Every finding on record at Pontiac Nursing Home

Based on observations, record review, and interviews during the recertification and abbreviated survey (reference # 532839 [NY00357482]) conducted 9/8/2024 - 9/12/2024, the facility did not ensure food was prepared, distributed, stored, and served in accordance with professional standards for the facility's food services. Specifically, the facility did not ensure prepared foods were cooled properly, stored properly, the food on the steam tables were served at an appropriate temperature during meal service, and nutrition rooms and storage areas were maintained in a clean sanitary condition. Findings included: The facility policy General Sanitation of Kitchen, reviewed 10/8/2024, required defined cleaning tasks, assigned responsibilities, and staff training. The facility did not follow this policy, as nutrition rooms and storage areas had not been maintained in clean and sanitary conditions.The facility did not have a food storage policy, food service policy, food handling policy, or pest policy as requested on 9/10/2025. Improper cooling:The facility's Cooling Log Sheet documented food must be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within two (2) hours or less. On 6/5/2025, 6/30/2025, 7/8/2025, 7/16/25, 7/21/2025, and 7/26/2025 macaroni salad and pasta salad were documented with temperatures that ranged from 73 degrees Fahrenheit to 78 degrees Fahrenheit after two (2) hours of cooling had been completed. No corrective actions were documented on those dates. During an interview on 9/10/2025 at 11:35 AM, the Food Service Director stated proper cooling allowed for six (6) hours to cool foods down to 41 degrees Fahrenheit and it should have been checked every 2-hours during the cooling process. They were not aware that food was required to have been cooled from 135 to 70 degrees Fahrenheit within two (2) hours. They stated that no corrective action was done for the items listed on the cooling log that had temperatures over 70 degrees Fahrenheit, those items should have been discarded and the process started over. Improper food storage (raw over ready to eat foods):During an observation and interview on 9/9/2025 at 11:49AM, the activities room refrigerator contained a dozen raw eggs stored directly above a drawer full of bottles of pop. The Rehab Director stated they were not aware of the storage requirements for the raw eggs and switched the location of the eggs and pop to avoid any possible cross-contamination. During an interview on 9/10/2025 at 11:35 AM, the Food Service Director stated the raw eggs should not have been stored above the ready to eat food items (bottles of pop) because that was a potential source of cross-contamination. Improper hot holding:During an observation on 9/9/2025 at 12:31 PM, the first-floor dining tray line served food from three (3) of the four (4) bays on the steam table. Tomato soup in the first bay was measured at 156 degrees Fahrenheit, grilled cheese sandwiches in the second bay were measured at 130 degrees Fahrenheit, and the fourth bay contained gravy at 90 degrees Fahrenheit, mashed potatoes at 108 degrees Fahrenheit, and riblets at 122 degrees Fahrenheit. The fourth bay did not have the light on by the knob like the first two bays and it did not appear to have been turned on. During an interview on 9/10/2025 at 2:00 PM, Dietary Aide #32 stated the third bay on the first-floor dining room's steam table did not work, the first, second, and fourth bays worked properly. They stated if the light wasn't on for the bay, then they probably didn't turn it on, and nothing should have been located in there because it was important food was kept hot during service for food safety and to ensure the residents received an enjoyable meal. During an observation on 9/10/2025 at 2:10 PM, the fourth bay of the steam table was on, and the indicator light was illuminated. During an interview on 9/10/25 at 3:22 PM, the Food Service Director stated food service staff should not have used the steam table for service if it wasn't turned on. Staff were supposed to turn it on about 30-minutes before service so they could ensure it was hot and ready during service. They stated all hot foods should have been maintained at or above 140 degrees Fahrenheit during meal service. They stated it was important the temperature of the food was maintained during service to prevent the growth of bacteria and to prevent food borne illness. Unsanitary conditions:During an observation on 9/8/2025 at 6:30 PM, the walk-in cooler had some white spills (both liquid and dried) on the floor below the milk shelving. On 9/9/2025 at 12:58 PM, the walk-in cooler had a significant amount of liquid milk spilled beneath the shelving that was tracked across the cooler floor and again on 9/10/2025 at 11:30 AM. During an observation and interview on 9/9/2025 at 11:14 AM, the second-floor nourishments room contained a pitcher of brown stagnant water located in the cupboard beneath the sink. There was a leak in the plumbing and dried puddle of brown liquid present within the cupboard and a hole through the back wall. A brown stained bed sheet was also balled up under the sink. Food debris and spills were present under the sink and around the refrigerator. The Environmental Services Director stated they were not aware of the leak and staff should have notified them so they could have cleaned and repaired the area. During an interview on 9/10/2025 at 11:35 AM, the Food Service Director stated the walk-in cooler was cleaned as needed. They stated they have had a problem with the milk leaking and that stained the floor beneath the shelving. They stated staff mopped that when it leaked, and they were not aware that puddles of milk were observed on the floor of the cooler for three days of survey. They stated the nourishment rooms should have been clean, the leaking sink, hole in the wall, and food debris provided food, water and potential harborage for pests. The Food Service Director stated the kitchen and nourishment storage areas should have been clean, with smooth and easily cleanable surfaces, without leaks and spills, so they could provide a better-quality food environment for the residents. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for one (1) of one (1) resident (Resident #52) reviewed and twelve (12) of twelve (12) anonymous residents present during a resident group meeting. Specifically, Resident #52 had intact decision-making ability, and the facility involved the resident's family in financial decisions without asking the resident and informed the resident they could not utilize another cognitively intact resident's cellphone even with permission; and twelve residents present at the resident group meeting voiced concerns they were not allowed to go to the enclosed area outside. Findings include:The facility was unable provide a resident rights and resident cellphone policy as requested.The facility admissions packet documented the residents as nursing home residents in New York State had the right to retain and use personal possessions, the right to privacy and confidentiality regarding medical, personal and financial affairs, to send and receive mail without interference, and to participate in social, religious, and community activities.1) Resident #52 had diagnoses including polyneuropathy (damaged peripheral nerves), hypothyroidism, and hypertension. The 5/10/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment. There was no documented evidence of a financial power of attorney.The 2/12/2025 Social Worker #30 progress note documented the resident had a Brief Interview of Mental Status score of 11 (moderately impaired cognition) but was alert and oriented to person, place, and time.The 4/11/2025 Social Worker #30 progress note documented the resident had a delivery of seven boxes from online shopping and was informed by staff the resident ordered additional items. They informed the resident they could not buy anything more because their room was only able to hold a small number of items. The resident was unhappy with the conversation and muttered under their breath as they left the room. Social Worker #30 called the resident's parents due to a history of the resident buying items they did not use and a large unpaid credit card debt.The 4/16/2025 Social Worker #30 progress note documented they and the resident's parents had a meeting with the resident which resulted in the resident giving their parents their debit card and getting $100 a month to spend.The 8/12/2025 Nurse Practitioner #9 progress note documented the resident had good judgment, was oriented to time, place and person, and had normal recent memory and normal remote memory. During an interview on 9/9/2025 at 10:04 AM, Resident #52 stated they were told they were ordering too many deliveries, and the facility sent an email to their parents to tell on them and forwarded the resident's debit card to their parents. Resident #52 stated when their cellphone broke, they used another resident's phone with that resident's permission. They were pulled out of an activity by the social worker and told they were not allowed to use another resident's cell phone. They stated the facility also sent another email to their parents and told them the resident was not allowed to use another resident's cellphone per their policy and the resident needed to order their own.During an interview on 9/11/2025 at 3:54 PM, Social Worker #30 stated residents should not use each other's cellphones, and it was discouraged to eliminate any conflict. They had a facility cellphone a resident could use if they did not have their own. They informed one resident that Resident #52 should not use their cell phone even though the resident had stated they were fine with it. They stated they highly discouraged it due to cellphones being able to access social media and Resident #52 posting information on social media. The other resident stated their phone was not able to access social media. Resident #52 had a history of posting comments online which the Director of Nursing had to remove. Resident #52 was alert and orientated and could be forgetful but was able to make their own care decisions. They involved Resident #52's parents when the resident was ordering too many packages and when they used another resident's cellphone. The resident was not responsible and had a history of overspending on things they did not need and not paying their bills per their family. They saw the online shopping boxes come in and was concerned as they did not want the resident to spend all their money. They were aware the resident was an adult, and they did not like the facility involving the resident's parents. They held the resident's debit card and had the resident's parents come in for a meeting at which time the resident agreed for their parents to have the card and a monthly amount the resident had access to.2) During a resident meeting on 9/9/2025 at 10:04 AM 12 of 12 anonymous residents stated they were not allowed to go outside by themselves, even in the fenced in areas of the facility grounds. Several residents stated as alert and orientated residents they should be able to go outside if they wanted to.The 6/10/2025 and 7/8/2025 Resident Council Meeting Minutes documented the residents were asking about increased outdoor access and it was referred to the Administrator. There was no documented follow up from the Administrator.During an interview on 9/11/2025 at 3:54 PM, Social Worker #30 stated residents, even alert and orientated residents, could not go out to the fenced in patio or go outside by themselves because it was a liability. A resident was allowed to go outside with friends and family present, but they were just trying to prevent accidents when residents were by themselves. It was for safety reasons. During an interview on 9/12/2025 at 9:10 AM, Certified Nurse Aide #17 stated even if a resident was alert and orientated, they needed to have someone with them to sit outside such as activities staff or a family member. They did not know why residents could not go outside by themselves if they were alert and orientated. The back patio was locked, and a code had to be put in by staff to access it.During an interview on 9/12/2025 at 9:55 AM, Registered Nurse Supervisor #4 stated alert and orientated residents were not allowed outside by themselves unless they had an order for a pass by the provider. They did not know why, it was just facility policy. The facility patio doors were locked and alarmed, but they unlocked them for families of residents who wanted to sit outside with a resident.During an interview on 9/12/2025 at 10:15 AM, Activities Supervisor #31 stated alert and orientated residents were not allowed to go outside alone. There was only one resident who was care planned for to be able to. They stated the residents were adults and should be allowed to go outside. They were trying to work on changing it.10 NYCRR 415.5(d)(1)(i)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for four (4) of four (4) residents (Residents #6, #21, #41, and #44) reviewed. Specifically, Resident #6 did not have a care plan that included the use of bed rails; Resident #21 did not have a current care plan addressing behaviors and diabetes with insulin use; Resident #41's care plan was not reviewed and/or revised after Minimum Data Set assessments; and Resident #44's care plan did not include the use of a urinary catheter (a tube to drain urine from the bladder). Findings include: The facility policy Comprehensive Care Planning, reviewed 9/16/2019, documented an individualized care plan was initiated by a registered nurse upon admission for all residents. The interdisciplinary team reviewed the care plan quarterly following the Minimum Data Set assessment completion; with a significant change; a return following a hospital admission; and as needed. All disciplines were responsible the plan of care was reviewed and documented goals, interventions, monitoring notes, and was updated as needed. 1) Resident #6 had diagnoses including morbid obesity and epilepsy (seizure disorder). The 4/26/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment, required moderate assistance for bed mobility, and did not use bed rails. During an observation and interview on 9/8/2025 at 6:38 PM, Resident #6 had bilateral enabler bars on their bed. The resident stated they used them when rolling in bed. The Comprehensive Care Plan documented a self-care deficit due to weakness and anxiety. Interventions included limited assistance for bed mobility and encourage resident to participate in bed mobility. There was no documented evidence of the use of bed rails. During an interview on 9/11/2025 at 1:52 PM, Registered Nurse Supervisor #4 stated physical therapy determined if a resident was appropriate for bed rails and updated the care plan to reflect that. They were not sure if the resident had bed rails. During an interview on 9/12/2025 at 9:15 AM, the Director of Rehabilitation stated if they determined bed rails were appropriate, it should be in the activities of daily living care plan under bed mobility. Resident #6 had bed rails, and their care plan did not reflect this. 2) Resident #44 had diagnoses including urinary retention, chronic obstructive pulmonary disease (airway disease), and hypertension (high blood pressure). The 8/18/2025 Minimum Data Set assessment documented the resident was cognitively intact, did not have any behaviors, and had an indwelling urinary catheter. The Care Area Assessment Summary triggered an indwelling catheter and was addressed in the care plan. The 8/14/2025 physician order documented to change the resident's urinary drainage device every 30 days. There was no documented evidence of a Comprehensive Care Plan related to the resident's urinary catheter. During an interview on 9/11/2025 at 11:05 AM Certified Nurse Aide #17 stated they knew how to care for a resident by the resident care instructions in the electronic medical record and by the book at the nurses' station. During an interview on 9/12/2025 at 9:13 AM Registered Nurse Supervisor #4 stated the staff knew how to care for a resident by the resident care instructions in the electronic medical record and by the paper care guide at the nurses' station. The resident care instructions did not always list everything needed due to the facility still transitioning to the electronic medical record. A resident who had a urinary drainage device should have a care plan. They did not know why Resident #44 did not have a care plan for their urinary drainage device. The resident did not have an admission assessment, so it was likely the care plan did not generate due to it not being triggered on the admission assessment. 3) Resident #21 had diagnoses including anxiety, intellectual disabilities, and diabetes. The 6/14/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment, did not exhibit behaviors, and received insulin injections, antipsychotics, antianxiety, and antidepressants daily. The Care Area Assessment Summary triggered behavioral symptoms and was addressed in the care plan. The Comprehensive Care Plan did not address the resident's behaviors, the diagnoses of diabetes, or the administration of insulin injections. Physician orders documented: -On 5/16/2025 sertraline (treats depression) 20 milligrams orally daily related to depression. -On 5/22/2025 buspirone (treats anxiety) 10 milligrams orally twice daily related to anxiety disorder. -On 6/9/2025 Abilify (mood stabilizer) 7 milligrams by mouth at bedtime related to anxiety disorder. -On 7/23/2025 Lantus (long-acting insulin) 80 units subcutaneously daily in the morning related to diabetes. Nursing progress notes documented the following: -On 7/21/2025 at 11:15 PM by Licensed Practical Nurse #5 the resident was experiencing behaviors beyond their baseline. The resident refused all medications and was cooperative with care after they were reapproached and offered coloring sheets and pens. The resident closed their eyes and pretended to sleep in their wheelchair and covered their face with a blanket. -On 8/23/2025 at 10:40 AM by Licensed Practical Nurse #5 the certified nurse aide staff informed them the resident was throwing things, cursing, and attempting to ambulate without their wheelchair despite being wheelchair bound and was threatening to hit the staff. The resident stated their green pen had been taken away and they wanted it back. -On 8/27/2025 at 5:24 AM by Licensed Practical Nurse #19 the resident came out of their room demanding a pen. They observed the resident repeatedly going behind the nurses' desk, standing at the desk frantically looking for a pen. At 5:30 AM, the resident was observed throwing a cup behind the nurses' station due to no pen available. At 5:59 AM, the resident was yelling staff was poisoning residents. They took their shirt off out of protest and staff attempted to deescalate without effect. The resident was observed at the following times: -On 9/8/2025 at 6:39 PM, self-propelling in their wheelchair in the hallway, asked the surveyor for their pen and persistently asked and raised their voice when they did not get the pen. -On 9/9/2025 at 1:29 PM, seated in their wheelchair just outside the nurses' station. They went behind the nurses' station and grabbed a stuffed animal on the desk. Licensed Practical Nurse #25 told the resident to let it go as it was not theirs and belonged to another resident. The resident refused to give the stuffed animal back. At 1:31 PM, they were in their wheelchair in the hallway with the stuffed animal. They raised their voice and demanded Certified Nurse Aide #26 write a name on a piece of paper for them with a heart. -On 9/10/2025 at 10:08 AM, in their wheelchair in the hallway yelling about not having a purple pen. The resident refused to go to their room and get changed with Certified Nurse Aide #26. Licensed Practical Nurse #25 stopped in the hallway where this encounter took place and attempted to reapproach the resident regarding getting changed. The resident then threw a pen down the hallway. There was no documented evidence of care planned interventions to address the resident's behavioral symptoms. During a telephone interview on 9/11/2025 at 12:55 PM, Certified Nurse Aide #11 stated the care plan was now located in the electronic record and there was a button they clicked on to see it. That was their normal unit, and they tried to reference the care plans at least every other day because things changed. The care plans used to be on paper, so this was a change. The care plan told them how to care for the residents. Resident #21 was diabetic because they were on a consistent carbohydrate diet. They were not sure if that was on the care plan or not. The resident was behavioral at baseline. They witnessed the resident hitting, kicking, throwing things, and refusing care. The care plan should document the resident had behaviors and interventions they should try when for behaviors, but they were not sure if it did. During an interview on 9/11/2025 at 3:56 PM, Licensed Practical Nurse #13 stated care plans were completed by the registered nurse supervisor. They did not know how to access a care plan in the computer, but they used to be on paper. The purpose of the care plan was to drive the care, inform them of the resident's needs and what care was required. Resident #21 had behaviors and was non-compliant. The resident should have a behavior care plan because staff should know how to handle the behaviors. The resident was also diabetic and was on insulin which was a high-risk medication so there should be a care plan for that. During an interview on 9/12/2025 at 9:55 AM, Registered Nurse Supervisor #4 stated they and the other supervisors were responsible for care plans. Residents who were diabetic should have a specific care plan and should include Insulin. The care plan instructed what needed to be followed and what needed to be monitored such as labs and blood sugars. Residents with behaviors should also be care planned for that. Resident #21 had been there for a long time, so they had a paper care plan. Upon viewing the paper care plan with the surveyor, they stated it was not reviewed quarterly as required. The resident's electronic care plan did not really have anything in it and had fallen by the wayside. One care plan came from physical therapy, one from activities, and one from section GG of the Minimum Data Set assessment and that was all the resident had on their care plan. The care plans switched to electronic in June, but it was impossible to get them into the electronic record. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for one (1) of two (2) residents (Resident #48) reviewed. Specifically, Resident #48 received continuous positive airway pressure therapy (a machine used to keep the airway open by delivering continuous air through the nose) without a physician order with a supporting diagnosis, a plan to regularly clean the machine to prevent contamination, and a care plan for use of the device. Findings include: There was no documented evidence of a policy for positive airway pressure therapy. Manufacturers recommendations for maintenance of continuous positive airway pressure equipment included daily cleaning of the mask cushion and the humidifier tub (reservoir for placing water), and weekly cleaning of the tubing. Resident #48 had diagnoses including anxiety, depression, and trisomy (a genetic condition causing developmental delays, intellectual disabilities and various physical health problems). There was no documented diagnosis to support the use of a continuous positive airway pressure machine. The 7/29/2025 Minimum Data Set assessment documented the resident had severely impaired cognition and did not receive any respiratory treatments including continuous positive airway pressure treatments. The 7/22/2025 hospital discharge summary documented a diagnosis of drug induced syncope (fainting) with hypoxia (low oxygen levels). The was no documentation the resident required or used a continuous positive airway pressure machine. The Comprehensive Care Plan did not document the use of a continuous positive airway pressure machine.The 7/23/2025 Registered Nurse Supervisor #4 admission assessment documented the resident had a continuous positive airway pressure machine from the group home but there were no orders from the hospital for it. They would reach out to the group home for settings for the machine. There was no documented evidence of follow up by Registered Nurse Supervisor #4 regarding the resident's continuous positive airway pressure machine.The 7/31/2025 Medical Director's admission History and Physical did not document a diagnosis for, or include the use of, a continuous positive airway pressure machine. The 7/29/2025, 7/31/2025, 8/5/2025, 8/12/2025, 8/14/2025, 8/28/2025, 9/2/2025, 9/4/2025, and 9/9/2025 Nurse Practitioner #9's clinical encounter summaries did not document a supporting diagnosis for us of a continuous positive airway pressure machine. The 9/6/2025 Licensed Practical Nurse #10's progress note documented the resident was awake most of the night and was difficult to console, the continuous positive airway pressure machine was on with short term effects. The September 2025 vital sign summary documented the resident's oxygen saturation was measured while on a continuous positive airway pressure machine on 9/3/2025 at 12:56 AM, 9/4/2025 at 12:44 AM, 9/5/2025 at 2:47 AM, 9/6/2025 at 1:32 AM, and 9/9/2025 at 12:11 AM.There was no documented evidence of physician order for the use of a continuous positive airway pressure machine or an order for cleaning or maintaining the machine. During an observation on 9/8/2025 at 6:43 PM, Resident #43 was lying in bed with continuous positive airway pressure mask on their face, yelling out nonsensical speech in their room. Certified Nurse Aide #11 had just exited the resident's room and turned the light off. They stated the resident frequently yelled, and they just tried different things to see if they would stop. The resident's continuous positive airway pressure machine had just been applied and that usually helped. During an observation on 9/10/2025 at 10:07 AM, the resident was sleeping in their bed with the nasal mask on their face and the continuous positive airway pressure machine was on. It was a black machine on the nightstand with gray corrugated tubing, and the water reservoir tub was approximately half full. During an observation and interview on 9/11/2025 at 1:28 PM, Certified Nurse Aide #12 stated Resident #48 had a continuous positive airway pressure machine. They placed the mask and turned the power on. They also filled the water reservoir. They were not allowed to touch any of the other buttons/ knobs. The resident was sleeping in the bed, and the mask was on the floor. Certified Nurse Aide #12 picked up the mask and put it on top of the machine on the nightstand. The mask had brown stains on the gray fabric of the mask. Certified Nurse Aide #12 stated they were not sure if the mask or the tubing was ever cleaned. During a telephone interview on 9/11/2025 at 2:26 PM, Licensed Practical Nurse #10 stated continuous positive airway pressure machines were already programmed to settings from wherever the machine came from. They were used when the resident slept. The use of the machine required an order, and it was signed off in the medication administration record or the treatment administration record depending on how the order was entered. Resident #48 used the continuous positive airway pressure machine at night since admission even though they did not have an order for it. They told the oncoming nurses many times and put it in the 24-hour report that an order was needed. They could have called for an order on the night shift, but they had not as they did not like to make the medical providers mad. They did not know if the resident needed the machine, their oxygen saturations were good even when they refused to wear it. During an interview on 9/11/2025 at 3:56 PM, Licensed Practical Nurse #13 stated Resident #48 used a continuous positive airway pressure machine. They were responsible to ensure the mask was put on but often asked the certified nurse aides for help. They did not sign off Resident #48 had the machine. The resident did not have an order but should have, and it should include settings. Continuous positive airway pressure machines were a treatment, and all treatments required orders. The registered nurse supervisor was responsible to obtain the order when the resident was admitted . Licensed Practical Nurse #13 stated they were not responsible for cleaning clean the mask or the tubing. The sleep apnea (a condition when breathing repeatedly stops and starts during sleep) clinic was responsible for any maintenance of the machine. They stated the resident did not even have a diagnosis of sleep apnea for the machine.During an interview on 9/12/2025 at 9:55 AM, Registered Nurse Supervisor #4 stated Resident #48 did not use a continuous positive airway pressure machine. Use of a continuous positive airway pressure machine required a physician's order. They completed the resident's admission assessment and referenced their notes. They were not sure who brought the machine into the facility. They talked to the group home many times but never got the settings for the machine. The nurses should not be applying the machine without an order. If it was applied and they noted it was not on the record to be signed for, they should obtain an order. The resident did not have the ability to independently place the mask and needed help from staff. During a telephone interview on 9/12/2025 at 10:11 AM, Nurse Practitioner #9 stated they did not believe Resident #48 used a continuous positive airway pressure machine and they did not see an order for it. Nursing should not have applied the continuous positive airway pressure machine without an order. 10NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for two (2) of five (5) residents (Resident #13 and 41) reviewed. Specifically, Residents #13 and #41 were administered long-acting insulin greater than 3 hours past the scheduled administration time and the insulin pens were not primed (removing trapped air) prior to dialing in the ordered dose. Findings include:There was no documented evidence of a facility policy on medication administration or insulin administration. 1) Resident #13 had diagnoses including diabetes. The 8/5/2025 Minimum Data Set assessment documented the resident had intact cognition and did not receive daily insulin injections. There was no documented Comprehensive Care Plan addressing the resident's diabetes or administration of insulin. During an interview on 9/8/2025 at 7:27 PM, Resident #13 stated they did not get their medications on time. They were supposed to get their medications, including the insulin, before breakfast but often did not get them until 10:00 AM or 11:00 AM. They had incidents when their blood sugars were high.The 7/29/2025 physician order documented Basaglar Kwik Pen (glargine, a long-acting insulin) solution pen injector 100 units/milliliters inject 25 units subcutaneously one time a day. During an observation on 9/10/2025 at 11:06 AM, Licensed Practical Nurse #5 administered 25 units of Basaglar Kwik Pen insulin. They did not prime the needle prior to dialing in the ordered dose. The resident complained to the nurse their medications were late and requested their glucose be checked prior to administration. The result of the glucose finger stick was 206.The September 2025 Medication Administration Record documented the 25 units of Basaglar Kwik Pen insulin was scheduled for 8:00 AM and was administered by Licensed Practical Nurse #5 on 9/10/2025.There was no documented evidence the provider was contacted regarding the delay in administration. 2) Resident #41 had diagnoses including diabetes. The 7/9/2025 Minimum Data Set assessment documented the resident had intact cognition and received daily insulin injections.The 6/2/2025 Comprehensive Care Plan documented the resident had unstable blood glucose levels. Interventions included administer medications as prescribed.The 8/25/2025 physician order documented Lantus (glargine, a long-acting insulin) Solostar subcutaneous solution Pen-injector 100 units/milliliters inject 120 unit subcutaneously every 12 hours. During an observation on 9/10/2025 at 11:22 AM Licensed Practical Nurse #5 administered 60 units of Lantus Kwik Pen insulin, removed the needle, applied a new needle, and administered a second dose of 60 units to equal 120 units. They did not prime the needles prior to dialing in the ordered doses.The September 2025 Medication Administration Record documented 120 units of Lantus Solostar Pen-injector was scheduled for 8:00 AM and 8:00 PM. The 9/10/2025 8:00 AM dose was administered by Licensed Practical Nurse #5.There was no documented evidence the provider was contacted regarding the delay in administration. During an interview on 9/10/2025 at 11:58 AM, Licensed Practical Nurse #5 stated they were never taught to prime pen needles prior to dialing up the dose. Residents #13 and #41 received their long-acting insulin late that day and they thought that was okay because there was no peak time. They would share in shift report they gave the insulins late and needed to call the provider to let them know as well. Insulins were prioritized and typically given on time. Short acting insulins were their focus and were given on time.During a follow up interview on 9/11/2025 at 12:02 PM, Licensed Practical Nurse #5 stated they did not notify the provider about the late insulin administration on 9/10/2025 but should have.During an interview on 9/11/2025 at 10:46 AM, Registered Nurse Supervisor #4 stated medications should be passed within one hour before or one hour after the scheduled time. If the nurse was behind on their med pass, the physician should be called to get permission to give the medication late and find out if the provider wanted to recheck the glucose before administering the insulin. An order should be taken to say it was okay to give at that later time. Insulin pens only had to be primed when they were first opened. Needles did not need to be primed. They were not aware that insulin was administered late yesterday or if a provider was notified.During an interview on 9/12/2025 at 9:33 AM, Nurse Practitioner #9 stated if long-acting insulin was scheduled for 8:00 AM a reasonable time frame it should be administered was an hour before or after. If insulin was not administered within that time frame they expected to be notified because there might be a need to adjust the dose. They were not notified Residents #13 and #41 did not receive their morning insulin until after 11:00 AM on 9/10/2025 and should have. 10NYCRR 415.11(c)(3)(i)

