Every finding on record at Premier Genesee Center for NRSG and Rehabilitation

Based on observation, record review and interviews during survey, the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents/hazards for one (Resident #1) of three residents reviewed for accidents. Specifically, on 05/01/2026, Resident #1 who had documented cognitive impairments, exit seeking and wandering behaviors, exited the facility undetected by staff approximately three hours after their admission to the facility. This resulted in no actual harm that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury or death to Resident #1's health and safety.The findings include: The facility policy and procedure titled Elopement Prevention dated 07/22/2025 documented the facility strives to provide an environment that is free from hazards over which the facility has control and provide supervision and assistance to each resident to prevent avoidable accidents. The facility strives to reduce the risks for elopement while optimizing residents' independence to safely attain or maintain their highest practicable physical, mental and psychosocial well-being. The facility will strive to identify residents at risk for unsafe wandering and exit seeking behavior. Assess the security of potential internal environmental hazards including but not limited to the following: elevators, exit doors, screens, stairwells, windows. Maintain door alarms and wander control systems in proper working order according to manufacturer's recommendation. Some systems track transmitter replacement manually. There are various types of electronic monitoring devices available for use in Long Term Care. The facility will follow the manufacturers' guidelines related to use, batteries, expiration dates, etc. (et cetera), based on the electronic monitoring device used on the facility. Elopement represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or medical complications, drowning, or being struck by a motor vehicle. The undated manufacturers User Manual version 2.5 provided by the facility on 05/21/2026 documented no security system can replace human vigilance. Creating a safe environment requires the combined efforts of nursing, physicians, security, and patients. No level of security can replace an informed and knowledgeable staff. Any electronic or physical security system should be considered as a supplemental deterrent. Tags (small wristwatch-sized devices worn by a resident which will activate the wander alert system) operate by internal battery and contain a visual pulse LED (light emitting diode) when activated. Over the course of normal operation, tags eventually lose battery power, and the tags will need to be replaced. The tag battery is not replaceable. For maximum protection of residents, the manufacturer recommends that tags be tested on a weekly basis. All tags are reusable but must be cleaned and sanitized between applications. To preserve battery life, tags must be turned off during storage or periods of non-use. Resident #1 had diagnoses that included dementia (a pattern of mental decline caused by different diseases or conditions), hypertension (high blood pressure) and osteoarthritis (cartilage that cushions the ends of bones in the joints gradually wears away). The hospital Discharge summary dated [DATE] documented Resident #1 was alert and oriented to self only. Review of video footage dated 05/01/2026 between 4:50 PM and 4:51 PM, provided by the facility on 05/19/2026 at 10:10 AM, revealed Resident #1 was observed to walk to the double glass doors on the unit, look out the glass doors, turn around, and continued to walk on the unit without any facility staff present. The Progress Note signed and dated 05/01/2026 at 3:16 PM by Licensed Practical Nurse #1 (Nursing Supervisor), documented Resident #1 was admitted to the facility on [DATE] around 2:00 PM. The Exit seeking/Elopement/Wandering evaluation, signed and dated 05/01/2026 by Licensed Practical Nurse #2, documented Resident #1 was physically able to move about on their own; was disoriented to place; was exhibiting restlessness or agitation; had verbally expressed the desire to go home, packed belongings to go home or stayed near the exit door; had a history of elopement at home; and was at high risk for elopement. The Progress Note signed and dated 05/01/2026 at 9:26 PM by Licensed Practical Nurse #2 documented Resident #1 was socializing with staff and peers in the common area on the unit, then staff realized at approximately 5:15 PM that the resident was no longer in the area. Extensive search ensued. Supervisor updated and call to all staff made via intercom to join search. Resident had exhibited wandering behavior, made several statements to various staff that I have to get going, and repeatedly asked what time they were being picked up. Gentle reminders that they will be staying at the facility for now and attempts to redirect resident and engage in solo and group activities. They were also given many snacks and drinks. Wander alert device placed on resident's left wrist at 4:30 PM for safety. During an interview on 05/19/2026 at 12:48 PM, Licensed Practical Nurse #1 stated they were working as the nursing supervisor on 05/01/2026 when Licensed Practical Nurse #2 requested a wander alert device for Resident #1. Licensed Practical Nurse #1 removed a wander alert device from the box, saw the red-light blinking, which indicated the device was activated and gave the device to Certified Nurse Aide #1 to take to Licensed Practical Nurse #2 for Resident #1. During a telephone interview on 05/19/2026 at 2:43 PM, Certified Nurse Aide #1 stated they retrieved the wander alert device from the nursing supervisor on 05/01/2026 to take to Licensed Practical Nurse #2. They stated they did not recall any audible alarms or resetting alarms when they entered/exited the elevator nor the unit, but they were unsure if they would specifically remember that secondary to frequently resetting alarms on elevator and entering/exiting units. During a telephone interview on 05/19/2026 at 3:26 PM, Licensed Practical Nurse #2 stated when they received the wander alert device from Certified Nurse Aide #1, the device was flashing red which indicated the device was activated. They placed the device on Resident #1's left wrist and were unaware Resident #1 had exited the unit, as no wander alert device alarms were activated on the unit. During a telephone interview on 05/19/2026 at 3:36 PM, Police Officer #1 stated they responded to the facility on [DATE] at 6:28 PM for a resident that had been missing from the facility for over an hour. They stated a Silver Alert (missing senior) was issued by State Police with several local agencies responding to assist in the search for Resident #1. They stated Resident #1 was located at approximately 10:00 PM by emergency responders approximately 2.3 miles from the facility in an area with no sidewalks, no streetlights, and speed limits of 45-55 miles per hour. During an interview on 05/20/2026 at 8:27 AM, the Assistant Director of Nursing stated the wander alert device tags are kept in the Nursing Supervisors office and all the tags kept in storage are deactivated. Staff have to activate the tag every single time one is removed from the Nursing Supervisor office. Additionally, they stated the tags that are in use are tested weekly per the manufacturers' recommendations, but the tags located in the Nursing Supervisor office are not tested weekly as the tags in storage should not be activated. During an interview on 05/20/2026 at 9:10 AM, the Director of Nursing stated they completed the facility investigation. Licensed Practical Nurse #1 reported the tag was activated when it was removed from storage and Licensed Practical Nurse #2 reported the tag was activated when they placed it on Resident #1's left wrist. They stated tags are supposed to be deactivated prior to placing back in storage and the tags in storage are not included in the weekly checks for functionality. They stated the facility did not maintain any logs of the tags such as activation/deactivation, confirming functionality or confirming tags are in good working order. Additionally, they stated the facility did not have a policy related to the wander alert device system nor the manufacturers user manual. During a telephone interview on 05/21/2026 at 9:05 AM, the Medical Director stated when resident exhibits exit-seeking behaviors, they expect staff to initiate a wander alert device and increase supervision. They would expect the facility to have a policy on the wander alert device system. Additionally, there are hazards a resident could experience when they exit a building without staff knowledge such as tripping, falling, and getting lost. During an interview on 05/20/2026 at 9:36 AM, the Administrator stated proper protocol was followed upon admission and a wander alert device was appropriately placed for Resident #1. Additionally, they stated the facility did not have a policy specific to the wander alert device system and expected staff to follow the manufacturers' recommendations on the system usage. During a follow up interview on 05/21/2026 at 11:43 AM, the Administrator stated what we have found when a situation like this happens is that it's a human error and not a systems problem. I don't think any of us were aware there could be activated tags in the nursing office. New York Code Rules and Regulations 415.12(h)(1)(2) The Survey team determined the immediacy was removed on 05/22/2026 at 12:01 PM based on the following corrective actions taken by the facility:- Resident #1 was moved to a non-ground floor unit when returned to the facility.- The facility conducted a full audit of residents with wander alert device system on 05/21/26.- The facility revised the policy Elopement Prevention/Electronic Monitoring Devices.- Implementation of weekly testing of wander alert device with documentation of date of activation, resident name, device serial number, and battery status.- 100% of licensed nursing staff reeducation on proper use and management of the wander alert device system.

Based on interview and record review conducted during the Standard survey completed on 4/11/25, the facility did not ensure there were services of a Registered Nurse for at least 8 consecutive hours, 7 days a week unless when waived. Specifically, the facility did not have 8 consecutive hours of Registered Nurse coverage on 11/10/24, 11/16/24, 11/30/24, 12/8/24, 12/14/24, 12/21/24, 12/25/24, 12/28/24, 1/4/25, 1/5/25, 1/11/25, 1/12/25, 1/18/25, 1/19/25, 1/25/25, and 1/26/25 as required and did not have a waiver. The finding is: The Facility Assessment, dated 4/1/25, documented the facility's bed capacity was 160 beds and the average daily census at the time of the assessment was 150-160. The Facility Assessment documented the minimum number of staff required to meet the needs of the residents in a 24-hour period. For the current census, they required 12 Licensed Practical Nurses and 20 Certified Nurse Aides to safely care for their residents. Additionally, Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. During an entrance conference interview on 4/7/25 at 9:15 AM, the Administrator stated the facility had no nursing staff waivers. The daily staffing sheets reviewed from 12/1/24 through 1/31/25, documented they did not have a Registered Nurse for 8 consecutive hours, in the facility on the following dates: 11/10/24, 11/16/24, 11/30/24, 12/8/24, 12/14/24, 12/21/24, 12/25/24, 12/28/24, 1/4/25, 1/5/25, 1/11/25, 1/12/25, 1/18/25, 1/19/25, 1/25/25, and 1/26/25. During an interview on 4/10/25 at 2:11 PM, the Scheduling Coordinator stated they were unaware of the regulation for a Registered Nurse in the facility for at least 8 consecutive hours a day, 7 days a week until 4/9/25. During an interview on 4/11/25 at 9:29 AM, the Director of Nursing stated they were not aware there was not a Registered Nurse for 8 consecutive hours, 7 days a week, prior to their employment. During an interview on 4/11/25 at 9:52 AM, the Administrator stated they became aware, after they started at the facility, there wasn't Registered Nurse for 8 consecutive hours, 7 days a week coverage. 10NYCRR 415.13(b)(1)

