18 PM an interview was conducted with the Director of Rehab, who stated that the rehab department sends a notice of discharge to the MDS and all the discharged orders were signed by the physician. The nursing is also notified. The resident in question improve greatly and we discharged him. 415.11(a)(3)(ii)

Based on observation and interview, the facility did not ensure that sufficient support staff were provided to carry out the functions of the dietary service. Specifically, during dining observations that were conducted for breakfast and lunch, meals were not served to residents within the scheduled timeframe's. This was evident during meal Dining Observations for 3 of 5 resident units. (Units 1, 2 and 4-Maple). The findings are: 1) On 9/19/16 at 8:00 AM the 4th floor (Maple) dining service was observed during breakfast. The observed posted time for breakfast was 8:00 AM. During the observation, the food was on the unit at this time. The Dietary staff did not start preparing the trays for service to the residents in the dining room until 8:30 AM. During the delay, there was a nurse observed in the dining room, sorting through the meal tickets after 8:00 AM in preparation for the meal service. 2) On 9/19/16 breakfast was observed on the first floor unit ( Pine). At 8:00 am, the residents were sitting in the dining room waiting for breakfast to be served. An RN (Registered Nurse) was also present. The CNA was observed serving juice and water to the residents at 8:20 AM. At approximately 8:35 AM, the staff began serving the residents food. 3) On 9/20/16 at 1:14 PM, Resident #225 was interviewed and stated he believed the meals could be served faster. He stated that residents often has to wait one half hour before the food trays are prepared and his meal is served. He further stated that the residents are just sitting in the dining room hungry and waiting. 4) On 9/21/16 from 11:54 AM to 1:11 PM, the 2nd Floor lunch service was observed. The posted lunch time was 12:15 PM. The staff offered hand wipes to residents at 12:02 PM, and food temperatures were taken at 12:17 PM. The meal service began at 12:32 PM. There were ten CNA's (Certified Nurse Assistants) assisting three FSWs (Food Service Workers) preparing plates. At 12:52 PM, there were residents that had not been served. Prepared food trays were placed on a cart for room service at 12:58 PM. At 1:09 PM, a resident who was waiting for his lunch on the Beech unit came out of his room, wheeled himself to the dining room and complained to staff about the delay in receiving his meal. At 1:11 PM, a CNA was observed entering the unit with a cart of food trays to dispense to the residents who were eating lunch in their rooms. On 9/19/16, at approximately 8:25 AM, the Dietary Aide was interviewed and stated that breakfast should be served at 8:00 AM, but before the meal service, she is responsible for taking the food temperatures, reviewing the production sheets, and ensuring that all the required items are there. She further stated that the meal tickets are also reviewed. Once all of these tasks are completed, she starts preparing the trays, and the CNAs can then serve the residents. On 9/23/16 at 2:45 PM, the Food Service Worker was interviewed and stated that she works as both a food server and a food helper. She stated that the food servers prepare the plates at the steam table, and the food helper takes the temperatures and obtains items from the kitchen. She stated that there are usually two people serving breakfast and lunch on all units except Pine and Maple/Poplar (1st and 4th floor), where there is only one server assigned. She further stated that meal service should begin at the posted times with the last tray served for breakfast by 9:00 AM and lunch at 1:15 PM. At times there are delays in meal service when the nursing staff does not sort the meal tickets or when the meal truck is late. The FSW further stated that the meal tickets should be sorted 15 minutes the before each meal service. On 9/23/16 at 2:53 PM, another FSW was interviewed and stated that today, he covered the 4th floor as a server for breakfast and lunch. He stated that breakfast in the Poplar unit starts at 7:50 AM, and he started preparing trays at 8:00 AM. The FSW stated that he began serving the residents in Maple (the larger room) at 8:15 AM and that it was the first time he had to serve the two dining rooms. On 9/23/16 at 2:59 PM, a 2nd floor Certified Nursing Assistant was interviewed and stated that meal tickets should be sorted by the nurses or the CNAs at 7:45 AM for breakfast and 11:45 AM for lunch. She further stated that the plates are served to the residents as they become available from the server. She stated that sometimes there are complaints about the wait times for the meal service, and residents have waited up to an hour for their food. The CNA stated that the meal service delay depends on who serves the food because some servers are faster than others. She also stated that the Food Service Supervisor and Dieticians observe the meals and are aware of the delays. On 9/23/16 at 3:04 PM, a FSW was interviewed and stated that the meal service should begin at the posted times, but the nurses have to give the servers the meal tickets first. She further stated sometimes the meal tickets are not given on time, resulting in a delay, this issue happens