Based on record review and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not provide specific services outside the facility when the facility did not employ a qualified professional to furnish the specific service for one (1) of one (1) resident (Resident #13) reviewed. Specifically, Resident #13 had a recommendation for an ankle-brachial index test (a test to diagnosis poor blood flow) that was not followed up in in a timely manner. Findings include:There was no documented evidence of an outside appointment/consult policy.Resident #13 had a diagnosis of diabetes and peripheral vascular disease (insufficient blood flow). The 8/5/2025 Minimum Data Set assessment documented the resident had intact cognition and two non-pressure related skin ulcers. The 7/29/2025 Comprehensive Care Plan, revised 9/10/2025, documented a wound management problem. Interventions included provide wound care per treatment order.The 7/29/2025 Registered Nurse Supervisor #4's clinical admission assessment documented a skin issue on both the left and right lower leg that were both likely cellulitis. The Wound Care Nurse Practitioner #20's weekly wound notes documented the following:-on 8/4/2025 the skin on both lower legs was macerated with blue/green drainage noted; the resident stated they could not feel their legs; and a recommendation for an ankle-brachial index test prior to Unna boot application (a type of compression dressing).-on 8/18/2025 heavy drainage was noted, soaking through leg wraps as well as into shoes. The resident stated they could not feel their legs. Discussed need for ankle-brachial index with waveform prior to applying Unna boots due to unknown arterial/venous status.-on 8/25/2025 no ankle-brachial index test on file for review as requested at last visit. -on 9/1/2025 no ankle-brachial index on file for review/scheduled, requested at previous two visits. -on 9/9/2025 no ankle-brachial index on file for review/scheduled. Unna boot pending vascular workup.There was no documented evidence an ankle-brachial index was ordered or completed. During an interview on 9/11/2025 at 10:46 AM, Registered Nurse Supervisor #4 stated they uploaded Wound Nurse Practitioner #20's weekly notes, put a basic blurb of what they said in a progress note, put in the order, and then updated the care plan. If a consult was needed, they put the order in as a consult and gave it to the scheduler who then made the appointment and set up transportation. Resident #13's legs wept and dripped all over their room. Their wounds were vascular type wounds and were followed by the wound nurse since admission. The 8/26/2025 Registered Nurse Supervisor #4's skin/wound note documented no ankle-brachial index on file for review as requested at last visit.The 9/1/2025 Registered Nurse Supervisor #4's skin/wound note documented no ankle-brachial index on file for review/scheduled, requested at previous 2 visits.During a follow up interview on 9/11/2025 at 2:02 PM, Registered Nurse Supervisor #4 stated they read the weekly wound notes and implemented any recommendations. Resident #13 did not have an order for a vascular work up or an ankle-brachial index study and Wound Nurse Practitioner #20 had not been asked them about it. They did have an email from Wound Nurse Practitioner #20 on 9/1/2025 questioning whether ankle-brachial index had been done and the order for the ankle-brachial index test should have been implemented prior to 9/11/2025.During an interview on 9/12/2025 at 9:48 AM, Wound Nurse Practitioner #20 stated their weekly skin notes were automatically uploaded into the electronic medical record. They also sent an e mail of their findings and any recommendations, to various staff including the dietitian, the registered nurses, the supervisors, and the Director of Nurses. They saw Resident #13 for leg wounds. They believed they were venous related and wanted Unna boots for the resident since week one. They usually started with an ankle-brachial index test and then possibly a vascular work up prior to Unna boot usage. They reached out to the Director of Nurses and the Administrator about this not being followed up on and was told by the Administrator they did not get involved in clinical things. That was about a week ago. They expected when asking for a test it should be set up within a week. They considered this a delay in treatment because for the past few weeks they had been doing what they could for the resident rather than what they wanted to do. During an interview on 9/12/2025 at 11:57 AM, the Director of Nursing stated they did not know anything about Resident #13 needing an ankle-brachial index study. Registered Nurse #4 was responsible for following up on wound round recommendations. They received the weekly skin note email but was unable to see the recommendations. Wound Nurse Practitioner #20 spoke to them about difficulty getting what they requested but was not sure it was in regard to the ankle-brachial index study. 10NYCRR 415.26(e)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025 the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of two (2) residents (Resident #55) reviewed. Specifically, Resident #55 was on transmission-based precautions (contact precautions) and Housekeeper #22 cleaned Resident #55's room without wearing required personal protective equipment and did not perform appropriate hand hygiene upon leaving the room; and Certified Nurse Aide #23 provided care to Resident #55 without appropriate personal protective equipment or washing their hands upon leaving the resident's room. Findings include:The facility policy Isolation and Transmission Based Precautions, revised 12/2023 documented the facility would use standard precautions based on the Center for Disease Control guidelines in patient care areas. When there were reasons to believe a resident had a communicable infectious illness/disease, transmission-based precautions were to be initiated. Contact precautions were used with residents with suspected or known cases of illness that could be spread by contact with the resident or indirect contact with items in the resident's environment. A physician's order was necessary to implement and discontinue contact precautions. The resident on contact precautions would be placed in a private room if possible. Clean gloves and a disposable gown were to be worn when entering the room and the removal of the gown and gloves along with hand hygiene were to be performed prior to exiting the room. Resident #55 had diagnoses including gastrostomy (feeding tube) and a chronic back ulcer.The 9/9/2025 physician's order documented the resident was on contact precautions for shingles. During an observation and interview on 9/9/2025 at 12:59 PM, Housekeeper #22 was sweeping the floor in Resident #55's room and was not wearing a gown or gloves and did not perform hand hygiene prior to exiting the resident's room. Housekeeper #22 stated they were unsure if they should wear a gown or gloves in Resident #55's room. They stated they read the transmission-based precaution signs posted outside the resident's room and they should have worn a gown and gloves. They did not see the sign on the wall next to the door when they entered the room. During an observation and interview on 9/09/2025 at1:02 PM Certified Nurse Aide #23 entered the resident's room and was not wearing a gown or gloves. Certified Nurse Aide #24 reminded Certified Nurse Aide #23 they were in a contact precaution room with no personal protective equipment on and provided ice to the resident. Certified Nurse Aide #23 exited the room without performing hand hygiene. Certified Nurse Aide #23 stated they were supposed to wear a gown and gloves in a contact precaution room. The resident had just moved to that end of the hallway, and the room was previously empty. They did not see the contact precaution sign when they had entered the room to answer the resident's call light. During an interview on 9/12/2025 at 9:13 AM, Registered Nurse Supervisor #4 stated staff knew what precautions a resident was on by their Kardex and by the posting on the wall in their office. Staff should wear a gown and gloves in a room with contact precautions. Resident #55 was on contact precautions for shingles, and staff should wear a gown and gloves every time they entered the room. They educated the staff and the resident's family. During a phone interview on 9/12/2025 at 12:31 PM Registered Nurse Supervisor/Infection Control Nurse #8 stated when a resident was on contact precautions the facility put the resident on isolation with a cart and a transmission-based precaution sign. They informed family members who visited and educated them. The staff was educated on an ongoing basis for enhanced barrier precautions. They followed up occasionally with resident specific education regarding precautions with the floor nurses who then educated the certified nurse aides. Staff should wear gowns and gloves into the resident's room and sanitize their hands prior to exiting. 10NYCRR 415.19(a)(b)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) of one (1) resident (Resident #20) reviewed. Specifically, Resident #20 had a change in condition and was not assessed timely by a qualified professional; Licensed Practical Nurse #25 notified Nurse Practitioner #9 via text message and there was no documented evidence of orders received for a chest x-ray and the application of oxygen; Licensed Practical Nurse #25 did not document a change in condition or that a medical professional and family were notified; and there was a delay in notifying the provider of the radiology results. Findings include: The facility policy Notification of Significant Changes, last reviewed 6/30/2023, documented the facility notified the resident, the resident's physician(s), and if known, the resident's legal representative or an interested family member when there was a significant change in the resident's physical, mental, or psychosocial status such as a deterioration in health either life threatening conditions or clinical complications as well as when there was a need to commence a new form of treatment. When a significant change was identified, the staff member who identified the change notified their Nurse Manager/ Shift Supervisor. The Registered Nurse Supervisor completed an assessment and notified the attending physician and the resident's legal representative as warranted. Notifications were documented in the progress notes with designation to the 24-hour report. Notification attempts to the family/ resident representative were documented in the medical record. Resident #20 had diagnoses including pneumonia, dysphagia (difficulty swallowing) amyotrophic lateral sclerosis (a progressive neurological disease). The 9/3/2025 Minimum Data Set Assessment documented the resident had severe cognitive impairment, required substantial/ maximum assistance with most activities of daily living, received nutrition via tube feeding (a tube placed in the stomach), and did not receive oxygen therapy. The Comprehensive Care Plan initiated 9/3/2025, documented the resident had little or no activity involvement related to immobility, physical limitations, disease process, and was non-verbal. Interventions included communication with a white board, and the resident would nod yes/no or thumbs up/ down to respond. The 8/28/2025 Registered Nurse Supervisor #4 admission assessment documented the resident was non-verbal, not short of breath, and was not on oxygen. Resident #20 was observed at the following times:-On 9/8/2025 at 6:57 PM, resting in bed with their eyes open and labored breathing. There was an oxygen concentrator set to 2 liters next to the bed and the nasal cannula tubing was on the floor and not on the resident. At 8:50 PM, lying in bed with the nasal cannula on and oxygen running at 2 liters. Their breathing was labored. -On 9/9/2025 at 8:44 AM, resting in bed with labored breathing. The nasal cannula was on their lap on top of the bedsheet and not on the resident. At 1:07 PM, the resident was in bed with the nasal cannula on and oxygen running at 2 liters. Their breathing was labored. -On 9/10/2025 at 9:32 AM, 10:38 AM, and 1:51 PM, lying in bed with the nasal cannula on, running at 2 liters with humidity. Their breathing was labored, and they were diaphoretic (sweating). There was no documented evidence of a physician order for the oxygen therapy, a nursing note indicating why oxygen was initiated, or a registered nurse assessment from admission on [DATE] through 9/10/2025.The 9/8/2025 radiology report documented a chest x-ray was performed at 1:51 PM. There was minor left base consolidation which could be atelectasis or pneumonia. The report was signed by Radiologist #29 at 3:29 PM and the results were reported to the facility at 3:30 PM. There was no documented evidence of a physician order for the chest x-ray, or a nursing note that indicated why it was completed. There was no documented evidence the medical provider was made aware of the x-ray results upon the facility receiving the report. The 9/10/2025 at 10:49 AM Registered Nurse Supervisor #4 progress note documented the chest x-ray results were read to the Medical Director on the phone (2 days after the results were sent to the facility). After they relayed the resident's assessment, the Medical Director advised to continue monitoring of the resident. There were no documented vital signs from 8/29/2025-9/10/2025. The resident passed away on 9/10/2025 at 11:50 PM. During a telephone interview on 9/11/2025 at 1:03 PM, Certified Nurse Aide #11 stated Resident #20 was not on oxygen when they were admitted . The resident had a decline a few days ago and when they came in for their shift, the resident was on oxygen. They did not know what day that was. During an interview on 9/12/2025 at 9:27 AM, Licensed Practical Nurse #25 stated Resident #20 had a change in condition on 9/8/2025 and started death breathing, their oxygen saturation on room air was 91 percent, and their respirations were 30. They texted Nurse Practitioner #9 and was instructed to put the resident on oxygen at 2 liters via nasal cannula and obtain a chest x-ray. They initiated the oxygen and faxed a requisition to the imaging company. They did not enter the orders, but they should have. They did not document a note, but they should have. They were just too busy. The resident's family was at the bedside at the time. They thought they told a registered nurse supervisor, but they were not sure who they told, and the registered nurse supervisor never came to see the resident. During an interview on 9/12/2025 at 9:55 AM, Registered Nurse Supervisor #4 stated they were notified of changes in condition so they could assess the resident. They were not notified of a change in condition on 9/8/2025 for Resident #20. They worked from 11:00 AM to 7:00 PM on that day. They knew a chest x-ray was ordered because a report came over on the fax. They showed the report to Nurse Practitioner #9 on 9/10/2025 and they said they were not assigned to the resident and did not have access to their medical record and to give the results to the Medical Director. They stated they did not assess the resident until 9/10/2025 when they called the Medical Director with the radiology results. The Medical Director asked what the resident looked like, so they went to assess the resident then. There was not an order in the system for a chest x-ray or for oxygen but there should have been. There should be a nursing note as well but there were no notes for the resident between 9/7/2025 and 9/10/2025. They were not sure why the oxygen or the chest x-ray was ordered. During a telephone interview on 9/12/2025 at 10:11 AM, Nurse Practitioner #9 stated Resident #20 was not assigned to them, and they did not have access to their medical record. They did not recall being notified of a change in condition or giving any orders for oxygen or a chest x-ray. 10NYCRR 415.12

