Every finding on record at Safire Rehabilitation of Northtowns, L L C

Based on observation, record review, and interview during survey, the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents/hazards for two (Resident #1 and Resident #2) of five residents reviewed for accidents. a.) Specifically, on 06/04/2026 Resident #1 who was severely cognitively impaired, wore a wander alert device due to being at high risk for elopement, exited the facility undetected through doors that were not secured by the wander alert system. Resident #1 was located 12 hours later approximately three miles away by local police. 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. b.) On 06/29/2026, Resident #2's wander alert device failed to alarm when tested.The findings include: The facility policy and procedure titled Missing Resident/Elopement Policy and Procedure Statement Prevention revised 05/21/2026 documented it is the policy of the facility to provide a safe and secure environment for all residents. The facility policy and procedure titled Accidents and Incidents-Investigating and Reporting dated 04/26/2018 documented the facility will ensure that the residents environment remains free from accident hazards as is possible while providing adequate supervision and assistive devices to prevent accidents. a. Resident #1 had diagnoses that included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), alcohol abuse and chronic obstructive pulmonary disease (a progressive, incurable lung condition that limits airflow). Minimum Data Set (a resident assessment tool) dated 06/08/2026 assessed Resident #1 as severe cognitive impairment. Resident #1 had no Minimum Data Set prior to the incident. The Nursing admission assessment dated [DATE] documented Resident #1 was checked for wandering, history of elopement, and exit seeking. Review of the baseline care plan dated 06/02/2026 revealed Resident #1 wore a wander alert bracelet to their right wrist and had wandering behaviors. The Nursing Progress Note dated 06/04/2026 completed by the Assistant Director of Nursing documented at 8:30 AM, they were notified by Unit Clerk #1 that Resident #1 was not in their room when breakfast was being served and instructed staff to search and called Dr. [NAME] (a search plan when a resident elopes from the facility). They notified the Director of Nursing, Administrator, Resident #1's spouse, and law enforcement. Review of the facility Incident Overview dated 06/04/2026 revealed the Administrator was made aware of the incident at 8:30 AM. The Dr. Walker procedure plan was announced, and the facility conducted an unsuccessful internal and external search. Local law enforcement and Resident #1's spouse were notified. The Nursing Progress Note dated 06/04/2026 documented that Resident #1 returned to the facility escorted by law enforcement at 6:51 PM on 06/04/2026. Review of the Police Report revealed on 06/04/2026, Resident #1 had been located at 6:10 PM approximately three miles from the facility and was returned to the facility. The Elopement/Wander Risk Assessment signed and dated 06/05/2026 by the Director of Nursing documented Resident #1 was a high risk for elopement. Review of video surveillance provided by the facility on 06/29/2026 at 9:59 AM, revealed on 06/04/2026 between 6:30 AM and 6:36 AM, Resident #1 was observed walking down the third floor west wing without any facility staff present fully dressed carrying a large duffle bag and proceeded down to the elevators across the third floor nurses station, then turned away from the elevators, proceeded to the emergency exit door, read the signs posted on the door, then proceeded down the third floor east wing hallway towards a stairwell door that leads down to the first floor exit door of the building to the parking lot. The video surveillance outside of the building revealed Laundry Aide #1 pulling up, parking, and remaining in the vehicle for a few minutes while Resident #1 left the facility at approximately 6:33 AM. During a telephone interview on 06/29/2026 at 12:18 PM, Laundry Assistant #1 stated they were unfamiliar with Resident #1. People go in and out of the building from that area often. They parked and sat in their car for a few minutes on 06/04/2026 at approximately 6:30 AM and stated someone came walking by carrying a bag but they thought Resident #1 was an employee, so they did not say anything to anyone. During an interview on 06/30/2026 at 9:38 AM, the Director of Maintenance stated the third-floor east wing hallway stairwell door has a keypad and a magnetic locking system that is used to open the door. The first floor exit door to the outside near the parking lot had no alarm system to alert when the door was accessed. They stated the facility has a wander alert system but the doors the resident exited through did not have this system on them. During an interview on 06/30/2026 at 11:05 AM, Maintenance Assistant #1 stated in the past, magnets had slipped on the magnetic locked doors because the screws got old and rusty, and the doors were frequently used by staff, which could cause the magnets to slip down, disengaging the locking mechanisms on the door. They stated they were informed that the Regional Maintenance Director had been in the facility the day of the elopement and had tightened the screws on the magnetic locked doors and changed the codes. During an interview on 06/30/2026 at 11:19 AM, the Administrator stated they did not have a facility policy regarding door checks. During a follow up interview on 06/30/2026 at 12:58 PM, the Director of Maintenance stated the Regional Maintenance Director came into the facility on [DATE], but they were unaware if they tightened any screws on magnetic locks. Additionally, they stated it could be beneficial to do more frequent checks on doors, including the magnetic locks; they stated a lot can happen between one Monday to the next Monday. During an interview on 06/30/2026 at 1:37 PM, the Administrator stated after they were advised on 06/04/2026 at 8:30 AM that Resident #1 was missing, they did a second sweep of the doors and found that the three east wing hallway stairwell door was unlatched. During a telephone interview on 07/01/2026 at 11:13 AM, the Medical Director stated that Resident #1's elopement from the facility on 06/04/2026 could have been a dangerous situation. Resident #1 could have walked into the busy street or could have been hit by a car. The Medical Director stated, our job was to keep the residents safe and would expect the facility to have a policy for the magnetic lock doors. During a follow up interview on 07/01/2026 at 3:00 PM, the Administrator stated they had no knowledge of any loose magnets on any magnetic locked doors. The facility wander alert system was appropriately applied but they did not take into consideration the magnetic lock doors as those doors were used only for emergency use. At that time of Resident #1's disappearance, the magnetic lock door had yet to be identified. The main stairwell was the only stairwell that was utilized by the general staff. When they arrived at the facility on 06/04/2026 at 8:30 AM and reviewed the camera footage they determined Resident #1 had exited the building to the parking lot. They went up to the third-floor east stairwell and saw for themselves that the door was unlatched. The Survey team determined the immediacy was removed on 07/02/2026 at 5:35 PM based on the following corrective actions taken by the facility: -Upon return to the facility on [DATE], Resident #1 was placed on fifteen-minute checks with door watchers present until staff procured for 1:1 on 06/05/2026 at all times.- All exterior exit doors have been alarmed and mag locked and are functional. Keys were limited to the Director of Maintenance, the Food Service Director, Director of Nursing, the Administrator and the Nursing Supervisor.- The facility conducted daily door checks. - The facility revised the policy Prevention of Elopement and Wandering Protocol. dated 06/05/2026. - If an outside vendor is in the facility that requires unlocking of an emergency exit door, Maintenance will be with the vendor until the work is completed, and the doors have been secured. - 91.5% of licensed nursing staff reeducation on door security and door safety and the elopement protocol by 07/02/2026.