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00355148) during a Standard survey completed on 4/11/25, the facility did not ensure the residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for three (3) (Residents #38, #121 and #355) of four (4) residents reviewed. Specifically, a resident's foley catheter was not changed monthly as per the physician order (#355) and infection control practices were not maintained (#38 and #121). The findings are: The policy and procedure titled Catheter Foley dated 4/25/22 documented a procedure to ensure the safe, sterile placement and removal of the foley catheter and provided guidelines for catheter care. When a catheterization is determined to be clinically indicated, verify physician order for catheter placement or catheter change, and gather the equipment. Additionally, infection control considerations included, do not allow catheter bag or tugging to lay on floor. If resident in low bed place catheter bag and tubing in dignity bag and or wash basin to avoid laying on floor. 1. Resident #355 had diagnoses including neurogenic bladder (a chronic condition that occurs when the nervous system's connection to the bladder is disrupted), benign prostatic hyperplasia (enlarged prostate), and cerebral infarction (a condition where a part of the brain is damaged or dies due to a lack of blood supply). The Minimum Data Set (a resident assessment tool) dated 6/27/24 documented Resident #355 was cognitively intact and had a urinary catheter. The comprehensive care plan dated 8/24/24 documented Resident #355 had an alteration in their elimination and utilized an indwelling foley catheter (22 French, 30 cc (cubic centimeter) balloon). Review of the Physician Orders dated 6/20/24 through 8/24/24 revealed an order dated 6/20/24 to change Resident #355's foley catheter monthly using a 22 French (refers to specific type), 30 (cc) cubic centimeter balloon. Review of Resident #355's Progress Notes dated 6/20/24 through 8/24/24 revealed the following: -6/20/24 2:30 PM Admission Note: Resident was treated for a urinary tract infection during hospitalization , failed multiple voiding trails, and had #22 French with 30 (cc) cubic centimeter balloon indwelling foley catheter intact. -8/9/24 at 6:57 AM, Licensed Practical Nurse #6 documented on 8/8/24 during the 7:00 PM - 7:00 AM the residents foley catheter port was leaking. Writer replaced the foley catheter using a 20 French 5 cc (cubic centimeter) balloon as the 22 French was not available. -8/11/24 at 6:41 PM Nurse Practitioner #1 documented an Acute Visit assessment. There was no evidence they were notified the 22 French, 30 cc (cubic centimeter) balloon foley catheter was not available, and that a 20 French 5 cc (cubic centimeter) was inserted. Review of the Treatment Administration Records (TAR) dated 6/20/24 through 8/24/24 revealed an order to change Resident #355's foley catheter monthly utilizing a 22 French 30 cc (cubic centimeter) balloon and had a start date of 6/20/24. Treatment Administration Records documented the following: - 7/7/24 Licensed Practical Nurse #7 documented - Not Administered - reason 22 French unavailable. Review dates 7/1/24 through 7/31/24 revealed there was no documented evidence the foley catheter was changed. -8/1/24 through 8/24/24 revealed there was no documented evidence a Foley catheter 22 French 30 cc (cubic centimeter) balloon was inserted as ordered. -8/7/24 was blank and there was no rational as to why the Foley catheter 22 French 30 cc (cubic centimeter) balloon was not changed as ordered. During an interview on 4/11/25 at 1:00 PM, Registered Nurse Unit Manager #1 stated Resident #355 had an order for the 22 French 30 cc (cubic centimeter) balloon foley catheter to be changed monthly. They stated they were not aware a 22 French 30 cc catheter was not available or that the foley had not been changed as ordered. Licensed Practical Nurse #6 and #7 should have informed them a 22 French 30 cc (cubic centimeter) was not available and would have expected them to also call a provider to obtain further orders. During an interview on 4/11/25 at 1:17 PM, Central Service stated the facility did not have a 22 French 30 cc (cubic centimeter) foley catheter in stock because it was a specialty item and they had not been asked to order any. Registered Nurse Unit Manager #1 should have notified them to place an order for the specialized item. During an interview on 4/11/25 at 1:20 PM, Registered Nurse Unit Manager #1 stated they were not aware a Foley catheter 22 French 30 cc (cubic centimeter) balloon was a specialized item that they needed to order from Central Service. During an interview on 4/11/25 at 1:27 PM, Nurse Practitioner #1 stated they would have expected Licensed Practical Nurse #6 and #7 to have changed Resident #355's foley catheter using a 22 French 30 cc (cubic centimeter) balloon as ordered monthly and to notify a provider if the foley size ordered wasn't available. They stated Licensed Practical Nurse #6 should not have inserted a 20 French 5 cc (cubic centimeter) without an order. During an interview on 4/11/25 at 1:36 PM, the Director of Nursing stated Resident #355 foley wasn't changed as ordered and Licensed Practical Nurse #6 replaced the foley catheter on 8/8/24 using an incorrect size catheter and balloon. They stated they were not aware Central Service did not stock a 22 French 30 cc (cubic centimeter) balloon foley catheter and would have expected Registered Nurse Unit Manger #1 to have ensured they had appropriate supplies to follow the orders. Licensed Practical Nurse #6 and #7 should have informed a provider when they were unable to follow the physician's orders. 2. Resident #38 had diagnoses including neurogenic bladder, cerebral infarction, chronic kidney disease. The Minimum Data Set, dated dated dated [DATE] documented Resident #38 was moderately cognitively impairment and had an indwelling foley catheter. The comprehensive care plan dated 8/26/24 documented Resident #38 had an alteration in their elimination and had foley catheter (16 French, 30 cubic centimeter balloon). Interventions included to change catheter as ordered, empty bag every shift and monitor for signs and symptoms of urinary tract infection. Review of Physician Orders dated 4/11/25 documented Resident #38 had an order to change their foley catheter with a 16 French 30 cc (cubic centimeter) balloon every month and had a start date of 8/26/24. During a continuous observation on 4/9/25 at 9:09 AM until 11:05 AM, Resident #38 was sitting in their wheelchair at the nursing station dozing on an off. Their foley bag (urine collection/drainage bag) was hanging on their wheelchair in a blue privacy bag and about 18 inches of the foley tubing was directly on the floor. The urine in the tubing was noted to be red tinged with mucous shreds. Numerous staff members walked past and at times interacted with the resident. At 11:05 AM Certified Nurse Aide #4 woke Resident #38, placed their foley tubing into the blue privacy bag and transported the resident away from the nursing station into the dining room. During a foley catheter care observation at 4/9/25 at 4:12 PM, Resident #38 was in bed, the bed was in the low position and there were floor mats to both sides of the bed. The residents foley catheter bag was touching the floor and there was no barrier in place. After Certified Nurse Aide #3 emptied the urine from the collection/drainage bag, they hung the bag from the bed frame. The bottom of the bag was directly on the floor. During an interview at this time Certified Nurse #3 stated that care was complete and the bag should never touch the floor. They stated the foley catheter/drainage bag should have been placed in privacy bag for dignity and to keep it off the floor for infection control purposes. During an interview on 4/10/25 at 2:47 PM, Certified Nurse Aide #4 stated on 4/9/25 Resident #38's foley tubing was directly on the floor while the resident was at the nursing station, and they had placed it into the privacy bag prior to transporting the resident into the dining room. Certified Nurse Aide #4 stated they did not want to run the tubing over and the tubing should not have been on the floor because of infection control reasons. During an interview on 4/9/25 at 4:16 PM, Licensed Practical Nurse #5 stated that Resident #38 had some hematuria (presence blood in urine) in their catheter tubing and bag for the past couple days. They stated the foley catheter bag and tubing should never directly touch the floor because of dignity, infection control and accident reasons. During a telephone interview on 4/10/25 at 11:45 AM, Nurse Practitioner #1 stated Resident #38 had a foley catheter. and stated Resident #38 did have a history of e-coli (Escherichia coli, which is a type of bacteria) in per a urine culture and sensitivity report. Nurse Practitioner #1 stated a foley bag should always be covered, with the tubing placed into the privacy bag and should never touching the floor for infection control purposes. During an interview on 4/11/25 at 9:53 AM, the Director of Nursing stated at no time should the foley catheter bag and tubing be touching the floor because of infection control concerns. During an interview on 4/11/25 at 10:35 AM, the Infection Preventionist stated that foley catheter tubing and collection bag should never be laying directly onto the floor because that could lead to infection. 3. Resident #121 had diagnoses including spastic diplegic cerebral palsy (cerebral palsy characterized by muscle stiffness and spasms primarily in the legs), neurogenic bladder, and epilepsy (seizure disorder). The Minimum Data Set, dated dated dated [DATE] documented Resident #121 had severe cognitive impairment and had an indwelling catheter. The comprehensive care plan documented Resident #121 had an alteration in elimination as evidenced by a suprapubic catheter (tube inserted into the bladder, through the abdomen, to drain urine. Interventions included change catheter monthly and monitor for signs and symptoms of urinary tract infection. During an observation on 4/9/25 at 2:22 PM, Resident #121 was lying in bed with approximately twelve (12) inches of the catheter tubing lying directly on the floor. During an observation on 4/11/25 at 7:39 AM Resident #121 was lying in bed with approximately ten (10) inches of catheter tubing and fifty (50) percent of the drainage bag lying directly on the floor. During an interview on 4/11/25 at 7:43 AM, Certified Nurse Aide #5 stated the catheter drainage bag was not attached to the bedframe correctly and the catheter drainage bag and tubing should not be directly on the floor for infection control purposes. During an interview on 4/11/25 at 7:52 AM, Licensed Practical Nurse #8 stated the catheter drainage bag and tubing should not be directly on the floor secondary to contamination. During an interview on 4/11/25 at 10:43 AM, Nurse Practitioner #1 stated anyone with an indwelling catheter was at risk for urinary tract infections. The catheter drainage bag should be hung from bedframe by something that keeps the drainage bag and tubing off the floor as there was an increased risk of infection when lying directly on floor. 10NYCRR 415.12(d)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with residents' wishes for two (2) (Resident #105 and #139) of two (2) residents reviewed for advanced directives. Specifically, the facility did not ensure Residents #105, and #139 advanced directives identifier was consistent with the resident's wishes and the provider's orders. Additionally, the MOLST (Medical Orders for Life Sustaining Treatment) binder for the 5th floor was not easily accessible to staff. The findings are: The policy and procedure titled Advanced Directives with a revision date of [DATE] documented the facility staff will verify the presence of advanced directives or the resident's wishes with regard to cardiopulmonary resuscitation. Nursing staff must verify medical records to determine whether or not any advanced directives have been issued by the resident. Nursing staff must use a means of identification for those residents who have a Do Not Resuscitate (DNR, allow natural death) in the medical records through advanced directives and written orders from the physician. Review of a sign posted in the facilities elevator and provided by the Director of Nursing, documented CODE BLUE: ALL MEDICAL EMERGENCIES: yell code blue and stay with the resident. Have a coworker page 'feature 630 and say, Nursing Supervisor, Code Blue and (your location). Repeat six times. The signage documented to check the wrist band, pink was a full code, resident wants cardiopulmonary resuscitation; and white was do not resuscitate (DNR). 1. Resident #105 admitted with diagnoses included Huntington's disease (genetic disorder that causes nerve cells in the brain to degenerate), chronic obstructive pulmonary disease (progressive lung disease) and anorexia. The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #105 was moderately cognitively impaired, was usually understood, and usually understands. The Care Plan Activity Report dated [DATE] documented Resident #105 wanted a do not resuscitate (DNR) status. Interventions included to assist with the completion of advanced directives and Medical Doctor to place initial advanced directives order. Review of the Physicians Orders dated [DATE] documented Resident #105 had an order to not resuscitate (DNR). The MOLST (Medical Orders for Life Sustaining Treatment) dated [DATE] located in Resident #105's chart at the nurse's station documented the resident had a do not resuscitate status. The interdisciplinary progress notes dated [DATE] at 3:32 PM documented the MOLST (Medical Orders for Life Sustaining Treatment) was changed per the Health Care Proxy (HCP) to (DNR) do not resuscitate and a new form was completed. During an interview on [DATE] at 10:32 AM, Licensed Practical Nurse #3 stated a resident's code status was identified by looking at the spine of the chart, the residents name band and the residents name placard (by the resident's door). Pink meant the resident was a full code and white meant the resident had a do not resuscitate order. Licensed Practical Nurse #3 stated they could also view a resident's code status in the electronic medical record (EMR) and on the resident's MOLST (Medical Orders for Life Sustaining Treatment) form. Licensed Practical Nurse #3 stated on the [NAME] floor the residents' chart and MOLST (Medical Orders for Life-Sustaining Treatment) forms were locked in the unit managers office at the end of the hallway. During an observation on [DATE] at 8:25 AM, Resident #105 was sitting in their wheelchair at the nurse's station the resident had a pink paper band (representing full code) on their left wrist, labeled with Resident #105's name. During an interview on [DATE] at 9:44 AM, Licensed Practical Nurse Unit Manager #2 stated a pink band identified a resident as having a full code status and a white band identified a resident as having a do not resuscitate (DNR) status. Residents wear a name band, or it was placed on their walker or wheelchair if they tend to remove it. The code status was also identified on the chart and door placard. They added the facility was in the process of eliminating the paper charts. During an interview on [DATE] at 9:58 AM, Licensed Practical Nurse #2 stated the pink dot on the computer identifies a resident as a full code, a pink bracelet, and the door name plate would be pink. They were unsure who was responsible to audit if all areas were correct and matched but believed it was social services responsibility. Licensed Practical Nurse #2 stated they were unsure of Resident #105's code status. At the time of the interview Licensed Practical Nurse #2 checked Resident #105's wrist band and stated Resident #105 was wearing a pink band so they were probably a full code. During an interview on [DATE] at 10:57 AM, the Administrator stated the facility did not have a specific policy for advance directive identifiers. During an interview on [DATE] at 11:20 AM, Licensed Practical Nurse Unit Manager #2 stated Resident #105 had the wrong bracelet on and it was a pink bracelet (full code) and Resident #105 had a do not resuscitate (DNR) order. Resident #105 could have potentially been resuscitated against their wishes. 2. Resident #139 had diagnoses that included fracture of the vertebra, chronic obstructive pulmonary disease and pressure ulcer of the sacrum. The Minimum Data Set, dated dated dated [DATE] documented Resident #139 was cognitively intact, was understood and understands. Review of Resident #130's MOLST (Medical Orders for Life-Sustaining Treatment) form dated [DATE] documented the resident had a do not resuscitate status. The Care Plan Activity Report dated [DATE] documented Resident #139 had advance directives that included: do not resuscitate (DNR), do not intubate (DNI) and comfort measures. Interventions included to provide alert for resident with advanced directive order and queue do not resuscitate symbol in the electric medical record. The Physician Orders dated [DATE] documented an order that Resident #135 had a DNR (do not resuscitate) order, a DNI (do not intubate) order and was comfort measures only and the nurse was to check the wristband. The order was dated [DATE] and timed 12:17 PM. Review of medical providers notes dated [DATE] at 12:57 PM revealed Nurse Practitioner #1 documented that Resident #139 had completed a new MOLST (Medical Orders for Life-Sustaining Treatment) and requested comfort care. During an observation on [DATE] Resident #139 was in bed wearing a name bracelet with their name written on pink paper (full code). The door name placard had their name printed on white paper (do not resuscitate). During an interview on [DATE] at 10:04 AM, Social Worker #1 stated they just started employment at the facility about a week ago and were not familiar with the facility's advance directives polices, processes or code status identifiers yet. At the time of interview Social Worker #1 was looking at the MOLST (Medical Orders for Life-Sustaining Treatment) book for the first floor, they reviewed Resident #139's form and stated that Resident #139 had a do not resuscitate (DNR) status. Social Worker #1 stated that a staff member probably would look in the MOLST (Medical Orders for Life-Sustaining Treatment) book, the electronic medical record or the care plan to identify a resident's code status. They stated they were unsure if the facility used any identifiers on name band or name placards. Social Worker #1 stated if any one of the facilities identifiers were incorrect then it would not be a good thing because there was a potential of the residents wishes not being honored. During an observation and interview on [DATE] at 10:15 AM, Registered Nurse #1 stated a pink name band meant the resident's code status was cardiopulmonary resuscitation (CPR), and a white name band meant do not resuscitate (DNR). At the time of the interview Registered Nurse #1 observed Resident #139's name band. They stated the name band was pink and that was not correct as Resident #139 was not to be resuscitated and was recently put on comfort measures. Registered Nurse #1 stated staff could have potentially performed cardiopulmonary resuscitation (CPR) on Resident #139 because they had the wrong-colored name band on. Registered Nurse #1 stated if they were to find a resident unresponsive, they would check two sources for the resident's code status and hoped staff would do the same. During an interview on [DATE] at 11:02 AM, Licensed Practical Nurse #1, Unit Manager #1 stated that Resident #139 was recently changed to comfort measures with a do not resuscitate (DNR) order. Licensed Practical Nurse #1 stated they would take responsibility for the error because at the time of Resident #139's order changed they only change Resident #139's name placard (door) to white but did not change their name band to white. They stated the potential outcome of the error could be that Resident #139 would have received cardiopulmonary resuscitation (CPR) against their wishes. 3. During an interview on [DATE] at 10:08 AM, Certified Nurse Aide #3 stated that on the 5th floor unit the resident care plans and a resident's MOLST (Medical Orders for Life Sustaining) Treatment form identified their code status. They stated the nurse manager had a key for the room where charts were kept. During an observation on [DATE] at 10:15 AM, the door to the unit manager's office on the 5th floor unit was locked. Behind the locked door was the residents' paper medical records and the Medical Orders for Life-Sustaining Treatment (MOLST) book. During an interview on [DATE] at 4:00 PM, the Assistant Director of Nursing stated that when staff found a resident unresponsive, they were to check the resident's MOLST (Medical Orders for Life-Sustaining Treatment) form for the resident's advance directive wishes. They stated other facility advance directive identifies would the resident name placard outside their door and the residents name band. They stated a pink name bracelet/placard meant full code and a white meant DNR (do not resuscitate). The Assistant Director of Nursing stated the facility was transitioning putting the MOLST (Medical Orders for Life-Sustaining Treatment) form into book and scanning them into the electronic medical record from the paper medical record. The Assistant Director of Nursing stated they would expect the certified nurse aide to identify a resident's code status by looking at the residents MOLST (Medical Orders for Life-Sustaining Treatment) form. They stated that on the fifth floor the charts and MOLST (Medical Orders for Life-Sustaining Treatment) forms were locked in the unit managers office and that would not be easily accessible at a time of emergency. They stated that if one identifier was inaccurate it could cause confusion, but staff should ultimately go by the MOST (Medical Orders for Life-Sustaining Treatment) form. During a telephone interview on [DATE] at 11:45 AM, Nurse Practitioner #1 stated that they were unsure that the advance directive identification process was in the facility. They stated they would expect the staff to review the residents MOLST (Medical Orders for Life-Sustaining Treatment) form as that was the most accurate for the residents wishes. They stated inaccurate identifiers could lead to a resident not receiving their wishes. During an interview on [DATE] at 9:40 AM, the Director of Nursing stated staff were to identify a residents codes stated by looking into the electronic medical record for the advance directive orders. They stated that the facility had completed their transition of scanning the MOLST (Medical Orders for Life-Sustaining Treatment) forms into the electronic medical record and then placing them into a book on the units. The fifth floor MOLST (Medical Orders for Life-Sustaining Treatment) book was not easily accessible locked in a unit managers office. They stated if the resident was wearing the wrong color name band there was potential the resident's wishes would not be honored. During an interview on [DATE] at 11:28 AM, the Administrator stated the staff were to confirm an advance directive wish of a resident with the MOLST (Medical Orders for Life-Sustaining Treatment). They stated the facility currently had other advance directive identifier practices in place such a color wrist band and a colored name placard but those were not included in the facility policy. The Administrator stated if the identifiers were inaccurate there was a potential for residents advance directives wishes not to be honored. The Administrator stated they did not support the MOLST (Medical Orders for Life-Sustaining Treatment) books being locked in an office because that was another step staff would have do and possible delay the process. 10 NYCRR 400.21