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025 the facility did not ensure the resident environment remained free of accident hazards for one (1) of four (4) residents (Resident #41) reviewed. Specifically, Resident #41 had a physician order for nectar thick consistency liquid and was provided thin liquid consistency hot cocoa. Additionally, Resident #41 was unhappy with their thickened liquids diet, was occasionally non-compliant and was not referred to speech language pathology for their new diet or care planned for their non-compliance. Findings include:The facility policy Dysphagia and Diet Consistency Changes, last reviewed 2/17/2022, documented dysphagia (difficulty swallowing) diets would be individualized with modifications made by the Speech-Language Pathologist, Occupational Therapist, Registered Dietitian, and physician as needed. Residents with observed indicators of dysphagia would be referred to the Speech-Language Pathologist for an evaluation. The evaluation would determine diagnoses, proper fluid thickness, and may recommend additional swallowing studies. The facility policy Comprehensive Care Planning, reviewed 5/5/2021, documented a care plan was to be individualized for each resident using a person-centered approach. Measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs that were identified from admission assessment, comprehensive assessments, and the application of the Care Area Assessment. Additional problems, strengths, or needs identified by the interdisciplinary team would be included as appropriate. All disciplines are responsible for reviewing the plan of care and documenting goals, interventions, monitoring notes, and updating as needed. Resident #41 had diagnoses including bacterial pneumonia, schizoaffective disorder bipolar type, and hypertension (high blood pressure). The 4/8/2025 Minimum Data Set documented the resident was alert and oriented, had no behavioral symptoms, required set up for eating, and had no swallowing disorders.The 8/25/2025 hospital discharge summary documented the resident had a diagnosis of pneumonia and their diet consistency was soft and bite size solids with a nectar thick liquid consistency. The resident had swallowing difficulties, and they were to have follow up appointments per the facility protocol.The 8/25/2025 physician order documented the resident was on a carbohydrate controlled with regular texture in soft bite sized solids (diet) and nectar/mildly thick consistency.There was no documented evidence the resident was referred to speech language pathology for dysphagia and the need for nectar thick liquids. Resident #41's certified nurse aide accountability record and assignment documented the resident was on a consistent carbohydrate diet, regular solids, and thin liquids.During an observation on 9/8/2025 from 7:41 PM to 8:36 PM, Resident #41 stated to Certified Nurse Aide #3 they wanted to drink a soda. Certified Nurse Aide #3 told the resident they needed to stick to their liquid consistency. They did not have any thickener for the soda as the kitchen did not send any the thickener packets. The kitchen offered to send up thickened ginger ale. The resident declined and stated they wanted their own soda and would get it themselves. Certified Nurse Aide #3 reminded the resident they could not have it as it was a thin liquid. The resident replied they had soda last night and the night before. Registered Nurse #8 stated they found thickener packets, and the resident allowed them to thicken the soda.During an observation and interview on 9/9/2025 from 12:19 PM to 12:30 PM, Resident #41 had a bottle of soda at their table in the dining room. Registered Nurse Supervisor #4 stated the resident was on nectar thick liquids and would not give the soda up and walked away from the resident. The resident had hot cocoa provided by staff that was thin when stirred. When brought to the attention of staff, Registered Nurse Supervisor #4 and Dietary Aide #14 stated the cocoa was thickened. Dietary Aide #14 stated sometimes the drink automatically thickened when thickener was added and sometimes it took a minute. It depended on who served the drink if they waited for the drink to thicken prior to serving. They stated Resident #41's drink was thickened with a thickener packet by the Food Services Director. Licensed Practical Nurse #5 informed the resident they were going to make the resident a cup of cocoa. Licensed Practical Nurse #5 stated the thickener packets were to be added to 4 ounces of liquid.Resident #41's 9/9/2025 meal ticket documented the resident was to receive mild thick beverages. During an interview on 9/9/2025 at 12:29 PM, the Food Services Director stated they added one packet of thickener before they gave Resident #41 their hot cocoa. Sometimes they waited until the drink thickened to give it to the resident and sometimes, they did not. They stated the thickener liquid they had in the kitchen worked better than the packets. They did not realize, until Licensed Practical Nurse #5 had pointed it out, the packet was only for 4 ounces, and the cocoa was 8 ounces, so they should have added two packets to the hot cocoa.A 9/9/2025 physician order documented referral to speech language pathology for upgraded diet consistency. During an interview on 9/11/2025 at 11:05 AM, Certified Nurse Aide #17 stated a resident's diet was listed in the nourishment room, on their face sheet, the Kardex in the electronic medical record and in the certified nurse aide accountability book. Resident #41 was on mildly thick liquids. They came back from the hospital with the new order. The resident was having difficulty with the new liquid texture and would go to the vending machine and get themselves a soda. They stated Resident #41 sometimes let them alter the soda to thicken it, but the resident did not respond well if their soda was taken away. They were unsure if there were interventions in place regarding the resident's refusal to follow their diet. They stated they let the charge nurse know when the resident was not complying with their diet consistency.During an interview on 9/11/2025 at 12:28 PM, the Rehabilitation Director stated they did not have a speech language pathologist on staff at the facility. They sent residents to the local hospital for outpatient services if it was needed. Nursing made the referral for the speech language pathologist. Sometimes the hospital placed a referral for a follow up if a resident returned from the hospital on altered textures. They did not know why the resident did not receive a referral until 9/9/2025 when they returned from the hospital on 8/25/2025. The resident was not happy with their current liquid texture.During an interview on 9/11/2025 at 2:23 PM, Licensed Practical Nurse #5 stated Resident #41 was on altered liquids, and it was new for the resident. Resident #41 was very non-compliant with their diet and needed to be reeducated when they refused. When they first came back from the hospital the resident attempted to have other residents give them thin liquids. They let the nurse practitioner know when Resident #41 was non-compliant with their diet. During an interview on 9/12/2025 at 9:13 AM, Registered Nurse Supervisor #4 stated the hospital sent recommendations for a resident's diet when they were admitted . Resident #41 was on altered liquids when they returned from the hospital on 8/25/2025. The resident was not very compliant with their ordered liquid consistency, and they tried to discuss it with the resident. Sometimes the resident would allow their soda to be thickened. The resident wanted to see the speech language pathologist, so they were working on that. The only intervention in place for the resident's refusals was to educate the resident. The provider was aware of the resident's non-compliance. They were unaware of why it took from 8/25/2025 until 9/9/2025 to get the resident a referral for speech language pathology. During an interview on 9/12/2025 at 10:05 AM, the Director of Nursing stated Resident #41 should have a care plan related to their non-compliance with liquid consistency when it became known to the staff.During an interview on 9/12/2025 at 10:11 AM, Nurse Practitioner #9 stated if a resident returned from the hospital with a new order for altered liquid textures, they should be referred to speech language pathology and did not know why Resident #41 was not referred until 9/9/2025. They should be notified if a resident on altered textures was not adhering to their diet. They were not informed that Resident #41 was drinking regular soda they should have been. 10 NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for two (2) of two (2) residents (Residents #7 and #8) reviewed. Specifically, Resident #7 had a significant weight loss that was not assessed timely, interventions were not reviewed after continued weight loss, and the resident was not provided with the ordered nutritional supplement; and Resident #8's tube feeding orders did not meet the calculated nutritional needs of the resident and did not include free water flushes. Additionally, Resident #8 was self-administering their tube feeding without a physician order or determination of physical and mental competency to self-administer the feeding. Findings include: The facility policy Self-Medication Administration, last reviewed 2/2022, documented the comprehensive care team would evaluate the resident to determine if they met the self-administration criteria to include physical and mental ability; the attending physician would initiate an order specifying permission to self-medicate; it would be noted on the medication record the resident self-administers; and the comprehensive care plan would reflect teaching, response, problems, revisions and evaluations of the process quarterly or as necessary. The facility policy Enteral (Tube) Feeding Procedure, last reviewed 2019, documented a bolus (volume of tube feeding formula administered by a syringe at one time) feeding included flushing with the appropriate amount of water per physician's order; the tube must be flushed with the appropriate amount of ordered solution; and if giving more than one medication the tube should be rinsed with 5 milliliters of warm water in between each medication. There was no documented Nutritional Assessment policy. 1) Resident #8 had a diagnosis including stroke and dysphagia (difficulty swallowing). The 8/1/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition; was dependent for eating; had a significant weight loss and was on a physician-prescribed weight loss regime; a gastrostomy tube; and total daily calories the resident received through a tube feeding was 51% or more. The Comprehensive Care Plan documented resident had dysphagia. Interventions included Osmolite 1.5 (a tube feeding formula) at 270 milliliters to run over 1-2 hours 4 times a day. There was no documented evidence the resident self-administered their tube feeding. The 7/28/2025 physician order, discontinued on 9/4/2025, documented the resident was to receive enteral nutrition via gravity (free flowing) or bolus (given all at once): Osmolite 1.5 Cal at 270 milliliters to run over 1-2 hours via pump with 115 milliliters of free water flushes before and after feeding four times a day (total calories 1620, total free water with feedings 920 m). The 9/4/2025 physician order documented the resident was to receive enteral nutrition via gravity or bolus: Osmolite 1.2 four times per day via gravity bolus (237 milliliters, four times per day). The order did not document a water flush, or the resident could self-administer the feeding. (Order provided 1138 total calories per day). The 8/2/2025 Registered Dietitian #6 readmission nutritional assessment documented the resident was receiving Osmolite 1.5 cal at 270 milliliters to run over 1-2 hours four times a day via pump with 115 milliliters of free water flushes before and after feeds; their weight was 168 pounds/76.4 kilograms; their height was pending. The current order was below estimated needs; weekly weights would be monitored to determine if tube feeding needed to be titrated up; and their recommendation was Osmolite 1.5 at 210 milliliters four times a day which provided 1260 kilocalories, 53 grams of protein, and 640 milliliters of free water. The resident's estimated needs were 1.1 grams/kilograms of protein to equal 84 grams, 25-30 kilocalories/kilogram to equal 2038-2445 calories, and 30 milliliters/kilogram of fluids to equal 2292 milliliters. The resident had the following weights: -on 8/1/2025 168 pounds -on 8/5/2025 168.8 pounds -on 9/5/2025 160.3 pounds (5% weight loss in 1 month) There was no documented evidence the tube feeding volume and water flushes were adjusted to meet the resident's estimated nutritional needs and weight goals. During an interview and observation on 9/8/2025 at 6:59 PM, the resident stated they administered their own tube feedings and water flushes. They were supposed to do their feeding four times a day but sometimes only did it three times if they were feeling sluggish or fell asleep. They used one 237 milliliter carton of Osmolite 1.5 kept in their room in a box next to their sink. They thought they were supposed to use 35 milliliters of water before and after each feeding but used a little more to dilute the feeding so it would flow quicker. There was a new nurse that came in to watch them administer their feeding otherwise they did it on their own without supervision. There was no documented evidence of a resident evaluation, or teaching provided regarding the self-administration of the resident's tube feedings. During a follow up interview and observation on 9/10/2025 at 11:33 AM, the resident stated when administering their tube feeding, they used one carton of Osmolite 1.5 and one plastic drinking cup of distilled water. They alternated between the Osmolite and the water to keep the feeding thin so it would flow quicker. They ended the feeding by flushing with about 40 milliliters of water. They did their own feeding that morning and no one checked in to ensure they had. The plastic cup used to hold the distilled water was measured using a piston syringe and held 180 milliliters. During an interview on 9/10/2025 2:10 PM Licensed Practical Nurse #5 stated the medication pass policy for tube feedings was usually 15-30 milliliters of water before and after the medication pass and 5-10 milliliters in between each medication. It was nursing's responsibility to make sure the feeding was done and administered correctly. They taught the resident to fill the plastic drinking cup to the top which was 240 milliliters. They could not find an order for water flushes with feedings or with medication administration but knew it had been 115 milliliters before and after each feeding. After looking at the feeding in the resident's room they stated it was Osmolite 1.5, but the order was for Osmolite 1.2. The resident should not receive Osmolite 1.5 without an order. During an interview and observation on 9/11/2025 at 9:40 AM the resident had only Osmolite 1.5 in their room and stated they continued to use this for their feeding. The September 2025 Medication Administration Record documented enteral feed order 4 times a day: Osmolite 1.2 four times per day via gravity bolus (1 can, 237milliters, four times per day). With a start date of 9/4/2025. The feeding was documented as being administered at 7:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM starting 9/4/2025 at 8:00 PM through 9/11/2025 at 11:00 AM except for one refusal. During an interview on 9/11/2025 at 10:46 AM Registered Nurse Supervisor #4 stated self-administered tube feedings and medications should be care planned for. Any changes in tube feeding orders came from a recommendation from the dietitian usually via an e mail. The recommendation was reviewed with the provider for approval. Resident #8 was just switched last week from a bolus via a pump to a gravity bolus and the resident was administering it themselves. The nurses should be supervising the resident to make sure it was being administered with the right formula and right amount. The orders did not include any water flushes but should. When giving medications, 60 milliliters of water should be given before and after medication administration. If there were no water flush orders the nurse should obtain one. They watched the resident self-administer their feeding and told them to use 60 milliliters before and after the feeding. During an interview on 9/12/2025 at 11:12 AM, Registered Dietitian #6 stated they typically followed the hospital tube feeding orders to start and adjusted if needed. They e-mailed any recommendations to Registered Nurse Supervisor #4 and the other nursing supervisors. Free water flushes should be part of the order, and each medication pass was a standard of 60 milliliter flush. When Resident #8 was readmitted , they received a bolus feeding four times a day via a pump and their recommendations was 270 milliliters of Osmolite 1.5 four times a day. The resident returned on 8/2/2025 and the recommendation was for 210 milliliters. They received an email on 8/30/2025 from Registered Nurse Supervisor #4 wanting to change from a pump to gravity in preparation for the resident to go home and the feeding amount changed at some point. On 8/30/3035 they recommended 270 milliliters four times. When the resident transitioned to gravity there was not a change in the formula or amount as the resident had been documented to be receiving 270 milliliters of Osmolite 1.5 four times a day. The impact of getting only 237 milliliters of feeding was a shortage of 120 milliliters a day. The 237 milliliters of Osmolite 1.5 would sustain their weight within 3% which would be 163 pounds. The resident dropped to 160 pounds. They were not aware the resident skipped some feedings, or their recommendation was not implemented as an order. Their water recommendation was 115 milliliters before and after the four time a day feeding and was the same recommendation as the 9/4/2025 feeding order. They stated their recommendations should be followed and was not. During a follow up interview on 9/12/2025 at 2:50 PM, Registered Nurse Supervisor #4 stated in a 9/1/2025 email, the registered dietitian stated the resident could be transitioned to a gravity bolus as they were already tolerating 4.5 cans of Osmolite 1.5 a day and their recommendation was 4.5 cans of Osmolite 1.5 a day. When they entered the order, they put in four cans a day, omitting the 0.5 of a can which was a difference of 132 milliliters a day. They also entered it as Osmolite 1.2 rather than Osmolite 1.5 formula. During an interview on 9/12/2025 at 2:22 PM the Medical Director stated caloric requirements were determined by the dietitian and they relied on their expertise and recommendations. They expected a resident's caloric needs be provided and if a resident did not get the correct amount of feeding, it could result in weight loss, weakness, skin breakdown and malnourishment. If a resident was not getting the required water flushes weakness, dehydration, low blood pressure and abnormal labs could occur. 2) Resident #7 had diagnoses including adult failure to thrive, dementia with agitation, and hypothyroidism. The 7/18/2025 Minimum Data Set documented the resident had mildly impaired cognition, inattention and disorganized thinking, required set up for eating, and had significant weight loss and was not on a physician-prescribed weight loss program. The 7/19/2025 Comprehensive Care Plan documented the resident had impaired nutrition and altered nutritional status related to significant weight loss with a past medical history of dementia, Parkinson's disease, constipation, and gastroesophageal reflux disease. Interventions included was to encourage intake of nutritional supplements between meals of Ensure Plus twice a day. The 8/13/2025 physician order documented Ensure Plus every day and evening shift to supplement the diet. The 9/9/2025 meal tickets for the breakfast, lunch, and dinner meal document the resident was lactose intolerant and was to receive an Ensure Clear Apple Supplement at every meal. The following weights were documented for Resident #7: - 137 pounds in March 2025; - there was no weight for April, May, and June 2025; - 118.8 pounds in July on the first weight and 117.4 pounds on the reweigh (14% loss in four months; - 106.8 pounds in August 2025 (9% loss in one month); - 106.8 pounds in September 2025. The 5/8/2025 Quarterly Nutrition Review from the resident's paper chart documented the resident received a regular consistency diet, had no new weight to assess, and they were unable to assess the resident's nutritional needs as there were no weights available for April and May 2025. The recommendation was continuing a regular diet with regular consistencies, offer snacks as needed, and monitor weights, intakes, skin, and labs. The 7/19/2025 Registered Dietitian #6 Quarterly Nutrition Assessment documented the resident was on a regular diet with thin liquids and was lactose intolerant. The resident had no chewing and swallowing issues and no skin breakdown. The resident had a weight change history of 13.28 % in one month and 14.53% in six months; had a fair appetite with meal intakes varying between 43-63%; and denied any changes to their meal profile. Due to the recent significant weight change, Ensure was recommended. The resident did not accept or decline the recommendation. Ensure was to be trialed twice a day to help improve calorie intakes. The resident's weight loss was due to an unknown etiology. The recommendations were to continue with a regular diet with regular consistencies and thin liquids, provide Ensure Plus twice a day, and continue to monitor the resident's weight, labs, and skin. There were no documented nutritional assessments for August 2025 or September 2025 to follow up on continued weight loss or effectiveness of nutritional interventions. During an observation and interview on 9/9/2025 from 12:49 PM to 1:07 PM, Resident #7's lunch tray was delivered by Certified Nurse Aide #17. Certified Nurse Aide #17 read off what was on the resident's tray which included: grilled cheese, apple juice, tomato soup, coffee, a cookie, and mixed berry Ensure Clear. The resident stated they could not have the grilled cheese and asked for an egg salad sandwich. The resident ate all the egg salad sandwich, three quarters of the tomato soup, and half of their coffee. The resident stated they did not like the clear apple Ensure and preferred the chocolate or strawberry Ensure. During an interview on 9/11/2025 at 10:51 AM, Certified Nurse Aide #28 stated weights were done once a month by the fifth and recorded in a binder at the nurses' station. If there was a weight loss or gain of five pounds or more, they should report it to the nurse. Resident #7 received Ensure every morning for breakfast and at lunch. The resident liked the lactose free milk Ensure strawberry or chocolate but did not like the clear liquid apple one and would not drink it. During an interview on 9/11/2025 at 12:25 PM, Certified Nurse Aide #17 stated Resident #7 preferred the chocolate or vanilla Ensure. They were unsure why the kitchen sent the clear apple or other fruit as the resident did not like it. During an interview on 9/11/2025 at 2:23 PM, Licensed Practical Nurse #5 stated weights were done at least monthly and recorded in a binder on the unit. If a weight was not collected, a progress note was put in for that resident. If a resident had a weight loss or gain, they should contact the provider, notify the dietitian, and add it to the 24-hour report. Resident #7 received clear Ensure on their tray and received an additional 237 milliliters twice a day that showed up on the Medication Administration Record. They did not know why the resident received the Ensure clear. If the resident refused their Ensure they reapproached and if they still refused, they should notify the nurse practitioner. During an interview on 9/12/2025 at 9:13 AM, Registered Nurse Supervisor #4 stated weights were done at least monthly on the first and recorded in the weight book at the nurses' station and in the electronic medical record. If a resident had a weight loss or gain, the dietitian was notified. They were unsure why Resident #7 was losing weight, and staff should encourage the resident to eat in the dining room or in the hallway. The resident received Ensure but they did not drink it. They were unaware the resident was receiving Ensure Clear instead of the Ensure Plus which was the resident's preference. The dietitian monitored the resident's continued weight loss. During an interview on 9/12/2025 at 11:41 AM, Registered Dietitian #6 stated they reviewed residents' nutritional status quarterly unless the resident was considered high risk then it was monthly. They stated they were only contracted to work at the facility six hours a week, so they tried to limit the monthly review list. When there was no weight for the previous two months to calculate a resident's nutritional needs, they followed up with the next month's weight and if there was no significant loss, they waited until the next quarter to reassess the resident. Weights were done by the fifth of the month and the reweighs were due two days after that. By mid-month they reviewed the residents for significant weight loss or gain of 5% or more. The 7/19/2025 review of Resident #7's weight loss from 137 in March of 2025 to 117.4 in July was delayed. They emailed the nursing staff to have Ensure added to the resident's orders. They did not follow up on the resident's weight in August 2025 even though the resident was down to 106 pounds. They stated they were on vacation for a significant portion of August and there was not sufficient coverage for the facility. They were currently reviewing the weights for August and September 2025. They stated they had not recommended Ensure clear for Resident #7; they had recommended Ensure Plus for the resident. They did not know why the resident was receiving Ensure clear as it should not have been on the resident's ticket without a physician's order, and the resident's physician order was for Ensure Plus. 10NYCRR415.12(i)(1)

Based on observations and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents were provided food and drink that was palatable and flavorful, and at an appetizing temperature for one (1) of two (2) meals reviewed (lunch meal on 9/9/2025). Specifically, the 9/9/2025 lunch meal entree was soft and had a soggy texture and the replacement entree was burnt. Findings include:There was no documented evidence of a food palatability or meal test tray policy. During an observation on 3/9/2025 at 12:38 PM, Resident #52's meal tray was tested, and a replacement tray was ordered. The grilled cheese sandwich was soft and had a soggy texture. At 12:43 PM, a replacement grilled cheese sandwich was provided to Resident #52. The sandwich was black in color on both sides, one side was darker than the other. During an interview on 9/12/2025 at 10:17 AM, [NAME] #27 stated they would not allow food to leave the kitchen if it did not look good. The burnt grilled cheese sandwiches should not have been served to the residents.During an interview on 9/12/2025 at 10:27 AM, the Food Service Director stated the grilled cheese sandwiches for the lunch meal on 3/9/2025 were grilled 45 minutes ahead of service. During the lunch service some of the sandwiches were dark in color and should have been switched out. Residents should not have been served burnt grilled cheese sandwiches. 10NYCRR 415.14(d)(2)

Based on record review and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every three months for two (2) of four (4) residents (Residents #25 and #52) reviewed. Specifically, Residents #25's and #52's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gather information about a resident's condition when completing the assessment).Findings include: There was no documented evidence of a Minimum Data Set assessment policy.Resident #52's Minimum Data Set assessment documented an Assessment Reference Date of 5/10/2025 and was not completed. Resident #25's Minimum Data Set assessment documented an Assessment Reference Date of 5/5/2025 and was not completed.During a telephone interview on 9/11/2025 at 1:54 PM, Minimum Data Set Coordinator #16 stated they kept track of the Minimum Data Set assessment schedule on a spreadsheet, but the facility just transitioned to a new electronic system, so they were still using both. They stated they were not at the facility and was not able to access the electronic system until later that day. They thought the Director of Nursing had access to the Minimum Data Set assessment schedule.During an interview on 9/11/2025 at 1:59 PM, the Director of Nursing stated Resident #52's and #25's quarterly Minimum Data Set assessments were overdue, and they should have been completed in early August 2025. They did not complete the Minimum Data Set assessments, so they were not sure why they were not completed. They thought they could have been missed when the facility transitioned to the new electronic system. 10NYCRR 415.11(a)(4)

Based on record review, observation, and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (lunch on 2/13/2024 and breakfast on 2/14/2024) reviewed. Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 2/13/2024 and the breakfast meal on 2/14/2024. Findings include: The facility policy, Monitoring Food and Liquid Temperatures, reviewed by the facility 9/08/2023, documented the dietary department was to maintain acceptable food temperatures during serving. Temperatures of the food were to be taken and recorded prior to serving. Hot foods were to be held at least 140 degrees (Fahrenheit) and cold foods were to be held at 45 degrees or below. If food items were out of acceptable range, they would be returned to the kitchen to be reheated or cooled to accurate temperature. During the resident council meeting on 2/12/24 at 2:03 PM, there were 9 residents present. An anonymous resident stated the food was cold and unappetizing and the remaining 8 anonymous residents agreed that the food was cold. During an observation on 2/13/2024 at 1:07 PM, Resident #52's tray was delivered to their room, used for a test tray, and a new tray was ordered for the resident. At 1:09 PM, the food temperatures on the tray were measured with the following results: the milk was 48 degrees Fahrenheit, the cold four bean salad was 59 degrees Fahrenheit, the chicken soup was 130 degrees Fahrenheit, the cheeseburger was 115 degrees Fahrenheit, the cold mixed fruit was 57 degrees Fahrenheit, the coffee was 140 degrees Fahrenheit, and the apple juice was 50 degrees Fahrenheit. The milk, four bean salad, chicken soup, cheeseburger, mixed fruit, coffee, and apple juice were not served at palatable temperatures. During an observation on 2/14/2024 at 8:10 AM, Resident #21's original tray was taken from the hot box on the unit at 8:10 AM and a replacement was provided. At 8:12 AM, the food temperatures were measured with the following results: the milk was 47 degrees Fahrenheit, the oatmeal was 117 degrees Fahrenheit, the scrambled eggs were 100 degrees Fahrenheit, the toast was 80 degrees Fahrenheit, the coffee was 108 degrees Fahrenheit, and the orange/pineapple juice was 53 degrees Fahrenheit. The milk, oatmeal, scrambled eggs, toast, coffee, and orange/pineapple juice were not served at palatable temperatures. During an interview on 2/14/2024 at 10:25 AM, night cook #8 and day cook #9 stated hot food items were to be served at 135 degrees Fahrenheit or higher and the cold food items were to be served at 45 degrees Fahrenheit. They both stated the mixed fruit was partitioned into smaller bowls in the kitchen then stored in the freezer for 15 minutes prior to being brought to the first-floor dining room to be plated. Night cook #8 stated the cans of fruit and vegetables were placed in the refrigerator one day prior to use. They stated the temperatures observed during lunch on 2/13/2024 and breakfast on 2/14/2024 were not palatable nor acceptable temperatures. Night cook #8 stated they checked the temperatures of the food when it entered the first-floor steam table on the Daily Steam Table Food Temperature log, and after all residents were served, they would take the temperature of the food items again and these temperatures had been recorded on a separate form. The facility's Daily Steam Table Food Temperature logs for February 2024 documented that food temperatures were not consistently recorded prior to meal service and were not documented for the after-service food temperatures for most of the daytime meals. During an interview and record review on 2/14/2024 at 11:00 AM, the Food Service Director stated the hot food items were to be served at 135 degrees Fahrenheit or higher and cold food items were to be served at 45 degrees Fahrenheit or lower. The temperatures observed during lunch on 2/13/2024 and breakfast on 2/14/2024 were not palatable temperatures. They had not reviewed the daily steam table food logs for that day. The Food Service Director reviewed the food temperature logs and stated they were missing documented food temperatures prior to service, had food temperatures that were not clear, and the after-service food temperatures for daytime meals were not logged for the majority of February 2024. They were not aware of any food palatability issues. It was important to ensure the food for the residents was served at palatable and safe temperatures. 10NYCRR 415.14(d)(2) 48446

Based on record review and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not electronically submit encoded, accurate and complete Minimum Data Set assessment data to the Centers for Medicare and Medicaid Services System within 14 days after the assessment completion date for 11 of 11 residents (Residents #2, 6, 8, 17, 19, 21, 23, 28, 35, 43, and 50) reviewed for resident assessments. Specifically, the Minimum Data Set assessments for Residents #2, 6, 8, 17, 19, 21, 23, 28, 35, 43, and 50 were not transmitted to the Centers for Medicare and Medicaid Services system within 14 days of completion. Findings included: The Centers for Medicare and Medicaid Services Minimum Data Set Resident Assessment Instrument Version 3.0 Manual documented that assessments must be transmitted electronically to the Quality Improvement Evaluation System Assessment Submission and Processing system using the Centers for Medicare and Medicaid Services wide area network within 14 days of the care plan completion date and all other Minimum Data Set assessments must be submitted within 14 days of the Minimum Data Set completion date. The facility [Minimum Data Set] 3.0 [Nursing Home] Final Validation Report and resident specific Minimum Data Set assessment documented the following: - on 11/26/2023 Resident #43 had a Minimum Data Set assessment with the target date of 10/3/2023. The Minimum Data Set assessment; Section Z documented a completion date of 10/17/2023. The Minimum Data Set assessment was transmitted on 11/26/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/9/2024 Resident #23 had a Minimum Data Set assessment with the target date of 12/14/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/9/2024. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/9/2024 Resident #21 had a Minimum Data Set assessment with the target date of 12/21/2023. The Minimum Data Set assessment; Section Z documented a completion date of 1/4/2024. The Minimum Data Set assessment was transmitted on 2/9/2024. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/13/2024 Resident #2 had a Minimum Data Set assessment with the target date of 12/23/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new comprehensive assessment. - on 2/13/2024 Resident #8 had a Minimum Data Set assessment with the target date of 12/23/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new comprehensive assessment. - on 2/13/2024 Resident #6 had a Minimum Data Set assessment with the target date of 12/26/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/13/2024 Resident #17 had a Minimum Data Set assessment with the target date of 12/26/2023. The Minimum Data Set assessment; Section Z documented a completion date of 1/9/2024. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/13/2024 Resident #28 had a Minimum Data Set assessment with the target date of 12/28/2023. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. An additional warning documented assessment completed late, more than 14 days after the assessment reference date. - on 2/13/2024 Resident #50 had a Minimum Data Set assessment with the target date of 12/29/2023. The Minimum Data Set assessment; Section Z documented a completion date of 1/12/2024. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. - on 2/13/2024 Resident #35 had a Minimum Data Set assessment with the target date of 12/29/2023. The Minimum Data Set assessment; Section Z documented a completion date of 1/17/2024. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. An additional warning documented assessment completed late, more than 14 days after the assessment reference date. - on 2/13/2024 Resident #19 had a Minimum Data Set assessment with the target date of 1/1/2024. There was no documented completion date. The Minimum Data Set assessment was transmitted on 2/13/2023. A warning message documented the record was submitted late; the submission date was more than 14 days after the new assessment. An additional warning documented assessment and care plan completed late, more than 14 days after the assessment reference date. During an interview on 2/15/2024 at 11:02 AM, registered nurse Minimum Data Set Assessment Coordinator stated they used a software program for the Minimum Data Set assessments. They stated they went to the facility on ce a week to gather information from the resident's medical record. The information had to be entered into the Minimum Data Set assessment software within 7 days, then 7 days for completion of the Minimum Data Set assessment, and 7 days for care planning. They kept track of the Minimum Data Sets by running a report to make sure they were done timely. The Minimum Data Set assessments were not up to date. They stated they were not done because their availability had decreased and the number of residents in the facility increased. They notified the Administrator of the incomplete Minimum Data Set assessments. It was important that the Minimum Data Set assessments were kept current to provide up to date care to the residents. The lack of timely Minimum Data Set assessments could impact the quality of care and reimbursements. During an interview on 2/15/2024 at 12:04 PM, the Administrator stated they knew there were some Minimum Data Set assessments that were late. They stated the registered nurse Minimum Data Set Assessment Coordinator was aware they were behind schedule. The Minimum Data Set assessment impacted reimbursements. It was important to keep the Minimum Data Set assessments up to date as they drove the care plan, showed changes in condition, and impacted the care of the residents. 10 NYCRR 415.11 (a)(5)