- The facility completed a 100% audit of all residents and ensured all residents had elopement assessments and no new residents were identified as a high risk for elopement. b. Resident #2 had diagnoses that included hypertension (high blood pressure), diabetes mellitus (high blood sugar), and depression (mood disorder that causes persistent sadness and a loss of interest in activities). The Minimum Data Set, dated [DATE] documented Resident #2 was independent with chair/bed to chair transfers and wheelchair mobility and had no wandering behaviors.There was no documented evidence that the facility had a policy related to wander alert system testing or testing resident wander alert devices for functionality. Review of the undated facility wander alert list verified as the current list of wanderers, provided by the Administrator on 06/29/2026, displayed a photograph of Resident #2 indicating they were a wanderer. During an observation and interview on 06/29/2026 at 11:25 AM, Unit Clerk #1 wheeled Resident #2 to the third-floor elevator and when the elevator door opened, they wheeled Resident #2 in their wheelchair onto the elevator. The wander alert device did not alarm. Unit Clerk #1 stated at that time, the alarm should have sounded, and the elevator should not move until a code is typed on the keypad but for some reason it did not work. Then Unit Clerk #1 notified the Assistant Director of Nursing. During an observation on 06/29/2026 at 11:47AM, the Assistant Director of Nursing replaced Resident #2's wander alert bracelet with a new wander alert bracelet, activated the bracelet with the detector box and then wheeled them onto the elevator. The wander alert system sounded. During an interview on 06/29/2026 at 12:45 PM, the Assistant Director of Nursing stated they replaced Resident #2's wander alert bracelet as the detector box they held next to the old bracelet indicated that the battery was no good. The Assistant Director of Nursing did not know how long the battery was dead. They were unaware of the process for checking the functionality of the wander alert bracelets. The staff would have knowledge of when the batteries were nonfunctioning because the alarm would not sound when they were brought onto the elevator. During an interview on 06/29/2026 at 12:49 PM, Maintenance Assistant #1 stated they did wander alert system checks monthly by going around with a wander alert bracelet to make sure the doors were activated but they had no documented evidence of doing such. They stated they did not ensure the wander alert bracelets were functioning as it was nursing's responsibility. During an interview on 06/29/2026 at 1:31 PM, the Director of Nursing stated they stopped doing checks for the wander device system when the new system was implemented two years ago. During an interview on 06/30/2026 at 9:37 AM, the Director of Maintenance stated they could not find a policy for the wander alert system. They stated they contacted the manufacturer today for the manufacturer guidelines for the new wander alert system. They stated a policy for the wander alert system would be beneficial as there would probably be more stuff to look for. They further stated the wander alert system is monitored by the receptionist at the front desk between 8:00 AM and 8:00 PM and was unsure who monitors the system between 8:00 PM and 8:00 AM. Further, at approximately 3:00 PM, the Director of Maintenance provided the surveyor with a printout of the guidance which they received via e-mail. During an interview on 06/30/2026 at 11:19 AM, the Administrator stated they were calling the manufacturer of the new wander alert system today to get the manufacturers guidelines for the system; they stated they did not have a facility policy regarding the wander alert system. Review of the wander alert quick reference guide dated 2023 revealed the battery life could be tested by the detector and recommended that the wander alert detector be used weekly to test the bracelet battery. Shelf life from the manufacturing date was eight months. Review of the wander alert wearable bracelet user sheet revealed weekly testing and maintenance of this product, as described in the product documentation is essential to verify the system is operating correctly and to ensure that the probability of detecting an alarm and/or locating the transmitter are maximized. The failure to undertake regular testing and maintenance will increase the risk of system failure to detect resident wandering. The failure to undertake testing and maintenance will increase the risk of false reports of resident wandering. During a telephone interview on 07/01/2026 at 11:13 AM, the Medical Director stated they would expect the facility to have a policy on the current wander guard system. It would be much smoother if everyone knew what the process was and to keep the residents safe. During an interview on 07/01/2026 at 11:30 AM, Registered Nurse #3 Unit Manager stated to check the wander alert bracelets they would walk every resident to the elevator because it was easier than going to get the detector to see if it set the alarm off and ensured the bracelets functioned. They stated they had no documentation that this was being done. During an interview on 07/01/2026 at 11:41 AM, the Administrator stated they abated the process of checking and signing off on the functionality of the wander alert bracelets when they implemented the new system eleven months ago. There were no sheets for the supervisors to physically check off for the wander alert bracelets. The Administrator stated the system monitored the functionality of the wander alert bracelets and that an alert would be displayed with a low battery indicator on the monitor at reception if one of the batteries needed to be changed. The Administrator stated the staff from Unit One were expected to monitor the wander guard alert device in the absence of the receptionist and to run to the reception desk and check the location of where the alarm was coming from. There was no policy on the current wander guard system. New York Code Rules and Regulations 415.12(h)(1)(2)

Based on interview and record review during survey, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to ensure a safe environment for cognitively impaired residents who wander and/or are at risk for elopement. a.) Specifically, Resident #1 was located 12 hours later approximately three miles away by local police on 06/04/2026. b.) On 06/29/2026, Resident #2's wander alert device failed to alarm when tested and the facility had no policy, current manufacturers guidance or system that monitored the functionality of the wander alert bracelets weekly per the manufacturers' recommendations. This has the potential to affect seven residents identified as at risk of unsafe wandering and at risk of elopement.The findings include: The facility policy and procedure titled Missing Resident/Elopement Policy and Procedure Statement Prevention revised 05/21/2026 documented it is the policy of the facility to provide a safe and secure environment for all residents. REFER TO: F 689 - Free from Accident Hazards/Supervision/Devices, Scope and Severity J a. Resident #1 had diagnoses that included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), alcohol abuse and chronic obstructive pulmonary disease (a progressive, incurable lung condition that limits airflow). Minimum Data Set (a resident assessment tool) dated 06/08/2026 assessed Resident #1 as severe cognitive impairment. During an interview on 06/29/2026 at 2:10 PM, Maintenance Assistant #1 stated that the maglock must have slipped and disengaged the magnet from the third floor east exit door and it caused the door to inactivate causing the alarm to not sound when someone entered through it and assumed that's how Resident #1 got out. During an interview on 06/30/2026 at 9:38 AM, the Director of Maintenance stated the third-floor east wing hallway stairwell door has a keypad and a magnetic locking system that is used to open the door. The first floor exit door to the outside near the parking lot had no alarm system to alert when the door was accessed. They stated the facility has a wander alert system, but the doors Resident #1 had exited though they did not have this system on them. The Director of Maintenance stated they were not made aware of any magnets slipping on doors on 06/04/2026 and were unaware if a magnet was fixed on any doors in the facility on that day. They stated if a magnet were to slip (slide down) on a mag locked door, the door would not be locked; the locking mechanism would not be engaged. The Director of Maintenance stated if the magnet was found to be slipping, they should have been made aware by staff; It would have helped them ensure that there were no longer elopement concerns or the safety of residents. During a telephone interview on 07/01/2026 at 11:13 AM the Medical Director stated they would expect the facility to have a policy for the magnetic lock doors. The Director of Maintenance stated they were not made aware of any magnets slipping on doors on 06/04/2026 and were unaware if a magnet was fixed on any doors in the facility on that day. They stated if a magnet were to slip (slide down) on a mag locked door, the door would not be locked; the locking mechanism would not be engaged. The Director of Maintenance stated if the magnet was found to be slipping, they should have been made aware by staff; It would have helped them ensure that there were no longer elopement concerns or the safety of residents. During an interview on 07/01/2026 at 3:00 PM the Administrator stated the main stairwell was the only stairwell that was utilized by the general staff. When they arrived at the facility on 06/04/2026 at 8:30 AM and reviewed the camera footage they determined Resident #1 had exited the building to the parking lot. They went up to the third-floor east stairwell and saw for themselves that the door was unlatched. There was no system for checking the doors prior to the incident. The Administrator stated they had no knowledge of any loose magnets on any mag locked doors. The facility systems were appropriately applied but they did not take into consideration the mag lock doors as those doors were used only for emergency use. At that time of Resident #1's disappearance the mag lock door had yet to be identified. Evaluation of all the non-mag locked doors were reviewed after the incident during Quality Assurance and Performance Improvement with recommendations made to mag lock other doors located in the emergency stairwells. The intermittent unsecured mag lock door allowed Resident #1 to leave undetected. b. Resident #2 had diagnoses that included hypertension (high blood pressure), diabetes mellitus (high blood sugar), and depression (mood disorder that causes persistent sadness and a loss of interest in activities). The Minimum Data Set, dated [DATE] documented Resident #2 was independent with chair/bed to chair transfers and wheelchair mobility and had no wandering behaviors. During an interview on 06/29/2026 at 12:45 PM, the Assistant Director of Nursing stated they were unaware of the process for checking the functionality of the wander alert bracelets. During an interview on 06/29/2026 at 1:31 PM, the Director of Nursing stated there was no documented evidence that the facility had a policy related to wander alert system testing or testing resident wander alert devices for functionality. During an interview on 06/30/2026 at 9:37 AM, the Director of Maintenance stated they could not find a policy for the wander alert system. They stated they contacted the manufacturer today for the manufacturer guidelines for the new wander alert system. They stated a policy for the wander alert system would be beneficial as there would probably be more stuff to look for. Further, at approximately 3:00 PM, the Director of Maintenance provided the surveyor with a printout of manufacturer guidance which the Director of Maintenance received via e-mail. During a telephone interview on 07/01/2026 at 11:13 AM, the Medical Director stated they would expect the facility to have a policy on the current wander guard system. During an interview on 07/01/2026 at 11:41 AM, the Administrator stated they assumed the wander alert system monitored the functionally of the bracelets. There was no policy on the current wander guard system. 10 New York Code Rules Regulations 415.26

Based on observation, interview and record review conducted during the survey, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse and do not result in serious bodily injury, to the State Survey Agency for one (1) (Resident #4) of three (3) residents reviewed. Specifically, the Administrator was notified of an injury of unknown origin to Resident #4's left hand and it was not reported to the State Agency as required. The finding is:The policy titled Abuse Reporting revised 10/24/22, documented all alleged suspected violations of abuse are required to be promptly reported to appropriate state agencies. Federal Regulation requires the reporting of all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported to the department of health immediately, but not later than two (2) hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than twenty-four (24) hour if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to other officials (including to the State Survey Agency) in accordance with State law.Resident #4 had diagnoses including vascular dementia with mood disturbances, cerebral vascular accident (stroke), and aphasia (absence or difficulty with speech). The Minimum Data Set (a resident assessment tool) dated 10/02/2025 documented Resident #4 had unclear speech, was severely cognitively impaired, was usually understood, and usually understands. Additionally, Resident #4 displayed physical and verbal behavioral symptoms, and rejected care.The Resident Care Profile (a guide used by staff providing care) dated 10/14/2025 documented Resident #4 was confused and agitated. Their decision making was severely impaired. Behavioral symptoms and interventions included poor safety awareness, noncompliance, staff were to redirect, provide reassurance, distraction, decrease stimuli, and use a calm reassuring voice.The comprehensive care plan dated 10/01/2025 documented Resident #4 had noncompliance related to memory problems, rejection of care, and behaviors; and at risk of injury related to osteoarthritis, stoke, and resistance to activities of daily living care. Interventions included to recognize right to refuse care and utilize behavior modification strategies. The Incident report dated 10/14/2025 at 8:30 AM, documented injury of unknown origin, the resident's left index finger was swollen, slightly bruised, and was discovered by Certified Nurse Aide #2. The medical provider was notified, and an x-ray of the left hand and wrist were ordered.The Witness Statement dated 10/14/2025 at 8:15 AM by Certified Nurse Aide #2 documented while providing morning care to Resident #4 they noticed their left index finger and knuckle to be swollen and beginning to bruise. Certified Nurse Aide #2 reported the concern to Licensed Practical Nurse #2.The Witness Statement dated 10/14/2025 at 8:15 AM by Licensed Practical Nurse #2 documented incident was reported to Registered Nurse Manager #1.The Witness Statement dated 10/14/2025 (untimed) by Certified Nurse Aide #3 documented on 10/13/2025 while putting Resident #4 to bed they became very combative and hit the aide several times. When they left Resident #4's room, they did not notice any marks or bruises.The radiology report dated 10/14/2025 at 4:15 PM, documented the resident had an oblique (slanted, diagonal) fracture (break) involving the second proximal (closer to the point of attachment to the body) phalanx (finger bone).Review of the facility's undated, untitled investigation report signed by the Administrator documented that Resident #4 had displayed behaviors since admission but with their decline in cognitive status, the incidents of combativeness with care were more frequent due to their increased need for care. The Administrator documented that on 10/14/2025, Resident #4 was noted to have a swollen finger. A Registered Nurse assessment was completed and the x-ray obtained showed an oblique fracture of the second phalanx. Resident #4 was sent to an orthopedic provider for follow up care and healing occurred without incident. The Administrator documented that they did not believe any abuse, mistreatment or neglect had occurred with Resident #4.During an observation and interview on 02/26/2026 at 11:35 AM, Resident #4 was sitting in their wheelchair at a table in the dining/common area on the unit across from the nurse's station. Staff wheeled Resident #4 to their room without concern. Resident #4 was unable to state whether anyone had hurt them or how they fractured their finger. Resident #4 was calm, did not appear scared or in distress at this time. There was no bruising or any injuries observed and they had no difficulty moving their hands.During an interview on 02/26/2026 at 11:45 AM, Registered Nurse #1, Unit Manger stated they were not involved in Resident #4's incident on 10/14/2025. They stated Resident #4 is combative with hands on care, they attempt to hit, kick, and grab staff. They stated all injuries of unknown origin should be reported to the Department of Health. They stated injuries of unknown origin need to be investigated to make sure there is no abuse, neglect or mistreatment involved. They stated an injury of unknown origin should be reported to the Department of Health two (2) hours after discovery. Registered Nurse #1, Unit Manger stated the Administrator does all the reporting to the Department of Health and believed Resident #4's incident was reported to the Department of Health. During a telephone interview on 02/26/2026 at 1:01 PM, Certified Nurse Aide #2 stated they were assigned to Resident #4 on 10/14/2025. Upon going in to provide morning care, the resident was in bed, and they discovered Resident #4's knuckles of their index finger, middle finger to be swollen, discolored and they were unable to move their fingers. They stated they notified Licensed Practical Nurse #2 immediately. They stated they had cared for Resident #4 two days prior, and their hand was fine.During an interview on 02/26/2026 at 1:15 PM, Certified Nurse Aide #3 stated they were assigned Resident #4 on 10/13/2025 and that Resident #4 was combative during care. They stated they did not remember if Resident #4's hand encountered anything in their environment during care, and they denied any abuse towards Resident #4.During a telephone interview on 02/26/2026 at 1:34 PM, Licensed Practical Nurse #5 verified they were the overnight nurse assigned to Resident #4 on 10/13/2025 into 10/14/2025. They stated no concerns regarding