often. She stated that all meals should be served, for the dining room and resident rooms, within 45 minutes to 1 hour. Most of the time breakfast is served by 9:00 AM and lunch by 1:00 PM. On 9/23/16 at 3:08:52 PM, the CNA assigned to the 2nd floor, was interviewed and stated breakfast should start at 8:00 AM, but sometimes the dietary staff are not ready or the nurse is not available. The CNA stated that residents complain about the wait time for meals. She stated that meals are served by table, and they rotate who is served first. She further stated that some residents wait up to 30 minutes or a little more for their meals. On 9/23/16 at 3:18 PM, the Food Service Director (FSD) was interviewed and stated that the breakfast service is between 8:00 AM and 9:00 AM, and lunch service is between 12:15 PM and 1:15 PM. She stated there are some residents that have complained about the wait time for service, so the staff alternates which side of the dining room is served first. The FSD further stated the nurse sorts the tickets according to which residents are in the dining room. In addition, as residents come in, the nurse asks for that residents tray if the resident is seated at a table where other residents are already eating. When residents complain about the wait, the nursing staff will go get the tray to accommodate them. The FSD stated there have been delays in the start of meal service related to the nursing staff coming to the dining room to sort the tickets. When this happens, the dietary staff attempts to find out which nurse is assigned to the dining room so the meal can begin. The facility policy and procedure for Meal Service Time reviewed 5/15 documented the meal service hours are as follows: Breakfast 8:00 AM, Lunch 12:15 Noon, and Dinner 5:15 PM. The policy further documented Meal service commences at these times and the first tray is served approximately 5 minutes later. 415.14(b)(1)(2)

Based on observation and interview, the facility did not ensure that infection control practices were maintained. Specifically, a residents oxygen tubing was observed on the floor. This was evident for 1 of 29 resident observations during Stage 2 (Resident #75). The finding is: Resident #75 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition.The MDS further documented the resident received oxygen therapy. On 9/20/16 at 9:54 AM, 10:35 AM, and 1:00 PM the resident was observed in bed with oxygen in use. The oxygen tubing was on the floor. On 9/21/16 at 12:59 PM, the resident's oxygen tubing was observed on the floor mat. On 9/23/16 at 11:08 AM, the resident was observed in bed with oxygen in use. The tubing was on the floor underneath the corner of the floor mat. On 9/23/16 at 11:15 AM, the Licensed Practical Nurse (LPN) was interviewed and stated that the oxygen tubing is changed weekly by the night nurse and checked every shift by the nurses. She further stated that she checks the tubing and changes it as needed if it is dirty. The LPN stated the oxygen tubing should be kept off the floor. On 9/23/16 at 11:26 AM, the Registered Nurse (RN) was interviewed and stated oxygen tubing should not be on the floor, and all staff are aware of that. She further stated that perhaps because the resident has a low bed, the oxygen tubing gets on the floor, but the staff could loop it to keep it off the floor. 415.19(a)(1-3)

Based on observation and interveiw, the facility did not ensure that the survey results were readily accessible to residents and visitors. The findings are: On 9/20/16 at 4:00 PM and 9/21/16 at 4:44 PM, the binder that holds the survey results, located in the facility's lobby was reviewed. The binder did not contain the survey results from the previous recertification survey. The binder contained the post-survey revisit letter and report for the previous recertification survey. On 9/19/16 at 11:06 AM the Resident Council President was interviewed and stated that the survey results are kept in a binder located in the lobby by security. On 9/21/16 at 4:41 PM, the Administrator was interviewed and stated that the Social Worker is responsible for posting the survey results for the residents. On 9/21/16 at 4:44 PM, the Director of Social Work was interviewed and stated that she puts the survey results in the binder as soon as the report is received by the facility. She further stated that she did not know why the results were not there, but it is possible someone removed them from the binder. 415.3(1)(c)(1)(v)

Based on observation, record review and interview the facility did not ensure that a resident who is fed by a gastrostomy tube receives the appropriate treatment and services to prevent complications. Specifically, during a Medication Administration Observation, the unit LPN ( Licensed Practical Nurse) did not check the placement of the resident's gastrostomy tube prior to administering medication and fluids. The findings are: Resident #175 is a [AGE] year old re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/23/16 at 9:42 am, during a Medication Administration Observation, the LPN was observed exposing the residents gastric tube prior to the administration of medication. The LPN connected an irrigation syringe to the gastric tube and administered approximately 10 cc (centimeters) of water. She continued to administer the ordered medication and flushed the tube with 30 cc of