Based on observation, record review, and interview during the recertification survey conducted 2/12/2024-2/15/2024 the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #11, and #32). Specifically, Residents #2, #11, and #32 were on droplet and contact precautions and staff were observed not applying appropriate personal protective equipment when entering the resident rooms, not removing personal protective equipment in a safe, or sanitary manor to prevent the spread of infectious organisms, and not performing appropriate hand hygiene. Findings include: The facility Infection Prevention and Control Program Manual revised 12/2023 documented standard and transmission-based precautions would be followed to prevent the spread of infections: - Handwashing with soap and water or hand hygiene with hand sanitizer (when hands are not visibly soiled) would be expected prior to contact with a resident, after touching contaminated items, after gloves were removed and between resident contacts. - Contact Precautions gloves and gown were to be worn prior to room entry and removed. Hand washing was required after removal, and prior to exiting the room. - Droplet precautions required a mask to be worn over the mouth, nose, and chin and donned prior to entry and removal prior to exit. - Non dedicated equipment shall be sanitized with germicidal or bleach wipes per standard precautions upon removal of the item from the room or in between patients. - The facility shall monitor, audit and re-enforce infection prevention techniques in use, with immediate re-education of staff. A 2/12/2024 nurse practitioner #15 progress note documented Resident #32 was diagnosed with respiratory syncytial virus (a contagious respiratory virus). During an observation on 2/12/2024 at 10:12 AM Resident #32's room had 2 signs on the room door that documented: - Contact Precautions: Staff are required to sanitize their hands before entry and when leaving the room. Providers and staff must also: put on gloves before room entry, discard before room exit, put on gown before room entry and discard before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. -Droplet Precautions: Everyone must: Clean their hands including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove Face protection before room exit. A red garbage can, and a three-drawer bin stocked with yellow isolation gowns and red garbage can liners, were located outside of the resident's room in the main hallway. During an observation on 2/12/2024 at 10:46 AM the Director of Nursing and nurse practitioner #15 were in Resident #32's room dressed in yellow isolation gowns, gloves, and blue surgical masks. They were not wearing eye protection. At 10:48 AM the Director of Nursing and nurse practitioner #15 removed their gown and gloves inside the room and held them with their bare hands as they exited the room. They discarded the rolled-up gowns and gloves into the red garbage can outside of the room and did not change their masks or sanitize their hands after contact with the contaminated items. A 2/8/2024 nursing progress note documented Resident #2 tested positive for influenza A (a contagious respiratory virus). A 2/9/2024 nursing progress note documented Resident #11 tested positive for influenza A (a contagious respiratory virus). During an observation on 2/12/2024 at 10:53 AM Resident #2 and #11 shared a room. There were 2 signs on the room door documenting Contact Precautions and Droplet Precautions (the same signs as Resident #32's room). A red garbage can, and a three-drawer bin stocked with yellow isolation gowns and red garbage can liners were outside of the room, in the main hallway. During an observation on 2/12/2024 at 10:54 AM the Director of Nursing and nurse practitioner #15 exited Resident #2's and #11's room into the main hallway holding rolled up yellow gowns in their hands. They disposed of the gowns in the red bin outside of Resident #32's room. They did not change their masks and nurse practitioner #15 did not complete hand hygiene. No eye protection was observed. During an observation on 2/13/2024 at 11:50 AM licensed practical nurse #10 put on a yellow isolation gown and stood at the medication cart outside of Resident #2's and #11's room. They entered the room, exited the room, and returned to their medication cart, wearing the yellow isolation gown. They picked up a pen from the top of the medication cart and began writing. At 11: 57 AM they put on gloves and reentered the room. At 11:58 AM they exited the room, walked down the hallway to a sanitizing wipe container that was secured to the wall. At 12:00 PM they removed the contaminated gown and gloves in the main hallway and discarded the items in the red garbage bin that was located outside of Resident #32's room. During an observation on 2/13/2024 at 1:11 PM licensed practical nurse #10 put on a yellow isolation gown and gloves and entered Resident #32's room. At 1:13 PM they exited the room wearing the gown, gloves, and mask. They removed the gown and gloves, rolled the gown into a ball, and discarded the contaminated items into the regular trash bin located in the main hallway. They did not change their mask or complete hand hygiene after disposing of the contaminated items. They did not wear eye protection. During an observation on 2/13/2024 at 12:12 PM certified nurse aide #19 exited an identified isolation room wearing a yellow isolation gown and removed it as they walked down the main hallway. They discarded the gown in the red garbage bin located outside of Resident #32's room. The bin was overfull, and the lid would not shut. At 12:19 PM they put on a new yellow gown and gloves and entered Resident #2's and #11's room without changing gown, gloves, or performing hand hygiene. They assisted Resident #11 with their tablet and held the tablet with both gloved hands. They exited the room at 12:23 PM with their gown and gloves on, removed the gown while walking through the main hallway, and discarded the isolation items in the regular garbage bin. During an observation and interview on 2/15/2024 at 8:36 AM licensed practical nurse #10 was in an identified isolation room wearing only a surgical mask. They stated that they did not wear gown or gloves because this resident received treatment for 6 days and was feeling much better. They stated they only provided medications and felt that it would be safe to just provide pills. They stated they should wear gloves, gown, and a mask as they could catch flu or could pass it to someone else. They stated personal protective equipment could be removed in hallway. During an interview on 2/13/2024 at 1:16 PM, certified nurse aide #19 stated that residents on isolation were quarantined to their rooms and were in one area of the facility. The signs posted on the room door informed staff what personal protective equipment was required to enter the room. The isolation personal protective equipment included a gown, gloves, and a mask. They stated they should also wear a face shield and they should wash or sanitize their hands after they removed their isolation garments. During an interview on 2/13/2024 at 1:24 PM, licensed practical nurse #10 stated staff should wear gowns, gloves, masks, and face shields in the isolation rooms. They should remove the items and dispose of them in the garbage bin located inside of the room. They stated they did not change their masks. During an observation and interview on 2/15/2024 at 9:29 AM, registered nurse #4 stated the Infection Committee Team decided the level of isolation needed and the Director of Nursing provided the isolation precaution signs to hang on the affected resident room doors. The charge nurse should monitor donning and doffing as the sign would indicate. Staff should be corrected at that time if they did not follow procedures. Donning of personal protective equipment should occur prior to room entry and doffing would occur inside the room, before exiting and washing hands. Staff should not remove personal protective equipment outside of the contaminated space as they could spread infection. Bins were to be stocked with face shields, masks, gowns, and garbage bags. Registered nurse #4 checked the personal protective equipment bins outside of resident rooms on isolation and did not include surgical masks and they should. During an interview on 2/15/2024 at 10:02 AM, the Director of Nursing stated the facility had 7 residents that were positive for Flu on Monday 2/12/2024, and by Tuesday afternoon a few more residents tested positive. Precautions were determined by the illness, and they made that decision. They informed nursing what they needed to do and provided the specific isolation signs on the rooms. Donning should be done outside the room before room entry and removed and disposed of inside the room. They stated on 2/12/2024 they and nurse practitioner #15 wore new surgical masks they obtained from the nurse's station. When they exited Resident #32's room they did not discard infectious items in the room because there was no garbage can in the room. The gown and gloves were disposed of in a red bin outside the room. Staff should not take off gowns as they exit an isolation room as they could spread infection. During an interview on 2/15/2024 at 12:26 PM, nurse practitioner #15 stated flu would be considered an infectious agent and the resident required droplet precautions. Staff should wear a gown, gloves, and a mask to enter the room. They should remove the gown, gloves, and the mask and dispose of them in the room before exiting. It would not be appropriate for trash bins to be outside of an isolation room. Removing personal protective equipment outside of an isolation room could risk transmission of the disease. 10 NYCRR 483.80 (a) 49831

Based on record review and interview during the recertification survey conducted 2/12/2024 through 2/15/2024, the facility did not ensure each resident was offered influenza immunizations and received education regarding the benefits and potential side effects of the immunizations for 2 of 6 residents (Residents #11 and #43) reviewed. Specifically, there was no documented evidence Residents #11 or #43 were offered, educated, received, or declined the influenza immunization for the 2023-2024 influenza season. Findings include: The facility policy Immunizations: Influenza Vaccination of Residents, Staff and Volunteers updated 3/2020 documents all residents should receive the influenza vaccine annually unless there is a documented contraindication or declination. Education shall be provided to all individuals; they have the right to refuse vaccinations, and this will be properly documented. All immunizations will be documented in the medical record. Current and newly admitted residents will be offered influenza vaccines from October of each year through the end of March the following year. Informed consent in the form of a discussion regarding risks and benefits of vaccination will occur prior to vaccination: this may be with the residents authorized representative when appropriate. Document the administration of the vaccine, including the injection site, in the immunization record. The New York State Health Commissioner declared influenza was prevalent in New York State on 12/6/2023. Resident #11 did not have documented evidence of immunizations or declination of immunizations. Resident #43's Minimum Data Set assessment dated [DATE] documented their last documented Influenza vaccine was received on 11/2/2022. Resident #43 did not have documented evidence of education, declination, or administration of the influenza vaccine for the 2023-2024 season. During an interview on 2/14/2024 at 11:44 AM, licensed practical nurse #6 stated resident vaccinations were in the medical record under the immunization tab. If a resident declined a vaccine that was offered, they should have a completed declination form in that section. During an interview on 2/14/2024 at 12:29 PM, licensed practical nurse #12 stated resident immunization records were in the medical record. If a resident refused a vaccine, they would have a signed declination page for the vaccine that was offered and refused. During an interview on 2/14/2024 at 11:49 AM, registered nurse #4 stated immunizations for residents were documented in their medical record under the immunization section and it should be up to date. During an interview on 2/15/2024 at 10:02 AM, the Director of Nursing stated the facility offered the influenza vaccine annually. If the vaccine was administered, it was documented in the resident's chart in the immunization record. The facility kept track of all vaccines that were offered, administered, or declined in a book that was kept in their office. During an interview on 02/15/24 at 11:37 AM, the Administrator stated the influenza vaccine should be offered every year to all residents and a documented declination would be obtained if they refused. Registered nurse #4 and the Director of Nursing also had a book to keep track of who was offered, received, or declined a specific vaccine. The actual record of vaccinations for individual residents would be found in the immunization section of their medical record. 10NYCRR 415.19 (a)(1-3)

Based on observation, record review, and interview during the recertification survey conducted [DATE]-[DATE], the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 2 of 3 food preparation areas (the main kitchen and the first-floor kitchenette). Specifically, in the main kitchen there was expired and undated food, a dented can of fruit cocktail in the dry food storage, and the clean drying rack had two unclean cooking pans with food debris; the first-floor kitchenette had expired and undated food. Findings include: Food Storage: The following observations were made in the main kitchen on [DATE]: - At 9:00 AM, there was a 64-ounce jar of peanut butter on a shelf with a best by date of [DATE], and a 108-ounce can of pre-made pasta with sauce with a best by date of [DATE]. - At 9:20 AM, there was a loaf of cinnamon raisin bread in the reach-in freezer with an expiration date of [DATE], four loafs of cinnamon raisin bread with an expiration date of [DATE], two packages of pureed ham with a best by date of [DATE], an undated wrapped hamburger, undated ground Swedish meat balls in a container, and barbecued pulled pork dated ,d+[DATE]. - At 9:30 AM, in the dry food storage room there was a dented 6-pound can of fruit cocktail. During an observation on [DATE] at 10:50 AM, the first-floor kitchenette cabinet had an opened 13-ounce jar of sweetened hazelnut cocoa spread with a best by date of [DATE]. Cleanliness: During an observation on [DATE] at 9:35 AM, the clean drying rack in the main kitchen had two cooking pans that were unclean and had baked debris. During an interview on [DATE] at 11:18 AM, the Food Service Director stated they were unaware of outdated or undated food items, the dented can in the dry storage room, and the unclean pans that were in the drying rack. They stated it was not acceptable to have undated or expired items in the reach-in freezer as those items should not be defrosted and served. Cans that were dented along the seams could affect the safety of the food inside and could be unsafe for the residents. Unclean pans with baked on food could affect the food quality when used. It was important that the kitchen be maintained in a clean manner, with no expired or undated food items and no dented cans for resident safety. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 2 medication carts (Unit 2) reviewed. Specifically, prescribed controlled drugs on the second-floor unit were stored in an untethered (free-moving) medication cart and not returned to the double-locked medication room narcotic storage cabinet after the medication passes were completed. Findings include: The facility policy Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles revised 6/2022, documented in New York, controlled substances must be securely locked in a double-locked cabinet, affixed to the wall or floor until the beginning of the medication pass. Upon completion of the medication pass, controlled substances must be returned to the cabinet. During an observation on 2/13/2024 at 11:18 AM, the Unit 2 medication cart was untethered against a wall in the hallway near the nurse's station. Licensed practical nurse #10 opened the locked drawer of the medication cart. The drawer contained controlled medications for 5 Residents (Residents #14, 30, 32, 35 and 36) on Unit 2. The controlled medications included: - tramadol (pain relief) 50 milligrams - 49 tablets - lorazepam (anti-anxiety) 2 milligrams -23 tablets - Oxycontin ER (extended-release opioid pain relief) 10 milligrams - 19 tablets - pregabalin (nerve pain medication) 75 milligrams - 19 capsules - oxycodone/APAP (oxycodone with Tylenol) 10/325 milligrams - 29 tablets During an interview on 2/13/2024 at 11:18 AM, licensed practical nurse #10 stated their medication pass was completed on Unit 2 at 10:00 AM. They stated their medication cart contained controlled medications for 5 residents (Residents #14, 30, 32, 35 and 36) and Resident #35 required a controlled substance for a medication pass at 2:00 PM. Licensed practical nurse #10 stated controlled substances should be locked away in the medication room when medication passes were completed. The risk of leaving controlled substances in the medication cart could result in a resident accessing their cart. During an observation on 2/13/2024 at 11:33 AM, the controlled medications remained in the untethered medication cart. During an observation on 2/13/2024 at 12:58 PM, licensed practical nurse #10 left the unit and the medication cart was against the wall untethered and unsupervised. At 1:04 PM licensed practical nurse #10 had returned to the unit and the controlled substances remained in the untethered medication cart. During an interview on 2/14/2024 at 9:10 AM, the Director of Nursing stated all licensed nurses were educated on medication administration and storage and when medication passes were completed, they expected nurses to put all the controlled medication away in a double locked cabinet. The Director of Nursing stated controlled medications should not remain in an unattended medication cart. Residents and visitors could gain access to them. 10NYCRR 483.45(h)(2)

Based on observation, record review, and interview during the recertification and abbreviated (NY00306949) surveys conducted 2/12/2024-2/15/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 2 residents (Residents #6) reviewed. Specifically, Resident #6 was observed with dirty and untrimmed fingernails and was not provided a shower as planned. Findings include: The facility policy Activities of Daily Living Care Guidelines, reviewed by the facility 11/17/2021, documented residents received routine morning and evening activities of daily living care to have their hygienic and comfort needs met. Caregivers were to review resident nursing care instructions at the beginning of the shift to ensure the residents were provided care according to their plan of care. All residents received a partial bed bath daily which included washing the resident's face, hands, back, underarms, and peri area. A shower or whirlpool bath replaced the partial bed bath once weekly and as indicated. Refusals of care were to be reported to the licensed nurse. Resident #6 was admitted to the facility with diagnosis including multiple sclerosis (a neurological disease) and seizure disorder. The 10/02/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, had no behavioral symptoms, and was dependent for all activities of daily living except for eating. The Certified Nurse Aide Accountability Records and Assignment sheet (care instructions) dated 6/15/2023, documented the resident was alert but confused, required total assistance with hygiene and bathing, and was to receive a shower and nail care on Tuesday and Thursday during the 11:00 PM-7:00 AM shift. The 2/12/2024 shower schedule documented the resident was to receive showers on the night shift on Tuesdays and Thursdays. The resident was observed: - on 2/12/2024 at 12:22 PM, sitting in the dining room for the lunch meal. Their thumb and fifth fingernails of the right hand were long and had a black substance under the nails. - on 2/13/2024 at 8:38 AM, in their room sitting in a chair. There was a dark substance in the right corner of their mouth and the same patterned shirt from the previous day. Their right hand had a black substance under all the fingernails. The thumb, fourth, and fifth fingers of the right hand had long unkept nails. At 10:13 AM and 11:13 AM, the resident's right hand had a black substance under all the fingernails and the nails of the thumb, fourth, and fifth finger were long and unkept. The resident had a dark substance in the right corner of their mouth. The certified nurse aide documentation sheet for February 2024 documented the resident received one shower for the month on the morning shift of 2/14/2024. During an observation and interview on 2/15/2024 at 8:54 AM, the resident was sitting in their room in their positioning wheelchair with brown debris under their thumbnail. The thumb, fourth and fifth nail of the right hand were long. The resident stated they would their nails them clipped, and they liked showers and did not refuse them. During an interview on 2/14/2024 at 8:55 AM, certified nurse aide #11 stated residents were scheduled for a shower twice a week. If a resident refused a shower, they were offered a bed bath. Resident #6 had not regularly refuse care and their shower day was Tuesday on night shift. The certified nurse aides were responsible for cleaning resident nails. Resident #6 was not a diabetic so their nails could be clipped by a certified nurse aide. They would expect resident #6's nails to be clean and clipped. Certified nurse aide #17 observed Resident #6's nails and stated they needed to be cleaned and clipped. During an interview on 2/14/2024 at 9:24 AM, licensed practical nurse #6 stated Resident #6 did not refuse care and should have received a shower on their shower day. They stated showers should always be given as residents could get infections. They expected to be notified if a resident refused a shower. The certified nurse aides did nail care on a resident's shower day unless the resident was diabetic. Resident #6 was not diabetic. During an interview and record review on 2/14/2024 at 9:49 AM, registered nurse #4 stated they were responsible updating the shower sheets and Resident #6 was scheduled for Monday nights. They reviewed the shower sheet and stated the resident had not received a shower. If a resident refused a shower, it would be documented as refused and they would sign off on it. They expected to be notified if a resident refused care and would encourage the resident. If a resident was not showered, they should monitor the resident's skin as breakdown could occur and it could be an infection control issue. They stated nail care was done by a certified nurse aide unless the resident was diabetic. They stated they noticed Resident #6 had long nails and debris under their nails at breakfast that day. They would expect the resident's nails to be cleaned and clipped. Long nails with debris could lead to an infection and the resident could create a skin tear with long nails. During an interview on 2/14/2024 at 12:08 PM, certified nurse aide #17 stated if they gave a shower, they documented it. If a resident refused a shower, they would reapproach the resident or provide a bed bath. Resident #6 had not received a shower this week but had received one last week. The resident should have received a shower on the day they were scheduled. The resident did not refuse their shower. They did not clean the resident's nails because the resident had not had a shower. They stated they should have asked the resident if they wanted their nails clipped and cleaned but they had not. They stated lack of nail hygiene and care could lead to open sores and infections. During an interview on 2/15/2024 at 9:17 AM, the Director of Nursing stated they knew a shower had been completed as both the certified nurse aide and the licensed practical nurse both signed for the shower. If a shower was refused and documented, the resident was reapproached. They would expect to be notified if a resident refused their shower by the 24-hour report and there were no showers refused documented on the 24-hour report that week. They stated if Resident #6 had received a shower, they would not have been in the same clothes the next day. They reviewed the shower book and stated the last documented shower was 2/6/2024. They stated the resident should have had a shower since then and had their nails cleaned and trimmed. The resident was at risk for health decline and infections if activities of daily living were not completed. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interview during the recertification and abbreviated (NY00326851 and NY00327641) surveys conducted 2/12/2024-2/15/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated and did not prevent further potential abuse for 1 of 4 residents (Resident #17) reviewed. Specifically, Resident #17 reported an allegation of abuse that was not investigated timely and did not remove the alleged perpetrator from access to residents pending the results of the investigation. Findings included: The facility policy Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property reviewed by the facility 6/23/2023 documented the facility was committed to providing residents with an environment that was free from verbal, physical, and mental abuse, mistreatment, neglect, exploitation, and misappropriation of resident property. All staff would be trained during orientation and annually on what constitutes abuse, neglect, and misappropriation of resident property and how to report abuse allegations. The resident would be protected from harm while the investigation was completed. Alleged violations were to be reported no later than two hours after notification and no later than 24 hours. Resident #17 was admitted to the facility with diagnoses including schizoaffective disorder (a mood disorder) and bipolar disorder (episodes of mood swings). The 12/26/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not exhibit behavioral symptoms, and required partial/moderate assistance with most activities of daily living. During an interview on 2/12/2024 at 11:00 AM, Resident #17 stated certified nurse aide #13 entered their room that morning when they asked for help getting into their chair. Certified nurse aide #13 said they would not help and punched them in the leg with a closed fist. They stated they reported it to licensed practical nurse #6. The comprehensive care plan initiated 8/21/2021 documented the resident had potential to be verbally and physically abusive at times. Interventions included a behavior flow sheet. The resident had a knowledge deficit related to mental illness. Interventions included giving alternatives for resident to choose from and providing positive feedback encouraging compliance. The resident had manipulative behaviors related to bipolar disorder and schizoaffective disorder. Interventions included utilizing a behavior flow sheet, setting limits on manipulative behavior, and giving positive feedback for non-manipulative behavior. The care instructions updated 6/14/2023 documented the resident required supervision with assistance of 1 for transfers from bed to chair. There was no documented evidence of nursing progress notes from 1/12/2024-2/14/2024. On 2/12/24 at 1:52 PM the surveyor notified the Director of Nursing Resident #17 had said during the resident screening they were punched by staff last evening. An undated and unsigned facility Accident and Incident form documented the date of the incident was 2/15/2024 and occurred in the hallway and was reported by a state worker. The resident made accusations about 2 certified nurse aides possibly hurting them on Monday (2/12/2024). The form was signed by the nurse practitioner #15 on 2/16/2024 at 8:00 AM. The Incident/Accident Follow-up completed by the Director of Nursing documented the date of the incident was 2/12/2024 at 10:00 AM. The documentation under contributing factors was illegible. The Resident statement was illegible. A progress note included with the Accident and Incident Report completed by the Director of Nursing dated 2/12/2024 documented the resident made statements to the State worker that 2 certified nurse aides had hit them. The Director of Nursing spoke to the resident and the resident's story kept changing. An assessment was completed and there were no signs and symptoms of injury or abuse. The social worker was made aware. The plan was to have medical see the resident for evaluation as resident had a history of making false allegations when upset. There was no documented evidence the certified nurse aides were removed from resident access pending the results of an investigation. An unsigned social services progress note dated 2/12/2024 documented the resident alleged 2 evening certified nurse aides hit them on the legs. The resident gave the name of one of the aides, The resident stated they reported their concerns and reddened legs to nursing staff. They spoke with the resident later and the resident stated they were in their bed and the aides came to answer the call bell, touched their legs, and they told them to get out. The resident was a reliable source of factual information and had a history of saying accusatory information about staff. The resident had intermittent confusion. The Interdisciplinary Team Review dated 2/15/2024 and signed by the Director of Nursing documented the resident made statements about certified nurse aides. The resident had a history of making false allegations. The camera verified that no abuse occurred. No physical signs or symptoms of abuse were noted. The resident was care planned for this type of behavior. During an interview on 2/14/2024 at 9:24 AM, licensed practical nurse #6 stated the overnight nurse reported Resident #17 had said certified nurse aide #13 hit them on their legs during the overnight shift when getting up in the morning on 2/12/2024. Licensed practical nurse #6 stated they immediately notified the Director of Nursing so the resident could be assessed, and an investigation could begin. During an interview on 2/15/2024 at 9:17 AM the Director of Nursing stated staff was to notify a nurse for all cases of witnessed or alleged abuse to allow for a proper investigation. Both the registered nurse and medical provider were notified to complete an assessment. The social worker was also involved in the investigation and all incidents were reported to the state. They stated they were notified on 2/12/2024 that Resident #17 had reported that a certified nurse aide hit them on their legs. They stated they did not get witness statements and should have gotten them. They stated they did not notify the medical provider for an assessment and should have notified the medical provider. They stated all abuse allegations required proper investigating so residents were safe, and they did not complete an investigation and should have. During an interview on 2/15/2024 at 10:06 AM, the Administrator stated the Director of Nursing, and the Administrator were notified of all alleged cases of abuse because the facility was required to report abuse to the Department of Health within two hours. They stated in all cases of abuse, the family and the medical provider were notified, and the resident was assessed by nursing and the medical provider. The family and the medical provider were not notified about this incident. The Administrator stated they were notified on 2/14/2024 that Resident #17 alleged a certified nurse aide hit them on their legs on 2/12/2024 and they should have been notified on 2/12/2024 so that a proper investigation was completed. The Administrator stated there were no witness statements obtained. They stated they realized they should have done an investigation and notified the Department of Health with their findings, and they did not. They stated when a complaint of abuse was not investigated properly, all residents were at risk for abuse and all residents were not safe. During an interview on 2/15/2024 at 10:27AM, Social Worker #3 stated they were notified sometime earlier this week by the Director of Nursing that Resident #17 had alleged a certified nurse aide hit them on their legs. The resident reported two certified nurse aides were in the room but only certified nurse aide #13 hit them in their legs. They did investigate the allegation and but did not ask who the second certified nurse aide was but should have. They did not notify the state of the alleged abuse. During an interview on 2/15/2024 at 11:26 AM, licensed practical nurse #6 stated it was unusual for Resident #17 to report abuse. They stated the resident had behaviors, but those behaviors did not include reporting staff abuse. Licensed practical nurse #6 stated they immediately reported the alleged abuse to the Director of Nursing on 2/12/2024 and was not asked for a witness statement. They stated certified nurse aide #13 allegedly hit Resident #17 in the legs when doing resident care and certified nurse aide #14 was in the room assisting with resident care. During an interview on 2/15/2024 at 12:21 PM nurse practitioner #15 stated they were notified of all allegations of abuse so the resident could be assessed and kept safe. They were not notified this week of any abuse allegations. They stated they were familiar with Resident #17 who had never reported abuse in the past. If Resident #17 reported abuse, it should have been investigated and they should have been notified. They stated they were not notified, and it was important to investigate abuse so that all residents were safe. 10NYCRR 415.4(b)