Resident #4's left hand was brought to their attention, nor did they observe Resident #4's hand that night. They stated if an injury of unknown origin had been brought to their attention they would have reported it immediately to the nursing supervisor. They stated Resident #4 is well known to be abusive towards staff during care.During an interview on 02/26/2026 at 1:56 AM, the Assistant Director of Nursing stated Resident #4's injury of unknown origin was reported to them on 10/14/2025 in the morning. They stated they completed the accident/incident report, notified a medical provider, family, and the Director of Nursing. They stated for injuries of unknown origin they go back 72 hours and collect statements from staff. The Assistant Director of Nursing stated the Director of Nursing and the Administrator complete investigations related to abuse and injuries of unknown origin are supposed to be reported to the Department of Health within a two (2) hour window.During an interview on 02/26/2026 at 2:03 PM, the Director of Nursing stated Resident #4's injury of unknown origin was brought to their attention during rounds the morning of 10/14/2025 and they reported it to the Administrator. They reported to the Administrator the injury of unknown origin to Resident #4's hand and the order for an x-ray. They stated the Administrator completes the reporting to the Department of Health and the investigation summary, conclusion. The Director of Nursing stated of course the Administrator should have notified the Department of Health within the first two (2) hours of being notified; it was an injury of unknown origin.During an interview on 02/26/2026 at 3:28 PM, the Administrator stated injuries of unknown origin, abuse, mistreatment, neglect are to be reported to the Department of Health two (2) hours after they were notified. The Administrator stated they had no reason to believe that abuse occurred and did not report the incident. They stated in retrospect they should have reported Resident #4's injury of unknown origin because it is regulation. They stated they ruled out abuse and believed that during an episode of combativeness with hands on care, Resident #4 wacked their hand, finger on something in their environment (headboard, bed frame, etc.). 10 NYCRR 415.4(b)(2)(4)

Based on observation, interviews and record review conducted during a survey, the facility did not ensure that menus were followed and prepared to meet resident choices and nutritional needs in accordance with established national guidelines for one (1) of one (1) kitchen. Specifically, on 02/25/2026 the kitchen did not prepare an adequate amount of the posted lunch meal to serve all residents. Additionally, during meal observation residents did not receive food/beverage items that were listed on their meal tickets. This involved Residents #2, #5, #6, and #7. The findings are:The policy titled Food and Nutrition Services dated 11/02/2017, documented that each resident is provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Reasonable efforts will be made to accommodate resident choices and preferences. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident.The policy titled Tray Identification dated 05/01/2017, documented appropriate identification/coding shall be used to identify various diets. The Food Services Department will use appropriate identification to identify the various diets and special considerations.Review of the Week at a Glance Fall/Winter Menu 25/26 Week 1 revealed on Wednesday 02/25/2026 the lunch meal consisted of stuffed shells, two (2) each; Italian vegetables, four (4) ounces; dinner roll, one (1) individual; and pie- various, one (1) piece. Alternative, one (1) egg salad sandwich. The dinner meal consisted of one (1) individual turkey and Swiss sandwich; sweet potato fries, four (4) ounces; buttered corn, four (4) ounces; and mandarin oranges, four (4) ounces.Review of the monthly Resident Council meeting notes revealed the following dietary issues/ concerns:-January 2026 food is out of stock and food supplies are low-February 2026 missing items, steak was hard to cut, running out of stuffDuring an interview on 02/24/2026 at 12:34 PM, Resident #5 stated they do not receive condiments on their trays, portion sizes are small, and the food is served cold.During an interview on 02/24/2026 at 12:43 PM, Licensed Practical Nurse #1 stated there are a lot of food complaints from the residents such as the food is not eatable, is cold, and does not look good. They stated the food that is served to the residents does not look appealing to them and they would not eat it. During an interview on 02/24/2026 at 1:31 PM Certified Nurse Aide #1 stated there are a lot of resident complaints regarding the food. They stated residents complain about there not being enough food, food being cold and unhappy with food provided. Certified Nurse Aide #1 stated the presentation of the meals are terrible, food is just slopped on the tray. They stated condiments, like creamers, sugar, salt and pepper are very rarely provided on resident trays per meal ticket. They stated the kitchen does not utilize bases under the plates to help keep food warm, plates are just placed on the trays.During a telephone interview on 02/24/2026 at 1:51 PM, Licensed Practical Nurse #3 stated residents' meal tickets never match what is provided on their trays due to menu changes, or lack of supplies. They stated there are no condiments on the units and residents are not provided with them as indicated on their meal ticket. They stated the residents deserve better; this is their home.During an observation and interview on 02/25/2026 at 8:53 AM, Resident #2's meal ticket indicated one (1) jelly and four (4) ounce apple juice. Resident #2 stated no jelly or apple juice was provided on their tray and they would have liked those items. The resident's breakfast tray was observed without jelly and apple juice.During an observation and interview on 02/25/2026 at 8:55 AM, Resident #5's meal ticket indicated they were to have a four (4) ounce orange juice and one (1) jelly. Resident #5 stated they did not receive jelly or orange juice and would have liked to. They stated they were not provided with sugar and would have eaten their oatmeal if they had received sugar. The resident's breakfast tray on their tray table was observed without orange juice, jelly, and their oatmeal was uneaten.During an interview on 02/25/2026 at 8:55 AM, Licensed Practical Nurse #1 stated they requested jelly and juice from the kitchen for the residents this morning and were told by kitchen staff there was none available.During an interview on 02/25/2026 at 9:22 AM, Licensed Practical Nurse #4 stated residents complain about the food all the time. The residents complain that the food is cold, edges of the toast are hard, they question what items on the tray are, and that the food is unappealing. Licensed Practical Nurse #4 stated there are no juices stocked on the unit to give to the residents, and the residents are sick of always receiving water. Licensed Practical Nurse #4 stated they must search for condiments, and it is hit or miss if they are available. Licensed Practical Nurse #4 stated the food at the facility is not something they would eat or allow their family to eat; it is not presentable or appealing.Observation and interview during the lunch meal tray line on 02/25/2026 from 11:54 AM-12:37 PM revealed:-at 12:00 PM the kitchen staff were discussing that there were not enough shells and meat sauce to complete all resident lunch trays. Dietary Supervisor #3 stated there was not enough food pulled out to prepare for the meal.-at 12:11 PM, the kitchen ran out of stuffed shells and were unable to complete the third-floor dietary carts per meal tickets. The Clinical Dietician/Food Service Director #1 stated they did not know what happened. They stated they ordered the same amount of shells as always, two (2) boxes and were not sure why they ran out. The Clinical Dietician/Food Service Director #1 stated the alternate was an egg salad sandwich but there was not enough to cover for the lack of shells. Kitchen staff were observed to be placing breaded chicken patties in the oven to serve. A few trays were served prepared stuffed shells with [NAME] sauce that were available for residents that did not like red sauce.-at 12:14 PM, the Clinical Dietician/Food Service Director #1 stated twenty (20) residents were unable to receive stuffed shells per the menu.-12:18 PM-12:30 PM Clinical Dietician/Food Service Director #1 stated kitchen staff were utilizing stuffed shells prepared with [NAME] sauce to use them up. Seven (7) trays were prepared with an egg salad sandwich in place of stuffed shells. The remaining trays were prepared with a breaded chicken patty on a roll without condiments and/or sauce. Insulated plate bases were observed to be utilized as lids to cover the plates on the trays and the plates were not completely covered. -at 12:31 PM the first dietary cart to the third floor left the kitchen; the second cart with eleven trays was prepared with chicken patty sandwiches.