Based on interview and record review conducted during a Complaint (#NY00369028) investigation completed on 2/3/25, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choice for one (Resident #1) of three residents reviewed. Specifically, Resident #1 was permitted by staff to leave the facility at 5:30 AM and independently walk to a nearby hospital. Upon their return the facility initiated an electronic monitoring device without adequate indications for its use. The findings are: Resident #1 had diagnoses which included intellectual disabilities, anxiety, and chronic obstructive pulmonary disease (airflow obstruction and breathing problems). The Minimum Data Set (a resident assessment tool) dated 1/8/25 documented the resident was cognitively intact and did not have wandering or exit seeking behaviors. a. The Physician Order Activity Report as of 1/12/25 revealed the resident did not have an order for ALOA (approved leave of absence). The Health Care Decision-Making Capacity Determination signed and dated 4/28/23 by the Medical Director documented Resident #1 lacked complete, lifelong, personal medical decision-making capacity secondary to intellectual disability. The Progress Noted dated 1/12/2025 at 11:58 AM, authored by Registered Nurse Assistant Director of Nursing, documented the resident requested to go to local hospital for evaluation of anxiety and insomnia. The resident was educated on staying in the facility and a call can be placed to on-call provider. Resident preferred to sign out on pass instead of being transferred by emergency medical services. Resident #1 signed out and left the facility around 5:30 AM. Documentation request was e-mailed on 1/31/25 at 9:10 AM to the Administrator for the facility to provide a Release of Responsibility form signed by the resident at their time of departure from the facility and they were unable to provide one. During a telephone interview on 1/31/25 at 10:30 AM, Licensed Practical Nurse #2 (11:00 PM -7:00 AM nursing supervisor on 1/12/25) stated on 1/12/25 Licensed Practical Nurse #3 reported Resident #1 couldn't sleep and was hearing voices. Licensed Practical Nurse #2 stated they responded to the unit and Resident #1 was very aggressive, adamant about seeing a doctor immediately. Licensed Practical Nurse #2 stated they had Resident #1 sign a Release of Responsibility form and the resident left the facility at 5:30 AM. During a telephone interview on 1/31/25 at 10:23 AM, Licensed Practical Nurse #3 stated they were assigned to Resident #1's unit on the 11:00 PM -7:00 AM shift on 1/12/25. Licensed Practical Nurse #3 stated at 5:00 AM Resident #1 was walking about the unit stating they were hearing voices, and they administered 5:00 AM medications to the resident. The nurse stated they were unaware Resident #1 had left the unit. During an interview on 1/31/25 at 11:45 AM, the Director of Nursing stated Licensed Practical Nurse #2 should have contacted them or the Assistant Director of Nursing to get direction on how to proceed with the resident. The medical provider should have been contacted if the resident required medical assistance and the resident should have been transported by emergency medical services to the emergency department. Additionally, the nursing supervisor should not have allowed the resident to leave the facility at 5:30 AM to walk through the parking lot to the hospital. During an interview on 1/31/25 at 1:42 PM, the Director of Social Work stated it was unsafe to allow a resident that complained of auditory hallucinations to leave the facility at 5:30 AM, when it was cold and dark outside. Additionally, the Director of Social Work stated Resident #1 lacked the capacity to make health care decisions. During a telephone interview on 1/31/25 at 1:53 PM, the Nurse Practitioner stated Resident #1 had cognitive impairments secondary to intellectual disabilities and serious mental health issues. Additionally, the resident lacked capacity to make complex decisions, the supervisor did the wrong thing. The facility policy Leave of Absence (LOA) last date revised 3/14/23, documented it is the policy of the facility to encourage outside socialization for the resident when appropriate. A cognitively intact resident can leave the facility independently with the appropriate physician order. The facility will track the departure and return of a resident on the Release of Responsibility for leave of absence form. When a leave of absence is to occur evaluate resident for a change in condition, notify physician of any concerns/changes. b. The Elopement Risk assessment dated [DATE] documented the resident was not an elopement risk. The Physician Order Activity Detail Report dated 1/12/2025 - 2/3/2025 revealed a physician's order dated the 1/14/25 that documented to check placement of wander guard (electronic monitoring device) to the LLE (left lower extremity) Q (every) shift and check functioning of wander guard to LLE (left lower extremity) Q (every) shift. The undated Certified Nurse Aide Care Guide included Safety: Wander Guard (electronic monitoring device). The Progress Note dated 1/12/2025 at 11:54 AM, authored by Licensed Practical Nurse #1, documented wander guard (electronic monitoring device) placed to left lower extremity, resident educated on needing to have a staff member take them off the unit. The Progress Noted dated 1/12/2025 at 11:58 AM, authored by Registered Nurse Assistant Director of Nursing, documented Resident #1 signed out on pass at 5:30 AM and left the facility to go to a local hospital. During an observation on 1/31/25 at 10:05 AM Resident #1 was observed with an electronic monitoring device on their left lower extremity. Resident #1 stated the facility placed the device on their ankle a few weeks ago, and the resident felt they were being punished. Resident #1 stated they enjoyed leaving the unit to go on the first floor to the vending machines, the facility store, and interacting with residents from other units. Additionally, the resident stated, I can't move around and go where I want to with this wander guard (electronic monitoring device) on. During a telephone interview on 1/31/25 at 11:28 AM, Licensed Practical Nurse #4 stated they placed a wander guard on the residents left lower extremity because it was reported the resident left the unit and didn't notify the nurse. During an interview on 2/3/25 at 10:58 AM, the Director of Nursing stated they removed the wander guard from Resident #1 on 1/31/25 secondary to the resident was not at risk for wandering, there was no reason for them to have a wander guard. Additionally, Resident #1 was educated to sign out at the nurses' station when they leave the unit. The facility policy Abuse Policy Prevention and Management dated 9/2023, documented the facility must provide a safe resident environment and protect residents from abuse including involuntary seclusion. Involuntary seclusion was defined as separation of resident from other residents against their will, that may take many forms including but not limited to confinement, restriction, or isolation of a resident. The facility policy Elopement Prevention and Management review dated 8/2023, documented the facility recognizes mobility as strength to be supported and promoted. The facility will strive to identify residents at risk for unsafe wandering and exit seeking behavior and to develop individualized prevention and management interventions based on Exit Seeking/Elopement Evaluation. 10 NYCRR 415.12(h)(2)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY00308552) completed during a Standard survey completed on 5/25/23, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for three (Resident #s 93, 109, and 212) of four residents reviewed for abuse. Specifically, there was a lack of an investigation for Resident #93's allegation of verbal abuse by Certified Nurse Aide (CNA #7) that was reported to Licensed Practical Nurse (LPN #9) Nursing Supervisor. Resident #109 had a bruise of unknown origin which lacked staff statements, root cause and analysis. Resident #212 had a description of bilateral chest bruising with lack of staff statements. The findings are: The policy titled Incident Reporting and Investigation of Accident Hazards, Supervision, Assistive Devices dated 1/17/23, documented the facility will thoroughly investigate any adverse occurrence that is not consistent with the routine operation of the facility or the care of a resident. All accidents/incidents where there is mistreatment, neglect, abuse, or injury of unknown origin will be reported to the Director of Nursing (DON) and Administrator immediately for further review. An incident report is to be completed for any happening which is not consistent with everyday operation of the facility or care of residents including but not limited to: resident injury related to falls, skin alteration. The unit manager/supervisor/charge nurse were to conclude investigations as needed, obtain staffing from the past 24 hours and obtain employee statements as appropriate (i.e., bruise/skin tear of unknown origin). The policy titled Abuse Policy-Prevention and Management dated 2/2022 documented the facility must provide a safe environment to protect residents from abuse. Verbal abuse includes oral language that willfully includes disparaging and derogatory words to the resident or within their hearing distance. Injuries of unknown source include the source of the injury was not observed by any person, the source of the injury cannot be explained by the resident, the injury is suspicious because of the extent and the location (in an area not generally vulnerable to trauma). 1. Resident #93 had diagnoses of Parkinson's disease (tremors and rigidity of movement), heart failure, and diabetes mellitus. A review of the Minimum Data Set (MDS-a resident assessment tool) dated 2/22/23 documented that the resident was cognitively intact, understands others, and is understood by others. Further review of the MDS documented that the resident was a supervision of one staff member with set up help. Resident #93's Care Plan Activity Report initiated on 4/12/22 documented that staff assist with toileting as necessary to promote continence, the resident has an activity of daily living self-care, and mobility deficit. Anticipate resident needs as it relates to present ADL (activities of daily living) status. Review of the Nurse Supervisor Log Sheet dated 5/12/23 for Unit 4 revealed the unit nurse called the Supervisor's phone regarding CNA #7 and Resident #93's transfer status and to see note. Review of a nursing progress note dated 5/12/23 at 6:54 PM revealed there was an altercation between CNA #7 and Resident #93. CNA #7 stated that the resident would not help toilet themselves. The resident stated that CNA #7 was nasty and mean and reported to LPN #8 that CNA #7 stated to them to pull their own pants down and would leave them on the toilet for hours. The nursing progress note documented that CNA #8 went to toilet the resident and had no issues assisting the resident. LPN #8 document in the progress note that the resident was visibly upset and that they would call the police if CNA #7 came back into their room. LPN #8 further documented they removed CNA #7 from the resident's assignment and LPN #9 Nursing Supervisor was notified. During an interview on 5/19/23 at 10:23 AM, Resident #93 stated CNA #7 swore at them during toileting care. The resident stated they asked CNA #7 to assist them with their pants and CNA #7 told them to do it themselves. They stated CNA #7 swore at them saying (explicit word) you and left them in the bathroom. During an additional interview on 5/23/23 at 10:20 AM Resident #93 stated they almost fell trying to get on the toilet without assistance and were very upset about the incident. During an interview on 5/23/23 at 10:28 AM, LPN #11 Unit Nurse Manager stated they saw a note from LPN #8 concerning Resident #93 on 5/15/23. LPN #11 stated the resident informed them that CNA #7 had an attitude with them and was very rude and nasty and told Resident # 93 they would leave them on the toilet for hours. LPN #11 stated that the resident can direct care and let staff know their needs. LPN #11 stated that on 5/15/23 during morning report they let the Director of Nursing (DON) know about the verbal abuse. During an interview on 5/23/23 at 10:59 AM, LPN #8 stated Resident #93 was very upset about the altercation with CNA #7. They stated that Resident #93 was a very nice person who would not make up an altercation about anyone. LPN #8 stated that they left a note with LPN #9 Nursing Supervisor concerning the altercation. A further interview at 3:15PM LPN #8 stated that they texted to the Nursing Supervisor's phone about the altercation and called the Nursing Supervisor's phone three times, and each call went straight to voicemail. LPN #8 stated they went and found LPN #9 Nursing Supervisor to tell them about the altercation between CNA #7 and Resident #93. They stated LPN #9 Nursing Supervisor wrote something on a piece of paper and that was the end of it. LPN #8 stated LPN #9 Nursing Supervisor did not come up to the floor and they were not asked to provide a witness statement. During an interview on 5/23/23 at 12:23 PM, LPN #9 Nursing Supervisor, stated LPN #8 may have sent a text to the Nursing Supervisor's phone, but they didn't notice it. On 5/24/23 at 12:48 PM, LPN #9 Nursing Supervisor stated they should have gone to the floor and initiated an investigation, if it involved an altercation between a resident and a staff member, especially if there was verbal abuse. LPN #9 also stated that they should have reported the incident to the DON. During an interview on 5/23/23 at 12:31 PM, the DON stated what CNA #7 did was verbal abuse. The DON stated they didn't have notes from morning report on 5/15/23 concerning any altercation between Resident #93 and CNA #7. The DON stated they did not recall LPN #11 telling them about any verbal abuse between Resident #93 and CNA #7. On 5/24/23 at 1:00 PM, the DON stated they expected their Nursing Supervisors to investigate any incident between staff and residents and expected them to initiate an investigation. During the interview, the DON verified that a text about the altercation between Resident #93 and CNA #7 was sent from LPN #8 to LPN #9 Nursing Supervisor's phone on 5/12/23. The DON also verified that there was no reply text from LPN #9 to LPN #8. During an interview on 5/23/23 at 1:07 PM, the Administrator stated they expect the Nursing Supervisors to investigate any altercation or incident between staff and residents and should initiate an investigation. 2. Resident #212 had diagnoses which included dementia, anxiety disorder, and adult failure to thrive (a state of decline that may be caused by chronic disease and functional impairments). The MDS dated [DATE] documented the resident had severely impaired cognition, wandered daily, ambulated independently, and had no falls since the prior assessment. Care Plan Activity Report effective 2/25/21 for Resident #212 documented the resident was at risk for being harmed by other residents due to verbal outbursts and socially inappropriate behavior, exhibited wandering behavior, and had poor safety awareness. The document titled Accident dated 3/14/22 at 7:30 AM, documented Resident #212 was reported to have two large areas of discoloration to their upper chest. Contributing factors included dementia and the resident may have fallen and gotten themselves back up. There were no staff statements included or description of the bruising to include color, shape, or measurements. The facility document titled Accident dated 3/14/22 at 12:20 PM, documented Resident #212 had a fall onto their back near the nurse's station, the nursing supervisor assessed the resident, no injury was noted. There were no other Accident reports related to falls from 3/1/22 to 3/14/22. Review of the Progress Notes dated 3/15/22 at 10:01 AM, written by current DON, revealed on 3/14/22 at 9:00 AM, they were Resident #212's room to help assist the provider. Two large bruises were noted to upper chest, one on the right and one on the left side. The resident complained of pain to the left hip and lower leg. The resident did not know what happened to cause the injury. During a telephone interview on 5/23/23 at 1:31 PM, the Registered Nurse (RN) Supervisor #1 stated they could not specifically remember this incident or incident report. The RN Supervisor #1 stated that if bruising was found on a resident, they would normally get statements from staff working and the staff that worked the prior 24 hours. During an interview on 5/24/23 at 8:33 AM, the DON stated they were the wound nurse in March of 2022. The DON stated they must have been doing wound rounds with a provider when the bruises were found. The DON stated they let the unit manager (UM) know about the bruises and the UMs were responsible to do an investigation and get staff statements. The DON stated they didn't remember the size or color of the bruising and they could have documented that information. During an interview on 5/24/23 at 8:35 AM, the Administrator stated they could not find any further documentation pertaining to the incident reports dated 3/14/22. During an interview on 5/24/23 at 8:42 AM, the Assistant Administrator stated they would expect documentation of a description of the bruise size and color to determine if it was old or new. During an interview on 5/24/23 at 8:50 AM, the LPN #3 MDS assistant (former 5th floor unit manager (UM)) stated they did not remember Resident #212's bruising from March 2022. The LPN #3 stated when a bruise was found, they do an accident report and investigation that included asking staff from all shifts if anyone knew anything or saw anything to explain the bruising. The LPN #3 stated whoever completed the accident report was responsible for obtaining the statements, and the UM was responsible to get statements from the staff who worked the prior 24-36 hours. During further interview on 5/24/23 at 10:54 AM, the DON stated they didn't specifically remember the color or size of the bruising and they documented the bruises were large in size, on the resident's upper chest which meant the clavicle area. The DON looked in the electronic medical record (EMR) and stated there were no skin assessments regarding the bruising. The DON stated that as the current DON, they would have expected staff statements. During an interview on 5/24/23 at 12:34 PM, the Assistant Administrator stated they were the DON in March of 2022. The Assistant Administrator stated they did not think the chest bruises were injuries of unknown origin because Resident #212 had falls and was able to get themselves up independently, so they contributed that ability to the chest bruising. The Assistant Administrator stated the chest area being a common area of trauma depended on the resident and that this resident was a wanderer and was hard to keep close watch of. The Assistant Administrator stated the bilateral nature of the bruising was not suspicious but would expect statements from the staff who worked on that unit when it was found, and the prior 24-48 hours. During an interview on 5/24/23 at 1:40 PM, the Administrator stated they expected an investigation of bruise of unknown origin to include staff statements to rule out abuse or neglect. They are supposed to do their best to get to the root cause. 3. Resident #109 had diagnoses including dementia, diabetes mellitus, and depression. The MDS dated [DATE], documented moderately impaired cognition, usually understands and was understood. The MDS further documented no falls. The Care Plan Activity Report revised on12/27/22 documented Resident #109 was a fall risk and maintain a safe environment. The undated CNA Assignments Summary (a guided tool used by staff to provide care) for REsident #109 documented the resident required limited assist for bed mobility, nonskid footwear, and left side bed assist with padding. Review of the Accident report dated 12/1/22 documented that at 8:00 PM Resident #109 had a bruise on the lumbar part of their back. Resident #109 was unaware of how the bruise occurred. There was no investigation into how the bruise occurred. The Investigation Statement dated 12/1/22, CNA #3 documented they did not witness a fall. Resident #109 refused help. There were no employee statements documented from additional staff members on how the bruise occurred. During an interview on 5/24/23 at 11:30 AM, CNA #3 stated they didn't recall the bruise to Resident #109's back and wasn't aware of any falls. During a telephone interview on 5/24/23 at 12:25 PM, LPN #4 stated the bruise was noted during Resident #109's shower. LPN #4 reported the bruise to LPN #5, Nursing Supervisor. Skin abnormalities were reported when there was an unknown cause. Resident #109 bruised easily. LPN #4 told Resident #109 to be more careful. LPN #4 stated Resident #109 would tell us if someone abused them. LPN #4 stated Nursing Supervisors were responsible for starting investigations, gathered employee statements and notified the DON. LPN #4 couldn't recall filling out a statement about Resident #109's bruise. During a telephone interview on 5/24/23 at 12:37 PM, LPN #5 could not recall the 12/1/22 incident. An investigation included the completed accident report, employee statements from CNAs who had contact with Resident #109 when the bruise was found, and the previous shift CNAs. A cause should have been determined to make sure abuse didn't occur. LPN #5 checked the medical record and ensured the bruise was new and notified the DON. The DON finished the investigation. During an interview on 5/24/23 at 12:45 PM, the DON stated there was one employee statement available. The investigation should have included additional employee statements, progress notes, medications and contributing factors which could lead to bruising. The DON stated the investigation for the bruise on 12/1/23 was incomplete. There was no reasonable cause determined for the bruise. During an interview on 5/24/23 at 1:04 PM, the Administrator stated the DON should have investigated further into the bruise on Resident #109's back and gathered more statements from staff and determined if the bruise was medically related. A completed investigation required looking at the big picture. This was not the big picture. 10 NYCRR 415.4(b)(3)

Based on observation, interview, and record review during the Standard survey, completed on 5/24/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary assistance to maintain grooming and personal hygiene for two (Resident #11 and #70) of five residents reviewed. Specifically, Resident #11 was not provided incontinence care as planned. In addition, Resident #70 had multiple long whiskers on their chin and upper lip, and long jagged fingernails beyond their fingertips on their right contracted hand. The findings are: The policy and procedure (P&P) titled ADL Care; Toileting-Bowel and Bladder Incontinence Care dated 4/25/22 documented the facility will ensure a resident who is incontinent of bladder, receives appropriate treatment and services to prevent urinary tract infections, and to keep the perineal (area between the anus and genitalia) area clean, dry and odor free. The P&P titled ADL Care/Personal Care/Grooming-Nail Care dated 4/20/22 documented nail care would be provided on shower days and as necessary to provide cleanliness, prevent the spread of infection, provide comfort, and prevent skin injuries. The P&P titled Dignity and Respect dated 5/2023, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her Self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). 1. Resident #11 had diagnoses including dementia, peripheral vascular disease, and depression. The Minimum Data Set (MDS-a resident assessment tool) dated 5/3/23, documented Resident #11 had severely impaired cognition, was totally dependent on staff for toileting, and was always incontinent of bowel and bladder. The Care Plan Activity Report dated 4/14/20 documented Resident #11 had urinary incontinence and interventions included to check and change upon waking, before or after meals, at bedtime and prn (as needed). During a continuous observation on 5/22/23 from 8:18 AM to 1:49 PM, Resident #11 sat in their Broda (wheelchair that provides supportive positioning) chair with a mechanical lift sling underneath them. The resident was not toileted by staff during this timeframe. During an observation on 5/22/23 at 1:49 PM, Certified Nurse Aide (CNA) #1 stated to CNA #2 that they had to lay Resident #11 down and transported the resident to their room. At 1:55 PM, the mechanical lift was brought into the resident's room. At 1:58 PM, the resident was in their bed and CNA #1 left the room to get more linens. At 2:03 PM, CNA #1 and #2 turned the resident and removed their pants, mechanical lift sling and brief. The resident's brief was soiled with urine. The resident's skin on their posterior thighs had indentation marks from wrinkles in their brief and clothing, and their skin was red in these areas. The resident also had an outline of the edge of the mechanical lift sling in their skin along their medial posterior (middle back) thighs to the lateral (outer) thighs. CNA #1 stated the indentations were from the resident's clothing and mechanical lift sling. During an interview on 5/2/23 at 2:12 PM, CNA #2 stated Resident #11 was in their chair since they arrived at work that morning at 7:00 AM and that's why they put the resident back to bed after lunch. During an interview on 5/2/23 at 2:13 PM, CNA #1 stated they tried to change residents every two hours and Resident #11 was not toileted before lunch. The CNA #1 reviewed Resident #11's care plan in the electronic medical record (EMR) and stated the resident was supposed to be changed before/after meals. CNA #1 stated they got to work late that day and had to catch up when they got there. During an interview on 5/23/23 at 1:42 PM, the Licensed Practical Nurse (LPN) #2 Unit Manager (UM) stated if a resident wasn't changed frequently enough, they worried about skin breakdown. The LPN #2 UM stated if Resident #11 was up in the morning, they should have been changed before lunch. The LPN #2 UM stated it was their responsibility to make sure the CNAs were following care plans, and that CNA #1 never told them they were running behind on their assignment. During an interview on 5/24/23 at 1:32 PM, the Director of Nursing (DON) stated the staff (CNAs) should check the residents every two to three hours to make sure they don't need to be changed. If an incontinent resident wasn't changed for an extended period, there was risk for infection and skin breakdown. The UM should make sure the CNAs followed the care plans. 2. Resident #70 had diagnoses which included hemiplegia (paralysis on one side of body) and hemiparesis (weakness of one side of body) following cerebral infarction (CVA-stroke) and diabetes. Review of the MDS dated [DATE], documented Resident #70 was sometimes understood/understands and required limited to extensive assistance for ADLs. Resident #70's Care Plan Activity Report comprehensive care plan (CCP) with active effective date of 10/24/2018 documented the resident had an ADL self-care and mobility deficit related to weakness secondary to CVA. Interventions included limited assistance of one-person physical assist for personal hygiene. During intermittent observations on 5/19/23 at 8:40 AM, 5/22/23 at 11:56 AM, 3:56 PM, and 5/23/23 at 8:30 AM, 9:31 AM Resident #70 had multiple dark facial hairs, half inch long, on their chin and left upper lip. Additionally, on 5/23/23 at 9:31 AM the resident's right hand index finger and thumb nail were observed long beyond the pad of fingers. The resident's right hand was contracted and fingers curled into the palm of their hand. Resident #70's Treatment Administration Record (TAR) dated May 2023, documented an order the nurse was to check skin, and trim nails on shower/bath days as needed on the 11:00 PM-7:00 AM shift. There was no documented evidence this was completed on Monday, 5/22/23 as ordered. Review of Resident #70's Progress Notes dated 3/2/23 - 5/22/23 revealed there was no evidence the resident refused to have their facial hair shaved from their chin and upper lip or their nails trimmed. During an interview on 5/23/23 at 11:44 AM, LPN #7 stated resident's nail care and shaving was to be completed on their shower day or when noticed to be needed. During an interview on 5/23/23 at 12:05 PM, CNA #5 stated the CNAs were responsible for trimming nails and shaving residents usually on their shower day or as soon they could. During an observation and interview on 5/23/23 at 12:15 PM, Registered Nurse Unit Manager (RNUM) #2 stated that full grooming was to be completed on the resident's shower day. Resident #70's shower day was scheduled on Wednesday evening shift. RNUM #2 extended Resident #70's fingers from the right palm of their hand, exposing all fingernails of right hand and stated they were long and should be trimmed. All nails of the resident's right hand were long, over pads of fingers, and jagged in appearance. RNUM #2 stated Resident #70 had facial hair present on their chin and upper lip and should be shaved. RNUM #2 stated nails need to be trimmed to prevent skin injuries, infection and facial hair present was a dignity issue. During a follow up interview on 5/24/23 at 11:25 AM, RNUM #2 stated Resident #70s shower day was recently changed from Monday 11-7 shift to Wednesday 3-11 shift. RNUM #2 reviewed the EMR for Resident #70 and stated the last documented weekly skin check was on Monday, 5/15/23 on the 11-7 shift. During an interview on 5/24/23 at 12:55 PM, the DON stated they would expect the nursing staff to trim residents' nails anytime they were noticed long. Shaving was to be done on shower days and as needed. Additionally, the DON stated the nursing were fully responsible for the care of dependent residents. 10 NYCRR 415.12(a)(3)