Based on record review, observation, and interview during the abbreviated survey (NY 348, NY 801 and NY 670), the facility did not ensure residents had the right to be free from abuse for 4 of 4 residents reviewed (Residents #1, 2, 3, and 4). Specifically, - Resident #2 was admitted with known sexual predator status and the facility did not develop and implement a plan to prevent sexual abuse. - Resident #2 sexually abused Residents #1, 3, and 4, who could not consent to sexual contact. This resulted in actual harm to Resident #1 and no actual harm with potential for more than minimal harm to Residents #3 and 4. Findings include: The 3/21/2019 facility Abuse policy documented all residents will be protected from abuse, neglect, mistreatment, sexual coercion, or assault. Resident #2 had [DIAGNOSES REDACTED]. The 5/1/2019 MDS assessment documented the resident had no short or long-term memory impairment and was independent with decision making. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The 8/4/2020 MDS documented the resident's cognition was severely impaired. Resident #3 had [DIAGNOSES REDACTED]. Resident #4 had [DIAGNOSES REDACTED]. INCIDENT #1 Resident #2's discharge instructions from the skilled nursing facility the resident was admitted from dated 5/24/2019, documented the resident was discharged because his needs could not be met. The resident was at high risk for heterosexual behavior and exposed his penis to others. Resident #2's comprehensive care plan (CCP) dated 5/24/2019 documented the resident had potential to abuse others. Interventions included to monitor frequently, update medical providers with any changes, and provide 1:1 activity. The incident/accident report and investigation dated 5/25/2019 at 5:00 PM, documented Resident #3 was found in Resident #2's room. Resident #3 was sitting in her wheelchair and Resident #2 was standing up in front of Resident #3. Resident #2 was holding Resident #3's hands and Resident #2 was sexually aroused. The facility reviewed the camera footage and observed Resident #2 wheel Resident #3 in the wheelchair into Resident #2's room. The residents were separated, and 15-minute checks were implemented. Later on, during the shift, staff again found Resident #2 sitting knee to knee with Resident #3. Both Residents #2 and 3 resided on Unit #2 at the time of the incident. Resident #2's CCP documented: - On 5/26/2019, the resident was attempting to get close to Resident #3. - On 5/27/2019, the resident made contact with an unidentified resident and 15-minute checks were initiated. This information was conflicting as the resident was placed on 15-minute checks on 5/25/2019 per the incident report and there was no documentation they were discontinued. The 5/29/2019 Administrator's progress note, included with the 5/25/2019 incident report, documented after admission, she became aware the resident was a known sexual predator from another state and on 5/25/2019, the resident took a non-consenting female into his room. Resident #2 was being sent out for an evaluation due to seeking out Resident #3. On 5/29/2019, the resident was returned to the facility and moved to Unit #1. There were no corresponding records from the hospital or psychiatric evaluation. The facility was unable to provide documentation the 15-minute checks were completed consistently after Resident #2 returned from the hospital or when they were discontinued. INCIDENT #2 The social services progress notes on 8/20/2019 documented the social worker asked Resident #2 to move to Unit #2 to accommodate a resident moving to Unit #1. The resident agreed and Resident #2 moved to Unit #2 on 8/23/2019. The 10/19/2019 investigation summary documented Resident #4 was observed by a certified nurse aide (CNA) holding Resident #2's penis while sitting in the day room. The residents were immediately separated after the incident and 1:1 supervision was initiated for Resident #2. Upon review of the camera footage, the facility determined prior to the incident, Resident #2 walked by the day room and showed his penis to Resident #4. Resident #2's medical record contained no documentation when 1:1 monitoring was discontinued. When requested, the facility was unable to provide documentation as to how Resident #2 was monitored to prevent further incidents from October 2019 through March 2020. Resident #2 remained on Unit #2 following this incident. INCIDENT #3 The 3/17/2020 facility investigation summary, completed by the Administrator, documented on 3/14/2020 at 12:31 PM Resident #1 was in Resident #2's room. Resident #2's head was on Resident #1's breast while Resident #1 held Resident #2's penis. The residents were immediately separated, the Supervisor was notified, 15-minute checks were initiated, and a stop sign was to be placed on both residents' doors. The social work note dated 3/14/2020 documented she talked with Resident #2 who waved his hand at her and would not speak. She educated the resident on not touching or being touched or allowing residents in his room. Resident #2's CCP was updated 3/16/2020 and documented a resident to resident incident on 3/14/2020 with interventions including staff to be observant of resident's location, redirect the resident, monitor behaviors and report any inappropriate behaviors. The CCP was updated and documented 15-minute checks and a stop sign was applied to the resident's door. The 3/17/2020 interdisciplinary team progress note documented at 11:00 AM Resident #2's 15-minute checks were discontinued, and 30-minute checks were initiated after a discussion with the physician. Staff were to monitor the resident for effect. Resident #2's nursing progress notes documented: - on 3/18/2020, Resident #2 was noted to encourage Resident #1 to wander off with him and Resident #2 was aware of Resident #1's locations on the unit. - On 3/21/2020, Resident #1 went to Resident #2's room and was redirected by staff. - On 3/23/2020, Resident #2 was wandering in the hall and redirected away from Resident #1's room. - On 3/24/2020, Resident #2 continued to wander toward Resident #1's room while Resident #1 was within eyesight. Resident #2 was redirected to his room and 30-minute checks continued. - On 3/25/2020, Resident #2 continued to seek where staff were with attempts to wander toward Resident #1. Resident #2 was redirected several times. - On 3/26/2020, 7:00 AM -3:00 PM 30-minute checks continued. INCIDENT #4 The 3/26/2020 facility incident summary documented at 4:30PM; - Resident #2 was found on Resident #1's bed on Unit 2. Resident #1 was unclothed and Resident #2 had his hand inside Resident #1's vagina. - The plan was for 15-minute checks and Resident #2 was to be moved to Unit 1 and have a motion detector on his door. - CNA #5's statement dated 3/26/2020 and included in the facility investigation, documented she found Resident #1 lying on the bed without clothes on and Resident #2 had his whole fist inside of Resident #1's vagina. She told Resident #2 to stop and made the resident leave the room. She notified a Supervisor. The 4/3/2020 psychiatric behavioral note documented approximately 1-week prior Resident #2 was engaged in sexual behavior. There was heightened concern because per the staff Resident #2 was on the sex offender's registry for a [AGE] year-old charge in another state. Resident #2 was placed on 15-minute checks to 30-minute checks. After that he was again found in the room. The resident was then moved to a floor below. The Director of Social Services was interviewed on 9/10/2020 at 1:18 PM, and stated she was informed of the incident between Residents #1 and 2 on 3/26/2020 at approximately 6:00 PM by LPN #1. She went to Unit 2 and saw Residents #1 and 2 who had been separated and were near the nursing station. She contacted the Administrator and Director of Nursing (DON) and the intervention was to move Resident #2 to Unit 1, place the resident on 30-minute checks, and place a motion sensor on the room door. Resident #2 was moved to Unit 1 on 3/26/2020. She stated Resident #1 had advanced dementia and would not be able to make an informed decision. She talked to Resident #2 the following day, and the resident denied touching Resident #1. She again provided education to Resident #2 not to enter female residents' rooms. Licensed practical nurse (LPN) #1 was interviewed on 9/10/2020 at 2:48 PM and stated she worked on 3/26/2020 on the 7:00 AM to 3:00 PM shift and then on the 3:00 PM to 11:00 PM shift. She stated when she was notified of the incident, she notified the Director of Social Services for further guidance. The residents were separated, and Resident #2 was placed on 15-minute checks and moved to Unit 1. She stated Resident #1 had severe dementia and Resident #2 had mental health issues. CNA #5 was interviewed on 9/11/2020 at 8:50 AM via telephone, and stated she worked on 3/26/2020 from 2:00 PM to 10:00 PM. While doing rounds that night she was not able to locate Resident #2. She went to look for the resident and found Resident #2 lying on top of Resident #1 with his fist, up to the wrist, inserted in Resident #1's vagina. She told Resident #2 to get out of the room and immediately reported the incident to the nurse. Both residents were placed on 15-minute checks. The Director of Nursing (DON) #6 was interviewed via telephone on 9/21/2020 at 9:54 AM, and stated she worked at the facility from March 2020 to mid-April 2020. She was notified via telephone of the incident on 3/26/2020. She directed the staff to provide 1:1 for Resident #2 while he remained on the unit and he was to be relocated to another unit. Resident #1 was to be placed on 15-minute checks. Once Resident #2 was moved to Unit 1, he was to be monitored every 15 minutes. INCIDENT#5 On 7/18/2020, Resident #2 was sent to the hospital for an unrelated medical issue. The resident returned to the facility on [DATE] and was readmitted to Unit 2 (the Unit where Resident #1 resided). Resident #2's 15-minute check sheet did not document Resident #2 was consistently monitored from 7/23/2020 -8/23/2020 per the plan of care. The facility incident/accident report dated 8/22/2020 documented at 3:15 PM on Unit 2, Resident #2 was found straddling Resident #1 on his bed. Resident #2 was observed half naked. Resident #1's pull up (adult brief) was just off the hips. Resident #1 stated you caught us just in the nick of time. The residents were separated. The responsible party and physician were notified. Resident #1 was removed from the room and Resident #2 was moved to Unit 1. The 8/22/2020 resident to resident summary of abuse documented at approximately 3:15 PM, CNAs #5 and 7 entered Resident #2's room, the door was closed, and they observed Resident #1 lying on Resident #2's bed with her brief pulled down on her hip. Resident #2 was naked from the waist down and kneeling over Resident #1 with his knees on the bed. The residents were separated and Resident #2 stated he did what he did and reported his hands were there while pointing to her genital area. Resident #2 was moved to Unit 1 and placed on 10-minute checks. CNA #7 stated during a telephone interview on 10/15/2020 at 8:42 AM that on 8/22/2020, her and another CNA (CNA #5) were providing care and answering call bells. Prior to leaving to answer a call bell, Resident #1 was sitting in the hall by the nursing station. When they returned to the nursing station, they were unable to locate Resident #1. They went to look for the resident and went to Resident #2's room. Resident #2 was straddled over Resident #1 on the bed. Resident #2's pants were around his knees and Resident #1's pants were below the vaginal area. She stated, it looked to her as though Resident #2 pulled his penis out of Resident #1's vagina when they entered the room. She stated she thought there was vaginal penetration. She yelled What are you doing? and the other CNA got the nurse. CNA #5 was re-interviewed on 10/15/2020 at 8:42 AM and stated on 8/22/2020 she went to find Resident #1 and was unable to locate the resident, so she and CNA #7 went room to room and located Resident #1 in Resident #2's room. When she entered, she found Resident #2 straddling Resident #1 on the bed. Resident #2's pants were pulled down to his knees and Resident #1's pants were pulled down below her vaginal area. Registered nurse (RN) #10 was interviewed on 10/6/2020 at 1:17 PM and stated she was notified by LPN #9 on 8/22/2020 of the incident between Residents #1 and 2. She was told Resident #2 was positioned over Resident #1 and Resident #1's attends were pulled down below the vaginal area. Resident #2 was straddled over Resident #1. By the time she arrived on the unit, 2-3 minutes, later Resident #1 was in her room and Resident #2 was in his room. When she went to see Resident #1, she observed the resident fully dressed sitting on the bed, confused. She asked her how she was, and the resident stated she was okay and stated, he did what he did. She asked Resident #1 what she meant, and the resident stated his hands were there as she pointed to her private parts. She then when to see Resident #2, she looked at him and did not notice anything in particular. Resident #2 was sitting in a chair with a sheet over him. RN #10 stated, that was that. She completed her note and signed that she assessed the residents. RN #10 stated she did not look at the resident's body parts including Resident #1's vaginal area because she was told nothing happened and the residents were separated. Both residents were on Unit 2 at the time of the incident. She told the DON what happened, and Resident #2 was moved to Unit 1. She did not know what day Resident #2 was moved from Unit 2. DON #7 was interviewed on 10/6/2020 at 2:00 PM, she stated she had been in the position since June 2020. She conducted the investigation of the August 2020 incident. She did not think 2 cognitively impaired residents could consent to sexual activity. She was not aware Resident #2 was a convicted sexual predator until she investigated the incident on 8/22/2020. She was not present at the time of the incident and was made aware, while at home, from the LPN charge nurse and RN #10. The residents had been separated at that time and she instructed the staff to move Resident #2 off the unit. She directed them to initiate an incident report and continue with 15-minute checks. She did not feel abuse occurred. The Administrator was interviewed on 9/10/2020 at 3:30 PM and stated the social worker was responsible to meet with residents after any resident to resident situation and address the behaviors. The Administrator was interviewed on 10/6/2020 at 2:40 PM and stated she defined abuse, according to the facility policy, as the willful intent to inflict injury that causes physical harm or mental anguish. Sexual abuse was encompassed under that definition. A resident's cognitive status played a role and if the residents BIMS (Brief Interview for Mental Status, a screening tool used to assess cognition) score was low that meant there was no intent. When a sexual interaction occurred between residents without capacity the residents should be separated, must be assessed including a whole-body check. She was aware of Resident #2's criminal sexual status right after his admission to the facility and had contact with a detective who followed the resident. She could not state if the resident was registered in NYS, did not believe any contact had been made and she had not contacted any one legally about his continued sexual behavior. She stated, It would be the facilities responsibility to follow up with the resident predatory status. She did not feel abuse occurred with the incident on 3/26/2020 due to the resident's cognitive level meaning Resident #1 and 2 did not have capacity to consent. She was informed of the incident on 8/22/2020 by the DON that the residents did not remember what happened and she did not believe there was abuse. She stated Resident #1 and 2 should have been assessed on 8/22/2020 and the fact that the male resident was straddling Resident #1 an assessment should have been done of the resident's vaginal area. After the staff called the doctor if he said to call the police, they would follow that directive. The physician did not so they did not call police or send Resident #1 to the hospital for a rape assessment. The 15-minute checks should be completed per the plan of care and after review of the 8/22/2020 incident between residents #1 and 2 stated the checks were not completed. The social worker was assigned to follow up on mental health issues after an incident. During the incident on 3/14/2020 the psychologist was consulted, and recommendations included a stopwatch across the door. She recalled the recommendation of Resident #1 being moved off the unit and the family refused. She did not recall if they considered moving Resident #2 off the unit. If Resident #1 continued seeking behaviors she would expect the resident to be protected and additional steps should take place for prevention. On 10/19/2020 at 10:47 AM the Director of Social Services was interviewed via telephone and stated she was made aware Resident #2 was a sex offender on 5/27/2019. She did not recall who told her and thought all the people in charge were aware of the resident's sex offender status. She stated she felt the facility took appropriate measures to protect other residents in the facility from Resident #2 and could not state any specific interventions that were implemented. On 10/19/2020 The physician was interviewed via telephone at 11:03 AM, and stated he was not aware of Resident #2's sexual predator status. He was aware of some interactions between Residents #1 and 2 and if penetration occurred, he would expect the resident's vaginal area be assessed, and the police notified. He was not made aware penetration occurred. He would expect the residents involved to be separated and alarms be used. If interaction continued between the residents, with Resident #2's history, they should not be in the same facility. On 9/10/2020 at 10:10 AM, Resident #2 was observed sitting in the wheelchair in their room (Unit #1). Resident #2 did not respond verbally when the surveyor tried to speak with them. On 9/10/2020 from 12:07 PM to 12:30 PM, Resident #1 was observed wandering on Unit #2. The resident was not able to be interviewed by the surveyor. 10NYCRR 415.4(b)(1)(i)

Based on record review and interview during the abbreviated survey (NY 469) the facility did not ensure the physician and family representative were notified of a change in resident condition for 1 of 6 residents (Resident #402) reviewed for quality of care. Specifically, Resident #402 had a decline in condition, remained compromised for several hours and the physician was not notified. Emergency Medical Services was called, and the resident expired in the hospital. This resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #402. The facility policy Notification of Changes for Residents updated [DATE] documented the facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring. The nurse will immediately notify the resident's physician of a significant change in the resident's physical status that is a deterioration in health. Resident #402 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired and he required supervision for bed mobility, transfers, limited assistance for personal hygiene and extensive assistance for dressing. A nursing progress note dated [DATE] by registered nurse (RN) #3 documented on [DATE] she was asked by a certified nurse aide (CNA #8) at 11:30 PM to check on the resident. The resident was in his room, unresponsive. At 12:40 AM on [DATE] the resident's oxygen saturation was [AGE]% and RN #3 placed 3 liters of oxygen on the resident and his oxygen saturation increased to [AGE]%. He remained unresponsive, 911 was called and the resident was sent to the emergency room . Hospital records documented the resident arrived at the emergency room at 1:22 AM on [DATE]. The resident arrived with secretions in his airway, obvious aspiration (inhalation of a foreign substance in the lungs) and was responsive only to pain. He was hypoxemic (lack of oxygen to the brain) with an oxygen saturation of 50% and was arousable to tactile (touch) stimuli only. The laboratory results from the emergency room included a white blood cell count (WBC, indicates infection) of 22.87 (normal ,[DATE]), blood glucose of 43 (normal ,[DATE]) and [MEDICAL CONDITION] (brain disease) in the setting of pneumonia and a urinary tract infection [MEDICAL CONDITION]. The resident expired in the hospital on [DATE]. During an interview with certified nurse aide (CNA) #8 on [DATE] at 10:10 AM she stated she had worked the evening and night shifts starting on [DATE]. When she arrived at 2:00 PM she saw the resident and he was complaining of leg pain. She told LPN #11 who stated he had already had [MED]. A little while later she checked on him and he was still complaining of leg pain. She told LPN #5 who started work at 3:00 PM and she said she would get him something for the pain. CNA #8 stated she checked on the resident again and he was still complaining of pain and wanted to go to bed. Once in bed he started yelling out, so they put him back in his wheelchair. Sometime after 5:00 PM she entered the resident's room and he was not responding and was drooling. She notified LPN #5 who obtained the resident's vital signs. His oxygen level was 82%. and the resident was put back to bed. LPN #5 obtained his blood sugar and it was in the 70's. CNA #8 stated she had tried to give him orange juice to raise his sugar level and he was not able to swallow it and just came back out of the sides of his mouth. She did not know if the supervisor (LPN #4) was called but sometime after 6:00 PM she saw LPN #4 talking with LPN #5 at the medication cart. She did not see LPN #4 go in the resident's room and check on him. CNA #8 stated she had checked on the resident periodically throughout the remainder of the shift and obtained his vital signs. At one point his oxygen level was reading in the 50's and she had notified LPN #4. When RN #3 came in around 11:00 PM she met her at the front door and asked her to check on the resident. During an interview with CNA #18 on [DATE] at 4:20 PM she stated she had worked the evening of [DATE] and when she started her shift at 2:00 PM there was something not right about the resident as he was normally more uppity. Sometime before 5:30 PM she noticed the resident was falling asleep and sluggish at which time LPN #5 instructed the CNAs to get vital signs. His oxygen saturation was lower than 70% at that time. Throughout the shift his oxygen saturations were in the 50's, he was not talking, was not able to keep his eyes open very long and he continued to struggle to breath. She had notified both LPN #5 and LPN #4 the resident was struggling to breathe, several times during the shift, and they did not do anything for him. During an interview with LPN #5 on [DATE] at 1:10 PM she stated she had worked the evening shift on [DATE] and when she went into Resident #402's room he was not responding, and he appeared to be struggling to breathe. She could not remember what time she went into to see him after the start of her shift at 3:00 PM. She took his blood glucose which was [AGE] and they put the resident to bed. She checked his oxygen saturation and it was fluctuating in the [AGE]'s and 90's, his baseline was usually in the high 90's. She notified LPN #4 who was the nursing supervisor. LPN #4 came to the unit and looked at the resident's [DIAGNOSES REDACTED].#5 it was part of his illness and there was nothing the hospital could do for him. She did not see LPN #4 go in to the resident's room. LPN #5 stated the resident remained in the same condition the rest of the shift. After 11:00 PM registered nurse (RN) #3 saw the resident and called the ambulance. LPN #5 also stated she had not called the physician to report the resident's change in condition as it was the responsibility of the supervisor to call the physician. During an interview with LPN #4 on [DATE] at 12:15 PM she stated she had worked the day and evening shift on [DATE] as a medication nurse and the nursing supervisor. On the evening shift she had been called and told the resident was complaining of pain in his knees. She did attempt to see the resident, but he was in his room sleeping. After dinner, she was called again and was told the resident was not eating and was hard to arouse. She was in the middle of a medication pass so when she finished she went to look at the resident and he was in bed sleeping and snoring. She stated she could not recall the time. She attempted to wake the resident up, he was hard to arouse and when he did awaken he said he was sleepy and went right back to sleep. She went out and asked the staff if that was normal for him and the CNA told her he was normally up, eating and watching television at that time. LPN #4 stated she reviewed the resident's [DIAGNOSES REDACTED].#5 the snoring was part of his illness. She did not remember being told his oxygen saturation was low. She did not call the physician as the resident was just sleeping and snoring. During an interview with RN #3 on [DATE] at 8:20 AM she stated on [DATE] when she arrived for the night shift around 11:00 PM she was immediately notified by CNA #8 that Resident # 402 was sick. She went into the resident's room around 11:30 PM and he was unresponsive. She tried to wake him, performed a sternal rub and there was no response. RN #3 stated his oxygen saturation was low, she applied oxygen and called 911. She had advised CNA #8 to call the ambulance herself next time as there were two nurses that worked that evening and they had not addressed the resident's condition. RN #3 stated this was an ongoing issue when LPN #4 was the supervisor as LPN #4 did not do anything when residents got sick. RN #3 stated she had previously communicated her concerns to administration about LPN #4. During an interview with the resident's attending physician on [DATE] at 10:45 AM, he stated if a resident had a change in condition and had a low oxygen saturation he would expect the resident to be assessed by an RN and the on-call provider notified. He was not aware the resident had a change in condition and the provider had not been notified. During a second interview on [DATE] at 10:05 AM, the physician stated he had discussed his concerns with the previous DON, RN #7 regarding the nursing staff working out of their scope of practice. During an interview with the RN #7 (Director of Nursing, DON at the time of the incident) on [DATE] at 2:00 PM she stated RN #3 had raised some concerns regarding LPN #4 and her care of the residents. LPN #4 had been working at the facility for years, did a lot and really was the top dog. LPN #4 was the wound nurse, the infection control nurse, the unit manager of one of the units and frequently worked as the nursing supervisor. On [DATE] at 8:00 AM when the surveyors entered the facility and asked for the supervisor, LPN #4 was called. During an interview with RN #7, (DON at the time of the incident)) on [DATE] at 10:25 AM she stated after she was notified of concerns on [DATE] she had a conversation with the owner and the Administrator regarding LPN #4's care and supervision of the residents. She requested LPN #4 be terminated and they told her LPN #4 was a great employee and had been working for the facility for a long time. The LPN was not terminated and continued to work in the same capacity. There had been no investigation into the incident with Resident #402 and there was no training or re-education provided to LPN #4. During a telephone interview with the current DON on [DATE] at 10:54 AM she stated she did not know much about Resident #402 as the previous DON had been looking in to that. She was aware there were concerns regarding LPN #4 and there had been no training or reeducation provided to her. When a resident exhibited a change in condition she would expect vital signs to be done, the physician notified, and a nursing progress note written. During an interview with the Administrator on [DATE] at 11:12 AM she stated she was the administrator on record as of [DATE]. After she was notified there were supervisory concerns regarding LPN #4 there was no investigation or re-education done. When a resident had a change in condition she would expect the physician to be notified. The Administrator was notified on [DATE] at 4:07 AM of an Immediate Jeopardy to the health and safety of the 52 residents currently residing in the facility. Immediate Jeopardy was removed on [DATE] prior to exit based on the following corrective actions taken. The facility -terminated LPN #4; -would provide RN Supervision or RN on-call coverage at all times; -would immediately initiate LPN education regarding the requirement to notify the RN and the physician of a change in condition as soon as it is observed; and -would review the job description including the scope of practice of each LPN working in the facility. 10NYCRR 415.3(e)(2)(ii)(d)