-at 12:36 PM, the second third floor (and last) dietary cart left the kitchen.During an interview on 02/25/2026 at 12:43 PM and 1:00 PM, the Dietary Supervisor #2 stated they took all the stuffed shells they had available out of the freezer and cooked everything. They stated they did not know it was not enough, and they should have counted them. They stated they thought residents were only going to be given one (1) shell not two (2). The Dietary Supervisor #2 stated they should have looked at their production sheets as it tells them how much each resident is to receive but that the sheets are confusing. They stated it was important for residents to receive the proper portion sizes, so they do not go hungry, and they receive what is on the menu/meal ticket. Dietary Supervisor #2 stated they were unable to provide orange juice, regular sugar packets, jelly packets on the breakfast trays that morning because they had run out of the supply. During an interview on 02/25/2026 at 12:48 PM, Dietary Supervisor #3 stated they had come in early today to help and did not realize there was not going to be enough stuffed shells. They stated a count should have been done to verify amount upon preparing them by Dietary Supervisor #2. They stated residents should receive all items indicated on their meal ticket including condiments, so they have what they need and do not become upset.During an interview on 02/25/2026 at 1:06 PM, the Clinical Dietician/Food Service Director #1 stated that they and the Assistant Food Service Director #2 complete the ordering for the kitchen. They stated usually two (2) boxes of stuffed shells is enough. They stated ordering is based on the resident census and menu. They stated the product description and quantity should be reviewed when ordering. Clinical Dietician/Food Service Director #1 stated it was important for residents to receive indicated items on their meal ticket to meet nutritional needs. They stated food vendors make substitutions if there is not enough of the ordered product without notifying them. They stated condiments should be readily available for resident satisfaction, enjoyment, and quality of life. They stated unfortunately orange juice was not available as the wrong item was received. They stated their scheduled food service delivery is on Thursdays. During an interview on 02/25/2026 at 1:30 PM, Assistant Food Service Director #2 stated production sheets should be used when preparing meals. The production sheets indicate the amount of each food item needed and how it is to be prepared. They stated the dinner meal was being changed for that evening due to not having any Swiss cheese. They stated the Swiss cheese was used last week. They stated the dinner meal was being changed to a hot dog, French fries, green beans, and chilled sliced pears and meal tickets were being changed to reflect that. They stated residents come down directly to the kitchen to complain about the food, usually regarding taste. During an interview on 02/25/2026 at 2:24 PM, Resident #6 stated they did not receive stuffed shells with red sauce and would have liked to. They stated they did not receive orange juice that morning with breakfast or any sugar and they minded.During an interview on 02/25/2026 at 2:38 PM, Resident #7 stated they hardly ever receive what is on their meal ticket. They stated they are told the same thing by kitchen staff all the time, we ran out of this, and we had to substitute for what was on the menu. They stated the kitchen staff does not care about what the residents eat as long as there are three (3) meals served. Resident #7 stated they received an egg salad sandwich for lunch today and it was crappy. They stated they should have received the stuffed shells with red sauce because that is what they expected and what was on the menu. Resident #7 stated orange juice, cranberry juice and apple juice are never provided as the facility does not have them. They stated the kitchen has been making and giving out a fruit punch made from a powder for over a year as the juice option and they do not like it. During an interview on 02/26/2026 at 3:28 PM, the Administrator stated the Food Service Directors should have recognized the quantity change on the stuffed shells when ordering and ordered the proper amount, so they did not run out. They stated the residents should receive what is stated on the menu and should have all items listed on their meal ticket, including condiments, because that is what they want; it is their preference. They stated the meal ticket should reflect what the resident is receiving on their tray as it is nutritionally approved for that resident receiving it. Additionally, they stated the facility has had issues with deliveries, receiving the wrong items and/or deliveries going to other facilities. They stated if they knew something was out of stock, they would get it, but it needs to be communicated to them. 10 NYCRR 415.14 (c)(1-3)

Based on observation, interview, and record review conducted during a Standard survey completed 3/28/25 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one main Kitchen and three (Unit 1, Unit 2, and Unit 3) of three Nourishment Kitchens. Specifically, the main Kitchen had issues with opened undated, outdated, and/ or unlabeled foods. The floors throughout the Kitchen and dry storage room had copious amounts of debris under the equipment, storage racks, and the floors had areas of dark black buildup. The equipment was dirty and sticky. The steam table was being held up by a canned good in one corner. Hoods and pipes along the ceiling had a thick layer of dust and grease buildup. Paint on the ceiling was peeling in areas and the ceiling had a buildup of multiple dark dirty spots. [NAME] restraints were not being worn during prepping and serving of food. In addition, the Nourishment Kitchens refrigerators had undated and/or unlabeled food. Refrigerators were dirty and had debris, dried, and/ or sticky substances inside. Floors were dirty with debris buildup and appeared to not have been swept or mopped. The findings are: The policy titled Kitchen Sanitization with review date 10/4/23 documented the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. The policy titled Food Receiving and Storage with review date 10/4/23 documented foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. All foods that are stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Food items and snacks kept on the nursing units must be maintained as indicated: all food items to be kept must be placed in the refrigerator located at the nurses' station and labeled with a use by date; all foods belonging to residents must be labeled with resident's name, the item and the use by date; beverages must be dated when opened and discarded after twenty-four (24) hours. Other opened containers must be dated and sealed or covered during storage. The policy titled Refrigerators and Freezers with revision date 2/27/20 documented the facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines for all refrigerators on the nursing units and Food Services Department. The Dietary Service Department personnel will surface clean the nourishment refrigerators on the nursing units daily and discard any outdated items. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Use by dates indicated once food is opened, and all food/ liquids dated pass 24-hours should be discarded. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. The policy and procedure titled Dietary - Hair Covering dated 10/13 documented all employees in the dietary department will wear a hair covering and a beard restraint while preparing or serving food. 1a. During an observation of the main Kitchen on 3/24/25 between 7:52 AM and 8:30 AM the following was observed: -The reach in cooler contained 4 undated chicken salad sandwiches, 1 opened large bag of lettuce with saran wrap around it not dated or labeled, 8 disposable plastic cups filled with a white liquid with no label or date, 2 opened bags of shredded cheddar cheese with no label or date one of which appeared to have mold growing on the cheese. -The inside of the reach in cooler was very dirty and dingy with dried food debris on it and in the back on the bottom a smashed plastic cup with a cream color substance all over the bottom and back of the cooler. The outside of the reach in cooler appeared greasy and grimy with dried food substance on it. -The walk-in cooler contained a large metal soup container with 2 empty juice containers inside and garbage. There were 11 disposable plastic cups filled with a white liquid, 7 disposable plastic cups filled with a red liquid and 2 disposable cups with a clear liquid all with no labels or dates. -The dry storage room floor had multiple mustard and sugar packets under the racks of food. Plastic cup covers were scattered on the floor throughout the room. An open cereal container and a top from a box were under the food racks on the floor. The floor had debris and was brown and dirty in