water. The Admission Minimum Data Set ((MDS) dated [DATE] documented: intact cognition, extensive assistance with bed mobility and total dependence for eating. The MDS further documents feeding tube. The Physician order [REDACTED]. LPS 15/30 Liquid 30 ml Via gastric tube 1 time a day. The CCP (Comprehensive Care Plan) dated 9/10/2016 documented: Potential for aspiration related to tube feeding. Patients with nasogastric (NG) or gastrostomy tubes-check placement before feeding. Check residuals before feeding. Hold feeding if residuals are high and notify the physician. Position head of bed An interview was conducted immediately with the LPN who stated that before any medication or fluid is administered via the gastric tube, she should check for placement. She stated that placement is checked by attaching an irrigation syringe, and checking the amount of aspirated stomach contents or by using a stethoscope and inserting 30 cc of air into the tube and listening for a swish sound over the stomach. The LPN then added that she had forgotten to do so during the observation. During the observation, the LPN was not observed in possession of a stethoscope. The policy titled Medication Administration General dated 9/2007 documents: Before administering any medication via an enteral feeding tube it is important to: Check the enteral feeding tube by injecting 30 cc of air into tube from syringe while auscultating the residents stomach with a stethoscope. Listen for the whooshing sound of air entering the stomach to indicate proper placement. 483.25(g)(1)

Based on observation, and staff interview the facility did not ensure that food was stored under sanitary conditions to prevent food borne illness. Specifically, expired food items were observed stored in the refrigerator. This was evident during observations conducted during the Kitchen Tour. The findings are : During the initial Kitchen Tour conducted with the Food Service Director (FSD) on 9/19/16 at 7:15 am. The following was observed: 1. A metal pan of puree fruit dated expired on 9/16/16 in the cold food prep refrigerator 2. A metal pan of sliced turkey dated 9/14-9/17/16 in the cold food prep refrigerator 3. A metal pan of muffins dated 9/10/16 to 9/14/16 in the cold food prep refrigerator 4. A metal pan of applesauce not dated in the cold food prep refrigerator 5. A metal pan of pureed fruit dated 9/10/16 to 9/15/16 in the cold food prep refrigerator 6. A metal pan of coleslaw dated 9/15/16-9/17/16 in the cold food prep refrigerator 7. A spice of Coriander seeds dated on 2/11/11 was observed in the store room. 8. In the Dairy/ Produce refrigerator two food items in separate pans were not dated; Sausage and muffins. An interview was conducted with the FSD immediately after the observations. The FSD stated that the Food service Manager is responsible for checking the prep refrigerator and the food items are kept in the refrigerator for three days. He further stated that the Chef is responsible for ordering and discarding spices. The chef was immediately interviewed and stated that the spices can be held for a year and added that this item is expired. The Policy on Food Supply Storage Procedures date 1/16 documents: All food, non food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Cover, label and date unused portions and open packages. Refrigerated Storage: Discard food past the use by or expiration date. 415.14(h)

Based on staff interviews and record review during an abbreviated survey the facility did not ensure that the physician a resident received the necessary care and services to maintain his highest practical well-being. This was evident for 1of 3 sampled residents (Resident is #1). Resident #1, who had no prior history of Diabetes, did not receive necessary treatment from the facility when two critical glucose levels were reported. Subsequently, the resident was hospitalized with a glucose level of 602 mg/dL (reference range 65-99 mg/dL) and a [DIAGNOSES REDACTED]. This resulted in actual harm that is not Immediate Jeopardy. Complaint #NY 923 The findings include: Resident #1 was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The 9/30/13 Minimum Data Set (MDS) 3.0 documented that the resident demonstrated moderately impaired decision making skills and required total assistance with activities of daily living. The 10/14/13 nurse ' s progress note documented that the resident was observed with bilateral wheezing. The Medical Doctor (MD) ordered Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP). The 10/15/13 laboratory (lab) report revealed that the resident ' s Glucose was 318 mg/dL (reference range 65-99 mg/dL), Blood Urea Nitrogen (BUN) was 72 mg/dL (reference range 7-25 mg/dL) and White Blood Count (WBC) was 11,900 uL (reference range 4,000-11,000 uL). The 10/15/13 entry for Resident #1 in the Critical Lab Value (CLV) log documented that Resident #1 had critical levels for Glucose and BUN. The 10/15/13 7:49AM Registered Nurse Supervisor (RNS) ' s progress note documented " Lab result with BUN 72 mg/dL; Glucose 318 mg/dL. " The RNS noted that the MD was notified and that the MD and dietician will follow up. The 10/15/13, 10:39AM dietician ' s note documented that the resident ' s BUN was elevated and that fluid was increased. The dietician documented that the resident will be monitored for 7 days. The 10/15/13 12:50PM " Monthly Tube Feeding Note " documented that the resident had no Diabetes Mellitus (DM) [DIAGNOSES REDACTED]. The 10/15/13, 3:54PM nurse ' s progress note documented that the MD was notified of the lab result. The MD ordered to check Fast Blood Sugar (FBS) and Hemoglobin A1C (HgA1C). The 10/16/13, 9:30AM Medical Director ' s note documented that fluid was increased due to the resident ' s elevated BUN level. The 10/16/13 lab report revealed that Glucose was 388 mg/dL and HgA1C was 7.2 mg/dL (reference range 4.0-6.0 md/dL). The report was initialed by the MD on 10/18/13 without any notation. The lab ' s phone notification record documented the resident ' s " panic " Glucose level of 388 mg/dL was reported to a nursing supervisor on 10/16/13 at 4:39 PM. The surveyor identified the nursing supervisor as the Nursing Administrator (NA) of the facility. On 1/17/14 at 11:40 AM, the Critical Lab Value (CLV) log was reviewed in the nursing office. There was no documented evidence that Resident #1 ' s 10/16/13 critical lab values were addressed in the CLV. The review of the nurse ' s and MD ' s notes from 10/16/13 to 10/25/13 revealed no documentation regarding the resident ' s critical Glucose level. The 10/27/13, 1:40PM nurse ' s progress note documented that the resident had foul smelling odor to the bilateral foot wounds. The resident had a temperature of 100.8 degrees Fahrenheit. The note also documented that the resident ' s wounds have been deteriorating despite all interventions by the team. The on-call MD ordered to start the resident on double antibiotics,[MEDICATION NAME]. The 10/27/13 9:21PM emergency room (ER) transfer note documented that the resident was observed to be lethargic with shortness of breath. The oxygen saturation was at 86-88%. The resident was given a nebulizer treatment with oxygen via face mask. The MD ordered to transfer the resident to the hospital with a [DIAGNOSES REDACTED]. The 11/8/13 hospital discharge summary documented that the resident was admitted to the hospital with [REDACTED]. The Endocrinology consult documented that the resident had a new onset [DIAGNOSES REDACTED]. The final [DIAGNOSES REDACTED]. " The 10/2013 Medication Administration Records and Treatment Administration Records did not reveal any documented evidence that medications or treatments were provided to the resident for diabetic management. The 10/2013 policy titled " Criteria for Notification of Change " documented that any resident who appears to have a deviation from normal and customary function should receive interventions, such as finger sticks and physical assessment by an RN. The policy documented that the changes of condition which warrant immediate attention and notification include low or high blood sugar, abnormal glycohemoglobin and any critical lab values. The 1/2003 policy titled " Diagnostic Services-Laboratory Services " documented that lab results requiring intervention will be promptly communicated to the MD by the nursing staff. Such notification should be documented in the resident ' s medical record. The policy also documented that the MD should review all lab reports and address abnormalities in the progress notes. Under " Critical Levels, " the policy documented that the RNS will ensure that all necessary information is communicated, followed up and documented in the CVL book within two hours receipt of telephone communication from the lab, and ensure that the MD is notified. The RNS will also document and place the resident on the 24 hour report. On 1/27/14 at 5:35PM an interview was conducted with two Registered Nurse Supervisors (RNS #1 and #2), who were assigned during the evening shift on 10/16/13. RNS #1 and RNS #2 stated that when they get a critical lab report, they check to see the resident ' s clinical status and then call the MD. If a resident with no prior history receives a critical Glucose level, the MD might order a repeat testing, finger sticks or sliding scale coverage. They stated that the MD orders should be entered and an RN should write a progress note. When asked about the critical lab value dated 10/16/13, they stated that they do not recall seeing the lab report and that " someone " must have taken the critical lab report to the unit without documenting in the CLV book. On 1/28/14 at 3:55PM an interview was conducted with RNS #3, who was assigned during the evening shift on 10/16/13. RNS #3 stated that she had no knowledge of Resident #1 ' s 10/16/13 critical lab result. She stated that it is possible that the lab faxed the critical lab report without calling the facility. She stated that if she was notified of or saw the critical lab result, she would have documented and notified the MD since the result could mean the beginning of DM or an infection. On 1/27/14 at 3:14PM an interview was conducted with the RN Nursing Administrator (NA). The NA stated that for critical lab results, the supervisors will receive a phone call from the lab and enter the result in the CLV book. The NA stated that an RN or a Licensed Practical Nurse (LPN) will notify the MD, but the RN must follow up with the LPN to monitor the outcome. During a subsequent interview with the NA on 1/29/14 at 1:35PM, the NA was asked about the resident ' s critical lab result that was reported to her by the lab on 10/16/13 at 4:39PM. The NA stated that she does not recall receiving a call