Based on record review and interview during the abbreviated survey (NY 469), the facility did not ensure residents received treatment and care in accordance with professional standards of quality for 2 of 6 residents (Residents #401 and 402) reviewed for quality of care. Specifically, Resident #402 had a change in condition that was not addressed timely. Resident #401 had an emergent decline in condition and there was no documented evidence of appropriate and timely treatment/interventions. Both residents required Emergency Medical Service response and expired in the hospital. This resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #402 and actual harm to Resident #401 that was not Immediate Jeopardy. Findings include: The facility policy Notification of Changes for Residents updated [DATE] documented the facility shall promptly notify the resident and/or the resident representative and his or her physician or delegate of changes in the resident's condition or status in order to obtain orders for appropriate treatment and monitoring. The nurse will immediately notify the resident's physician of a significant change in the resident's physical status that is a deterioration in health. 1) Resident #402 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired and he required supervision for bed mobility, transfers, limited assistance for personal hygiene and extensive assistance for dressing. The Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] and signed by the resident documented he was a do not resuscitate (DNR, do not perform cardiopulmonary resuscitation) and he wanted limited medical interventions which included receiving medications by mouth or through a vein, heart monitoring and all other necessary treatment. A nursing progress note dated [DATE] by registered nurse (RN) #3 documented on [DATE] she was asked by a certified nurse aide (CNA #8) at 11:30 PM to check on the resident. The resident was in his room, unresponsive. At 12:40 AM on [DATE] the resident's oxygen saturation was [AGE]% and RN #3 placed 3 liters of oxygen on the resident and his oxygen saturation increased to [AGE]%. He remained unresponsive, 911 was called and the resident was sent to the emergency room . Hospital records documented the resident arrived at the emergency room at 1:22 AM on [DATE]. The resident arrived with secretions in his airway, obvious aspiration (inhalation of a foreign substance in the lungs) and was responsive only to pain. He was hypoxemic (lack of oxygen to the brain) with an oxygen saturation of 50% and was arousable to tactile (touch) stimuli only. The laboratory results in the emergency room included a white blood cell count (WBC, indicates infection) of 22.87 (normal ,[DATE]), blood glucose of 43 (normal ,[DATE]) and [MEDICAL CONDITION] (brain disease) in the setting of pneumonia and a urinary tract infection [MEDICAL CONDITION]. The resident expired in the hospital on [DATE]. During an interview with certified nurse aide (CNA) #8 on [DATE] at 10:10 AM she stated she had worked the evening and night shifts starting on [DATE]. When she arrived at 2:00 PM she saw the resident and he was complaining of leg pain. She told LPN #11 who stated he had already had [MED]. A little while later she checked on him and he was still complaining of leg pain. She told LPN #5 who started work at 3:00 PM and she said she would get him something for the pain. CNA #8 stated she checked on the resident again and he was still complaining of pain and wanted to go to bed. Once in bed he started yelling out, so they put him back in his wheelchair. Sometime after 5:00 PM she entered the resident's room and he was not responding and was drooling. She notified LPN #5 who obtained the resident's vital signs. His oxygen level was 82%. and the resident was put back to bed. LPN #5 obtained his blood sugar and it was in the 70's. CNA #8 stated she had tried to give him orange juice to raise his sugar level and he was not able to swallow it and just came back out of the sides of his mouth. She did not know if the supervisor (LPN #4) was called but sometime after 6:00 PM she saw LPN #4 talking with LPN #5 at the medication cart. She did not see LPN #4 go in the resident's room and check on him. CNA #8 stated she had checked on the resident periodically throughout the remainder of the shift and obtained his vital signs. At one point his oxygen level was reading in the 50's and she had notified LPN #4. When RN #3 came in around 11:00 PM she met her at the front door and asked her to check on the resident. During an interview with LPN #5 on [DATE] at 1:10 PM she stated she had worked the evening shift on [DATE] and when she went into Resident #402's room he was not responding, and he appeared to be struggling to breathe. She could not remember what time she went into to see him after the start of her shift at 3:00 PM. She took his blood glucose which was [AGE] and they put the resident to bed. She checked his oxygen saturation and it was fluctuating in the [AGE]'s and 90's, his baseline was usually in the high 90's. She notified LPN #4 who was the nursing supervisor. LPN #4 came to the unit and looked at the resident's [DIAGNOSES REDACTED].#5 it was part of his illness and there was nothing the hospital could do for him. She did not see LPN #4 go in to the resident's room. The resident remained in the same condition the rest of the shift. After 11:00 PM registered nurse (RN) #3 saw the resident and called the ambulance. LPN #5 had not called the physician to report the resident's change in condition as it was the responsibility of the supervisor to call the physician. During an interview with LPN #4 on [DATE] at 12:15 PM she stated she had worked the day and evening shift on [DATE] as a medication nurse and the nursing supervisor. If a resident had a change in condition she would look at the resident and notify the physician for further instructions. On the evening shift LPN #4 was called and told the resident was complaining of pain in his knees. She did attempt to see the resident, but he was in his room sleeping. After dinner she was called again and was told the resident was not eating and was hard to arouse. She was in the middle of a medication pass so when she finished she went to look at the resident and he was in bed sleeping and snoring. She could not recall the time. She attempted to wake the resident up, he was hard to arouse and when he did awaken he said he was sleepy and went right back to sleep. She went out and asked the staff if that was normal for him and the CNA #8 told her he was normally up, eating and watching television at that time. LPN #4 stated she reviewed the resident's [DIAGNOSES REDACTED].#5 that the snoring was part of his illness. She did not remember being told his oxygen saturation was low. She did not call the physician as the resident was just sleeping and snoring. During an interview with RN #3 on [DATE] at 8:20 AM she stated on [DATE] when she arrived for the night shift around 11:00 PM she was immediately notified by CNA #8 that Resident # 402 was sick. She went into the resident's room around 11:30 PM and he was unresponsive. She tried to wake him, performed a sternal rub and there was no response. RN #3 stated his oxygen saturation was low, she applied oxygen and called 911. She had advised CNA #8 to call the ambulance herself next time as there were two nurses that worked that evening and they had not addressed the resident's condition. RN #3 stated this was an ongoing issue when LPN #4 was the supervisor as LPN #4 did not do anything when residents got sick. RN #3 had communicated her concerns to administration in the past. During an interview with RN #7 (Director of Nursing, DON at the time of the incident) on [DATE] at 2:00 PM she stated RN #3 had raised some concerns regarding LPN #4 and her care and supervision of the residents. LPN #4 had been working at the facility for years, did a lot and really was the top dog. LPN #4 was the wound nurse, the infection control nurse, the unit manager of one of the units and frequently worked as the nursing supervisor. During an interview with the resident's attending physician #16 on [DATE] at 10:45 AM, he stated if a resident had a change in condition and had a low oxygen saturation he would expect the resident be assessed by an RN and the on-call provider notified. He was not aware the resident had a change in condition and the provider had not been notified. During a second interview on [DATE] at 10:05 AM, the physician stated he had discussed his concerns with the previous DON, RN #7 of the nursing staff working out of their scope of practice. On [DATE] at 8:00 AM when the surveyors entered the facility and asked for the supervisor, LPN #4 was called. During an interview with RN #7 (DON at the time of the incident) on [DATE] at 10:25 AM she stated after she was notified of concerns on [DATE] she had a conversation with the owner and the Administrator regarding LPN #4's care and supervision of the residents. She requested LPN #4 be terminated and they told her LPN #4 was a great employee and had been working for the facility for a long time. The LPN was not terminated and continued to work in the same capacity. There had been no investigation into the incident with Resident #402 and there was no training or reeducation provided to LPN #4. During a telephone interview with the current DON on [DATE] at 10:54 AM she stated she did not know much about Resident #402 as the previous DON had been looking in to that. She was aware there were concerns regarding LPN #4 and there had been no training or reeducation provided to her. When a resident exhibited a change in condition she would expect vital signs to be done, the physician notified, and a nursing progress note written. During an interview with the Administrator on [DATE] at 11:12 AM she stated she was the administrator on record as of [DATE]. After she was notified there were supervisory concerns regarding LPN #4 there was no investigation or re-education done. When a resident had a change in condition she would expect the physician to be notified. The Administrator was notified on [DATE] at 4:07 AM of an Immediate Jeopardy to the health and safety of the 52 residents currently residing in the facility. Immediate Jeopardy was removed on [DATE] prior to exit based on the following corrective actions taken. The facility: -terminated LPN #4; -would provide RN Supervision or RN on-call coverage at all times; -would immediately initiate LPN education regarding the requirement to notify the RN and the physician of a change in condition as soon as it was observed; and would review the job description including the scope of practice of each LPN working in the facility. 2)Resident #401 was admitted to the facility on [DATE] and readmitted on [DATE] and had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and he was totally dependent for all activities of daily living (ADLs). The resident's Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] documented the resident was a do not resuscitate (DNR, do not perform cardiopulmonary resuscitation) and a do not intubate (DNI, do not place a breathing tube) and he wanted limited medical interventions which included oral and intravenous medications and cardiac monitoring. The [DATE] 24-hour report (nursing communication) documented on the 7:00 AM- 3:00 PM shift the Resident #401's heart rate was 240 beats per minute (normal ,[DATE]). The nurse practitioner (NP) #15 was aware and increased the [MEDICATION NAME] (used to treat heart failure) to 50 milligrams (mg). A physician order dated [DATE] at 1:00 PM documented to increase the [MEDICATION NAME] to 50 mg daily. The order documented the prescriber was nurse practitioner (NP) #15 and the order was taken by licensed practical nurse (LPN) #4. The physician order was not signed by a provider. The ,[DATE] medication administration record (MAR) documented the [MEDICATION NAME] 50 mg was not administered until [DATE] at 9:00 AM. The [DATE] 24-hour report documented the resident was pale, lethargic and staring off. His temperature was 100.8 degrees Fahrenheit (normal 98.6) and heart rate was 113. NP #15 documented on [DATE] the resident was being reviewed for a gradual dose reduction (GDR) of his [MEDICAL CONDITION] medications. The resident was resting comfortably in his chair and had a [MEDICAL CONDITION] (fast heart rate) rhythm (rate was not documented). The resident was recently hospitalized for [REDACTED]. There was no documentation regarding the heart rate of 240 or increasing the [MEDICATION NAME] dosage on [DATE]. There was no physician order for [REDACTED]. The 24-hour report documented the following: -On [DATE] on the night shift the resident was tired and weak and his heart rate was 122. On the day shift he was weak and tired. On the evening shift he had emesis (vomiting) x 1, difficulty swallowing his medications and drinking. -On [DATE] during the night the resident was weak, tired and had difficulty swallowing. On the day shift his blood pressure was ,[DATE] and heart rate was 120. On the evening shift he had emesis x 1. -On [DATE] the resident had a large jelly like stool and he was lethargic and had a heart rate of 115. -On [DATE] the resident had a heart rate of 122 and his temperature was 100.0. There was no documentation in the medical record reflecting what was documented on the 24-hour report. A nursing progress noted completed by LPN #4 dated [DATE] documented the resident was pale and sweating, cool compresses were applied, the resident did not have a temperature (there was no temperature documented) and NP #15 was aware. There were no instructions or new orders documented in the medical record. A nursing progress note dated [DATE] documented the resident was tired and pale. He was reaching out for staff when they entered the room. The [DATE] 24-hour report documented on the night shift the resident was awake most of the shift and diaphoretic (sweating heavily). No vital signs were documented. There was no documentation in the medical record reflecting what was documented on the 24-hour report. A nursing progress note dated [DATE] completed by LPN #4 documented the resident had a temperature of 104.4 (no other vital signs were documented), [MED] was given at 9:00 AM and cool compresses were applied. Physician #16 noted. The resident's temperature was rechecked at 12:00 PM and was 103.2. Physician #16 was notified, and he ordered [MED]. The temperature was rechecked at 2:00 PM and was 103.3, heart rate was 126, blood pressure was ,[DATE] and respirations were 44. Physician #16 was notified, and he ordered the resident to the hospital. Review of the ,[DATE] MAR did not document any [MED] administration from [DATE] - [DATE]. A facility resident transfer form dated [DATE] at 2:15 PM documented the resident had a fever [MEDICATION NAME] 2 shifts, [MED] did not bring it down and he was recently hospitalized 2 weeks ago for the same issue. The ambulance form dated [DATE] documented they responded to the nursing home to find the resident not able to speak or comprehend. The resident appeared pale and warm and was hypotensive, [MEDICAL CONDITION] with shallow respirations. The hospital record dated [DATE] documented per the nursing facility the resident had symptoms of decreased mentation, [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] febrile (high fever) illness x 3 days. The resident's hospital blood work documented he had a white blood cell count of 26,000 (normal 4,,[DATE],000), [MED] of 1[AGE] (normal ,[DATE]) and chloride of 124 (normal ,[DATE]). The resident arrived at the hospital on [DATE] at 2:53 PM and expired at 4:35 PM. During an interview with certified nurse aide (CNA) #10 on [DATE] at 11:00 AM she stated she was notified at the beginning of the day shift on [DATE] the resident felt warm and she took the resident's temperature rectally and it was 104.6. Later in the shift she took another rectal temp and it was over 103. She notified LPN #4 who was the nursing supervisor and LPN #4 said she did not want to send him to the hospital because it was a holiday. The Dietary Director told LPN #4 that she should send him to the hospital. At 2:00 PM, LPN #4 called the physician and received an order to send the resident to the hospital. CNA #10 stated the resident had not been doing well for some time prior to that day. She stated one day his heart rate was in the 200's. During an interview with the Food Service Director on [DATE] at 11:15 AM she stated she was in the facility on [DATE] when Resident #401 had a really high temperature. The Food Service Director witnessed LPN #4 state she did not want to send the resident to the hospital as it was a holiday. The Food Service Director recommended to LPN #4 the resident should be sent out for treatment or he would not be around for another holiday. During an interview with LPN #4 on [DATE] at 12:15 PM she stated she was the Unit Manager for the resident's unit and she frequently worked as the nursing supervisor. On [DATE] Resident #401 had a really high temperature and she could not recall what it was. He had a lot of medical issues and had a decline over the past several weeks. The elevated temperature was very scary, but she had called the physician and he told me to just monitor him. She gave the resident [MED] but that did not help the temperature. At 2:00 PM, the physician gave her the order to send the resident to the hospital. She did not recall saying she did not want to send the resident to the hospital because it was a holiday. She stated she recalled saying the resident would probably wait until the end of her shift to be sent out. During an interview with LPN #13 on [DATE] at 7:35 AM she stated she had worked the night shift on [DATE] going into [DATE]. Resident #401 had not been doing well for a few days prior to that night. On the morning of [DATE] CNA #10 told LPN #13 the resident felt warm. The resident's skin was hot to the touch and he was breathing heavily. LPN #13 took an axillary (arm pit) temperature and it was normal, but she put cool compresses on him as he felt hot. She did not notify the physician and there was no RN in the building at the time. When CNA #10 took the resident's rectal temperature and it was high. LPN #13 stated she notified LPN #4 prior to leaving and LPN #4 said she was not sending the resident to the hospital as it was a holiday. During an interview with physician #16 on [DATE] at 10:45 AM he stated if a resident was running a high temperature, he would expect to be notified. If the temperature was greater than 104 the resident was probably septic and would require hospitalization for intravenous antibiotics. He did not recall being notified of Resident #401's history of high temperatures or his decline in condition, and he would not have given the directive to just monitor and give [MED]. He was notified of the resident's condition just prior to the resident being sent to the hospital on [DATE]. LPN #4 was interviewed a second time on [DATE] at 11:40 AM she stated she had been very concerned when the resident had a high temperature and she had reported the temperature to the physician. She stated the physician just wanted the resident to have [MED]. She did not know why [MED] was not documented on the MAR. She had directed the medication nurse, LPN #5, to give the resident [MED]. She did not know what the resident's other vital signs were. She had been very concerned about the resident, but she needed a physician order to send the resident to the hospital. During an interview with LPN #5 on [DATE] at 2:25 PM she stated she had worked the day shift on [DATE] and Resident #401's temperature was really high. She had given him [MED] once that shift, could not remember the time she gave it and may have forgotten to document it. She had applied cold compresses throughout the shift. Later in the shift when the CNA rechecked the resident's temperature it was still high. LPN #5 kept asking LPN #4 about sending the resident to the hospital and LPN #4 did not want to. LPN #5 stated she had not called the physician herself as that was the responsibility of the supervisor, LPN #4. During a follow up interview with LPN #4 on [DATE] at 10:30 AM she reviewed the [DATE] 24-hour report and stated one of the CNAs had reported to her the resident had a heart rate that was 240, she went and rechecked it herself radially (in the wrist) and it was high. She notified NP #15 who wanted to increase his [MEDICATION NAME] which would have started the next day. The NP did not direct her to do anything else for the resident. She did not know why the physician order was unsigned or why the [MEDICATION NAME] was not started until [DATE]. During an interview with NP #15 on [DATE] at 11:30 AM he stated he did not recall being notified Resident #401 had a heart rate of 240. If the heart rate was reported to him as 240, he would have nursing verify the heart rate and obtain vital signs. A heart rate of 240 was life threatening and he would have sent the resident to the emergency room . He would not have ordered to increase the [MEDICATION NAME]. If he did order a change in medication, he would expect it be given at that time and not two days later. He did see the resident on [DATE] for a Gradual Dose Reduction (GDR) and wanted blood work done because the resident was recently treated for [REDACTED]. If he had been notified the resident had elevated temperatures and heart rates he would have included that in his note on [DATE]. The labs should have been done on the next lab day and he was not aware the labs had not been done. He could not recall being notified on [DATE] the resident was pale, sweating and had a poor appetite and had been having an elevated heart rate and temperature. 10 NYCRR 415.12

Based on record review and interview conducted during the abbreviated survey (NY 598), it was determined for 1 of 6 residents reviewed for abuse/neglect (Resident #1), the facility did not implement written policies and procedures that prohibit neglect of residents. Specifically, Resident #1 was not provided with a staff member or a gait belt for safe transfer at [MEDICAL TREATMENT]. This resulted in actual harm to Resident #1, who sustained worsening of a prior head injury after a fall when he transferred himself out of a transport vehicle at a [MEDICAL TREATMENT] center. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan dated 3/9/2016 documented the resident required extensive assist of two persons and a gait belt for transfers and ambulation. The Minimum Data Set assessment dated [DATE] documented the resident had severe cognitive impairment, and had total dependency of two persons for transfers. The Accident/Incident Report dated 3/26/2016 documented the facility received a call from the [MEDICAL TREATMENT] center where the resident received [MEDICAL TREATMENT] services. The resident fell when the taxi cab driver went into the building to get a wheelchair for him. Emergency medical services (911) was called, and the resident was transferred to the hospital. The facility's conclusion was there was no reasonable cause to believe abuse, neglect or mistreatment occurred. The report documented the resident was care planned for non-compliance with transfers and refused to wait for assistance. It was noted the resident's intake was poor, which may have contributed to the fall. The hospital discharge summary dated 4/1/2016 documented prior to admission, the resident was in the [MEDICAL TREATMENT] parking lot and had a fall in which he hit his head. The CT (computerized tomography) scan of the brain noted known left subdural hematoma had increased in size compared to prior study (performed 3/1/2016). There was increased mass effect upon the adjacent brain parenchyma, most pronounced over the left frontal lobe. The unit manager was interviewed on 5/24/2016 at 10:00 AM. The unit manager stated the resident was transported to [MEDICAL TREATMENT] via a taxi cab, which the facility was paying for due to an insurance issue preventing him from being able to use the county transport van. She stated the resident was very unsteady. He had a fall at home prior to his admission, in which he had sustained a head injury. She said he would attempt to self-transfer all the time. She said a staff member would accompany him to [MEDICAL TREATMENT], but he had no escort that day, which was a Saturday. She stated she was not sure why no one escorted him to [MEDICAL TREATMENT], but stated staff should have gone with him and used a gait belt. During a telephonic interview on 6/10/2016 at 11:05 AM, the Director of Nursing was asked if the facility had a written policy addressing the transfer of residents to other facilities or for appointments. She was not aware of a resident transfer policy, and confirmed the lack of such a policy via fax statement sent at 11:16 AM. 10NYCRR 415.4 (b)(1)(ii)

Based on observation, record review, and staff interview conducted during the extended and abbreviated surveys (Complaint #NY 297 and NY 263), it was determined for 11 of 13 residents (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19) reviewed for falls/fractures and/or injuries of unknown origin, and for 1 of 1 resident (Resident #3) reviewed for elopement, the facility failed to thoroughly investigate and report incidents when required to the New York State Department of Health (NYSDOH). For 4 of 5 newly hired employees (Employees #1, 2, 3, and 5), the facility did not complete required pre-employment screening. Specifically, for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19, the facility: - failed to consistently conduct investigations of falls, injuries of unknown origin, and elopements to rule out abuse, neglect, or mistreatment; and - failed to notify the Director of Nursing (DON), the Supervising Administrator, and the Acting Administrator of every incident. For Residents #1, 3, 4, and 8, the facility failed to report incidents to the NYSDOH when required. For Employees #1, 2, and 3 the facility did not verify the employee's licenses or check references prior to hire; and for Employee #5, the facility did not verify the employee with the certified nurse aide (CNA) registry prior to hire. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19, and regarding lack of employee screening no actual harm with potential for more than minimal harm that is not immediate jeopardy to residents. The facility implemented corrective measures to remove the Immediate Jeopardy prior to the survey exit on February 12, 2013. Findings include: FALLS 1) Resident #1 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 9/12/2012 documented the resident was at risk for falls and required extensive assistance of 2 persons for transfers. The CCP recorded the resident had a history of [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired. The Accident/Incident Report dated 10/1/2012, documented the resident was found on the floor at 10 PM and sustained an "aprox" one inch skin tear" above his right ear. The report included: - 10/3/2012, certified nurse aide (CNA) #8 documented the resident was on the floor and wanted to get up. The resident's head was bleeding and "we" got the resident up for further assessment. The resident was placed in the wheelchair and his head was bandaged. - 10/1/2012, licensed practical nurse (LPN) #3 documented the resident's left temple was bleeding. The resident did not complain of pain; range of motion was done; he was assisted to a wheel chair; brought to the nurse's station for monitoring; and oxygen was given. The resident stated he hit his head "hard", neurological checks (an assessment of neurological functioning) were started and the physician was notified. The resident was sent to the emergency room due to a "deep cut on his left temple." - 10/1/2012, LPN #4 documented the resident denied he was hurt and stated he wanted to get up. A cut was observed on the left side of the resident's head, a pressure dressing was applied and the resident was assisted to the wheelchair. Neurological checks were started and were within normal limits. - The physician was notified at 10:30 PM and the resident was sent to the hospital at 10:45 PM for evaluation and treatment of [REDACTED]. - The "Designee Administrator" signed the Accident/Incident report as complete on 10/03/2012. The director of Nursing (DON) signed the report without a date. - The "Conclusion" section of the Accident/Incident Report was not completed (was blank) including, whether the accident/incident was avoidable or unavoidable and whether the investigation revealed there was cause to believe abuse, mistreatment or neglect occurred. The facility's investigation dated 10/1/2012 included no documented evidence it was beyond the LPN's scope of practice to: - assess the resident after he was found on the floor; and - move the resident off the floor into a wheelchair, before he was assessed by a qualified person (physician, registered nurse). The resident's medical record included no documented evidence the resident was assessed by a qualified person, following a head injury, and in addition the incident was not reported to the NYSDOH. In an interview with the Assistant Administrator on 11/28/2012 12:50 PM she stated LPN #3 was the nursing supervisor when the resident was found on the floor on 10/2/2012. LPN #3 was interviewed on 11/28/2012 at 1:28 PM and 2:26 PM and stated she was the nursing supervisor when the resident was found on the floor. She said she assessed the resident and determined there was no change in his cognition or range of motion. LPN #3 stated she determined the resident was able to be assisted up from the floor. During an interview with LPN #3 on 12/05/2012 at 7:15 AM, she stated at her direction two staff members lifted the resident off the floor, using a gait belt, as she pushed the wheelchair under the resident. LPN #3 stated she did not call the physician until after the resident was lifted off the floor placed in a wheelchair and brought out to the nursing station. She said she called the physician because she thought the resident needed stitches to the head wound. She said she did not notify the Director of Nursing as she saw "a little blood" and thought the resident needed "stitches." LPN #3 stated she did not check the resident's vital signs until he was in the wheelchair at the nurses station. The DON was interviewed on 12/05/2012 at 8:12 AM, and stated she did not know whether it was beyond an LPN's scope of practice to assess residents. She said the facility's investigation was incomplete as there was no determination if the incident was unavoidable. She stated she obtained, reviewed, and signed investigations. The DON said an LPN could move a resident after doing an assessment if there was no injury. She stated an RN would assess the resident when one was available. During an interview with the Acting and Supervising Administrators on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Supervising Administrator stated he signed all Accident/Incident Reports and when he signed them they did not always include staff statements or additional investigation. The DON stated in an interview on 2/7/2013 at 9:35 AM, she was newly hired, was aware the facility was not completing thorough investigations of incidents, and had not gotten around to making any changes. On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed. They stated the facility's incident reporting process had changed and they did not know where investigations of incidents were documented. They stated there used to be investigations attached to Accident/Incident Reports and there no longer were. The Acting Administrator stated it was the responsibility of "whoever signs off" an Accident/Incident report to ensure it was a complete investigation. INJURIES OF UNKNOWN ORIGIN 2) Resident #4 had [DIAGNOSES REDACTED]. A nursing progress note dated 8/12/2012 documented the resident had [MEDICAL CONDITION] (swelling) to the right ankle, pain, "grimacing" with standing and an x-ray was ordered. The 8/12/2012 x-ray report documented the resident had a non-displaced [MEDICAL CONDITION] ankle. A nursing progress note dated 8/12/2012 documented the resident was to be transferred with a mechanical lift as he had pain and swelling of the right ankle. The licensed practical nurse (LPN) #2's progress note dated 8/13/2012 documented she phoned the resident's family member to tell her about the fracture and the family member asked how it happened. LPN #2 documented she responded "I'm unsure d/t (due to) his condition and movement it could be a possibility of anything." The 8/21/2012 physician's progress note documented the resident's fractured ankle was to be "investigated as per facility policy." The facility was unable to provide an investigation upon request by the surveyors. The 12/13/2012 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, he was dependent on staff for activities of daily living (ADL), and he had falls without injury. The resident was observed on 2/5/2013 at 12:25 PM sitting, in the hallway, in a reclined geri-chair. The physician stated in an interview on 2/7/2013 at 11:45 AM, he was aware of the resident's fractured ankle and was involved with the care. He stated the facility should have completed an investigation to determine how the fracture occurred. During an interview with the Director of Nursing (DON) on 2/7/2013 at 10 AM, she stated she could not find an investigation for the resident's fractured ankle. During an interview with the Acting and Supervising Administrators on 2/7/2013 at 12:05 PM, the Supervising Administrator stated he did not remember the resident's fracture and was not employed by the facility at that time. The Acting Administrator stated she remembered the resident having [MEDICAL CONDITION] and thought he did not have a fractured ankle. The Acting Administrator stated the fracture should have been investigated and reported to the New York State Department of Health (NYSDOH) and was not. The Acting Administrator stated the facility did not have a mechanism in place to ensure incident reports or investigations were completed for each incident, including injuries of unknown origin. ELOPEMENT 3) Resident #3 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 9/26/2012 documented the resident had moderate cognitive deficits, was visually impaired, was able to see only large print, had trouble finding the correct word when speaking, was at high risk for falls, and wore a Wanderguard (a device to detect wandering) bracelet. The 9/26/2012 Wandering Risk Assessment documented the resident was cognitively impaired with poor decision making skills, ambulated independently without assistance devices, had visual or auditory deficits, and a history of attempting to leave the facility without supervision or informing staff. The 10/7/2012 Director of Nursing (DON) progress note documented at 8:50 AM, the resident went out the patio door and was seen opening the patio gate. The staff noticed the resident through the window and the resident was easily re-directed back into the facility. The 10/7/2012 Accident/Incident Report documented the resident went out to patio, attempted to get through the gate and staff (certified nurse aide, CNA, #2) saw him from the window of another resident's room. The corrective action was "maintenance to check gate to make sure it is latched daily." The report included an unsigned staff statement documenting the staff person went to another resident's room to pick up a meal tray, looked out the window, and saw the resident walking "under the ramp outside." The report was signed as reviewed by the Administrator, the DON, the licensed practical nurse (LPN) Manager #1, the Medical Director, and the physical therapist. The report documented the incident was "unavoidable" and was not reported to the NYSDOH. During an interview with LPN #1 on 2/5/2013 at 10 AM, she stated the resident wore a Wanderguard bracelet and had an incident in October 2012, where he went out the patio door, that had no Wanderguard alarm. She stated the patio gate was left open by the lawn crew, the resident exited the gate, and was walking under the ramp when he was seen by a staff member from another resident's room. She stated she did not know how long the resident was outside, or outside of the patio. During an interview with the DON on 2/6/2013 at 12:50 PM, she stated she did not consider the resident's incident an elopement as staff "caught him," he came back inside easily, and he did not leave the facility grounds. She stated he was in an area that he should not have been as she would not allow residents with Wanderguards to go to the patio without supervision. She stated his care plan was not changed to prevent reoccurrence as over time he relied on a wheelchair more for mobility. She stated the Acting and Supervising Administrators made the determination of which incidents should be reported to the NYSDOH and she did not have a copy of the NYSDOH incident reporting manual. During an interview with the Acting and Supervising Administrator on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Acting Administrator stated she was not aware of the resident's elopement until today as she did not sign off on accident/incident reports. The Supervising Administrator stated he signed the report and did not remember the incident. The Supervising Administrator stated the incident should have been reported to the NYSDOH. He stated he signed all incident reports and when he signed them they did not always include staff statements or investigation to determine if abuse or neglect occurred. On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed. They stated the facility's incident reporting process changed and they were not sure where they could find thorough investigations of incidents. The Acting Administrator stated "whoever signs off" on the accident and incident reports should be ensuring they were complete. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to the survey exit on 2/12/2013 based on the following corrective actions taken by the facility: - revised the Accident and Incident Report form to include a thorough investigation of all allegations of abuse, neglect, and mistreatment; - trained the majority of staff members on abuse prevention and completing thorough investigations, and the remaining staff would be inserviced before returning to duty; - revised policies and procedures to address post-fall practices; and - revised the LPN job description to ensure assessments were conducted by qualified professionals. --------------------------------------------------------------------------------------------- EMPLOYEE SCREENING: 4) Per an undated list of new employees (Probationary Employee Listing): - Employee #1 was a registered nurse (RN) hired 11/30/2012; - Employee #2 was a licensed practical nurse hired 12/21/2012; - Employee #3 was an RN hired 11/15/2012; and - Employee #5 was a certified nurse aide (CNA) hired 1/21/2013. The facility could provide no documented evidence the license status of Employees #1, 2, and 3 was checked with the state education department. The facility could provide no documented evidence reference checks were done, as part of the hiring process, for Employees #1, 2, and 3. Per the Candidate Search Details (CNA registry check) dated 2/5/2013, the CNA registry check for Employee #5's status as a CNA was done on 2/5/2013. The Acting Administrator was interviewed on 2/6/2013 at 3 PM. She stated individual departments were responsible for screening their employees. The Director of Nursing (DON) was interviewed on 2/6/2013 at 3:05 PM. She stated she had not been involved in the recent hiring of nurses. She was not sure if the nursing department was responsible for screening new nursing employees. She stated the part time receptionist usually checked two references for new employees. She stated she was aware the license status of licensed employees could be checked online; she did not check the license status of each newly hired licensed nurses. The part-time receptionist was interviewed on 2/6/2013 at 3:30 PM. She stated she checked the CNA registry for new employees, and did not check the online license status of licensed employees. 10NYCRR 415.4(b)(1)(ii)