Based on interview and record review conducted during a Standard survey completed on 5/24/23, it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made to the Administrator and State Survey Agency for two (Resident #93 and #109) of four residents reviewed for abuse. Specifically, Resident #93 was involved in an alleged staff-to-resident verbal abuse, involving Certified Nurse Aide (CNA) # 7 which was not reported to the Administrator and to the State Agency. In addition, Resident #109 was found to have a bruise of unknown origin and it was not reported to the State Agency within the required timeframe of two hours. The findings are: A policy and procedure (P&P) titled, Abuse Prevention and Management revised on 9/8/22 documented that the facility will report allegations of abuse, neglect, misappropriation, or injury of unknown source. The responsible manager will report any abuse allegation or injury of unknown source to the Administrator or the Director of Nursing (DON) immediately and that the State agency will be notified within two hours after the identification of the allegations. 1. Resident #93 had diagnoses of Parkinson's (tremors and rigidity of movement) disease, heart failure, and diabetes mellitus. The Minimum Data Set (MDS - a resident assessment tool) dated 2/22/23 documented the resident was cognitively intact, understands others, and is understood by others. Further review of the MDS revealed the resident was a supervision of one staff member with set up help. Review of the resident's Care Plan Activity Report initiated on 4/12/22 revealed staff assist with toileting as necessary to promote continence, the resident has an activity of daily living (ADL) self-care, and mobility deficit. Anticipate resident needs as it relates to present ADL status. Review of a facility generated Accident/Incident Report dated 5/22/23 revealed that there were no accidents or incidents reported for Resident #93 between 11/22/22 to 5/22/23. Review of the Nurse Supervisor Log Sheet dated 5/12/23 for Unit 4 revealed the unit nurse called the Supervisor's phone regarding CNA #7 and Resident #93's transfer status and to see note. Review of a nursing progress note dated 5/12/23 at 6:54 PM revealed there was an altercation between CNA #7 and Resident #93. CNA #7 stated that the resident would not help toilet themselves. The resident stated that CNA #7 was nasty and mean and reported to Licensed Practical Nurse (LPN) #8 that CNA #7 stated to them to pull their own pants down and would leave them on the toilet for hours. The nursing progress note documented that CNA #8 went to toilet the resident and had no issues assisting the resident. LPN #8 document in the progress note that the resident was visibly upset, and they would call the police if CNA #7 came back into their room. LPN #8 further documented they removed CNA #7 from the resident's assignment and LPN #9 Nursing Supervisor was notified. During an interview on 5/19/23 at 10:23 AM, Resident #93 stated CNA #7 swore at them during toileting care. The resident stated they asked CNA #7 to assist them with their pants and CNA #7 told them to do it themselves. They stated CNA #7 swore at them saying (explicit word) you and left them in the bathroom. During an additional interview on 5/23/23 at 10:20 AM Resident #93 stated they almost fell trying to get on the toilet without assistance and were very upset about the incident. During an interview on 5/23/23 at 10:28 AM, LPN #11 Unit Nurse Manager stated they saw a note from LPN #8 concerning Resident #93 on 5/15/23. LPN #11 stated the resident informed them that CNA #7 had an attitude with them and was very rude and nasty and told Resident # 93 they would leave them on the toilet for hours. LPN #11 stated that the resident can direct care and let staff know their needs. LPN #11 stated that on 5/15/23 during morning report they let the Director of Nursing (DON) know about the verbal abuse. During an interview on 5/23/23 at 12:23PM, LPN #9 Nursing Supervisor, stated LPN #8 may have sent a text to the Nursing Supervisor's phone, but they didn't notice it. An additional interview on 5/24/23 at 12:48 PM, LPN #9 Nursing Supervisor stated they should have gone to the floor and initiated an investigation, if it involved an altercation between a resident and a staff member, especially if there was verbal abuse. LPN #9 also stated that they should have reported the incident to the DON. During an interview on 5/23/23 at 12:31 PM, the DON stated what CNA #7 did was verbal abuse. The DON stated they didn't have notes from morning report on 5/15/23 concerning any altercation between Resident #93 and CNA #7. They stated they don't recall LPN #11 telling them about any verbal abuse between Resident #93 and CNA #7. The DON stated that they expect nursing supervising staff to report any type of altercation to themselves or the Administrator as soon as possible in case it may be a reportable incident to the State Agency. During an interview on 5/23/23 at 1:07 PM, the Administrator stated the Nursing Supervisor should call the DON or themselves for any allegation of abuse so it can be reported timely. 2. Resident # 109 had diagnoses including dementia, diabetes mellitus, and depression. The MDS dated [DATE] documented moderately impaired cognition, usually understands and was understood. The MDS further documented no falls. The Care Plan Activity Report with a revised date 12/27/22 documented Resident #109 was a fall risk and maintain a safe environment. The undated CNA Assignments Summary (a guided tool) documented limited assist for bed mobility, nonskid footwear, and left side bed assist with padding. Review of the Accident report dated 12/1/22 revealed at 8:00 PM Resident #109 was noted with a bruise on the lumbar part of their back, discovered during their shower. The bruise measured 15 1/2cm (centimeters) x (by) 7 cm. Resident #109 was unaware of when and how the bruise occurred. The Accident report was signed by the DON on 12/2/22 as reviewed. Review of the NYS(New York State) DOH(Department of Health) Automated Complaint Tracking System (ACTS) revealed no complaint/investigation report was submitted by the facility for Resident #109 on 12/1/22. During an interview on 5/24/23 at 12:45 PM, the DON stated the bruise was an injury of unknown origin therefore should have been reported to the NYS DOH within 2-hours and was missed. During an interview on 5/24/23 at 1:04 PM, the Administrator stated the 12/1/22 incident should have been investigated thoroughly and immediately. Injuries without a known cause were reported to the NYS DOH within a 2-hour window. This bruise was not reported and should have been. 10 NYCRR 415.4(b)(4)

Based on interview and record review conducted during a Standard survey completed on 5/24/23, it was determined that the facility did not ensure that a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #84) of four residents reviewed for dignity. Specifically, a resident, who was continent of bowel, was told to have their bowel movement in their brief instead of being toileted. The finding is: A policy and procedure (P&P) titled, Dignity and Respect dated 9/8/22 documented that residents shall be treated with dignity and respect. Further review of the P&P documented that staff shall promote dignity and assist residents by promptly assisting a resident with their toileting needs. 1. Resident #84 was admitted to the facility with diagnoses of fractured right leg and arthritis. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/17/23 documented that the resident was cognitively intact, understood by others, understands others, and is a limited assist (guiding limbs or other non-weight bearing assistance) of two staff members for toileting. Resident #84's Care Plan Activity Report initiated on 3/10/23 documented the resident had impaired balance issues related to their broken right leg, required assistance from staff, and the resident may have episodes of bowel incontinence. Review of the resident's Occupational Therapy (OT) Evaluation & Plan of Treatment dated 4/28/23 documented that the resident is totally dependent on others for transfers from bed to chair. Review of the resident's Physical Therapy (PT) Evaluation & Treatment Plan dated 3/10/23 documented that the resident was dependent for chair to chair and toilet transfers. Review of the resident's Resident CNA (Certified Nurse Aide) Documentation Record for May 2023 did not have documented toileting activities on the 11:00 PM to 7:00 AM shift from 5/19/23 to 5/22/23. During an interview on 5/22/23 at 11:01 AM, Resident #84 stated that they were incontinent of bowel on a 11:00 PM to 7:00 AM shift. They stated that they rang their call light because they had to go to the commode at 4:30 AM on 5/20/23. After they rang their call light, a CNA (unidentified) came into their room, turned off their call light, and would not put them on the commode. They stated that they still needed to use the commode and rang their call light again. Another CNA, CNA #9, came in their room, turned off their call light, and told the resident to go in their brief. They stated that they couldn't hold it anymore and had a bowel movement in their brief. The resident stated they were embarrassed and they were an assist of two staff members to use the commode with a sit to stand lift (mechanical lift used for someone is unable to perform positional transitions on their own). Resident #84 stated that they stayed in the soiled brief until breakfast time. During an interview on 5/22/23 at 11:29 AM with CNA #10, they stated they took care of Resident #84 that morning (5/20). CNA #10 stated that they changed the resident and the resident had dried feces on their skin and in their brief. CNA #10 stated Resident #84 kept apologizing about the mess in their brief. CNA #10 stated, it is a dignity thing to make a resident go in their brief when they can use a commode. During an interview on 5/22/23 at 11:40 AM, Licensed Practical Nurse (LPN) #6, stated they expect CNAs to put a resident on a commode if the resident requested it. LPN #6 stated that it was unacceptable for the CNA to tell a resident to go in their brief and that it was undignified for a resident to go in their brief. During an interview on 5/23/23 at 1:00 PM, the Director of Nursing (DON), they stated they expected CNAs to answer the call light and take care of the resident's needs. The DON stated that they have no words to say about this incident. During an interview on 5/24/23 at 8:32 AM, CNA #9 stated that they were busy during their shift (5/20) and could not toilet Resident #84. CNA #9 stated that it was undignified to tell a resident to go in their brief and not to toilet the resident. 10NYCRR 415.3(c)(1)(i)

Based on observation, interview, and record review conducted during a Standard survey completed on 5/24/23, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community for one (Resident #70) of two resident reviewed for activities. Specifically, Resident #70 was not asked to participate in activities on a daily basis and was not provided with one-on-one visits/activities. The finding is: The policy and procedure (P&P) titled Activity Department Practice dated 4/2023, documented the facility will provide an ongoing program to support residents in their choice of activities, both facility sponsored groups and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encourage both independence and interaction in the community. 1. Resident #70 had diagnoses which included hemiplegia (paralysis on one side of body), hemiparesis (weakness of one side of body) following cerebral infarction (CVA-stroke), aphasia (absence or difficulty with speech) and depression. Review of the MDS dated [DATE], documented Resident #70 sometimes understands, sometimes understood and was unable to complete a cognitive interview. The MDS dated [DATE] documented the Activity Preferences were somewhat important to do things with groups of people, to do favorite activities, go outside to get fresh air and participate in religious services or practices. The document titled Activities-Quarterly assessment completed on 4/17/23 documented Resident #70 prefers to go outside to get fresh air when the weather is good and to participate in religious services. The assessment documented activity participation will be monitored and encouraged. The Care Plan Activity Report for Resident #70 entered on 5/26/2021 documented the resident had limited ability to participate was a passive observer in relation to participation in activities secondary to cognition. Goals included the resident would participate in 1:1 visits to maintain socialization to see that leisure needs are being met; maintain present level of socialization and leisure interests through participation in various programs; Resident will participate in person centered life enrichment and engagement activities, such as room visits or one to one programming, a minimum of 1x daily to prevent loneliness, helplessness and boredom. Interventions included the resident would receive 1:1 visit with the Activity Aides, provide monthly calendars, remind, invite and escort to recreational programs, provide stimulation using radio or television and maintain preferred independent leisure activity. The activity report documented Resident #70 was at risk for social isolation and depression since being encouraged to practice social distancing to minimize exposure to COVID-19. Interventions included: involve resident in activities of interest during room visits and 1:1 programming, offer 1:1 out of room to prevent feeling of isolation, provide 1:1 activity outdoors if weather permits, and offer exercise, stretching, movement activities during 1:1 programming. Review of the Record of One-on-One Activities for Resident #70 from December 2022 through April 23, 2023, documented two visits on 3/3 and 3/5. Review of Resident #70's activity list and attendance for May 2023 identified by AD, indicated S for resident sleeping. Review of April 1st though the 30th attendance, revealed Resident #70 attended 4 activities. During intermittent observations on 5/19/23 at 8:40 AM and 12:21 PM Resident #70 was sitting at a table in the lounge by them self in a Geri-chair not facing the television (TV was on). There were no other activities in session in lounge during the observations. The attendance log for May 19th documented an S - sleeping. During an interview on 5/19/23 at 10:04 AM, Resident #70's responsible party stated they have requested the resident to be taken to activities, they want them to have stimulus. Resident #70's responsible party also stated the facility chronically does not get Resident #70 out of bed and when they ask questions, they get the run around. During an observation on 5/22/23 at 8:59 AM, Resident #70 was in bed awake, there was no activity calendar available in the resident's room (radio, music), there were no in room activities available, and the TV was not on. During an observation on 5/23/23 at 9:31 AM, Resident #70 was sitting in Geri-chair awake in room by them self with the door closed. There were no activities available in the room, and the TV off. Review of the May 2023 activity calendar revealed: May 22nd: 10:00 AM Coffee/Chat, 2:00 PM Cooking Club, 6:00 PM Helping Hands 5th Floor May 23rd: 10:00 AM Coffee/Chat in mall walk (MW), 11:00 AM Catholic Bible Study (MW), 2:00 PM Karaoke (MW) and 6:00 PM Helping Hands 5th floor. During an interview on 5/24/23 at 8:26 AM, the Activities Director (AD) stated they were short staffed and just hired a bunch of activity staff. Depending on the day of week there were 2 to 4 activity staff in the facility. Attendance logs were completed daily for resident attendance in activities. AD stated Activity Aides were responsible to encourage and get residents to attend activities. The Activity Aides should be to going floor to floor, asking residents if they want to attend the activity, and bring some of the residents down. The AD stated there were not always enough nursing aides to get Resident #70 out of bed, so they were unable to attend activities off the unit. The AD stated they have never seen Resident #70 off their floor for an activity and upon reviewing Resident #70's Record of One-on-One Activities noted they haven't had any 1:1 activity documented for April. The AD stated it was important for residents to have activities to make them happy, provide stimulation and interaction. Additionally, the AD stated it was especially sad that Resident #70 hadn't received any 1:1 visits from the Activity Aides. During an interview on 5/24/23 at 11:25 AM, RN #2 stated they have not seen activity staff offer or take Resident #70 to activities. RN #2 stated it wasn't just important for Resident #70, but all residents should be offered activities to keep their functionality and quality of life. RN #2 stated Resident #70 should be receiving some activities, likes to be outside, look out window, 1:1, and offered other sensory activities. Additionally, RN #2 stated if the activities staff communicated with nursing, they could help with designating staff to assist with getting residents to activities. During an interview on 5/24/23 at 11:43 AM, Activities Aide #1 stated they were familiar with Resident #70 and they usually were not awake for activities. Activity Aide #1 did not recall Resident #70 recently attending any activities. Activity Aide #1 stated they don't usually try and wake the residents up. Additionally, Activity Aide #1 stated they do not document activity refusals, but it would be an idea so staff know if it had been offered and refused. During an interview on 5/24/23 at 12:55 PM, Director of Nursing (DON) stated their expectation was that activities would make rounds several times a day and offer activities. The DON stated it was important to keep residents as active as possible, keep them engaged, occupied, and happy. 10 NYCRR 415.5(f)(1)(i)