from the lab about the critical lab result. She stated that it was not in her practice to not follow up on a critical lab result. On 1/27/14 at12:40PM an interview was conducted with the Director of Nursing (DON). The DON stated that there was no mention of the resident ' s elevated Glucose level on 10/16/13 in the " MD communication book " on the unit. The DON stated that the supervisors are required to document the lab values and the interventions in response to receipt of any critical lab report. The DON was not able to explain what interventions were provided in response to the 10/16/13 critical lab result. On 1/27/14 at 3:00PM an interview was conducted with the MD. The MD stated that when she was notified of the Glucose level of 318mg/dL on 10/15/13, she ordered repeat labs to determine if the resident had any infection. The MD stated that generally if there is an infection and the infection is treated, the Glucose level would decrease. She stated that she saw the resident on 10/15/13 and spoke to the nurse about the lab result. When asked about the 10/16/13 lab report with the Glucose level of 388 mg/dL, she stated that she is not sure if the nurse called her to notify the lab result. The MD stated that she saw the critical lab report on 10/18/13 and initialed it. When the MD was asked how the facility managed the resident ' s critical Glucose level of 388 mg/dL, she did not respond. The MD stated that she does not recall if she went to see the resident after seeing the critical lab result. On 1/27/14 at 4:05PM an interview was conducted with the Medical Director. The Medical Director stated that Resident #1 had [MEDICAL CONDITION] and might have had a new onset DM. The Medical Director stated that he would expect the nursing staff to notify the MD of any critical lab and document accordingly. The Medical Director stated that he would expect the MD to write a progress note explaining the abnormalities and determine if the resident was hyperosmolar. The Medical Director stated that he would counsel the MD regarding this case. 415.12

Based on observation, staff interviews and record review during an abbreviated survey, the facility did not ensure that a resident received adequate supervision to prevent accidents. This was evident in 1 out of 6 sampled residents (Resident #1). Specifically, Resident #1 sustained first and second degree burns after being out in the sun without staff supervision for approximately 3 hours. This resulted in actual harm that is not Immediate Jeopardy. Complaint #NY 324 The findings include: Resident #1 was a [AGE] year old who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 05/31/2013 assessed that the resident was cognitively intact. The hourly monitoring sheet dated 05/31/2013 documented that Resident #1 was Out of Bed (OOB) from 8:00 AM to 2:00 PM. The monitoring sheet did not specify the resident ' s whereabouts. The nurse ' s progress note dated 05/31/2013 at 4:02 PM documented that Resident #1 was not present in the dining room during lunch service. The Certified Nurse Aide (CNA) left the unit to look for Resident #1. The CNA found the resident at the gazebo on the first floor and observed him to be unresponsive. The nurse documented that the resident was warm to touch with the oral temperature of 103.8 degrees Fahrenheit. The nurse immediately placed ice to the resident ' s neck, groin, armpits, forehead and chest. The resident was placed on oxygen via non-rebreather mask. The resident was observed with closed blisters on his feet and arms. The Medical Doctor (MD) assessed the resident and ordered to transfer the resident to the hospital. Resident #1 ' s hospital record dated 05/31/2013 documented that the resident suffered from heat exhaustion from sitting outside under the sun for 3 to 4 hours and had blisters with epidermal loss due to a second degree burn of the neck. The resident ' s rectal temperature was 101.7 degrees Fahrenheit. The hospital record also documented that the resident had first degree burns with blisters on both lower extremities. The hospital discharge summary dated 06/09/2013 documented that the resident was given intravenous fluid hydration and treated with Silver Sulfadiazine for the blisters. The hospital wound care consult instructed to provide daily dressing changes with Bacitracin. A review of the video surveillance of the facility ' s lobby revealed that on 05/31/2013 Resident #1 was independently wheeling himself in the wheelchair in the lobby at 9:41 AM and made a right turn to the area leading to the gazebo. The video surveillance did not show the resident or any staff member going towards the gazebo between 9:41 AM to 1:10 PM. At 1:11 PM a staff was observed walking in the lobby and making a right turn leading to the gazebo. At 1:12 PM, the same staff was observed pushing Resident #1 in the wheelchair. The resident was observed sitting upright with his pants rolled up with no footwear. The resident ' s head was hanging low. At 1:13 PM, the staff put the shoes on the resident. At 1:17 PM the staff tried to push the resident ' s wheelchair but the resident ' s lower extremities were dragging on the floor. The staff then pulled the wheelchair backwards. The facility ' s policy for hourly monitoring dated 05/04/2011 documented that CNAs will ensure rounds are made of the entire unit at the designated time to