Based on record review and staff interview conducted during the extended and abbreviated surveys (Complaint #NY 297 and NY 263), it was determined for 11 of 13 residents reviewed for falls/fractures and/or injuries of unknown origin (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19) and 1 of 1 resident reviewed for elopement (Resident #3), it was determined the facility failed to operationalize policies and procedures that prohibit mistreatment, neglect, and abuse of residents. For 4 of 5 newly hired employees (Employees #1, 2, 3, and 5), the facility did not operationalize policies to ensure pre-employment screening was completed. Specifically, for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19, the facility: - failed to consistently conduct investigations of falls, injuries of unknown origin, and elopements to determine if abuse, neglect, or mistreatment occurred; and For Residents # 1, 3, 4, and 8, the facility failed to report injuries and incidents to the New York State Department of Health (NYSDOH). Regarding Employees #1, 2, 3, and 5, the facility did not complete all required pre-employment screening. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Residents # 1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19, and no actual harm with potential for more than minimal harm that is not immediate jeopardy regarding the lack of employee screening. The facility implemented corrective measures to remove the Immediate Jeopardy prior to the survey exit on February 12, 2013. The facility's undated "Job Description and Performance Standards for LPN (licensed practical nurse) Clinical Coordinator/Charge Nurse" documented the LPN was to "supervise and assess resident care and take appropriate action" and to "perform comprehensive assessment/observation of residents as assigned." The facility's current Abuse Prevention and Reporting policy dated 8/25/09 documented all alleged or suspected incidents of abuse or neglect would be thoroughly investigated and the findings documented in a report format. If abuse or neglect were identified or if a conclusion could not be drawn the incident would be reported to the NYSDOH. Findings include: FALLS 1) Resident #1 had [DIAGNOSES REDACTED]. The Accident/Incident Report dated 10/1/2012, at 10 AM, documented the resident was found on the floor with an "aprox" one inch skin tear above his right ear on the side of his head. The report included: - 10/1/2012, licensed practical nurse (LPN) #3 documented the resident's left temple was bleeding. The resident did not complain of pain, range of motion was done, and he was placed in a wheel chair and oxygen was applied. The resident was brought to the nurse's station desk for monitoring. The resident stated he hit his head "hard", neurological checks (an assessment of neurological functioning) were started and the physician was notified. The resident was sent to the emergency room "d/t (due to) a deep cut on his left temple." -The "Conclusion" section of the report was not completed (was blank) including whether the accident/incident was unavoidable or avoidable and whether the investigation revealed there was cause, or no cause, to believe abuse, mistreatment or neglect occurred. -The "Designee Administrator" signed the Accident/Incident report as complete on 10/03/2012. The Director of Nursing (DON) signed and did not date the report. There was no documented evidence the facility identified it was beyond the scope of practice for the LPN to assess and move the resident off the floor before an assessment by a qualified professional (physician, registered nurse). There was no documented evidence the facility reported to the NYSDOH the LPN assessed the resident. The Acting Administrator was interviewed on 1/3/2013 at 12:45 PM, and stated the Supervising Administrator was responsible for operationalizing the facility's policies and procedures. The Supervising Administrator was interviewed on 1/23/2013 at 9:10 AM, and stated he was ultimately responsible for operationalizing the facility's policies and procedures. During an interview with the Acting and Supervising Administrators on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Supervising Administrator stated he signed off all Accident/Incident Reports and when he signed them they did not always have staff statements or an investigation. In an interview on 2/7/2012 at 9:30 AM the DON stated in an she was newly hired by the facility, she was aware the facility was not completing thorough investigations of resident incidents, and had not gotten around to making any changes. On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed and they both stated the facility's incident reporting process changed and they were not sure where they could find thorough investigations of incidents. They stated investigations used to be attached to Accident/Incident Reports and no longer were. The Acting Administrator stated "whoever signs off" on the accident and incident reports should be ensuring they were complete. The Acting Administrator said the facility did not have a mechanism in place to ensure incident reports or investigations were completed for each incident. INJURIES OF UNKNOWN ORIGIN 2) Resident #4 had [DIAGNOSES REDACTED]. An 8/12/2012 nursing progress note documented the resident had [MEDICAL CONDITION] to the right ankle, pain, "grimacing" with standing, and an x-ray was ordered. The 8/12/2013 x-ray report documented the resident had a non-displaced [MEDICAL CONDITION] malleolus (ankle bone) and mild [MEDICAL CONDITION] changes in the ankle. At on 2/5/2013, the facility's investigation of the resident's fractured ankle was requested. The facility was not able to provide an Accident/Incident Report or an investigation. During an interview with the Acting and Supervising Administrators on 2/7/2013 at 12:05 PM, the Acting Administrator stated when the resident was found with a fracture of unknown origin, it should have been investigated and reported to the NYSDOH and was not. ELOPEMENT 3) Resident #3 had [DIAGNOSES REDACTED]. The 10/7/2012 Accident/Incident Report documented the resident went out to patio, attempted to get through gate and staff (certified nurse aide, CNA, #2) saw the resident from the window of a another resident's room. The corrective action was listed as "maintenance to check gate to make sure it is latched daily." Attached to the form was an unsigned staff statement documenting the staff person went to another resident's room to pick up a meal tray, looked out the window, and saw the resident walking "under the ramp outside." The report was signed as reviewed by the Administrator, the Director of Nursing (DON), the licensed practical nurse (LPN) Manager (LPN #1), the Medical Director, and the physical therapist. The report documented the incident was "unavoidable" and was not reported to the NYSDOH. During an interview with the Acting and Supervising Administrators on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Acting Administrator stated she was not aware of the resident's elopement until today as she did not sign accident and incident reports. The Supervising Administrator stated he signed the report and did not remember the incident. The Supervising Administrator stated the incident should have been reported to the NYSDOH. He stated he signed off on all incident reports and when he signed them they did not always include staff statements or investigations. On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed. They stated the facility's incident reporting process changed and they were not sure where they could find thorough investigations of resident incidents. The Acting Administrator stated "whoever signs off" on an accident/incident report should ensure the investigation was completed. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 2/12/2013 based on the following corrective actions taken by the facility: - revised the Accident and Incident Report form to include a thorough investigation of all allegations of abuse, neglect, and mistreatment; - trained the majority of staff members on abuse prevention and completing thorough investigations, the remaining staff would be trained before returning to duty; - revised policies and procedures to address post-fall practices; - revised the LPN job description to ensure assessments were conducted by qualified professionals. --------------------------------------------------------------------------------------------- EMPLOYEE SCREENING: 4) Per an undated list of new employees (Probationary Employee Listing): - Employee #1 was a registered nurse (RN) hired 11/30/2012; - Employee #2 was a licensed practical nurse hired 12/21/2012; - Employee #3 was an RN hired 11/15/2012; and - Employee #5 was a certified nurse aide (CNA) hired 1/21/2013. There was no documented evidence the license status of Employees #1, 2, and 3 was checked with the state education department. There was no documented evidence reference checks were done, as part of the hiring process, for Employees #1, 2, and 3. Per the Candidate Search Details (CNA registry check) dated 2/5/2013, the CNA registry check for Employee #5's status as a CNA was done on 2/5/2013. The Acting Administrator was interviewed on 1//6/2013 at 3 PM. She stated individual departments were responsible for screening their employees. The Director of Nursing (DON) was interviewed on 1/6/2013 at 3:05 PM. She stated she had not been involved in the recent hiring of nurses. She said she was not sure if the nursing department was responsible for screening new nursing employees. 10NYCRR 415.4(b)

Based on observation, record review, and staff interview conducted during the extended and abbreviated surveys (Complaint # NY 263, NY 297, and NY 387), it was determined for 11 of 13 residents reviewed for falls/fractures and/or injuries of unknown origin (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19), 1 of 1 resident reviewed for elopement (Resident #3), and 1 of 1 resident for unsafe smoking (Resident #23), the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, 19, and 23, the facility: - failed to assess the effectiveness of the residents' comprehensive care plan (CCP) after each accident; - failed to determine the root cause of all accidents; and - failed to notify the Director of Nursing, Acting Administrator, Supervising Administrator of all accidents. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, 19, and 22. The facility implemented corrective measures to remove the Immediate Jeopardy prior to survey exit on 2/12/2013. Findings include: SMOKING: 1) Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's hospital records included: - an admission history dated 1/11/2013, documented the resident was a smoker; - a history and physical note dated 1/13/2013 documented the resident smoked a pack of cigarettes a day for the past [AGE] years; - a social work progress note dated 1/15/2013 documented the resident's IQ was below 70; and - hospital discharge instructions/medication list dated 2/7/2013 documented the resident was on a Nicotrol inhaler while in the hospital. The resident's admission physician's orders [REDACTED]. The Director of Nursing's (DON) progress note the dated 2/8/2013 at 7:05 PM, documented she was called to the resident's unit due to the smell of smoke in the hallway because the resident tried to smoke in her room. The DON documented a certified nurse aide (CNA) noticed the "smoldering trash can," removed the resident from the room, called for assistance, and poured water over the trash can. The resident's room was searched and cigarettes and a lighter were found, and removed. The note recorded nurse practitioner (NP) was called who gave an order for [REDACTED]. The facility's Administrator was called and the resident was placed on hourly checks. The inventory of the resident's personal affects dated 2/8/2013 did not document cigarettes or a lighter were found with the resident's possessions at the time of admission. The sections where the form was to be signed by the CNA and Unit Manager were blank. The 2/8/2013 Incident Report included: - a statement from CNA #9 documented she noticed the hallway was "smokey," she observed the resident's "trash can was on fire," she went to the nurse's station to get the charge nurse, she removed the resident from the room, and she "helped contain the fire." - a statement from CNA #7 documented he observed a "couple of paper towels and plastic on fire in the trash can" and when the trash can did not fit under the faucet, he poured cups of water over the trash can. CNA #7's statement documented the trash can was "smoldering with a little bit of flames." - a statement from licensed practical nurse (LPN) #3 documented when she went to the room she observed a "small red glow" at the bottom of the trash can, she instructed a staff to pick the trash can up and place it under the faucet, and when the trash can did not fit under the faucet, they doused the "embers" with water. - an investigation summary and conclusion written by the Director of Nursing (DON) documented the resident was newly admitted to the facility and attempted to smoke in her room. Staff smelled smoke and found the garbage can "smoldering." Staff removed the resident and poured water on the garbage can. - The report documented the resident's comprehensive care plan (CCP) was updated. - The investigation was signed as reviewed by the DON and the current Administrator (hired on 2/8/2013). - There was no documented evidence the resident was interviewed. - The investigation: - did not address the resident's smoking status at the time of admission; - did not determine a reason for not providing the smoking cessation medication the resident received in the hospital; - did not determine how the resident was able to have smoking materials in her possession; and - did not address that facility staff did not follow the facility's fire procedure. On 2/9/2013 at 1:45 PM, the current Administrator stated in an interview, the resident was admitted to the facility on [DATE] around 3 PM. He stated the staff did not thoroughly check her belongings and were not aware she had smoking materials. He said staff smelled smoke and when they went to her room they realized she had thrown a cigarette in the trash can. The staff poured water on the trash can, did not pull the fire alarm, and put the fire out on their own. After the incident, three lighters and cigarettes were found in the resident's room. The resident's current undated CNA care instructions documented the resident was on 1 hour checks. The instructions did not document the resident's smoking incident, the fire, or the reason for 1 hour checks. The resident's undated Interim Plan of Care contained no documentation related to smoking or the fire. The comprehensive care plan (CCP) dated 2/9/2013 documented the "resident requires 1:1" and included activity preferences. The CCP contained no documentation of smoking history, the fire, or the reason for 1:1 supervision. A 2/9/2013 activities progress note written by the Acting Administrator documented the resident was "observed smoking in her room" and required 1:1 visits. On 2/11/2013 at 10:10 AM, the Acting Administrator stated in an interview, the facility reviewed hospital records prior to the resident being admitted and knew she used a Nicotine inhaler in the hospital. She stated since the resident did not smoke in the hospital from 1/11/2013 - 2/8/2013, she was a former smoker. She said the facility did not expect the hospital to send a resident to the facility with smoking materials. On 2/11/2013 at 10:10 AM, the resident stated in an interview, she smoked a pack of cigarettes a day since she was [AGE] years old. She stated she did not start the fire accidentally from trying to smoke, she lit tissues on fire on purpose, as she did not want to be in this nursing facility. On 2/11/2013 at 11:20 AM, the DON stated in an interview, she interviewed the resident as part of the investigation and the "resident wanted to smoke." She stated after the resident smoked in her room, she obtained a nicotine patch for her. She said she did not know why this was not done before the smoking/fire incident. On 2/11/2013 at 11:47 AM and 12:10 PM, the LPN Manager (LPN #2) stated in an interview, when the resident was admitted , she faxed the hospital discharge summary to the physician and the physician called her with the admission orders [REDACTED]. She stated she read all orders back to the physician over the phone. On 2/11/2013 at 2:05 PM, the Acting Administrator stated she wrote the resident's CCP on 2/9/2013 documenting the need for 1 hour checks. She stated she only wrote an "activities care plan" as her background was in activities and she would have expected nursing to write a CCP that addressed the resident's smoking history and the fire. The Acting Administrator stated she remembered the DON telling her right after the fire that the resident set the fire on purpose. She stated she did not know why this was not addressed in the resident's medical record or the facility's investigation. FALLS: 2) Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Fall Risk assessment dated [DATE] documented the resident was not at high risk for falls. The assessment documented "unable to verify" in the section for history of falls and the section assessing gait/balance was crossed out. Nursing progress notes documented: - on 11/26/2012, the resident was unable to participate in the admission assessment related to him "slapping out," having an inability to answer questions, biting the bed linens, and an "unstable condition;" - on 11/27/2012, the resident was "very shakey," "throwing himself around the bed." The nurse noted the bed was placed against the wall; and - on 11/29/2012, the resident was found standing in his room, tipped over the bed side table, and was shaky. The comprehensive care plan (CCP) dated on 11/30/2012, documented the resident was cognitively impaired due to Alzheimer's dementia and was at risk for falls. Interventions included educating the resident on safety awareness "as able;" reminding him to use the call bell; moving his room closer to the nurse's station "as indicated;" transferring him with a mechanical lift, and providing a semi-low bed against the wall. The nursing progress note dated 12/1/2012 at 1:45 AM, documented the resident was found on the floor next to his bed and sustained an open scab on the right foot, second toe. The Fall Risk Assessment, dated 12/1/2012, documented the resident was at high risk for falls. The CCP dated 12/1/2012, documented a protective alarm system (PAS) was applied. The physician's orders [REDACTED]. Nursing progress notes documented: - on 12/6/2012, the resident attempted to stand on his own and removed the PAS; - on 12/6/2012, the resident was "non-complaint" had the PAS alarm on and leaned forward in the chair, setting the alarm off; - on 12/7/2012, the resident was walking in the hall alone and had removed the PAS; - on 12/7/2012 and 12/9/2012, the resident was leaning forward in the chair; and - on 12/10/2012, the PAS rang frequently as resident leaned forward in chair. The CCP dated 12/12/2012, documented staff witnessed the resident slide out of his wheelchair and land on the foot pedals, sustaining an abrasion to the rib area. The resident was sent to the emergency room for evaluation and returned the same day. There was no documentation if the PAS was in place or sounding at that time. The 12/15/2012 and 12/16/2012 nursing progress notes documented the resident removed the PAS many times. A physician's note, dated 12/18/2012, documented the resident had a recent fall which was "most likely multifactorial but primarily due to lack of safety awareness." The resident was to continue on fall precaution and he was "advised on fall prevention." The CCP documented on 12/22/2012, the resident was found kneeling on the floor. There was no documented change to the planned interventions or rationale for continuing the same plan. Nursing progress notes documented: - on 1/3/2013, the resident could not use a call bell related to confusion; - on 1/6/2013, the resident attempted to self-transfer; and - on 1/7/2013, the resident could not use a call bell, slid to his knees and laid down on the floor. The nursing notes did not document the use of a PAS on these dates. The CCP dated 1/7/2013, documented the resident's body was stiff and rigid due to his Parkinson's disease and he was totally dependent on staff for bed mobility. The plan included the use of 1/2 side rails in bed to aide in bed mobility and to use a PAS. Nursing progress notes documented on 1/8/2013, the resident was found lying on the floor near the bed and the PAS was sounding. The resident's CCP was updated to include the falls and did not document changes to the planned interventions or a rationale for continuing the same plan. A physician's progress note, dated 1/8/2013, documented the resident "apparently had two falls since last night." The physician documented the falls were "most likely multifactorial but primarily due to lack of safety awareness." The resident was to continue on fall precautions. The note did not document specific fall precautions for the resident. The Minimum Data Set (MDS) assessment, dated 1/15/2013, documented the resident was cognitively moderately impaired and required total dependence for most activities of daily living (ADL). The MDS recorded the resident did not have any falls since the admission assessment, and the resident did not use restraints. Nursing progress notes documented: - on 1/18/2013, the alarm sounded and the resident was found on floor on his knees, near the bed; - on 1/19/2013, the resident was observed self-transferring with the alarm sounding; - on 1/25/2013, the resident was observed walking down hall unassisted and had removed the PAS; and - on 2/1/2013, the resident fell forward from the wheelchair at 2 AM, there was no documentation if the PAS was in place or sounding. The RN Supervisor stated in an interview on 2/5/2013 at 10:25 AM, the resident fell frequently. The resident was observed on 2/6/2013 at 10:14 AM. He was lying in bed with one end of the PAS attached to his shirt and the box of the PAS resting on the bed unsecured. The resident's bed was against the wall and both 1/2 side rails were in the up position. On 2/6/2013 at 11:15 AM, CNA #4 stated in an interview, the resident used a PAS at all times and 2 side rails when he was in bed. She stated when he was first admitted , he rolled out of bed, and the side rails were started at that time. She stated when she applied a PAS to a resident in bed, she clipped one end to the resident's shirt and clipped the box to the bed sheet. On 2/6/2013 at 11:25 AM, CNA #3 stated in an interview, when a resident was in bed, she clipped the PAS to their shirt and laid the box on the bed. She stated the resident was to use the PAS and side rails when he was in bed. Observations of the resident included: - on 2/6/2013 at 9:50 AM, he was lying in bed, the bed was against the wall, and both half side rails were in the up position; - on 2/6/2013 at 10:55 AM, the resident was sitting on the side of the bed with his feet on the floor and the PAS was not sounding. As the resident moved around and tried to stand, the PAS sounded, and staff responded. - on 2/6/2013 at 3 PM, the resident was in bed with both side rails up, the PAS was clipped to the resident's shirt and the box was attached to the pillow case; and - on 2/6/2013 at 3:20 PM, the resident was standing up trying to put his pants on. The PAS was clipped to his shirt and the box was on the bed, and the PAS was not sounding. On 2/6/2013 at 5:10 PM, LPN #1 stated in an interview, admission fall risk assessments were done by the RN Supervisor or Director of Nursing (DON). She stated therapy provided all fall prevention interventions at the time of admission. She stated the Supervisor or DON were responsible for completing the initial CCP and implementing fall prevention interventions at the time of admission. She stated after admission, if a resident fell , whoever completed the accident and incident report was responsible for implementing changes to the CCPs as needed. On 2/7/2013 at 8:50 AM, the physical therapist stated in an interview, he would expect a referral if a resident removed their PAS repeatedly. He stated if that was occurring, staff should also position the PAS in a place where the resident could not access it. He stated when the PAS was used in bed, it was clipped to the resident's shirt and the box was to be secured to a fixed object, such as the head board. He stated he was not aware the PAS alarms were not being applied properly. He stated he recommended the side rails for the resident for fall prevention as they "reduce risk significantly," "protects" residents, and "keeps them in bed." He stated the facility discussed resident falls 3 times a week at morning meeting and this resident should be discussed as he fell frequently. The therapist stated nursing discussed the resident with him when he was on the nursing unit. On 2/7/2013 at 9:40 AM, LPN #2 stated in an interview, the resident was to wear a PAS at all times. She stated the team met weekly on Tuesdays to discuss falls and interventions. On 2/7/2013 at 9:40 AM, the DON stated she was responsible for updating CCPs after falls and she was trying to delegate that to the Supervisors as she was having difficulty keeping up with them. On 2/7/2013 at 1:40 PM, CNA #11 stated in an interview, when a PAS was used, she clipped the PAS to the resident's clothing and secured the box to the bottom sheet or pillows. She stated she was not instructed on how to apply the PAS properly. On 2/7/2013 at 2:22 PM, the resident was sitting in the wheelchair. The PAS was secured to the back of the wheelchair and it was not clipped to the resident's clothing. On 2/12/2013 at 12:20 PM, the resident was sitting in the wheelchair. The PAS was secured to the back of the wheelchair and it was not clipped to the resident's clothing. ELOPEMENT 3) Resident #3 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 9/26/2012 documented the resident had cognitive deficits with an expected continued decline, was visually impaired, able to see large print only, had trouble finding the correct word when speaking, was at high risk for falls, and wore a Wanderguard (a device to detect wandering) bracelet. The 9/26/2012 Wandering Risk Assessment documented the resident was cognitively impaired with poor decision making skills, ambulated independently without assistance devices, had visual or auditory deficits, and had a history of [REDACTED]. The 9/26/2012 social services progress note documented the resident was very confused, had advanced dementia, and rarely articulated a sentence or responded appropriately. The 10/7/2012 Director of Nursing (DON) progress note documented at 8:50 AM, the resident went out the patio door and was seen opening the gate. A staff member noticed the resident through the window and the resident was easily re-directed back into the facility. The 10/7/2012 Accident/Incident Report documented the resident went out to patio, attempted to get through the gate and certified nurse aide (CNA) #2 saw the resident from the window of a another resident's room. The corrective action was listed as "maintenance to check gate to make sure it is latched daily." Attached to the form was an unsigned staff statement documenting the staff person was in another resident's room picking up a meal tray and saw the resident out the window walking "under the ramp." The report was signed by the Supervising Administrator, the Director of Nursing (DON), the licensed practical nurse (LPN) Manager (LPN #1), the Medical Director, and the physical therapist. The CCP dated 12/18/2012 documented the resident continued with a Wanderguard bracelet. During an interview with LPN #1 on 2/5/2013 at 10:00 AM, she stated the resident wore a Wanderguard and had an incident where he went out the patio door unsupervised. She stated the gate off the patio was left open, the resident exited the gate, walked under the ramp outside, and was seen walking outside by a staff member who was in another resident's room providing care. She stated she did not know how long the resident was outside. During an interview with LPN #1 on 2/6/2013 at 11 AM, she stated since the resident eloped in October of 2012, maintenance checked the patio gate to ensure it was latched. During an interview with a maintenance staff person on 2/6/2013 at 11:10 AM, he stated the gate off the patio had a lock and they were not allowed to lock it. He stated he was not told to check that the gate was latched, he did not keep a log that the gate was latched, and he did not routinely check the gate. During an interview with the DON on 2/6/2013 at 12:50 PM, she stated she was aware there was not a Wanderguard mechanism on the patio doors and residents with Wanderguards should not go out to the patio by themselves. She stated all residents were checked every 2 hours. She stated the resident's CCP was not changed to prevent reoccurrence because the resident currently relied more on a wheelchair for mobility. During an interview with the Acting Administrator and Supervising Administrator on 2/6/2013 at 1:40 PM, the Acting Administrator stated she was not aware of the resident's elopement until today. The Supervising Administrator stated he signed the accident/incident report and did not remember the incident. They stated residents with Wanderguard bracelets were allowed to go outside to the patio alone as it was a "resident common area." They stated the patio doors did not have Wanderguard alarms on them and there was no policy addressing the use of the patio by residents. The Acting Administrator stated if LPN #1 wrote on the accident and incident report that maintenance was going to check that the gate was latched every day, then LPN #1 should have followed-up with maintenance to ensure this was implemented. The DON stated in an interview on 2/7/2013 at 9:35 AM, she was responsible for updating residents' CCPs following any type of incident. She said she was trying to delegate some of that to the Supervisors. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 2/12/2013 based on the following corrective actions taken by the facility: - revised the Falls policy and Post Falls policy to include evaluating CCPs for effectiveness and revising interventions as needed and trained staff regarding the new policies. - revised the Smoking and Fire Prevention policies to include educating newly admitted residents with a history of smoking of the smoke free status of the facility and with their permission inspect their personal belongings to ensure there are no smoking materials and trained staff regarding the revised policies. - revised and updated Resident #23's CCP to include a history of smoking, and the fire incident, and trained staff regarding these changes. - revised the Elopement policy to include resident's with Wanderguards not being allowed to exit the building to the patio unsupervised and trained staff on the revised policy. - all staff will be trained before returning to duty. 10NYCRR 415.12 (h)(1)(2)