areas under the racks, along the walls and in the corners, appearing to not have been swept and mopped. In addition, there was a black cart being stored in the room that was filthy with crumbs, debris and a sticky substance Multiple racks on dried food and dirt on them. -The kitchen equipment appeared very greasy and grimy which includes the stoves and ovens. The can opener had a sticky substance and dark black debris stuck to it. The mixer bowl was on the floor. Both the mixer and the bowl had a white powdery substance on them. The mixer had dried food debris on it. -The hoods from the stove/ ovens had a thick layer of grease and dust build up. -The main Kitchen floor had multiple debris and dark black/ brown dirt build up under the stoves, sinks and ranks and along the walls and in the corners. -One corner of the working steam table used on tray line was being held up by a canned good which appeared to be greasy and dark brown/ black in color. -The pipes along the ceiling which go over the tray line had a thick layer of grease and gray/ brown dust build up. -The ceiling throughout the kitchen appeared dirty with black/ brown spots on it. Areas of the ceiling had paint peeling. During an interview on 3/24/25 at 8:25 AM, the Food Service Director stated open foods in the refrigerator should be tossed out after 3 days. After the surveyor showed the Food Service Director the undated or outdated foods found they took all the food items and voluntarily threw them out. They stated the reach in cooler definitely needed some TLC and needed to be cleaned. They stated they clean the refrigerators twice a week. They stated the can opener had a build up on it and it needed to be soaked and cleaned at least once a week. They stated the floors were swept at least once a day. During a further interview at 12:25 PM the Food Service Director stated the canned good holding up the steamtable has been there since they have been there which is almost 2 years. They stated the steam table was new when they started at the facility, and they looked for a foot for it but at the time they could not find one. During a follow-up interview on 3/25/25 at 9:00 AM, the Food Service Director stated they spoke with maintenance about a week ago and they are planning on scraping the paint off the ceiling and hire a company to come in and spray paint the entire ceiling. They stated the pipes along the ceiling were to be cleaned by maintenance as they were going to get a swifter to clean them. They stated the dust was thick on the pipes and they thought they were last cleaned this past summer. They stated the hoods looked dusty and they have a company come in and clean them. During an interview on 3/25/25 at 11:00 AM, the Administrator stated the kitchen is much improved but still needs more work. They stated they were aware of the problems in the kitchen and that they hired a Registered Dietitian full time to help. They stated the Food Service Director was still not certified for varies reasons and more changes need to be made in the kitchen but were waiting for the Department of Health to come in for survey before these changes were made. b. During a continuous observation on 3/26/25 from 11:43 AM through 12:50 PM, the Food Service Supervisor/Cook was not wearing a beard restraint while preparing and serving tray line during the noon meal. They had a dark goatee that was approximately 2-3 long on their chin. During an interview on 3/26/25 at 12:51 PM, the Food Service Supervisor/Cook stated they should have worn a beard restraint when they were preparing and serving on tray line because hair could fall into the food. During an interview on 3/26/25 at 2:42 PM, the Food Service Director stated the Food Service Supervisor/Cook should have worn a beard restraint during tray line because they had a goatee thing going on. They stated beard restraints protect the food from any hair that might fall out. During an interview on 3/28/25 at 11:24 AM, the Administrator stated they expected all staff in the kitchen to follow the regulations and wear what they are required to wear. [NAME] restraints should be worn whenever anyone with facial hair was in the food preparation area because that was the regulation. They stated they frequently go into the kitchen and were constantly reminding the staff to wear beard restraints. During an interview on 3/28/25 at 11:56 AM, the [NAME] President of Clinical Services stated whenever they have been in the kitchen, sometimes the Food Service Supervisor/Cook was wearing a beard restraint and sometimes they were not. A beard restraint should have been worn by the Food Service Supervisor/Cook whenever they were in the kitchen because it was an infection control concern. 2 a. During an observation of Unit 2 Nourishment Kitchen on 3/24/25 at 8:33 AM the following was observed in the refrigerator: - One take-out box dated 3/15 with no name, a bag of green and red grapes with no date or name, a bowl covered with tin foil labeled with a room number but no date, two bowls with plastic covers on them, labeled soup with no name or date, a small pizza box with no date or name, one take-out container with a room number written on it, but no date. b. During an observation of Unit 3 Nourishment Kitchen on 3/24/25 at 8:40 AM the following was observed: -Inside the refrigerator the following food items were stored with no date or label on them: a sandwich wrapped in saran wrap, 2 brown bananas in a plastic bag, an opened 68 fluid ounce container of hazelnut creamer, a red bag filled with 4 yogurts, 2 cans of soda, 1 bottle of water and 2 containers of an orange drink, 3 plastic containers one appeared to have bread and dip, one had sliced strawberries and one with watermelon which appeared to be very old, one bag with 2 tomatoes both with mold growing on them, 2 plastic cups with a dried up white substance in them, 1 container of French onion dip dated 2/27 and a large take out bag filled with 4 pieces of breaded meat with sauce and a bag of tortilla chips. -The refrigerator was dirty and had dried debris and dried spilled liquid inside and under the drawers. -The freezer contained multiple frozen food with no date or label, 4 small freezer ice packs and 1 large freezer ice pack and a black and blue unknown plastic looking filter. -The floor of the of the Nourishment Kitchen was dirty and had debris under the counter, in the corners and along the walls. During an interview on 3/24/25 at 9:00 AM, Registered Nurse #2 Unit Manager stated the food items in the refrigerator on the unit need to be labeled with the resident name and date the food was brought in. It is dietaries responsibility to clean the refrigerators out. During an interview on 3/24/25 at 1:30 AM, the Food Service Director stated the refrigerators on the units were monitored by the dietary staff. They stated they place the nourishments in the refrigerators daily and at that time they should be taking the temperatures of the refrigerator and clean out foods that are not labeled, dated or outdated. c. During an observation on 3/25/25 at 3:04 PM the refrigerator located in the Unit 1 dining room the following was observed: -One large, about a pound size bag, of green grapes in the door that was not dated or labeled with a resident name. -The refrigerator was dirty and had various dried drip spots and dried food debris on the shelves including the door shelves. -The freezer was observed to have red and pink dried drips on the bottom shelf. During an interview on 3/25/25 at 3:04 PM, Licensed Practical Nurse # 3 stated the refrigerator and freezer were dirty and needed cleaning. They stated if they had extra time, they would clean the refrigerator, but it was really the responsibility of the kitchen. They stated they did not know who the green grapes belong to, and they should have been dated and labeled with a resident's name. 10 NYCRR 415.14(h) 14-1.43(e);14-1.110(b)(c)(d);14-1.170;14-1.1.90;14-1.171;14-1.60(d)