ensure safety of residents, positioning in the wheelchair, and environmental issues. The policy did not include monitoring of residents when they are off the unit. A review of the form " Resident in the Gazebo Area " revealed that starting 06/01/2013, the security guards documented the names of the residents going to the gazebo and the time they were in and out of the gazebo. On 06/06/2013 at 11:25 AM an observation of the gazebo and security desk was conducted. The gazebo was located 8 to10 feet from the security desk. There were canopies in the gazebo that did not cover the entire area. Two unaccompanied residents were observed sitting by a canopy. The security monitor at the front desk did not have a view of the gazebo area. On 06/06/2013 at 12:15 PM an interview was conducted with the CNA, who was on duty from 7:30 AM to 4:00 PM on 05/31/2013. The CNA stated that on 05/31/2013 at approximately 12:15 PM she did not find Resident #1 in the dining room for lunch. She informed the unit manager and went downstairs to look for the resident. The CNA found the resident in his wheelchair in the gazebo near the door with shoes off. According to the CNA the resident seemed to be " sun tanning. " The CNA stated that she called the resident ' s name but he only opened his eyes and did not verbally respond. The CNA wheeled the resident back to the unit and the RN assessed him. The CNA stated that the last time she saw the resident before the incident was at approximately 9:30 AM when he received his medication on the unit. The CNA also stated that she was never assigned to supervise residents who are in the gazebo. She stated that there was no way for the staff to know the residents ' whereabouts in the building when they are off the unit. On 06/06/2013 at 10:00 AM an interview was conducted with the Registered Nurse (RN). The RN stated that Resident #1 was allowed to go out to the gazebo and did not need supervision. The resident left the unit at approximately 9:30 AM on 05/31/2013 after taking his morning medication. During lunch time the CNA informed the RN that the resident was not in the dining room for lunch. The CNA went downstairs to look for the resident. As the RN was waiting for the elevator to help search for the resident, the CNA brought the resident back to the unit. The RN stated that the resident was observed with closed blisters on both feet and arms. The RN stated that the resident was unresponsive and his skin was hot. The RN applied ice to the resident to cool him down. The RN stated that it was more than 90 degrees outside that day. The resident was transferred to the hospital via 911. On 06/06/2013 at 1:30 PM an interview was conducted with the Security Guard (SG), who was on duty on 05/31/2013 from 8:00 AM to 4:00 PM. The SG stated that he was responsible for making rounds and patrolling the entire building, but not the gazebo. The SG stated that he constantly patrolled the building throughout the day on 05/31/2013. He stated that he did not patrol the gazebo on 05/31/2013. He also stated that there is no view of the gazebo from the monitor screen at the security desk. On 06/06/2013 at 12:15 PM an interview was conducted with the Director of Nursing (DON). The DON stated that Resident#1 was allowed to be in the gazebo area. The DON stated that no one actively monitors the residents in the gazebo. When the DON was asked how they will respond if there is an emergency in the gazebo, the DON replied, " As I said there was really no one monitoring that area. " On 06/06/2013 at 12:45 PM an interview was conducted with the Administrator. The Administrator stated that it is not the security guards ' function to monitor the residents in the gazebo area. The Administrator stated that the gazebo is not monitored, but the security monitors the traffic that goes in and out of that area. He stated that there are 128 camera views but they are not all operational. He stated that the cameras inside the building are functional but the outside cameras, including the camera in the gazebo, are not functional. 415.12(h)(2)

Based on observations, record review and interviews the facility did not ensure that residents maintained their highest practical level of physical, psychosocial and mental well being. Specifically the facility that 3 of 46 residents reviewed for quality of care received the necessary care and treatment in a timely manner; this was evidenced by 1) a resident who is Legally Blind did not receive services to address discomfort to his eyes (#291) and 2) residents who reported itching and a burn to the left hand with hot coffee to the staff. (#116) and (#104) This resulted in actual harm that is not immediate jeopardy for residents 116 and 291. This resulted in no actual harm with potential for more than minimal harm for resident #104. The findings are: 1) Resident #291 is a [AGE] year old male admitted on [DATE]. [DIAGNOSES REDACTED]. The MDS (minimum data set) 3.0 dated 6/26/11 documented no pain or pain medication. The CCP (Comprehensive Care Plan) for legally blind documents Ophthalmology appointment as needed, monitor visual status and report any changes to MD (medical doctor) The Nursing pain assessment dated [DATE] for pain documents no pain, vision severely impaired. The physician's orders [REDACTED]. The vision consult sheet was filled out and signed by the MD (medical doctor) and