Based on record review and staff interview conducted during the extended and abbreviated surveys (Complaint #NY 297, NY 263, and NY 387), it was determined for 11 of 13 residents (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19), reviewed for falls/fractures and/or injuries of unknown origin, for 1 of 1 resident (Resident #3), reviewed for elopement and for 1 of 1 resident (Resident #23), reviewed for unsafe smoking the facility failed to ensure Administrative staff administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the Administrator failed to ensure thorough investigations were completed for accidents and incidents; failed to ensure care plans were reviewed for effectiveness after each incident; failed to ensure the root cause of incidents was determined, and failed to report incidents when required to the New York State Department of Health (NYSDOH). Refer to F225, F226, and F323. This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, 19, and 23. Findings include: During an interview with the Acting and Supervising Administrators on 2/6/2013 at 1:40 PM, they stated they were both able to report incidents to the NYSDOH. The Supervising Administrator stated he signed off on all Accident/Incident Reports and when he signed them they did not always have staff statements or investigations attached. The Acting Administrator stated she did not review or sign off on all Accident/Incident Reports and was notified of resident incidents from 24 hour report or in the team meeting which was held three times a week. During an interview with the Director of Nursing (DON) on 2/7/2012 at 9:35 AM she stated she was newly hired at the facility, she was aware the facility was not completing thorough investigations of resident incidents, and had not gotten around to making any changes. On 2/7/2013 at 12:05 PM, the Supervising and Acting Administrators were interviewed a second time. They both stated the facility's incident reporting process changed and they were not sure where they could find thorough investigations of resident incidents. They stated investigations used to be attached to Accident/Incident Reports and no longer were. The Acting Administrator stated "whoever signs off" on the accident/incident reports should be ensuring they were completed. The Acting Administrator stated the facility did not have a mechanism in place to ensure incident reports or investigations were completed for each resident incident, including injuries of unknown origin. On 2/9/2013 at 1:45 PM, the current Administrator stated in an interview, Resident #23 was admitted to the facility on [DATE] around 3 PM. He stated the staff did not thoroughly check her belongings and were not aware she had smoking materials. He said staff smelled smoke and when they went to her room they realized she had thrown a cigarette in the trash can. The staff poured water on the trash can, did not pull the fire alarm, and put the fire out on their own. After the incident, three lighters and cigarettes were found in the resident's room. On 2/11/2013 at 2:05 PM, the Acting Administrator stated she wrote Resident #23's comprehensive care plan (CCP) on 2/9/2013 documenting the need for 1 hour checks. She stated she only wrote an "activities care plan" as her background was in activities and she expected nursing to write a CCP that addressed the resident's smoking history and the fire. The Acting Administrator stated she remembered the DON telling her right after the fire that the resident set the fire on purpose. She stated she did not know why this was not addressed in the resident's medical record or the facility's investigation. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 2/12/2013 based on the following corrective actions taken by the facility: - revised the Accident and Incident Report form to include a thorough investigation of all allegations of abuse, neglect, and mistreatment, and of accidents; - trained the majority of staff members on abuse prevention and how to complete thorough investigations, remaining staff will be trained before returning to duty; - revised policies and procedures to address post-fall practices; - revised the LPN job description to ensure that assessments were completed by qualified professionals. 10NYCRR 415.26

Based on record review and staff interview conducted during the extended and abbreviated surveys (Complaint #NY 297, NY 263, and NY 387), it was determined for 11 of 13 residents (Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, and 19), reviewed for falls/fractures and/or injuries of unknown origin, for 1 of 1 resident (Resident #3), reviewed for elopement and 1 of 1 resident (Resident #23), reviewed for unsafe smoking the facility's quality assurance (QA) committee failed to identify significant concerns with accident and abuse investigations. Specifically, the facility's QA committee failed to identify concerns with the investigation process as thorough investigations were not completed; failed to identify concerns with the effectiveness of residents' care plans in preventing incidents/accidents, and failed to identify which incidents, accidents, or injuries of unknown origin were required to be reported to the New York State Department of Health (NYSDOH). Refer to F225, F226, and F323. This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of Residents #1, 3, 4, 5, 6, 8, 10, 11, 15, 18, 19, and 23. Findings include: During the entrance interview on 2/5/2013 at 9:50 AM, the Acting Administrator stated herself and the Director of Nursing (DON) were the Quality Assurance (QA) coordinators. During an interview with the DON on 2/7/2013 at 9:40 AM, she stated the Acting Administrator was in charge of QA. The DON stated she missed the last QA meeting. The DON said she did not know if the facility was auditing or reviewing resident falls or injuries of unknown origin. The DON stated she was aware the facility was not completing thorough investigations of resident incidents and since she was newly hired, she was not yet able to implement changes. During an interview with the Acting Administrator on 2/7/2013 at 12:05 PM, she stated the facility did not have a mechanism in place to ensure incident reports or investigations were completed. She stated this could only be caught if the facility conducted chart audits and compared the chart audits to the accident/incident reports, and she stated they did not do that. The Acting Administrator was interviewed on 2/8/2013 at 9:30 AM and stated audits conducted in regards to accident and incident reports included whether or not the accident and incident reports were signed by the Supervising Administrator and physician and- whether there was a change in physician's orders [REDACTED]. She stated the facility did not audit or review whether thorough investigations were completed following incidents. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ The Immediate Jeopardy situation was removed prior to survey exit on 2/12/2013 based on the following corrective actions taken by the facility: - revised the Accident and Incident Report form to include a thorough investigation of all allegations of abuse, neglect, and mistreatment; - trained majority of staff members on abuse prevention and how to complete thorough investigations, remaining staff will be trained before returning to duty; - revised policies and procedures to address post-fall practices; and - revised the LPN job description to ensure assessments were completed by qualified professionals. 10NYCRR 415.27(a-c)

Based on record review, observation, and interview with staff and residents conducted during the standard survey, it was determined for 4 of 4 residents (Residents #8, 10, 11, and 13), reviewed for pressure ulcers, the facility did not ensure a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically, for Resident #8 the facility - did not monitor and assess pressure ulcers regularly; - did not observe the resident's skin integrity regularly to ensure pressure ulcers were identified timely; and - did not ensure the resident's 3 Stage II pressure ulcers received appropriate treatment; For Resident #13, the facility: - did not monitor and assess pressure ulcers regularly; - did not observe the resident's skin integrity regularly to ensure pressure ulcers were identified timely, and - did not ensure the plan of care was revised when needed to prevent the progression of pressure ulcers. For Residents #10 and 11, the facility - did not ensure a comprehensive plan of care was developed and implemented for pressure ulcer prevention and - did not ensure the resident's skin was monitored regularly to identify pressure ulcers timely. This resulted in actual harm, multiple Stage II pressure ulcers, for Residents #8 and 13 and no actual harm with the potential for more than minimal harm that is not immediate jeopardy for Residents #10 and 11. Findings include: 1) Resident #8 had [DIAGNOSES REDACTED]. The nursing note dated 12/24/12 documented the resident had an open area on the coccyx and Allevyn (a type of dressing was applied) The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, required extensive assistance with bed mobility, total dependence with toileting, personal hygiene, and bathing, was frequently incontinent of bladder and bowel, and had unhealed pressure ulcers. The Pressure Ulcer Risk Assessment Tool dated 12/25/2012 documented the resident was at high risk for developing pressure ulcers. The Pressure Ulcer Record (Weekly Pressure Ulcer Assessment) dated 12/25/2012 documented the resident had a Stage II pressure ulcer on the right buttock/sacrum area which measured 2 centimeter (cm) x 3 cm, and an unstageable pressure ulcer on the left buttock which measured 7 cm x 8 cm. A nurse practitioner (NP) order dated 12/25/2012 documented to cleanse both pressure ulcers with wound cleanser, pat dry, apply Allevyn border (a dressing), and change every 3 days and prn (as needed) when soiled. On 1/2/2013 the resident's Pressure Ulcer Record documented there was improvement to the pressure ulcers, and the treatment was changed to periguard ointment (a skin protectant). The Nurse Practitioner (NP) orders dated 1/2/13 documented the resident was to have periguard ointment applied to the buttocks and inner groin area every shift for 14 days. The MDS dated [DATE] documented the resident was at risk for developing pressure ulcers, had 2 Stage I pressure ulcers and 3 Stage II pressure ulcers. The MDS recorded the resident had pressure relieving devices for the chair and bed. The Comprehensive Care Plan (CCP) dated 1/9/2013 documented the resident had pressure ulcers on the buttocks and sacrum. Interventions included to provide treatment as ordered, monitor status on weekly skin rounds and prn, and notify the physician/NP of progress and the need to change treatment as needed. The CCP documented the resident was frequently incontinent of bowel and bladder, required extensive assistance with mobility, transfer, locomotion, dressing, personal hygiene, toileting, and bathing. The CCP did not document the use of pressure relieving devices for the resident's bed or chair. The Pressure Ulcer Record dated 1/16/2013 documented two pressure ulcers on the resident's left buttock, one measured 1 cm x 1 cm, and the second measured 2 cm x 1 cm. The pressure ulcer on the resident's right buttock/sacrum area was resolved. There was no documented evidence, in the resident's medical record, the pressure ulcers on the resident's left buttock were assessed after 1/16/2013. The 1/2013 treatment administration record (TAR) documented periguard ointment was applied, as ordered, to the resident's buttocks from 1/5/2013 - 1/31/2013. The certified nurse aide (CNA) accountability record dated 2/2013 did not document the use of pressure relieving devices for the resident's bed or chair. On 2/5/2013 at 10:20 AM, the resident stated to the surveyor he had "two big sores" on his hips and "no one does anything for them." He stated staff applied cream "once in a while." On 2/5/2013 at 10:25 AM, licensed practical nurse (LPN) #2 stated the resident had an allergic reaction to the disposable briefs. She said periguard was used on the residents buttocks. LPN #2 stated there were no resident's with pressure ulcers residing on the unit. On 2/7/2013 at 9:40 AM, the resident stated to the surveyor he had pain in his buttocks. Upon observation, (at that time) the resident had two open areas on his left buttock, both measured approximately 1 cm x 0.5 cm, and one open area on his right buttock, which measured approximately 2 cm x 1 cm. The wound beds were pink with no drainage or odor. On 2/8/2013 at 10:40 AM, the surveyor observed the Director of Nursing (DON) and NP assess and provide wound care treatment to the resident's open areas. The DON stated both open areas on the left buttock were Stage II pressure ulcers measuring 1 cm x 0.3 cm. The DON said the resident had a Stage II pressure ulcer on the right buttock measuring 2 cm x 1.5 cm. When interviewed on 2/8/2013 at 10:43 AM, the DON stated pressure ulcer assessments were performed weekly by herself or the registered nurse (RN) Supervisor. She stated she had not yet developed a schedule to determine who was responsible for skin/wound rounds. When interviewed on 2/8/2013 at 10:45 AM, the LPN #2 stated she did not see any pressures ulcers on this resident two days ago when she applied periguard ointment to his buttocks. An NP order dated 2/8/2013 documented the resident was to receive a compound of Balmex/[MEDICATION NAME]/[MEDICATION NAME] Butyrate (topical ointment to promote healing) to the buttocks and coccyx each shift. When interviewed on 2/11/2013 at 11:15 AM, the DON stated any open areas or issues with resident skin would be reported initially to an LPN. The LPN would then contact the RN Supervisor or DON, and the physician or NP for a treatment order. When interviewed on 2/11/2013 at 1:30 PM, Certified Nurse Assistant (CNA) #7 stated he was aware this resident had pressure ulcers, was not sure if the resident's pressure ulcers developed in the facility or not, and did not know how they developed. When interviewed on 2/11/2013 at 1:40 PM, CNA #6 stated she was aware the resident had pressure ulcers. She said he came to the facility, from the hospital with pressure ulcers because of his refusal of care. She stated the resident would not stay off his back even though he was encouraged to. When interviewed on 2/11/2013 at 2:20 PM, LPN #6 stated the resident was originally on the first floor unit and when he was transferred to the current unit, he had the pressure ulcers. She stated the pressures ulcers may have developed from shearing, he tends to stay in bed and at times he slides across the incontinence pad and his pants get twisted. When interviewed on 2/11/2013 at 3:35 PM, LPN #2 stated any problems related to residents' skin were reported to her. She and a CNA examined 8 residents' skin every Monday through Friday and if any issue was found, it was reported to the RN Supervisor or DON who would assess the area. She stated she did not keep documentation of these skin checks. She stated she would contact the NP or physician for treatment orders. Skin/wound rounds were performed on Tuesdays by the physician and wounds/pressure ulcers were tracked on a wound tracking sheet kept in the residents' chart. She stated she told the physician which residents to assess and did this by giving him the pressure ulcer record from each medical record. When interviewed on 2/12/2013 at 10:30 AM, the Acting Administrator, who was the quality assurance (QA) coordinator, stated to her knowledge, skin checks were done weekly on bath days by RNs or by the NP with the LPN Nurse Managers. She did not know if this was documented. She stated QA audits included positioning, preventative devices, and whether residents with skin breakdown had interventions or orders. The 2/2013 TAR documented periguard ointment was applied to the resident's buttocks from 2/1/2013 - 2/11/2013. Balmex/[MEDICATION NAME]/[MEDICATION NAME] Butyrate was applied to the resident's buttocks/coccyx from 2/8/2013 - 2/10/2013. 2) Resident #13 had a [DIAGNOSES REDACTED]. The Resident Status Sheet (care instructions) dated 10/28/2012 documented the resident was to be turned and repositioned every 2 hours. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, required total dependence with bed mobility, toileting, personal hygiene and bathing, and was always incontinent of bladder and bowel. The resident had pressure reducing devices for the bed and chair and was on a turning and repositioning program. The comprehensive care plan (CCP) dated 12/19/2012 documented the resident had fragile skin with potential for skin breakdown, and was incontinent of bowel and bladder. Interventions included inspect the skin with morning care, evening care and bathing, provide incontinence care every 2 - 4 hours and prn (as needed), and provide preventative skin care after each incontinent episode. The CCP did not document the use of pressure relieving devices. The Pressure Ulcer Risk Assessment Tool dated 12/19/2012 documented the resident was at moderate risk for pressure ulcer development. The treatment administration record (TAR) documented the resident received [MEDICATION NAME] ointment (skin barrier) to his buttocks every shift from the 12/23/2012 day shift through the 1/6/2013 day shift. The Pressure Ulcer Record (Weekly Pressure Ulcer Assessment) dated 12/31/2012 documented a Stage II abrasion to the resident's sacrum/buttocks area which measured 0.5 centimeters (cm) x 0.5 cm, and to monitor response to [MEDICATION NAME] (a type of dressing) treatment. The nursing note dated 12/31/2012 documented the resident developed a small open area on the sacrum/coccyx. The CCP updated 12/31/2012 documented the resident had a Stage II pressure ulcer. The location of the pressure ulcer was not identified. An intervention was to apply [MEDICATION NAME] dressing as ordered, change every three days and prn. There was no documented physician or nurse practitioner (NP) order to treat the resident's pressure ulcer with a [MEDICATION NAME] dressing (as in the care plan) until 1/3/2013. An NP order and progress note dated 1/3/2013 documented the resident was to receive Allevyn (a type of dressing) to the coccyx (sacrum/buttocks area) and to change the dressing every 72 hours and prn. The open area was documented as a Stage III pressure ulcer which measured 1.0 cm x 1.5 cm. No other documentation in the resident's medical record described this open area as a Stage III. The resident's Pressure Ulcer Record dated - 1/6/2013 documented "open abrasions noted to sacrum and buttocks"; - 1/13/2013, the record documented "treatment continues with Allevyn to small open abrasions"; and - 1/20/2013, documented "continues with current treatment to abrasions, Allevyn dressings." The resident's Pressure Ulcer Record dated 1/6/2013, 1/13/2013, and 1/20/2013 did not document the stage or size of the pressure ulcer on the resident's sacrum/buttocks. The Pressure Ulcer Record and a registered nurse progress note dated 1/25/2013 documented: - three Stage II open areas to the posterior left thigh which were caused by scratching; - a Stage II open area to the right buttock which measured 1.0 cm x 0.5 cm x 0.3 cm; and - a Stage II open area to the coccyx which measured 0.5 cm x 0.5 cm x 0.3 cm. The RN did not stage the pressure ulcers, with depth, as Stage III. There was no further documentation on the Pressure Ulcer Record regarding these ulcers. There was no documented evidence the CCP was updated. An NP progress note dated 1/25/2013 documented the resident had three Stage II open areas on his posterior left thigh area, one Stage II open area on his right buttock, and one Stage II open area on his coccyx. An NP order dated 1/25/2013 documented the resident was to receive wound gel (medicated gel to treat wounds) to all open areas on buttocks, A&D ointment to the surrounding tissue and cover with a [MEDICATION NAME] (non-stick) dressing, change daily and prn. The resident's Treatment Administration Record (TAR) documented an Allevyn dressing was applied to the resident's coccyx every 72 hours from 1/4/2013 - 1/25/2013; and wound gel was applied to the open areas on the resident's buttocks, A&D to the surrounding tissue, and covered with a [MEDICATION NAME] dressing daily from 1/26/2013 - 2/10/13. A nursing progress note dated 2/6/2013 documented an open area on the resident's right outer heel which measured 1.2 cm x 1 cm. After the development of the open areas, there was no documented evidence the CCP was updated, a cause was determined, or a plan implemented to prevent worsening. On 2/7/2013 between 5:45 PM - 6:40 PM the resident was observed in his geri-chair being fed supper and sitting in his room. When interviewed on 2/8/2013 at 9:30 AM, the registered nurse (RN) Supervisor stated all pressure ulcer assessments were completed by herself or the Director of Nursing (DON). She stated they had not developed a system to determine who specifically performed the assessments. When interviewed on 2/8/2013 at 10:43 AM, the Director of Nursing (DON) stated pressure wound assessments were performed weekly by either herself or the RN Supervisor. She stated she had not yet developed a schedule to determine who was responsible for skin rounds. On 2/11/2013 at 10 AM, the surveyor observed the resident's incontinence care provided by two certified nurse assistants (CNA) #6 and #14. The resident's brief was wet and he had been incontinent of stool. After the resident was cleansed there were no open areas or skin breakdown visible, specifically on the coccyx or sacrum. There was a dressing observed on the resident's right buttock and a dressing on the right heel. On 2/11/2013 at 10:45 AM, the surveyor observed the DON and NP provide wound treatment to the right buttock and right heel. -The right buttock had a pressure ulcer which was rectangular in shape, approximately 4 cm x 3 cm, 100% red, moist with no drainage, and no odor. - The right heel had a pressure ulcer which was round in shape, approximately 2 cm x 2 cm, and 100% slough (soft, moist, dead tissue). The NP stated, to the surveyor, the heel pressure ulcer was a Stage II, and there was maceration (softening of skin) around the ulcer. The Pressure Ulcer Record dated 2/11/2013 documented the coccyx/sacrum (surveyor observed as right buttock) pressure ulcer was Stage II, 4 cm x 3.2 cm, 100% red, and "resident has old areas of previous healed ulcers on buttocks and sacrum, fragile skin." There was no further progress note or assessment of the pressure ulcer from 1/25/2013 - 2/11/2013. (On 1/25/2013, this pressure ulcer measured 1.0 cm x 0.5 cm x 0.3 cm). When interviewed on 2/11/2013 at 11:15 AM, the DON stated any open areas or issues with resident skin would be reported initially to the Licensed Practical Nurse (LPN). The LPN would then contact the RN Supervisor or DON. The LPN would also contact the physician or NP. When interviewed on 2/11/2013 at 1:30 PM, CNA #7 stated he was aware this resident had pressure ulcers, was incontinent and could not move on his own, and staff had difficulty repositioning him in his recliner chair. When interviewed on 2/11/2013 at 1:40 PM, CNA #6 stated she was aware this resident had pressure ulcers and that he developed them in the facility. She was not sure if they were healing or not. When interviewed on 2/11/2013 at 2:20 PM, the LPN #6 stated the resident did not have the pressure ulcers very long. She didn't think the resident's nutrition was as good as it used to be and that it was difficult to turn and reposition him when he was in his recliner chair. 3) Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. The Pressure Ulcer Risk Assessment Tool dated 12/10/2012 documented the resident was at risk for developing pressure ulcers. The comprehensive care plan dated 12/18/12 documented the resident had [MEDICAL CONDITION] with potential for pain and skin breakdown. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired, he was dependent on staff for most activities of daily living (ADLs), was at risk for pressure ulcers, did not have a current pressure ulcer, and used a pressure relieving device in the bed and chair. The CCP dated 1/2/13, documented the resident developed an ulcer on the left heel, which was documented as healed on 1/10/13. There was no documentation, in the CCP of preventative interventions for the resident's heels. On 2/5/2013 at 10 AM, licensed practical nurse (LPN) Manager #1 stated in an interview, the resident did not have a pressure ulcer. The Resident Status Sheet (CNA care instructions) dated 2/7/13 documented the resident was to wear heel protectors at night. The 2/2013 Nursing Assistant Clinical Accountability Record used by the certified nurses aides (CNA), had no documentation of interventions used for pressure ulcer prevention. The resident was observed on 2/8/13 at 9:55 AM sitting in a wheelchair near the nurses station wearing his shoes and socks. At 11:05 AM the surveyor saw a gauze dressing on the resident's left lower leg. The registered nurse (RN) Supervisor stated she did not know the reason for gauze dressing. On 2/8/13 at 12:10 PM, a surveyor and the RN Supervisor observed the resident's skin: - left heel unstageable pressure ulcer measuring 2 cm x 2 cm with "gray spongy" eschar (dead tissue) measuring 1 cm x 0.7 cm in the center; and - right foot Stage I measuring 3 cm x 3 cm with the center brown measuring 0.6 cm x 0.2 cm; - the gauze wrap and dressing were removed from the left lower leg, there was green drainage noted halfway up the left leg. The RN Supervisor stated the dressing must have been over the resident's left heel ulcer and had fallen off. She stated the resident's plan included heel protectors and he should be wearing them. On 2/8/2013, the nurse practitioner (NP) ordered skin prep to the resident's left heel every shift for an unstageable pressure ulcer. On 2/11/2013 at 8:55 AM CNA #12 stated in an interview, if she saw an issue with a resident's skin she would go to the charge nurse. She stated to her knowledge, routine skin checks were not done on all residents. On 2/11/2013 at 9 AM, CNA #7 stated in an interview, he looked at residents' skin every 2 hours when he provided care and let the nurse know if there was a concern. On 2/11/2013 at 9:05 AM, LPN #5 stated in an interview the charge nurse checked 8 residents' skin each day Monday through Friday. She stated none of these skin checks were documented. 10NYCRR 415.12(c)(1)(2)