Based on interview and record review conducted during a Complaint investigation (#NY00348183, #NY00338640) during a Standard survey completed on [DATE], the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not have sufficient nurse staffing on a 24-hour basis to adequately care for residents' needs 15 out of 30 days and falling below the State average daily staffing hours per resident per day. The finding is: Refer to F 658 Refer to F 677 Refer to F 561 The policy and procedure titled Nursing Department Staffing dated [DATE] documented the facility provides adequate staffing to meet needed care and services for their resident population. The ACTS Complaint/Incident Investigation Report #NY00338640 dated [DATE] documented the facility was consistently short staffed on the weekends. The ACTS Complaint/Incident Investigation Report #NY00348183 dated [DATE] documented the facility was consistently short staffed with one Licensed Practical Nurse for two units, that administration was aware of the staffing issues, and residents were not getting the care they need pertaining to activities of daily living including personal hygiene. The Payroll Based Journal Staffing Data Report Fiscal Year Quarter 1 ([DATE] to [DATE]) 2025 documented that submitted weekend staffing was excessively low for that quarter. Review of the undated Facility Assessment Tool revealed the facility planned on having at least one Registered Nurse for eight hours a day, seven days a week; two Licensed Practical Nurses in the building for all three shifts; and Certified Nurse Aides were to be staffed with five (5) aides on the 6:00 AM to 2:00 PM and the 2:00 PM to 10:00 PM shifts; and three (3) aides on the 10:00 PM to 6:00 AM shift. Review of the Dear Administrator letter ,d+[DATE] dated [DATE] sent to nursing home administrators informing them that starting [DATE] nursing homes were required to have an average daily staffing of 3.5 hours of care per resident per day with 2.2 hours for Certified Nurse Aides and 1.1 hours for Licensed Practical Nurses or Registered Nurses. Review of the Executive Order 4.22 from the New York State Governor's office documented that the emergency staffing waivers expired on [DATE]. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care documented the following: [DATE] - Resident census 92; Registered Nurses 0.61 hours per resident per day; Licensed Practical Nurses 0.61 hours per resident per day; Certified Nurse Aides 1.91 hours per resident per day; 3.13 total hours per resident per day. [DATE] - Resident census 90; Registered Nurses 0.36 hours per resident per day; Licensed Practical Nurses 0.98 hours per resident per day; Certified Nurse Aides 1.78 hours per resident per day; 3.12 total hours per resident per day. [DATE] - Resident census 90; Registered Nurses 0.36 hours per resident per day; Licensed Practical Nurses 1.07 hours per resident per day; Certified Nurse Aides 1.78 hours per resident per day; 3.21 total hours per resident per day. [DATE] - Resident census 93; Registered Nurse 0.52 hours per resident per day; Licensed Practical Nurse 0.86 hours per resident per day; Certified Nurse Aides 1.81 hours per resident per day; 3.19 total hours per resident per day. [DATE] - Resident census 93; Registered Nurse 0.34 hours per resident per day; Licensed Practical Nurse 0.77 hours per resident per day; Certified Nurse Aides 1.89 hours per resident per day; 3.0 total hours per resident per day. [DATE] - Resident census 93; Registered Nurse 0.34 hours per resident per day; Licensed Practical Nurse 0.77 hours per resident per day; Certified Nurse Aides 1.81 hours per resident per day; 2.92 total hours per resident per day. [DATE] - Resident census 93; Registered Nurse 0.43 hours per resident per day; Licensed Practical Nurse 0.95 hours per resident per day; Certified Nurse Aides 1.63 hours per day; 3.01 total hours per resident per day. [DATE] - Resident census 96; Registered Nurse 0.50 hours per resident per day; Licensed Practical Nurse 1.0 hours per resident per day; Certified Nurse Aides 1.58 hours per resident per day; 3.08 total hours per resident per day. [DATE] - Resident census 96; Registered Nurse 0.67 hours per resident per day; Licensed Practical Nurse 0.75 hours per resident per day; Certified Nurse Aides 2.0 hours per resident per day; 3.42 total hours per resident per day. [DATE] - Resident census 96; Registered Nurse 0.50 hours per resident per day; Licensed Practical Nurse 1.0 hours per resident per day; Certified Nurse Aides 1.83 hours per resident per day; 3.33 total hours per resident per day. [DATE] - Resident census 96; Registered Nurse 0.58 hours per resident per day; Licensed Practical Nurse 0.92 per resident per day; Certified Nurse Aides 1.67 hours per day; 3.17 total hours per resident per day. [DATE] - Resident census 96; Registered Nurse 0.33 hours per resident per day; Licensed Practical Nurse 0.92 hours per resident per day; Certified Nurse Aides 1.67 hours per resident per day; 2.92 hours per resident per day. [DATE] - Resident census 96; Registered Nurse 0.25 hours per resident per day; Licensed Practical Nurse 0.83 hours per resident per day; Certified Nurse Aides 1.67 hours per resident per day; 2.75 total hours per resident per day. [DATE] - Resident census 97; Registered Nurse 0.41 hours per resident per day; Licensed Practical Nurse 0.91; Certified Nurse Aides 1.90 hours per resident per day; 3.22 hours per resident per day. [DATE] - Resident census 97; Registered Nurse 0.49 hours per resident per day; Licensed Practical Nurse 0.98 hours per resident per day; Certified Nurse Aides 1.98 hours per resident per day; 3.45 total hours per resident per day. The facility fell below both State average of hours of care per resident per day. During an interview on [DATE] at 8:56 AM, Resident #396 they stated that sometimes there were only one to two Certified Nurse Aides on the unit, and they cannot keep up taking care of the residents. During an interview on [DATE] at 11:21 AM, Resident #74, they stated that they have not gotten a shower or gotten out of bed because there has only been two Certified Nurse Aides working. During an interview on [DATE] at 11:31 AM, Resident #25 stated sometimes there was only one Certified Nurse Aides on the unit. They stated on the weekends that it was like a ghost town and you can wait hours before someone answers a call light. During an interview on [DATE] at 8:00 AM, Resident #18's representative stated at times there has been only one Certified Nurse Aide on the entire unit. Additionally, the resident had to wait get their medications and they were not on time. During an interview on [DATE] at 8:43 AM, Resident #47 stated they have to wait between one to two hours for a Certified Nurse Aide to help them. They stated they can wait for up to two hours before their call light was answered. During an interview on [DATE] at 9:46 AM, Resident #19 stated the facility was always short staffed and that they have to wait for incontinent care. They stated it does not matter what shift or day it was as staffing always changes. During an interview on [DATE] at 8:32 AM, Certified Nurse Aide #14 stated that when there were only two aides working on a unit, they cannot do showers or get people changed and dressed. They stated that residents do not get the care they need, especially if the resident was a two assist. They stated that it was hard to pass food trays in a timely manner. During an interview on [DATE] at 2:31 PM, Licensed Practical Nurse #4 stated they feel they cannot get their duties completed. They stated they must help the Certified Nurse Aides when a resident was a two assist. They stated they can get some of their treatments and some of their vitals completed but not everything. During an interview on [DATE] at 3:53 PM, the Staffing Coordinator stated that the minimum staffing was: Unit 1- one Certified Nurse Aide and one Licensed Practical Nurse for all shifts. Unit 2 and Unit 3 - three Certified Nurse Aides on the 6:00 AM to 2:00 PM shift and the 2:00 PM to 10:00 PM shift with one Licensed Practical Nurse on each unit and one Licensed Practical Nurse that would float between the units. -10:00 PM to 6:00 AM shifts were one Licensed Practical Nurse and two Certified Nurse Aides. They stated if there were call offs after they were done for the day, then whoever was the nursing supervisor must call in people. They stated that they do get people to sign up for extra shifts but that was before they end their day. During an interview on [DATE] at 11:11 AM, the Administrator stated they expected the building to be fully staffed. They stated they expected staff to take care of the residents, to keep the residents safe and dry. During an interview on [DATE] at 12:20 PM, the Assistant Director of Nursing they stated they do the best they can with staffing. 10 NYCRR 415.13(a) (1) (i-iii)