two Nurses including the Unit Manager. On 7/6/11 at 1:35 PM, the resident was observed sitting in a wheelchair in front of the nurse station, stating: "my eye is killing me" he continued talking out loud and asked if the eye doctor was coming .The Nurse Supervisor responded and stated that the eye doctor is not in the building yet. The resident was observed on 7/13/11 at 1PM with a clear discharge from both eyes. On 7/13/11 at 11AM, the CNA (Certified Nursing Assistant) was interviewed, she stated that is was her first day working with the resident. She stated that his eyes are always running and in need of frequent wiping. On 7/13/11 at 11:15AM, the Nurse Supervisor was interviewed and stated that the resident started with tearing of the eye and crusting in the morning about 2 weeks ago . She stated that she did not let the doctor know because she did not think it was any infection or anything like that. She further stated that "all old peoples' eyes crust in the morning". When asked about the Vision Consult she stated that the eye doctor comes every other Thursday (every 2 weeks) and should have seen the resident. She stated that she did not follow up on the Vision Consult ordered on [DATE] because the Clinic people should be taking care of that. She further stated that consults are sent to the Clinic and when its received an appointment is made, The Clinic secretary sends a list to the Unit so the staff will know who is to be seen. The Clinic appointment scheduler was interviewed on 7/13/11 at 11:30 AM, and stated that the timeliness of the Vision consult depends on the resident's insurance. She also stated that in an emergency the resident is seen as long as the MD says he needs to be seen right away. She further stated that she had no evidence that the nursing staff had sent a request for resident #291 to have a vision consult. The Clinic appointment list for Optometry dated June 23, 2011 and July 11, 2011 was reviewed, there is no documented evidence that the resident was scheduled for an appointment. On 7/13/11 at 11:40 AM, the Primary Physician was interviewed and stated that he had not been made aware of any eye complaint by the resident. He stated that he would expect the resident to be seen within 2 weeks of an order. He stated that the resident is legally blind and should have a base line exam upon admission so he would know how to proceed with his eye care. Subsequently, the Physician wrote an order for [REDACTED]. On 7/13/11 at 12:30 PM, the Medical Director was interviewed and stated that no consult should be held because of the payor source. On 7/13/11 at 1PM, the resident was observed in his wheelchair in the yard after lunch. The resident was asked how his eyes were and he responded: "not so good..you see how they are watering ? I have been complaining for over one week, that they are bothering me and they have not done a thing" On 7/13/11 at 1:05 PM, the medication Nurse was interviewed and stated that she observed the watering of the resident's eyes "on and off" but was unable to specifically state the time frame. She further stated that she told the RN (Registered Nurse) Manager and thought he had done something about it. A second supervising nurse was interviewed on 7/13/11 2:30 PM, and stated that if a resident has crusted or watery eyes she cleans them with warm water and informs the MD because crusting is usually due to something being wrong such as infection. The Policy and Procedures for Consults dated 10/08 documents that: "The Licensed Nurse: 1. will review all consults, follow up as appropriate, 2. Contact Clinic/Designee to ensure appointment is scheduled, 3. Will contact primary MD/designee to advise of consult/recommendations, 4. ... ensure any physician order [REDACTED]. 2) Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 1/1/2011 documented that the resident is completely dependent for all ADLs (activities of daily living) and was independent in decision making abilities. The resident was interviewed on 07/06/2011 at 10 AM, and stated that he has been asking the staff for cream to treat his itching back for several days but it was not provided to him. The resident stated that he used to receive treatment for [REDACTED]. Review of the resident's record revealed monthly physician's orders [REDACTED]. An Allergist consult dated 10/6/10 documented a [DIAGNOSES REDACTED]. An Allergist consult dated 12/15/10 documented a [DIAGNOSES REDACTED]. An Allergist consult dated 4/20/11 documented a [DIAGNOSES REDACTED]. An interview was conducted with the unit's treatment nurse on 7/11/11 at 10:40 AM. She stated she was aware that the resident was under the care of the allergist for a skin rash that subsided. She also stated that the resident told her that his back itches but she did not inform the MD A CNA (certified nursing assistant) was interviewed on 7/12/11 at 1:50 PM, and stated she took care of the resident from 7/2/11 to 7/5/11 and the resident reported itching to his groin and back. She further stated that she reported it to the supervising nurse who responded that "he is always itching". The CNA also stated that the resident just lays there and does not usually complain about anything. The resident's physician was interviewed on 7/13/11 at 12:30 PM, and stated that he was not informed until 7/12/11 that the resident's skin was itching. He stated that he reordered the [MEDICATION NAME] cream. The supervising nurse was interviewed 7/13/11 2:30 PM, and stated that she remembers being told by the CNA over the 4th of July weekend that the resident skin itched but could not say what day. She further stated that she did not inform the MD until 7/12/11 "because he did not complain again". 