Based on interview and record review during the Standard survey completed 5/24/23, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs, when used without adequate monitoring for one (Resident #83) of five residents reviewed for unnecessary medications. Specifically, the resident received metoprolol (medication used to treat high blood pressure) twice daily without their heart rate being monitored per the physician's order. The finding is: The policy titled Medication Management-Utilizing and Prescribing dated 2/2023 documented medications shall be administered in a safe manner as prescribed by the physician. 1. Resident #83 had diagnoses including dementia, supraventricular tachycardia (heart condition with abnormally fast heart rate), and epilepsy (neurological disorder). The Minimum Data Set (MDS - a resident assessment tool) dated 4/26/23 documented Resident #83 had moderate cognitive impairment, sometimes understands, and was sometimes understood. Review of an untitled document identified by the Administrator as the metoprolol order history, revealed Resident #83 had an order dated 4/14/21 at 3:46 PM for metoprolol 25 milligrams (mg), with instructions to give 0.5 tablet (12.5mg) twice daily, and to hold for heart rate under 60. The monitor section was blank. This order was discontinued for an order change on 5/24/23 at 9:21 AM by the Licensed Practical Nurse (LPN) #2 Unit Manager (UM). The updated order dated 5/24/23 at 9:21 AM monitor section documented pulse. Review of Medication Administration Records (MARs) dated 5/1/2022 to 5/24/23 revealed there was no documented evidence that Resident #83's heart rate was monitored twice daily when the metoprolol 12.5 mg was administered. Review of an untitled document, identified by the Administrator as the EMR (electronic medical record) vital sign monitoring documentation, dated 5/1/22 to 5/24/23 revealed the resident's pulse was obtained on 20 occasions. During an interview on 5/24/23 at 9:04 AM, LPN #1 stated they were the regular, full-time nurse for Resident #83. LPN #1 stated if a resident had parameters ordered for a medication, the blood pressure or pulse would be under the administration time in the MAR. The LPN #1 stated they didn't check the residents blood pressure or pulse that morning before administering their medications because nothing popped up. LPN #1 checked Resident #83's MAR and stated they never noticed the part of the order to hold the medication for a pulse below 60. LPN #1 reviewed the metoprolol blister pack, and the blister pack was labeled with the parameter to hold the medication for a heart rate under 60. LPN #1 checked the physician orders in the electronic medical record (EMR) and stated whoever put the order in, should have put in to monitor the pulse, and it looked like the former Assistant Director of Nursing put the original order in. LPN #1 stated the resident's vital signs were ordered monthly and last had them completed on 5/10/23. During an interview on 5/24/23 at 9:10 AM, the LPN #2 UM stated the order for the metoprolol has been in place since 4/14/21 and nothing had been changed with the order since then. The LPN #2 UM stated nobody had pointed out the lack of pulse monitoring for this medication. The LPN #2 UM stated who ever put the order in needed to complete a separate part in the protocol section for the pulse monitoring to show up for the nurses. During an interview on 5/24/23 at 9:23 AM, Physician Assistant (PA) #1 stated they expected the nurses to check the resident's pulse if it was part of the order. The PA stated this medication had the potential to lower the heart rate and in the EMR if certain boxes weren't checked, it wouldn't trigger for the nurses (to complete a pulse). During an interview on 5/24/23 at 10:37 AM, the Pharmacy Consultant stated Resident #83 was on metoprolol for supraventricular tachycardia, which means the heart rate can go very high, but doesn't mean their heart rate can't go low at times, so that's the reason for the hold parameter. The Consultant Pharmacist stated the resident's recent pulses were documented on 4/12/23 and 5/10/23. During an interview on 5/24/23 at 10:49 AM, the Director of Nursing (DON) stated the nurses should be verifying and checking that they are doing what coincides with each medication. They should be reading the MAR and the blister pack label to double check they are following the order. 10 NYCRR 415.12(l)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 5/24/23, the facility did not 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 infection for one (Resident #70) of two residents reviewed for infection control practices during incontinence care. Specifically, staff did not perform adequate hand hygiene while providing fecal incontinence care and staff emptied the dirty washbasin water directly into the sink of a shared bathroom. The findings are: The policy and procedure (P&P) titled Hand Hygiene revised 10/27/22, documented all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Alcohol-based hand rub (ABHR) is the preferred method for routine hand hygiene. Use an ABHR; or, alternatively, soap and water for the following situations: before and after direct contact with residents; before moving from working on a soiled body site to a clean body site on the same resident; after contact with a resident's intact skin; after contact with objects in the immediate vicinity of the resident; and immediately after removing gloves. Wash hands with soap and water for the following situations: when hands are visibly soiled. 1. Resident #70 had diagnoses which included hemiplegia (paralysis on one side of body) and hemiparesis (weakness of one side of body) following cerebral infarction (CVA-stroke), aphasia (absence or difficulty with speech) and type 2 diabetes mellitus. The Minimum Data Set (MDS - a resident assessment tool) dated 4/13/23 documented Resident #70 was sometimes understood and sometimes understands and was unable to complete the cognitive interview. The MDS documented the resident required total assist of two persons for toileting and was always incontinent of urine and bowel. The Care Plan Activity Report, comprehensive care plan (CCP) dated 5/26/2021 documented Resident #70 had an alteration in elimination related to CVA. Interventions included to provide peri care with each episode of incontinence. Ensure skin, linens and clothing are clean and dry. Total dependence of 2-person physical assist for bladder and bowel incontinence. During a continual observation on 5/23/23 at 9:38 AM to 10:37 AM, certified nurse aide (CNA) #5 and #6 applied gloves. CNA #6 provided fecal incontinent care to Resident #70 and removed a large amount of feces (stool) with a washcloth. CNA #6 did not remove their visibly soiled (with feces) gloves and wash their hands prior to continuing incontinent care. CNA #6 placed their hands into the wash basin containing clean water, touched clean linen (towel), adjusted the clean bed linen, and moved the location of the garbage can. CNA #6 dried the resident's buttocks and rectal area with the contaminated towel. CNA #6 did not remove their soiled gloves prior to opening room door to exit room to obtain additional linens. CNA #6 was observed to remove their soiled gloves after exiting the room in hallway prior to entering soiled work room. Upon returning to the resident's room with additional linen, CNA #6 applied clean gloves obtained from front the pocket of their scrub top, then applied a clean brief to the resident, picked an item up off floor, and placed it in the garbage can. While wearing the same gloves CNA #6 then placed their hands, on Resident #70's exposed skin during positioning, reapplied the resident's pants and then transferred Resident #70 via mechanical lift into their Geri-chair. CNA #6 then removed the wash basin from tray table and dumped contaminated water into bathroom sink. While wearing the same gloves repositioned bed, touched the bed remote, call bell and repositioned the tray table in room. CNA #6 then proceeded to remove garbage/linen and mechanical lift from room without removing both gloves and washing hands. CNA #6 entered the soiled work room with same gloved hands, sorted the soiled disposable items from the soiled linen items, then removed their gloves from both hands and washed hands with soap and water. During an interview on 5/23/23 at 10:38 AM, CNA #6 stated they should have changed their gloves if they were soiled, and Wouldn't want feces to get all over them. CNA #6 stated they should have noticed their gloves were soiled prior to touching anything clean and changed their gloves so they didn't contaminate anything. CNA #6 stated they should wash their hands before and after incontinent care. CNA #6 stated they should have removed both their gloves, washed hands prior to leaving the resident's room to obtain additional linens, and should have only had one gloved hand upon transferring soiled linen/garbage to soiled work room. Additionally, CNA #6 stated the dirty water from the basin should have gone into the bathroom toilet because it was contaminated. During an interview with CNA #5 that was present during incontinent care on 5/23/23 at 10:50 AM, CNA #5 stated anytime gloves were soiled they should be changed due to contamination. CNA #5 stated, CNA #6 should have changed their gloves when they got poop on them and before they touched clean things. CNA #5 stated wash basins were to be emptied in the toilet because residents use the sink to brush their teeth and wash their faces. During an interview on 5/23/23 at 11:44 AM, Licensed Practical Nurse (LPN) #7 stated they would expect CNAs to remove their gloves and wash their hands anytime they are soiled, prior to touching anything clean, prior to entering the hallway, and after/between resident care to prevent cross contamination. LPN #7 stated only one gloved hand was to be used to carry soiled linen to utility room. Additionally, LPN #7 stated wash basin water should be dumped into the toilet. During an interview on 5/23/23 at 12:15 PM, the Registered Nurse Unit Manager (RNUM) #2 stated they expected the CNA to absolutely change their gloves after cleaning feces during incontinent care and prior to touching any clean linen for infection control purposes. Additionally, RNUM #2 stated for sanitary and infection control purposes the water should be disposed of in the toilet. During an interview on 5/23/23 at 12:15 PM, the Director of Nursing (DON) stated it was an inappropriate practice to pour wash basin water into the bathroom sink. During a follow up interview on 5/24/23 at 12:55 PM, DON stated gloves need to be removed and changed if soiled due to risk of infection, contamination, and infection control practice; and hands should be washed prior to care then when care is finished on a resident. 10 NYCRR 415.19 (a)(1)(b)(4)

Based on interview and record review conducted during the Standard survey completed 5/24/23, the facility did not ensure MDS (Minimum Data Set- a resident assessment tool) data was electronically transmitted to the CMS (Centers for Medicare & Medicaid Services) System within 14 days after the resident's assessment was completed for 8 (#15, 60, 71,101, 102, 117, 122, 138) of 8 residents reviewed for Resident Assessments. The findings include but are not limited to: The policy and procedure (P&P) MDS Assessment Submission Process revised 2/2023 documented MDS assessments will be submitted per RAI (Resident Assessment Instrument) guidelines. MDS assessments will be submitted twice weekly at a minimum at the beginning and the end of each month for timely billing. Validation reports need printed after MDS assessments are submitted. The MDS Coordinator is to review reports with errors/warnings/rejections and follow up as appropriate on validation reports. 1. Resident #15 had diagnoses which included hypertension (HTN), anxiety, and depression. Review of the discharge return not anticipated MDS with an assessment reference date of 1/6/23 and completion date of 1/11/23 revealed the transmission of the MDS had not been accepted as of 5/22/23. The facility did not submit the completed assessment within 14 days of completion. 2. Resident #60 had diagnoses which included HTN, anxiety, and diabetes mellitus. Review of the death ii facility assessment with an assessment reference date of 1/18/23 and a completion date of 1/18/23 revealed the transmission of the MDS had not been accepted as of 5/22/23. The facility did not submit the completed assessment within 14 days of completion. 3. Resident #71 had diagnoses which included dementia, mood disturbance, and anxiety. Review of the discharge return not anticipated assessment with an assessment reference date of 1/4/23 and completion date of 1/11/23 had not been accepted as of 5/22/23. The facility did not submit the completed assessment within 14 days of completion. Review of the MDS 3.0 Missing OBRA Assessment Report provided by the facility dated 5/23/23 revealed Residents #15, 60, 71, 101, 102, 117, 122, and 138 were missing assessments. During an interview on 5/23/23 at 1:31 PM, Registered Nurse (RN) #3 MDS Coordinator stated MDSs were to be completed by day 14 and submitted 14 days after the completion. RN #3 stated they never submitted the assessments, did not review the validation reports therefore the assessments were over 100 days late. RN #3 stated the assessments were never submitted to CMS due to computer issues. During an interview on 5/24/23 at 1:31 PM, the Administrator stated accurate reimbursement was dependent MDS assessments. MDS's were expected to be submitted 14 days after completion. The Administrator was not aware the assessments were over 100 days late. 10 NYCRR 415.11

Based on observations, interviews, and record reviews conducted during the COVID-19 Infection Control Focus Survey completed on 6/2/22, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of COVID-19. Specifically, the facility did not implement the contingency plan for Health Care Personnel (HCP) (Facility Screener) with a medical exemption as evidence by not requiring a medically exempt HCP to wear an N95 mask and goggles or face shield at all times during working hours (except when eating). Additionally, a hairdresser was observed not wearing a surgical mask while cutting unmasked residents' (hair (within 6 feet); and an unmasked activity aide was observed conversing with an unmasked resident (within 6 feet). The findings are: The Centers for Medicare & Medicaid Services (CMS) Infection Prevention, Control & Immunizations (January 2022) documents Personal Protective Equipment (PPE) Use for Standard Precautions: All staff are following appropriate source control (e.g., facemasks or respirators) in accordance with national standards; Requiring staff who have not completed their primary vaccination series (including those who have a pending request or been granted an exemption or who have a temporary delay) to use a National Institute for Occupational Safety and Health (NIOSH)-approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with residents. This included resident #1, 2, and 4. The facility policy and procedure (P&P) titled COVID-19 Mandatory Vaccinations HCP revised 2/4/22 documented, if the HCP meet the requirements for an accommodation/ exemption, they will also need to follow the facility HCP policy regarding PPE, i.e., N95 mask and googles or face shield during working hours at all times. Unvaccinated staff will only remove their N95 to eat and then replace promptly when finished. The facility P&P titled COVID-19 Core Infection Prevention and Control Measures revised 2/26/22 documented HCP should wear well-fitting source control at all times when they are in the healthcare facility; Fully vaccinated HCP should wear respirator or well-fitting facemask throughout their entire work shift. During an interview on 6/2/22 at 8:45 AM, the Director of Nursing (DON) stated the facility census was 152 with a bed capacity of 160. There were no active COVID-19 infections. 1. During an observation on 6/2/22 at 8:30 AM, the Facility Screener was observed wearing a surgical mask and no face shield or goggles. Review of the facility document titled COVID-19 Vaccination Medical Accommodation/Exemption Form signed and dated 2/10/22 by the Facility Screener and a physician documented the employee was granted a medical exemption for the Pfizer, Moderna, and [NAME] COVID-19 vaccinations. During an interview on 6/2/22 at 10:24 AM, the Facility Screener, wearing a surgical mask and no face shield or goggles, stated they were required to wear a N95 mask at all times while in the facility, and they did not have a good excuse as to why they were not wearing a N95 mask. Additionally, the Facility Screener stated they were required to wear eye protection if they were providing direct resident care. During an interview on 6/2/22 at 11:04 AM, the Infection Preventionist (IP) stated the Facility Screener was not fully vaccinated for COVID-19 and was required to wear a N95 and eye protection at all times while in the facility to help mitigate the spread of COVID-19. During an interview on 6/2/22 at 11:15 AM, the DON stated any employee with a medical exemption was required to wear a N95 mask and eye protection to decrease the risk of COVID-19 transmission. 2. Resident #2 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The undated facility resident vaccination matrix documented Resident #2 was fully vaccinated and had received a booster vaccination for COVID-19. Resident #1 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The undated facility resident vaccination matrix documented Resident #1 was fully vaccinated and had received a booster vaccination for COVID-19. During an observation on 6/2/22 at 10:14 AM, the unmasked hairdresser was observed in the beauty salon, within 6 feet of unmasked Resident #2, conversing with Resident #2. During an observation on 6/2/22 at 10:37 AM, the unmasked hairdresser was observed in the beauty salon, within 6 feet of unmasked Resident #2, cutting and styling Resident #2's hair. During an observation on 6/2/22 at 10:56 AM the unmasked hairdresser was observed in the beauty salon, within 6 feet of unmasked Resident #1 using electric clippers to style the resident's hair. Review of the undated facility staff vaccination matrix documented the hairdresser was fully vaccinated for COVID-19. During an interview on 6/2/22 at 10:17 AM, the hairdresser stated they wear their surgical mask when on resident care units, and they should probably wear it while in the beauty salon. During an interview on 6/2/22 at 11:04 AM, the IP stated the hairdresser was required to wear a surgical mask at all times while in facility as part of the Infection Control Plan. During an interview on 6/2/22 at 11:15 AM, the DON stated all staff are required to wear a surgical mask at all times while in the facility to decrease the risk of COVID-19 transmission. 3. Resident #4 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The undated facility resident vaccination matrix documents Resident #4 was fully vaccinated and had received a booster vaccination for COVID-19. During a continuous observation on 6/2/22, between 10:23 AM and 10:37 AM, the unmasked Activity Aide was conversing within 6 feet of unmasked Resident #4 in the gift shop. Review of the undated facility staff vaccination matrix documented the Activity Aide was fully vaccinated for COVID-19. During an interview on 6/2/22 at 10:37 AM, the Activity Aide stated they were required to wear a surgical mask at all times in the facility, except when eating or drinking. Additionally, the Activity Aide stated that it was easier for Resident #4 to hear them without wearing the surgical mask. During an interview on 6/2/22 at 11:04 AM, the IP stated the Activity Aide was required to wear a surgical mask at all times while in facility as part of the Infection Control Plan. During an interview on 6/2/22 at 11:15 AM, the DON stated all staff are required to wear a surgical mask at all times while in the facility to decrease the risk of COVID-19 transmission. 415.19(a)(1)

Based on interview and record review conducted during the Standard survey completed on 11/3/21, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees A, B, C, D) of nine employees reviewed who were hired in the last four months and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their employment. The findings are: The facility's policy and procedure titled, Abuse Prevention, revised 3/12/21, documented that all potential employees are screened for a history of abuse, neglect, or mistreating residents/patients during the hiring process. Screening will consist of, but not be limited to, inquiries into the state nurse aide registry. 1a. Review of the personnel file for Employee A (Temporary Nurse Aide) on 10/29/21 revealed Employee A was hired (start date) on 10/5/21 and the New York State Nurse Aide Registry Verification Report was dated 10/29/21. During an interview on 11/1/21 at 3:25 PM, the Senior Executive Assistant stated Employee A worked as a full-time Temporary Nurse Aide on Unit 1 on the 7:00 AM to 3:00 PM shift. 1b. Review of the personnel file for Employee B (Activities Aide) on 11/1/21 revealed Employee B was hired (start date) on 10/5/21 and the New York State Nurse Aide Registry Verification Report was dated 11/1/21. During an interview on 11/1/21 at 3:25 PM, the Senior Executive Assistant stated Employee B worked as a full-time Activities Aide throughout all four resident units on the 9:00 AM to 5:00 PM shift. 1c. Review of the personnel file for Employee C (Social Work Assistant) on 11/1/21 revealed Employee C was hired (start date) on 10/12/21 and the New York State Nurse Aide Registry Verification Report was dated 11/1/21. During an interview on 11/1/21 at 3:25 PM, the Senior Executive Assistant stated Employee C worked as a part-time Social Work Assistant on the 9:00 AM to 2:00 PM shift and has the potential to work with all skilled nursing residents. 1d. Review of the personnel file for Employee D (Country Store Attendant) on 11/1/21 revealed Employee D was hired (start date) on 10/12/21 and the New York State Nurse Aide Registry Verification Report was dated 11/1/21. During an interview on 11/1/21 at 3:25 PM, the Senior Executive Assistant stated Employee D worked as a part-time Country Store Attendant in various four-hour shifts during daytime hours, and the Country Store was open to skilled nursing residents. During an interview on 11/1/21 at 2:25 PM, the Senior Executive Assistant stated it was the responsibility of the Human Resources (HR) staff to check the New York State Nurse Aide Registry for all new hires, but HR staff left employment at this facility in September 2021. The Senior Executive Assistant stated it was not clear who took over the responsibility of Nurse Aide Registry checks in the absence of HR staff. During an interview on 11/3/21 at 12:00 PM, the Administrator stated the purpose of checking all new hires on the New York State Nurse Aide Registry was to see if that person ever worked as a Certified Nurse Aide and if that person had any abuse findings in their past. Additionally, the Administrator stated the facility missed the nurse aide registry checks on new hires because HR unexpectedly left their position at the end of September or early October 2021. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview, and record review conducted during the Standard survey completed 11/3/21, the facility did not ensure that the residents' environment remains as free from accident hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents. Four (Units 1,3,4,5) of four resident care units had issues with water temperatures exceeding 120 degrees Fahrenheit (°F) in resident rooms and care areas. In addition, one (Resident #117) of two residents reviewed for accidents had an issue involving a resident smoking without supervision and lacked completion of timely smoking assessment. The findings are: 1) The facility's undated policy and procedure called, Hot Water Temperatures and Testing, documented that the facility will provide a consistently controlled domestic hot water temperature throughout the facility that prevents residents, visitors, and staff from injury due to scalding. Also, water temperatures will be maintained between 100 and 120 degrees and temperatures that exceed 120 degrees will require an investigation and resolution by Maintenance personnel. Additionally, any area(s) affected with high readings will be closed for use until the problem is resolved. Review of the facility's Water Management Plan, dated 7/2/21, revealed it contained a description of the facility's hot water heating and distribution system. It stated cold water enters two 800-gallon heat exchangers and is heated to a temperature of 145 degrees, one loop goes directly to dietary and housekeeping, the second loop goes through a mixing valve and is reduced down to 115 degrees and sent to domestic hot water, and both loops are on a constant recirculating system. Observations on 10/28/21 between 9:15 AM and 10:11 AM revealed the following hot water temperatures were obtained in resident rooms and care areas using digital stem-type thermometers: Resident Room #103 - 128.4 °F Resident Room #104 - 130.0 °F Resident Room #109 - 128.4 °F Resident Room #115 - 127.0 °F Resident Room #R-3 - 128.4 °F Shower head Unit 1 Shower Room - 124.0 °F Resident Room #302 - 128.4 °F Resident Room #303 - 127.9 °F Resident Room #304 - 128.3 °F Resident Room #317 - 129.1 °F Resident Room #322 - 127.3 °F Shower head Unit 3 Shower Room - 126.8 °F Resident Room #403 - 128.3 °F Resident Room #406 - 125.0 °F Resident Room #417 - 125.1 °F Resident Room #421 - 130.1 °F Resident Room #502 - 130.6 °F Resident Room #503 - 129.6 °F Resident Room #504 - 126.3 °F Resident Room #514 - 121.5 °F Resident Room #517 - 126.7 °F Shower head in Unit 5 Shower Room - 123.6 °F During an interview on 10/28/21 at 9:50 AM, the Maintenance Director stated the ideal hot water temperature at resident sinks was 112 to 114 °F and if temperatures went over 120 °F, they would adjust the mixing valve. The Maintenance Director added that hot water temperatures should not got over 120 °F because the residents have sensitive skin. Observations in the Boiler Room, at this time and in the presence of the Maintenance Director, revealed the gauge located on the hot water pipe, after passing through the mixing valve, read 125 °F. Immediately, the Surveyor and the Maintenance Director walked to Resident Room 103 and took a hot water temperature from the sink inside Resident Room 103 (126.3 °F) using the Surveyor's digital thermometer. The Maintenance Director stated that temperature was too high. The Maintenance Director added that the mixing valve was installed about one and a half to two years ago and there had been no recent work on it. They added that the mixing valve was a mechanical device, not electrical, and the temperature was set by turning a nut and was not equipped with electrical controls such as temperature limits or alarms. At this time, the Maintenance Director stated hot water temperatures were taken daily by staff on weekdays on each resident unit and recorded in their automated maintenance record-keeping system. Review of the facility's hot water temperature records taken between 10/11/21 through 10/27/21 revealed the hot water temperatures on the resident units ranged from 111 °F to 116 °F during that time period. During an interview on 10/28/21 at 9:58 AM, the Maintenance Director stated they would manually adjust the mixing valve immediately. At this time, the facility increased their hot water monitoring from once daily on weekdays only to three times daily, including weekends. During an interview on 10/28/21 at 10:55 AM, Certified Nurse Aide (CNA) #3 stated sometimes the water does get hot and they have to turn the cold water on. CNA #3 further stated some days the water was hotter than others, and when they washed their hands in the staff bathroom, the water was too hot, but they had not told anyone that the water was hot, they adjusted the water. Observation of hot water temperatures on 11/1/21 between 8:20 AM and 9:30 AM revealed the following hot water temperatures were obtained in resident rooms using digital stem-type thermometers: Resident Room #101 - 122.0 °F Resident Room #308 - 121.1 °F Resident Room #403 - 129.9 °F Resident Room #502 - 122.4 °F Resident Room #514 - 121.6 °F During an interview on 11/1/21 at 8:25 AM, the Maintenance Director stated since 10/28/21, the mixing valve had been adjusted as low as it would go, but there were still some hot water temperatures above 120 °F over the weekend on 10/30/21 and 10/31/21. Observation in the Boiler Room, in the presence of the Maintenance Director, on 11/1/21 at 8:30 AM revealed the digital thermometers on the hot water boilers read 145 °F and 146 °F and the gauge located on the hot water pipe after passing through the mixing valve read 120 °F. At the time of the observation, the Maintenance Director stated the mixing valve had been adjusted to its lowest setting, but some water temperatures were still rising to above 120 °F. The facility planned to lower the set point of the two hot water holding tanks to 130 °F. On 11/1/21 at 9:25 AM, the Maintenance Director stated after reviewing the weekend water temperature logs on Monday morning, there water temperatures that were above 120 °F over the weekend. The Maintenance Director stated they were not of water temperatures above 120 °F over the weekend by the staff members who took the temps, a Maintenance Assistant and two Custodians. The Maintenance Director added that direction was not provided to the Maintenance Assistant or the Custodians as to what to do or who to call if temperatures exceeded 120 °F over the weekend, but the Maintenance Director should have done so. During an interview on 11/1/21 at 9:30 AM, Maintenance Assistant #1 stated they did monitor hot water temperatures over the weekend and the highest temperature reached was 123.4 °F. Additionally, at 11:30 AM, Maintenance Assistant #1 stated they did not call the Maintenance Director, when some water temperatures above 120 °F were identified. Maintenance Assistant #1 added that the Maintenance Director had advised that 120 °F was the upper limit for water temperatures on 10/28/21, when the facility began monitoring water temperatures on each shift, but the Maintenance Director did not provide further instruction. During an interview on 11/3/21 at 11:25 AM, Custodian #1 stated they did monitor hot water temperatures over the weekend. Custodian #1 further stated they did not know what water temperature was too hot and they were given no instruction to call anyone if a certain temperature was reached. During an interview on 11/1/21 at 10:45 AM, the Administrator stated hot water temperatures should not exceed 120 °F. The Administrator stated they were made aware that water temperatures exceeded 120 °F on 10/28/21 and knew that the mixing valve was adjusted at that time. The Administrator also stated water temperatures were stable when they left the faciity on Friday afternoon, they were not aware that water temperatures above 120 °F were identified during the weekend until this morning, and they probably should have been notified at the time the elevated water temperatures were identified over the weekend. During an additional interview on 11/1/21 at 12:15 PM, the Administrator stated they did not communicate any instruction to the staff members who were taking water temperatures and they should have done so. During an interview on 11/01/21 at 11:15 AM, Resident #91 stated the water in the bathroom gets really hot, you can make oatmeal and tea with it. Resident #91 further stated they couldn't recall telling any staff member about it and they knew where to put the dial so the water was right for them. 2) Resident #117 had diagnoses including [CONDITION(S)] (loss of strength or paralysis on one side of the body)- affecting left nondominant side, [CONDITION(S)] (group of diseases that cause airflow blockage and breathing related problems), [MEDICATION(S)] dependence-cigarettes. The Brief Interview for Mental Status (BIMS) dated 4/28/21 revealed Resident #117 scored a 12 indicating moderately impaired cognition. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 9/29/21 for significant change revealed that the resident required extensive assist for locomotion on and off unit and required limited assist for personal hygiene. The facility policy titled Smoking dated 1/21/21 documented that the facility did not permit smoking inside the facility, unless inside the designated smoking room. Smoking was permitted at outside designated area. Residents would be supervised by a staff member. Smoking materials must be retained by facility staff at the area the facility keeps cigarettes/lighters. Residents may not keep smoking materials with them or in their rooms. Smoking materials must be retained by staff, in the designated area. Patient's safety awareness status would be evaluated quarterly or as determined by the interdisciplinary team. Review of Nursing-Smoking evaluation revealed last smoking assessment completed on Resident #117 was on 11/10/17. During an observation on 10/29/21 at 9:34 AM, Resident #117 was outside of the facility exit door, near room #107 on rehab unit, sitting with the back of wheelchair positioned against the brick wall of building, smoking a cigarette. Resident #117 was smoking unsupervised. No facility staff was observed with the resident. During an interview on 10/27/21 at 12:05 PM, Resident #117 stated they go outside every morning to smoke. They keep their cigarette's and lighter in their room. During an interview on 11/2/21 at 2:07 PM, Director of Activities stated no one is to be left unsupervised while smoking. Everyone is observed in the smoking room or outside of the facility, for safety. Smoking used to be allowed outside, off the rehab unit, but was stopped during March or April. The Director of Activities stated Resident #117 doesn't smoke anymore, to my knowledge, and Activities has not had any smoking material for Resident #117 since early summer. During an interview on 11/3/21 at 11:54 AM, Licensed Practical Nurse (LPN) #7 stated smoking materials are kept with activities or locked in the medication room. The smoking area is designated to the smoke room at the front of the building. Resident's do smoke where they aren't supposed to smoke. Residents smoke outside of the rehab unit. During an interview on 11/3/21 at 12:12 PM, LPN #4 stated that resident #117 smoked and occasionally the LPN will hold onto their smoking materials. Smoking outside of the rehab unit, in the courtyard, was allowed prior to COVID and during the summer. During an interview on 11/3/21 at 12:42 PM, LPN #6 stated Resident #117 gave them their cigarettes and lighter that were in their room without a problem on 11/2/21. Resident #117 can leave unit independently and wheel self to and from the smoke room. Resident #117 smoking material was placed inside the locked nursing cart. LPN #6 did not know why or how resident #117 even had smoking stuff in their room. LPN #6 further stated that if a resident left the facility due to being sent to hospital, had a change in level of consciousness or a change in physical ability to manage smoking on their own, a smoking assessment should be done. Resident smoking is to take place in the smoking room in the front of the building past the lobby. During an interview on 11/3/21 at 1:53 PM, Director of Nursing (DON) stated that if a resident smokes, a smoking assessment is completed upon admission and then quarterly. Residents can smoke on the first floor in the smoking room near the staff entrance at the end of the hall. Smoking is also allowed outside in the courtyard, at least 30 feet away from the building, off the rehab unit and outside near smoke room. Residents who smoke are supervised and should not be maintaining their own smoking materials, for safety purposes. The DON stated they do not want other residents to have the ability to access smoking material. During an interview on 11/3/21 at 2:07 PM, the Administrator stated the expectation is that a smoking assessment be done quarterly by nursing staff because resident status can change. Residents are not supposed to have any smoking materials on them. Smoking materials are maintained by the activity department and nursing. 415.12 (h)(2)