3) Resident # 104 is an [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documents the resident's cognitive status as moderately impaired (Brief Interview for Mental Status score 12/15). The Resident Accident Report dated 6/28/2011 at 8 AM documented "Res. (resident) stated "My left hand was burned by coffee two nights ago," when asked what happened to his left hand. Resident was downstairs in Atria, heating up his coffee in the microwave. Resident did not report this to the nursing staff." The nursing note dated 6/28/11 at 8am, documented "V/S (vital signs) T(temperature) 98 P(pulse) 59 R(respirations)20 B/P (blood pressure) 159/85. D3/3 S/P (status [REDACTED]. Verbalized understanding." There is no documented evidence of an assessment of the resident's injury by the registered nurse noted on the accident report and nurse's note dated 6/28/11. The nursing note dated 6/28/2011 at 2PM documented "Monthly review done c (with) MD (Medical Doctor)..." with no reference to the resident's injury. The monthly physician's note dated 6/28/2011 documented no skin irregularities. The nursing note dated 6/28/11 at 6pm, documented " Resident stated " I got this two nights ago with hot coffee when it spilled on my arm." When asked what happen to your wrist. MD (medical doctor) T/O (telephone order) Apply [MEDICATION NAME] c (with) DSD (dry sterile dressing) after cleansing L (left) wrist area c N/S (Normal Saline). The Treatment Administration Record (TAR) dated 6/28/2011 documented "Cleanse L (left) hand open blister c (with) N/S (Normal Saline), apply [MEDICATION NAME] c DSD (dry sterile dressing) & kling daily until healed" The Resident Accident report MD assessment dated [DATE] at 12:50 PM, documented " L (left) hand - thumb and dorsal of palm - (radial aspect) [DIAGNOSES REDACTED]tous & (with) open blister area ...., no discharge...Follow up treatment required Yes [MEDICATION NAME] cream/ZnO2 (with ZincOxide) BID (twice daily) x (times) 5 days & (and) cover with DSD (dry sterile dressing)." The first assessment of the resident's injury (by the attending Medical Doctor) was documented 28 hours after the injury was reported to staff. On 7/5/2011 at 4:57 PM, the resident was observed to have a reddened area and a small open blister on the resident's left wrist. The resident stated that he had accidentally spilled hot coffee. On 7/13/2011 at 9:40 AM, when interviewed the resident stated he is served coffee at supper. Several days ago he reheated his cup of coffee in the microwave used by staff. The resident stated that this was the first time he had reheated his coffee. "My coffee got cold and I took it downstairs. It spilled when I wanted to take it out. I will not do it again..." On 7/13/2011 at 1:10 PM the Registered Nurse (RN) Unit Manager was interviewed and stated that the Certified Nursing Assistant, who came to escort the resident to his group therapy session, noted redness on the resident's hand and reported it around 8 AM on 6/28/11. The RN further stated she immediately went to speak with the resident and to assess his left hand. When she saw the resident at approximately 8 AM his left hand was pink, had no blister and the resident did not complain of pain. She did not document her assessment, but contacted the physician and obtained the MD order, which she documented on the TAR only and administered to the resident before he left the facility. The RN stated that when the attending physician came to do the resident's monthly assessment later in the day, she forgot to mention that the resident had an injury. The RN stated she remembered the resident's injury only after he returned to the facility, and that is when she noted an open blister on his left hand. She called the attending MD at that time and documented that the resident an injury, but forgot to document a description of the resident's injury. On 7/13/2011 at 12:20 PM, the attending Physician was interviewed and stated she routinely completes physical examination when doing monthly assessment and she would document if the resident is not available. The Physician stated she saw the resident on 6/28/2011, but does not recall the resident reporting anything about his hand. She further stated that she did not notice any injury. She stated that she received the phone call from nursing on the evening of 6/28/2011, reporting that the resident had sustained an injury to his hand. On 6/29/2011 when she came in to examine the resident she saw a second degree burn on the resident's left hand. On 7/13/2011 at 2:35 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated that per protocol immediately after the injury is reported, the Registered Nurse is required to assess the resident, notify the physician to obtain orders, and to notify designated representative within a reasonable time frame (approximately 2 hours). The ADNS stated that the RN should document everything in the resident's medical record. In addition the RN is required to start an investigation and to report injury to the nursing office. 415.12