Based on observation, interview and record review conducted during the Standard Survey and Complaint (NY 800) completed on 11/3/2021, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, four (Unit 3, 4, 5, and Rehabilitation) of four resident care units did not have adequate staff based on the facility's established minimum number of staff for each unit and each shift. In addition, the Facility Assessment did not address Certified Nursing Assistants (CNAs). The finding is: Review of the Facility Assessment Tool 2021 dated 6/22/21 documented the average daily census 150 - 155 and the facility resources needed to provide competent support and care for the resident population every day and during emergencies include a staffing plan of: Days Shift - 1 Licensed Practical Nurse (LPN) per long term care (LTC) unit and 2 LPN's for rehab unit; Evening shift - 1 Registered Nurse (RN) or LPN Supervisor and 4 LPN's, Night Shift - 1 Registered Nurse (RN) or LPN Supervisor and 4 LPN's. There was no documented evidence of a Certified Nursing Assistant (CNA) Plan in the Facility Assessment Tool. Review of a facility policy titled On Call Procedure for Nurse Coverage and Supervision dated 8/22/2020 documented, to implement an on-call system with nurse managers and the upper nursing management team (Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Nurse) to ensure adequate nurse and aide staffing coverage of nursing units and supervision for all shifts. Additionally, identified by the DON, they (facility) hand wrote the Bare Minimum Staffing requirements for each shift on the policy: 7 AM - 3 PM shift - 4 Nurses and 8 CNAs 3 PM - 11 PM shift - 4 Nurses and 8 CNAs 11 PM - 7 AM shift - 4 Nurses and 4 CNAs. a.) Review of an undated, untitled documented identified by the DON as the current number of residents requiring total assistance with meals was 14 residents; and the total number of residents requiring 2 staff to assist with transferring was 59 residents in the facility. Review of the Daily Nursing Schedule from 9/27/21 through 10/26/21 revealed the facility did not meet their minimum staffing requirements as documented by the DON with a census from 153 to 158 residents per day on the following dates and shifts: -9/27/21 evening shift -9/28/21 night shift -10/1/21 evening shift -10/3/21 day shift -10/4/21 evening shift -10/5/21 day shift and evening shift -10/10/21 evening shift -10/23/21 evening shift During an interview on 11/3/21 at 10:43 AM the Scheduling Coordinator stated the staffing plan for each unit was as follows: Day Shift - 2 nurses and 4 CNA on each unit to equal 8 nurses and 16 CNAs, plus a nursing supervisor. Evening Shift - 2 nurses and 4 CNAs on each unit to equal 8 nurses and 16 CNAs, plus a nursing supervisor. Nights 2 nurses on the rehabilitation unit and 1 nurse on the skilled units and 2 CNAs on each unit to equal 5 nurses and 8 CNAs, plus a nursing supervisor. The Scheduling Coordinator stated for the past year the facility has been having difficulty getting enough staff to meet the Bare Minimum requirements the facility had determined. The Scheduling Coordinator stated, they are aware some shifts are below the facility's minimum number and the DON is aware. The Scheduling Coordinator reviewed the following dates and verified the facility did not meet their minimum staffing requirements for the following dates and times: -On 9/27/21 9:00 PM - 11:00 PM Unit 5 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 9/28/21 11:00 PM - 3:00 AM Unit 3 documented 1 CNA below the minimum number - the facility did not provide 1 CNA to each unit as planned. -On 10/1/21 7:00 PM - 11:00 PM Unit 5 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/3/21 7:00 AM - 11:00 AM Rehabilitation Unit documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/4/21 3:00 PM - 7:00 PM Rehabilitation Unit documented 1 CNA below the minimum number, 7:00 PM - 11:00 PM Unit 3 documented 1 CNA below the minimum number and 9:00 PM - 11:00 PM Unit 5 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/5/21 7:00 AM - 3 PM Rehabilitation Unit 1 CNA below the minimum number and 3:00 PM - 7:00 PM Rehabilitation Unit and Unit 4 documented 1 CNAs below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/10/21 3:00 PM - 4:00 PM Rehabilitation Unit documented 1 CNA below the minimum number and 3:00 PM - 7:00 PM Unit 3 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. -On 10/23/21 3:00 PM - 5:00 PM Unit 5 documented 1 CNA below the minimum number - the facility did not provide 2 CNAs to each unit as planned. During an interview on 11/3/21 at 11:17 AM, the DON stated they were not aware the facility was below the minimum staffing numbers on all the identified dates (dates listed above). At 11:33 AM the DON stated they were aware the residents have voiced complaints there was not enough staff to provide care (what kind of care). During interview on 11/3/21 at 12:03 PM, the Scheduling Coordinator stated the facility's minimum staffing numbers for the resident care units was approximately a ratio of 1 CNA to 20 residents and believes it was not feasible for day and evening shift staff to provide all the care required by the plan of care for all residents. During an interview on 11/3/21 at 12:19 PM, the Administrator verified the facility's minimum staffing numbers to be correct as written by the DON. The Administrator stated they were not aware the facility was not meeting their minimum staffing numbers and should have been notified to prevent being below the facility's minimum staffing requirements. The Administrator stated they do not believe all aspects of resident care such as showers can be accomplished with a staffing ratio of approximately 1 CNA to 20 residents on the day and evening shifts. b.) During continuous observations on 11/2/21 from 9:06 AM to 10:45 AM and 10:55 AM to11:53 AM Resident #76 self-propelled in their wheelchair around the unit or sat in their wheelchair near the nurse's station, wearing a maroon shirt and light gray pants. The resident was not toileted or changed during this timeframe. At 11:53 AM the resident self-propelled back to nurse's station and was noted to be visibly soiled in their groin region, their light gray pants were dark gray, and the resident had a urine odor. The resident continued to sit in their wheelchair near the nurse's station. At 12:26 PM LPN #3 told CNA #2 that Resident #76 needed to be changed. During an interview on 11/2/21 at 12:27 PM, CNA #2 stated they got Resident #76 out of bed around 8:00 AM and hadn't toileted or changed them since that time. The CNA #2 stated Resident #76 was always incontinent, and CNA #2 hadn't had time to toilet the resident because there were 14 residents on their assignment that were mostly mechanical lifts and two assist transfers. c.) Review of Resident Council Minutes dated 9/28/21 documented, residents voiced concerns call lights were not being answered, long wait times for call lights to be answered and waiting over 30 min to have incontinent care provided. During the Resident Council Meeting on 10/27/21 at 2:15 PM, revealed residents stated there was not enough staff; they were waiting too long for call lights to be answered; and when only 2 CNAs are assigned on a unit, showers were not able to be provided. In addition, residents voiced concerns there was only 1 CNA scheduled on Unit 3 for the entire floor at times. d.) Additional interviews: During an interview on 10/27/21 at 12:26 PM, Resident #92 stated the facility was short staff and sometimes they wait 1 - 2 hours for staff to provide assistance for toileting. During a confidential interview on 10/29/21 at 12:50 PM, a family member of a resident stated the facility does not have enough staff and recalled their loved one was still in bed 20 minutes before supper during a visit because there was only one CNA working on the unit. During an interview on 11/2/21 at 8:23 AM, CNA #8 stated they only have 2 CNAs right now. CNA #8 stated the facility was very short staffed and frequently we are unable to get all the residents out of bed. During an interview on 11/2/21 at 8:30 AM, CNA #5 stated the staffing was terrible and they frequently work short staffed. Usually working with two CNAs on the evening shift and one CNA on the night shift. CNA #5 stated sometimes showers were not provided because there was not enough time, and some residents don't get turned and positioned timely. During an interview on 11/2/21 at 1:10 PM, LPN #3 stated they've had several communications with the DON and ADON about staffing issues and they were told Administration was working on it. Some days they work with two CNAs and two nurses on the floor, and they can't get all the meal trays passed and residents fed. LPN #3 stated staffing has been an issue for a long time and residents aren't getting the care they need. During an interview on 11/2/21 at 1:18 PM, LPN Unit Manager (UM) #2 stated sometimes there are only 2 CNAs on the unit, the expected care was impossible to provide, and the facility was still taking new admissions. During an interview on 11/3/21 at 8:41 AM, CNA #2 stated they have worked alone as the only aide on day shift on the rehab unit a few times. The nurses help when they can, but showers don't get done, oral care does not get completed, and the incontinent residents only got checked once per shift. During a confidential interview on 11/3/21 at 9:01 AM, a family member of a resident stated the facility does not have enough CNAs and Nurses to provide care; causing the call lights not being answered timely and insulin administered late. During an interview on 11/3/21 at 9:11 AM, CNA # 3 stated they worked alone on the rehabilitation unit on 10/3/21 until approximately 11:00 AM and was not able to provide oral care and get all the residents out of bed that should have been. CNA #3 stated they frequently were unable to provide showers to residents because of being short staffed. During an interview on 11/3/21 at 9:30 AM, RN # 3 stated the facility was frequently short staffed. RN #3 stated there were some days the residents were unable to get up at 6:00 AM per their request and some residents were not gotten out of bed at all. During an interview on 11/3/21 at 9:56 AM, CNA # 6 stated the facility was frequently short staffed. Working with 2 CNAs on the evening shift and 1 CNA on the night shift does not allow all residents to receive oral care and ROM (range of motion) to those who require it and timely incontinent care. 415.13(a)(1)(i-iii)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY 885) during the Standard survey completed on 11/3/21, the facility did not ensure that a resident has a right to choose health care and providers of health care services consistent with his or her assessments and plan of care, including arranging transportation to outside medical appointments for one (Resident #131) of two residents reviewed for choices. Specifically, the resident missed two neurological appointments on 7/2/21 including an imaging scan and provider follow up. The finding is: The facility policy and procedure titled Consultations dated 7/2017 documented the facility would obtain additional assessment from an outside source for a resident to assist in care and treatment. Prior to consult they would secure an order with consultant's name, specialty, and reason for consult and make transportation arrangements. On the day of the appointment, they would document the resident's departure to see consultant, mode of transportation, with whom, etc. in nurse's notes. 1. Resident #131 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 9/30/21 documented Resident #131 was cognitively impaired and required total assist for locomotion (how resident moved between locations in their room and corridor). Review of the Care Plan Activity Report effective 4/15/21 revealed Resident #131 had neurological diseases: [CONDITION(S)] and was at risk for falls due to a malignant brain tumor. Review of the Appointment Note (from the neurologist's office) dated 5/21/21 documented Resident #131's next appointment was on 7/2/21 at 11:30 AM. Review of the Appointment Request Form dated 5/21 revealed Resident #131 had a follow up appointment scheduled on 7/2/21 at 11:30 AM for a CT (computed tomography) scan, then an MD appointment after the scan. The form did not document which transportation company was to be used or a pick-up time. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing Progress Notes dated 7/2/21 revealed there was no documentation Resident #131 was transported to a neurology appointment on that date or that the appointment was rescheduled. During an interview on 11/1/21 at 12:36 PM, Licensed Practical Nurse (LPN) Unit Manager (UM) #1 stated when a resident had an appointment, they would fill out a form and send it to the scheduler, who then would set up transportation. The LPN UM #1 stated when Resident #131 came back from an appointment, it would say on their paperwork if there was a follow up appointment, and the LPN UM #1 wasn't aware of any missed appointments. LPN UM #1 stated Resident #131 was transported to appointments via non-emergency ambulance because their chair didn't fit in a wheelchair van. During an interview on 11/2/21 at 8:30 AM, the LPN UM #1 reviewed the nurse progress notes and stated they didn't know if Resident #131 made it to any appointments on 7/2/21, the consultation order said the resident had an appointment on that date but that didn't mean they actually went to the appointment. The LPN UM #1 stated there might have been a transportation issue and didn't know if the transportation was scheduled or not. During a telephone interview on 11/2/21 at 9:11 AM, the Neurooncology Nurse Care Coordinator (from the neurologist's office) stated the resident had two no shows on 7/2/21, which meant no imaging (CT/MRI) was done and the follow up with the provider was also not done that day. During a telephone interview on 11/2/21 at 12:04 PM, the per diem Resident Scheduler stated they remembered the resident's transportation needed to be changed at some point over the summer and they required a stretcher for appointments. They didn't know for certain if the resident's July 2nd transportation was set up as they did not have documentation to review during this interview. The Resident Scheduler stated if the resident didn't make it to the appointment on 7/2, there was probably a miscommunication and that the Unit Managers should have filled out the appointment request form. During an interview on 11/3/21 at 9:17 AM, the current Resident Scheduler reviewed the Appointment Request Forms for Resident #131 and stated they couldn't tell from the forms if transport was set up for the appointments on 7/2/21 as they didn't see a pick-up time or transport company listed. The Patient Scheduler stated there might have been a change in the type of transport the resident needed, but it should have been worked out in time for the appointment. The Patient Scheduler stated they did not have the appointment list for July. During an interview on 11/3/21 at 11:07 AM, the Physician's Assistant (PA) stated the resident went to a lot of specialists' appointments due to their history of brain cancer, traumatic brain injury (TBI) and had frequent MRIs (magnetic resonance imaging) and CT scans to monitor a subdural hematoma. The PA stated it was important that the resident attended these specialists appointments because they were the ones that primarily managed those conditions and would make changes if needed. The PA stated the facility needed to make sure the resident made it to their appointments. During an interview on 11/3/21 at 11:59 AM, the Director of Nursing (DON) stated if they knew about the 7/2/21 appointments then the DON would have expected the Scheduler to set it up for the resident. The DON stated if there was no nurse's note about the appointment, it was possible it was an error, and the Scheduler didn't make the transportation appointment at all. During an interview on 11/3/21 at 12:47 PM, the Administrator stated they don't know why the resident's July appointment was missed, and it was the Scheduler's responsibility to arrange transportation. The Administrator stated there was nobody that oversaw that the Scheduler made the transportation arrangements and that process needed to be tightened up. The Administrator also stated there may have been lack of communication as to the type of transportation the resident needed for their appointments. 415.5(b)(1)

Based on interview and record review during a Complaint investigation (Complaint #NY 939) during the Standard survey completed on 11/3/21, the facility did not ensure that all alleged violations involving abuse are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, to appropriate officials (including the State Survey Agency) for two (Resident #36, 62) of four residents reviewed for alleged abuse. Specifically, an alleged incident of sexual abuse was not reported timely to the New York State Department of Health (NYS DOH) within the two-hour timeframe as required. The findings are: Review of facility policy and procedure (P&P) titled Abuse Policy revised 3/2021 documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing (DON) immediately and initiate gathering requested information. An investigation must be directed by the Administrator or designee immediately. The Administrator, DON, or designee shall notify the DOH, via the Event Reporting System electronically, or by phone in the event of the electronic system being unavailable within two hours of knowledge of the alleged incident. 1. Resident #62 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #36 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident was cognitively intact. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a facility investigation dated 8/23/21 at 5:00 PM documented that on 8/23/21, at approximately 5:00 PM, Resident #36 was witnessed by Certified Nursing Aide (CNA) touching Resident #62 breast/chest area in the hallway. Both residents were fully clothed. Resident #36 stated Resident #62 told me to do it. Resident #62 could not answer questions, appropriately, when questioned. The residents were immediately separated, assessed by a Registered Nurse (RN) and placed on 15- minute safety checks. Resident #36 was provided with health teaching/education. A police report was filed for inappropriate touching. Review of the NYS DOH Automated Complaint Tracking System Complaint/Incident Investigation Report revealed; Date/Time of occurrence: 8/23/21 at 5:00 PM. Submitted by facility: 8/24/21 at 1:41 PM. During an interview on 11/3/21 at 12:26 PM, the DON stated that they (the DON) were immediately informed, the evening of the incident, by the Registered Nurse (RN) Supervisor on duty. The DON stated they were aware of regulatory reporting requirements. Additionally, the DON stated that is my fault. I guess I wasn't looking at it as abuse because it was inappropriate touching, in a common place, and the residents were fully clothed. I could not rule out that Resident #62 did not take Resident #36 hand and place it on their shirt when it was witnessed by the CNA. During an interview on 11/3/21 at 1:41 PM, the Administrator stated they were aware of the incident and depending on the time we find out about an allegation it should be reported within two hours, as required. 415.4(b)(4)

Based on observation, interview, and record review conducted during the Standard survey completed on 11/3/21, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain personal hygiene for two (Residents #76 and 135) of five residents reviewed for ADLs. Specifically, the lack of timely toileting/changing of an incontinent resident (Resident #76) and lack of proper hand hygiene and glove changes during incontinence care (Residents #76 and 135). The findings are: The facility policy and procedure (P&P) titled Hand Hygiene dated 12/2020 documented single use disposable gloves should be used when anticipating contact with blood or body fluids and staff were to perform hand hygiene for the following situations: before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's skin, after contact with bodily fluids, and after removing gloves. The facility P&P titled Bladder and Bowel Incontinence Care dated 2/2020 documented the policy was to prevent breakdown due to incontinence and keep perineal area clean, dry and odor free. The staff were to wash hands, don gloves, clean perineal area with washcloth, wash front to back, dry thoroughly, apply moisture barrier cream and a new incontinence brief. Reposition resident to ensure safety, place call bell in reach, then remove gloves, dispose of soiled items then wash hands. The policy did not include changing gloves and washing hands after providing the incontinence care before touching clean items in the resident's environment. 1. Resident #76 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 9/8/21 documented Resident #76 was cognitively impaired, was totally dependent on staff for toileting, was occasionally incontinent of bladder, always incontinent of bowel, and was at risk for developing pressure ulcers. Review of the Care Plan Activity Report effective 6/3/21 revealed Resident #76 had urinary incontinence. Interventions included bedpan upon waking, after meals, at bedtime and as needed (PRN). The resident also had impaired skin integrity moisture associated skin damage (MASD-redness/excoriation to abdominal folds and buttocks). Review of the Certified Nurse Aide (CNA) Assignments Summary dated 11/2/21 revealed Resident #76 was totally dependent on staff for toilet use and was incontinent, bedpan upon waking, after meals, at bedtime and PRN. During continuous observation on 11/2/21 from 9:06 AM to 10:45 AM and 10:55 AM to11:53 AM Resident #76 self-propelled in their wheelchair around the unit or sat in their wheelchair near the nurse's station, wearing a maroon shirt and light gray pants. The resident was not toileted or changed during this timeframe. At 11:53 AM the resident self-propelled back to nurse's station and was noted to be visibly soiled in their groin region, their light gray pants were dark gray, and the resident had a urine odor. The resident continued to sit in their wheelchair near the nurse's station. At 12:26 PM Licensed Practical Nurse (LPN) #3 told CNA #2 that Resident #76 needed to be changed. During an interview on 11/2/21 at 12:27 PM, CNA #2 stated they got Resident #76 out of bed around 8:00 AM and hadn't toileted or changed them since that time. The CNA #2 stated Resident #76 was always incontinent and CNA #2 hadn't had time to toilet the resident because there were 14 residents on their assignment that were mostly mechanical lifts and two assist transfers. During an observation of incontinence care on 11/2/21 at 12:34 PM, CNA #2 and CNA #9 donned (put on) gloves and transferred Resident #76 into bed with a mechanical lift. The CNAs then turned the resident onto their right side and CNA #2 removed the pants and brief which was saturated with urine and a moderate amount of stool. The resident's skin on buttocks and upper thighs was moist, red, with excoriated areas and indented lines where the brief had been wrinkled underneath the resident. Resident #76's pants were soaked through and the mechanical lift sling that was under the resident while in the wheelchair was also wet. CNA #2 provided urinary and bowel incontinence care using a wet washcloth. CNA #2 did not remove their gloves and wash their hands after incontinence care was completed. CNA #2 wore the same gloves and proceeded to apply a clean brief and pants to Resident #76. LPN #3 was in the room and stated the resident had an excoriated area on their buttocks that they had been putting cream on. CNA #2 wore the same gloves and put a clean sling under the resident, hooked it to the mechanical lift, used the bed remote to put the head of bed up, and touched the wheelchair handles to position it for the transfer. Once Resident #76 was back in their wheelchair, the CNA #2 applied the nasal cannula tubing to the resident's nose. The CNA #2 then removed their gloves and washed their hands. During an interview on 11/2/21 at 1:05 PM, CNA #2 stated they didn't change their gloves and wash their hands, but they should have because they touched dirty stuff and then touched clean stuff. The CNA #2 stated they should have used clean hands to apply the resident's oxygen tubing. During an interview on 11/2/21 at 1:10 PM, LPN #3 stated the resident was up before breakfast, should have been changed sooner and should not have been soaked through. LPN #3 stated they only had three aides on the unit today, it was difficult to get everything done, and that they really needed at least four aides on the unit because they had many mechanical lifts and incontinent residents and not a lot of independent residents. During an interview on 11/2/21 at 1:21 PM, LPN Unit Manager (UM) #2 stated Resident #76 was care planned for toileting upon waking, after meals, at bedtime and as needed. The LPN UM #2 stated they expected staff to change the resident prior to being visibly soiled and that the nurses on the unit should make sure CNAs were toileting the residents as care planned, but a lot of times those nurses were helping with hands on care because they didn't have enough CNAs. During an interview on 11/3/21 at 9:36 AM, the Registered Nurse (RN) Infection Preventionist (IP) stated the CNA should have removed the gloves, washed their hands and put on a new pair of gloves prior to touching clean items in the resident's room, including the clean brief, clothing, wheelchair handles and oxygen tubing in order to prevent transmission of germs. During an interview on 11/3/21 at 11:51 AM, the Director of Nursing (DON) stated Resident #76 should have been changed before they were visibly soiled and sitting in urine for too long could cause skin breakdown. The DON stated the resident should have been changed after breakfast and usually incontinent residents are changed every 2-3 hours. 2. Resident #135 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #135 was cognitively impaired, was totally dependent on staff for toileting, and was always incontinent of bowel and bladder. Review of the Care Plan Activity Report effective 7/24/18 (identified as current) revealed Resident #135 had urinary incontinence. Interventions included to check and change the resident every 2-3 hours and prn when out of bed and to provide peri care with each episode of incontinence to ensure skin, linens, and clothing are clean and dry. During observation of incontinence care on 10/29/21 at 11:28 AM, CNA #1 donned gloves and turned Resident #135 onto their left side while CNA #9 assisted to keep the resident on their side. The resident's brief was soiled with stool. CNA #1 provided bowel incontinence care using a washcloth. The CNA #1 rinsed and dried the resident's skin then applied a [MEDICATION(S)]-based barrier cream using their left hand. CNA #1 removed their left glove and kept the right hand glove on (the hand used to wipe/clean the resident's buttocks) and did not wash their hands. CNA #1 applied a new brief and the resident's pants, then removed their right glove. CNA #1 did not wash their hands and opened the closet doors, touched the bed control to put the bed in low position, placed a fleece blanket on the resident, put the call light within the resident's reach, and touched the handles of the mechanical lift to move it out of the way. CNA #1 then washed their hands. During an interview on 10/29/21 at 11:52 AM, CNA #1 stated they weren't taught when to change their gloves, they took the left glove off because it had barrier cream on it. CNA #1 stated the other glove wasn't visibly soiled, so they got confused about when to remove their gloves and wash their hands. During an interview on 11/1/21 at 12:30 PM, the LPN UM #2 stated they expected CNAs to change their gloves and wash hands after they change a resident's soiled brief, and the CNA should not have touched the clean items without washing their hands first. During an interview on 11/3/21 at 9:32 AM, the RN IP stated they expected staff to change gloves and wash their hands after providing fecal incontinence care, prior to touching clean items to prevent transmission of germs. During an interview on 11/3/21 at 11:49 AM, the DON stated they expected the staff to take their gloves off and wash their hands after incontinence care for infection control purposes because they don't know what germs they are leaving behind on those clean surfaces. 415.12 (a)(3)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 845) completed on 8/17/17, the facility did not ensure that residents received the necessary care and services to attain and maintain the resident's highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. Specifically, one (Resident #1) of three residents reviewed for quality of care related to consultation services had an issue involving more than a two-month delay obtaining an angiogram (surgical procedure to evaluate blood flow) as recommended by a Vascular Surgeon. In addition, there was an ongoing lack of a Registered Nurse (RN) Assessment of the resident's pain and declining vascular status. The resident's Comprehensive Care Plan (CCP) did not address the resident's pain and chronic [MEDICAL CONDITION] ([MEDICAL CONDITION], poor circulation of the lower extremities). The resident required emergency surgery that resulted in an above the knee amputation of the left lower extremity. This resulted in actual harm that is not immediate jeopardy. The findings are: 1. Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/28/17 revealed that the resident was cognitively intact and sometimes understands and is understood. Review of the MDS dated [DATE] revealed the resident was on scheduled and as needed pain (PRN) medication for occasional pain and the resident's pain was documented as limiting her day-to-day activity. Additional review of the MDS dated [DATE] revealed the resident was on scheduled and PRN pain medication for frequent severe pain which limited her day-to day activity and made it hard for her to sleep at night. Review of a Care Plan Activity Report dated 8/11/17 revealed there was no care plan development for pain or [MEDICAL CONDITION]. Review of physician's orders [REDACTED]. Review of a Nursing Progress Note dated 4/25/17 revealed the resident was examined by the Nurse Practitioner (NP) for an acute visit. The resident's L (left) foot noted to be purple. Upon examination, it was noted that pedal (foot) pulses were faint. Resident also c/o (complained of) pain in legs and shoulders. N.O. (new orders) resident needs a vascular surgeon appointment ASAP (as soon as possible). Discontinue current [MEDICATION NAME] order and start [MEDICATION NAME] 50 milligrams twice daily. Review of a Vascular Consultant Nurse Practitioners Progress Note dated 5/12/17 revealed the resident was evaluated for left foot pain, swelling and discoloration. The note documents the resident seems to be having worsening symptoms related to her [MEDICAL CONDITION] including short distance claudication (pain caused by too little blood flow, usually during exercise) symptoms as well as worsening ischemic rest pain (pain associated with decreased blood flow while at rest). Additionally, the resident reports she has been taking pain medication at night to allow her to sleep. Review of a Vascular Surgeon Consult dated 5/12/17 revealed the resident was evaluated for ischemic (restriction in blood supply) left foot pain. The consultant documented that the resident needed a left femoral angiogram and a possible bypass in future. The plan was for the resident to continue with pain meds as needed and to call and arrange the angiogram. Dependency better for foot than elevation. Review of a Nursing Progress Note dated 5/13/17 at 3:17 AM by Licensed Practical Nurse (LPN #2) revealed the resident had increased complaints of pain and discomfort to mid lower back as well as the left foot, medicated with Tylenol, minimal effect noted. Review of a Nursing Progress Note dated 5/16/17 at 11:45 AM by LPN #1 Nurse Manager revealed a late entry was documented for 5/12/17; resident was seen by vascular surgery, resident has an upcoming appt (appointment) for a L (left) femoral angiogram. N.O. (new orders) for house lotion and daily foot checks. Review of the entire medical record revealed preoperative instructions were not located in the resident's medical record. Review of the preoperative instructions dated 5/15/17 which were obtained from the Vascular Surgery office by the Surveyor on 8/14/17 revealed the resident was scheduled for a left femoral angiogram on 5/22/17 at 11:45 AM with an arrival time of 9:45 AM. The instructions included the resident could not eat six hours prior to the procedure or drink two hours prior to the procedure. Review of a physician progress notes [REDACTED]. The physical examination revealed the resident had mild acrocyanosis (blue or cyanotic discoloration) in the lower extremities with absent dorsal (upper side of foot) pulses and limited tibial pulses. The resident is scheduled to have an angiogram of the left leg due to severe [MEDICAL CONDITION]. The note does not address a pain control plan for the resident. Review of a physician's orders [REDACTED]. Review of a Nursing Progress Note dated 5/22/17 revealed the resident left for a Physician's appointment at 9:00 AM. Review of a Vascular Surgery Note dated 5/22/17 at 11:45 AM, obtained by the Surveyor from the provider on 8/14/17, revealed the left femoral angiogram could not be completed because the resident ate breakfast at 8:00 AM. Review of a Certified Nursing Aide (CNA) Documentation History Detail dated 5/22/17 revealed the resident ate 100% (percent) of her breakfast. During an interview on 8/9/17 at approximately 2:23 PM, LPN #1 Nurse Manager stated the resident was scheduled for an angiogram on two separate occasions but the angiograms were not completed because staff had fed the resident breakfast on the day of the scheduled procedures. The LPN Nurse Manager could not recall the exact dates of the procedures. LPN #1 Nurse Manager further stated that a facility scheduler makes the consult/ procedure appointments and makes arrangements for transportation for appointments out of facility, keeps track of them, and distributes the appointment list weekly to each Nursing Unit. The Nurse Manager stated when the appointment list is delivered to the unit she gets the resident(s) ready for the appointment. If a resident is to be NPO (nothing by mouth) for an appointment, the order would be transcribed into the physician's orders [REDACTED]. The LPN Nurse Manager stated it is her responsibility to place the pre-operative NPO order in the medical record. In addition, if someone is NPO it should be on the 24-hour report. During an additional interview on 8/10/17 at 2:50 PM, LPN #1 Nurse Manager stated a pre-op form was sent to the facility and she recalled seeing the form. LPN #1 further stated once she reviewed the form she threw it away. The LPN Nurse Manager stated there was a delay in scheduling the appointment because the resident required an earlier appointment due to transportation issues. Interview on 8/10/17 at approximately 11:00 AM with the Director of Nursing (DON) revealed there should be a physician's orders [REDACTED]. During an additional interview on 8/10/17 at approximately 2:40 PM, the DON stated that for a left femoral angiogram, the orders should come on the consult form and the Nurse Manager would enter the physician's orders [REDACTED]. Further review of the Nursing Progress Notes revealed the following: - 5/29/17 at 4:11 AM by LPN #2 revealed the resident was having complaints of increased severe pain to her left foot, as needed Tylenol given with little to no effect. - 5/29/17 at 9:23 PM by an agency LPN revealed the resident's left lower extremity appears very dark purple- cold to touch. No open areas or drainage present. Resident complains of some pain to site. Positive pedal pulses, extremity elevated. - 5/30/17 at 2:52 AM by LPN #2 revealed the resident experienced severe pain to the left foot and was medicated with Tylenol at 2:00 AM with little to no effect. - 5/31/17 at 6:27 AM by LPN #2, Resident had increased severe pain to the left foot, as needed Tylenol given at 6:00 AM, with no effect thus far. - 6/1/17 at 9:09 PM by an agency LPN, revealed the resident experienced severe amounts of pain in extremity, resident's left foot very dark purple/ blue color. Medicated with scheduled [MEDICATION NAME] and as needed Tylenol. Review of an Acute Visit physician progress notes [REDACTED]. Further review of the Nursing Progress Notes revealed the following: - 6/2/17 at 2:44 AM by LPN #2 revealed the resident experienced severe pain/discomfort to left foot. PRN Tylenol given with little to no effect. - 6/5/17 at 10:50 PM by an agency LPN revealed the resident had complaints of left foot pain and burning, foot red and slightly warm to touch Scheduled and PRN pain meds administered. Review of an Interval Visit physician progress notes [REDACTED]. Review of the Nursing Progress Notes dated 6/9/17 at 2:21 PM by LPN #2 revealed the resident continues to have increased severe pain/discomfort to left foot. Left foot purple in color. Review of 6/12/17 Interval Visit physician progress notes [REDACTED]. Continued review of the Nursing Progress Notes revealed the following: - 6/19/17 at 1:44 PM by an agency LPN revealed the resident's left foot remains purple/blue in color and was painful to touch - 6/21/17 at 12:17 AM by LPN #2 revealed the resident continues to experience severe pain to her left foot. Scheduled pain medications and PRN pain meds given with little to no effect. Purple in color, open areas noted on left great toe and second toe. Review of the Vascular Surgery note dated 6/28/17 obtained by Surveyor from the provider revealed the left femoral angiogram was canceled; no reason was provided. The resident's medical record, and Physician Notes did not have any information regarding the rescheduled angiogram for 6/28/17. Review of a CNA Documentation History Detail dated 6/28/17 revealed the resident ate 50% of her breakfast Continued review of the Nursing Progress Notes revealed the following: - 7/3/17 at 12:32 AM by LPN #3 revealed the resident had complaints of increased pain in her left foot. Resident stated, Tylenol and [MEDICATION NAME] are not working anymore. - 7/3/17 at 9:10 PM by an agency LPN revealed the resident was sitting up in wheel chair crying in pain at times. - 7/5/17 at 10:23 PM by LPN #3 revealed the resident was complaining of increased left foot pain. The resident's foot was purple/ blue in color and cool to touch with a positive pedal pulse, the resident received Tylenol at 3:35 PM with some relief. - 7/12/17 at 4:17 AM by LPN #2 revealed the resident was having severe increased complaints of pain and discomfort to left foot, PRN Tylenol given with minimal effect. -7/17/17 at 3:42 PM by an agency LPN revealed due to increased pain in her left foot, the resident needs extra help with Activities of daily living (ADL's) and transfers. - 7/19/17 at 7:58 AM by LPN #1 Nurse Manager revealed that she called the vascular office to set up another angiogram, the writer was informed the resident would need a CT Scan (image taken to assist a medical diagnosis) to determine the next step for the resident's foot. Additional review of the Nursing Progress Notes dated 7/18/17 through 8/1/17 revealed the resident continued to have pain in her left foot despite routine [MEDICATION NAME] and PRN Tylenol. During a phone interview on 8/16/17 at approximately 3:30 PM, LPN #2 stated that the resident always had pain in her foot. The LPN stated she is sure that she told the Nursing Supervisor; however, she does not recall checking on the resident, and she doesn't know what happened. Review of the Medication Administration Records (MARs) dated May 2017 through July 2017 revealed the resident received the scheduled [MEDICATION NAME], Nitro patch as well as the PRN Tylenol. During an interview on 8/16/17 at approximately 3:29 PM, LPN #3 stated she recalled that she administered [MEDICATION NAME] and PRN Tylenol on multiple occasions for the resident's left foot pain. The resident would often state it hurts or cry; however, frequently when she would recheck the resident, she would be napping. The LPN #3 stated she recalls she told the LPN Nurse Manager or the Nursing Supervisor on multiple occasions about the resident's pain. Review of a NP Vascular Surgery Note, obtained from the consultant by Surveyor on 8/14/17 and not contained in the resident's facility Medical Record, dated 7/11/17 revealed the facility called today to reschedule the resident for imaging. The previous plan for the angiogram was canceled twice in the past and the surgeon was unable to palpate a femoral pulse when the resident arrived; and the resident had eaten breakfast which prompted the cancellation on 6/28/17. Review of the 7/20/17 computerized tomography (CT - image taken to assist medical diagnosis) Scan of the left foot, signed by the facility's nurse and Physician on 7/25/17 revealed the resident had a stent in the left superficial femoral artery (major artery to the foot) with probable occlusion of the stent with no contrast to the distal superficial artery or proximal popliteal artery near the stent with minimal perfusion in the left proximal popliteal artery. Review of a LPN #2 Nursing Progress Note dated 7/21/17 at 3:38 AM revealed the resident had increased complaints of severe discomfort of the left foot and given Tylenol with little to no effect noted, will continue to monitor, CT results pending; there was no documentation of RN assessment or notification to the Nursing Supervisor. During an interview on 8/16/17 at, LPN #2 stated that the resident always had pain in her foot. The LPN recalled that on 7/21/17 the resident was moaning in pain and she had to make the resident wait to give her more Tylenol because she had no other pain medication that she could administer. The LPN stated she is sure that she told the Nursing Supervisor; however, she does not recall checking on the resident, she doesn't know what happened. Review of the 8/1/17 Vascular Surgery Office Visit revealed the resident presented for evaluation of her left foot and leg. The resident's foot had worsened and required an emergency admission for an ischemic leg and pain control. The residents large toe was discolored and will require an amputation. Review of the 8/8/16 Hospital Discharge Summary by the Vascular Surgeon dated 8/8/17 revealed the resident was admitted on [DATE] for surgical intervention and pain control with an ischemic left leg. On 8/2/17 the resident had an angiogram which showed no revascularization options and a left above the knee amputation was performed on 8/3/17. During a phone interview on 8/17/17 at approximately 3:30 PM, the DON stated that when a resident is having breakthrough pain and the nurses have no additional medication they can administer they should call the Nursing Supervisor who can call the Physician on call. The Nursing Supervisor should evaluate and document their evaluation in the resident's record. Most of the Supervisors are RN's. The Unit Managers are responsible to complete the Care Plan and this resident's Care Plan should have included a Care Plan for pain. In addition, the DON stated, someone should have called the Physician to let them know about the breakthrough pain. During the interview the Surveyor reviewed the Nurse Progress Notes from 4/25/17 to 7/31/17 and determined there was no RN assessment of the resident's left foot and left foot pain. The DON stated for this resident who had a deterioration in her vascular status and two canceled left femoral angiograms due to staff error, there should have been an RN assessment within the two months. During an interview on 8/10/17 at approximately 2:00 PM, the Medical Doctor (MD) stated that the resident had dry gangrene and she had informed the resident she probably would not keep her leg, which already had a stent in it. The MD stated that the nursing staff are supposed to schedule procedures, they should get orders from consultant and follow them. During an additional phone interview on 8/17/17 at 3:12 PM the MD stated that when the resident was assessed, the resident did not exhibit discomfort or pain, nor verbalize pain. The Physician stated that she was informed when the resident missed one angiogram due to staff feeding her breakfast; however, she was unaware that the resident missed two angiograms. The MD stated that she did not know the vascular surgeon's plan for the resident after the angiogram, she believed the resident was in bad shape; the Physician stated she only read the resident's records she did not speak to the consultant. The MD stated she made rounds with the LPN Nurse Manager; however, she was never informed that the resident was having breakthrough pain with the pain medication, especially at night. The MD stated that if she had known she would have increased the resident's pain medication. During a phone interview on 8/16/17 at approximately 10:30 AM the Vascular Surgeon MD stated that the resident had chronic [MEDICAL CONDITION] and was known to him. The plan on 5/12/17 was to perform a left femoral angiogram and perform a bypass to salvage the resident's limb and give her comfort. The 5/22/17 left femoral angiogram was canceled because staff fed the resident; the resident was actually in the hospital in the preoperative area. The second attempt to reschedule the angiogram was delayed because the nursing home had personnel issues. The MD stated that the delay was not good for the resident because her vascular status in the left limb was compromised and she was showing signs of vascular deterioration and in addition she needed a resolution for her pain issues. Eventually a CT of the limb was obtained; however, when the resident presented on 8/1/17 she required immediate hospitalization and ultimately had an above the knee amputation. The Physician stated due to the lack of coordination and delay in her care that the resident suffered needlessly. Review of the Facility's policy entitled Pain Management, last revised on 6/17, revealed pain assessment documentation required completion of the nurse to include date, time, scale, rating, medication given and evaluation of pain after 1 hour. The nurse should notify the Unit Manger/ Designee if there is any indication that pain medication is not effective and the Unit Manager reviews the pain management forms weekly. The Nursing Unit Manager is to review the Pain Documentation with the Physician during each routine visit to evaluate the pain management plan and the Physician must document that pain was addressed during visits including the medications and treatment. Pain management should be documented in the Care Plan, including measurable goals, frequency of monitoring and outcomes. 415.12