Based on observation, interview and record review conducted during the Standard survey completed on [DATE], the facility did not ensure a Quality Assurance and Performance Improvement program (QAPI) developed, implemented, monitored, maintained effective systems, and used feedback to develop an appropriate plan of action to correct identified deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not maintain effective systems to maintain compliance, and there were repeated deficiencies from the previous Standard survey [DATE] and Compliant survey [DATE] in Food and Nutritional Services. In addition, there were patterned and wide spread cited deficiencies. The findings are: F 812 Food Procurement, Store/Prepare/Serve Sanitary scope and severity F 584 Environment F 836 Administration F 880 Infection Control The policy and procedure titled Quality Assessment/Quality Assurance Committee (QAA) and QAPI (Quality Assurance/Performance Improvement) revised [DATE], documented the facility will monitor and improve functions that significantly affect resident outcomes, the cost to achieve these outcomes, and the perceptions of residents and their families about the quality and value of our services while maintaining a non-retaliatory atmosphere. The Quality Assessment and Assurance (QAA) committee responsibilities include but are not limited to the identification and response to quality deficiencies throughout the facility, and oversight of the QAPI program. The policy documented the committee will develop and implement corrective action and monitoring to ensure performance goals or targets are achieved and revising corrective action when necessary. 1. Review of Standard Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of [DATE] revealed the facility was cited for the following: -F 812 Issues identified in the kitchen were as follows: floors throughout the kitchen, walk in cooler and dry storage room had debris build up and/or dark black substance along the perimeters/corners; outdated, undated and/or unlabeled foods in the refrigerators and dry storage; dark black build up on racks in walk-in cooler; dry food spills/debris on reach in cooler; and unit one nourishment room had expired food items. Review of the Complaint Investigation Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of [DATE] revealed the facility was cited for the following: F 812- Issues identified in the kitchen included the following: undated and outdated food; cooked items stored adjacent to raw meat: multiple soiled surfaces; missing wall and floor tiles. Review of the Quality Assurance and Performance Improvement Meeting Minutes dated [DATE] documented that Dietary had taken several deficiencies from the Department of Health complaint visits. The minutes documented that it was a daily challenge to get the basics completed. The root cause was the staff and lack of formal supervision. Review of the Quality Assurance/Performance Improvement dated February-[DATE] documented the kitchen sanitation and following proper preparation requirements were 80%. Review of the Quality Assurance/Performance Improvement dated [DATE] documented the kitchen sanitation and following proper preparation requirements were 80%. Review of the Quality Assurance/Performance Improvement dated [DATE] documented the kitchen sanitation and following proper preparation requirements were 80%. It was documented on all three reports that 100% education was completed to the staff about safe storage of all food and prepared food items with labeling and dating. Revised job descriptions and creating a check sheet for supervisor giving out daily cleaning tasks/assignments was done. Supervisor were also educated that they were responsible for the follow up of all things related to tasks performed in the kitchen and the daily function of our staff. Review of an undated facility document titled Kitchen Sanitation documented that an audit was completed randomly each month. Kitchen sanitation received a poor rating in [DATE] and [DATE] and a fair rating in [DATE], [DATE], [DATE], [DATE], [DATE], February 2025 and [DATE]. It was documented that the expectation was a good rating for the sanitation of the kitchen. During an interview on [DATE] at 11:00 AM, the Administrator stated the kitchen had much improved but still needed more work. They stated they were aware of the problems in the kitchen and they hired a Registered Dietitian full time to help. They stated the Food Service Director was not certified for varies reasons and more changes need to be made in the kitchen, but the facility was waiting for the Department of Health to come in for survey before these changes were made. 2. F 584- the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior issues included: with dirty floors; dirty window curtains in disrepair; stained privacy curtains in disrepair; window blinds with missing or broken slats; walls had chipped paint and spackled areas that were not sanded or painted; dirty wall register covers; resident's bed had missing molding around the footboard; soiled fall mats; strong urine odors in resident rooms; dirty windows; spider webs on windows and walls; door threshold was missing; missing or broken tiles in the shower rooms; basins and graduated cylinders on the floor in shared bathrooms; missing lightbulbs in a wall lamp; broken dresser drawers and an over the bed table soiled with food debris and dried liquid. During an interview on [DATE] at 9:55 AM, the Director of Housekeeping stated they realized this was the residents' home and the rooms could be cleaner. During an interview on [DATE] at 10:00 AM, the Maintenance Director stated that they were aware of issues in the resident rooms and resident areas. They stated that it was a constant battle to repair things in resident rooms due to the age of the building and they could do better maintain the building. During an interview on [DATE] at 11:11 AM, the Administrator stated that the building could be cleaner. They stated that they expected housekeeping to keep the building clean and that maintenance should repair things. During an interview on [DATE] at 11:44 AM, the [NAME] President of Clinical Services stated that they believed the building could be cleaner. They stated they expected the housekeepers to clean the resident rooms, and that maintenance staff should repair things in resident rooms. Review of the Quality Assurance and Performance Improvement Meeting Minutes dated [DATE] documented environmental services had obtained a new floor machine, but it was not effective or efficient. It was documented that floors, edges and corners were in dire need of addressing and the department had been without a floor technician since the beginning of February. 3. F 880- the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections. Issues included: staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) during care. Staff did not maintain infection control practices during foley care and wound care, medication administration and post care activities. During an interview on [DATE] at 12:15 PM, Regional Quality Assurance Nurse/Infection Preventionist #1 stated when a resident was on enhanced barrier precautions, they expected all staff to wear gloves, a gown, and a mask when providing care. They stated the unit manager was responsible for ensuring all staff wore appropriate personal protective equipment when providing care and the Director of Nursing was responsible for follow through. 4. F 836- the facility did not have sufficient nurse staffing on a 24-hour basis to adequately care for residents' needs 15 out of 30 days, falling below the State average daily staffing hours per resident per day. During an interview on [DATE] at 11:11 AM, the Administrator stated they expected the building to be fully staffed, and they expected staff to take care of the residents, to keep the residents safe and dry. During an interview on [DATE] at 12:20 PM, the Assistant Director of Nursing they stated they do the best they can with staffing. The (QAPI) Quality Assurance and Performance Improvement Meeting minutes dated [DATE], documented the resident council report had complaints of short staffing. During the QAPI/Quality Assessment and Assurance (QAA) interview on [DATE] at 1:47 PM the Administrator, with the [NAME] President of Clinical Services present, stated the interdisciplinary team would meet monthly for the Quality Assurance meetings. The Administrator stated they would track and discuss family and resident's complaints at the meetings and then they (the Administrator) would ultimately decide on what performance improvement project would be created. The Administrator stated they also talk with the nursing management weekly about resident care, such as showers and activities of daily living. They stated it was a constant struggle to get nursing staff to think post COVID-19 because care that was done to get through those times were still in practice. The Administrator stated that they are consistently doing a performance improvement project in the dietary department. The team was always looking for a 100% compliance rate, but 95% compliance was the goal. The Administrator stated the project could not stop until that 95% compliance rate was reached and that threshold has not yet been met. Through root-cause-analysis they had discovered they continued to have repeat deficiencies in the dietary department because of the labor pool. They needed to match the right person with the right task and there was a lack of adequate and appropriate supervisor. The Administrator stated they would not say their performance improvement project for the dietary department was ineffective because the department had so much improvement from where it was a year ago. They stated the internal changing within the dietary department had been slow, but they were making permanent changes and progress. They stated it was a cautious effort and process to make successful changes to build a solid foundation. They stated they are trying to empower the management to grow their department. They also stated they have completed some recent education to staff regarding infection control practices. In addition, they were aggressively handling the attitudes of staff, and it was working because staff were actually arriving to work on time, but the union was also fighting them. 10NYCRR 415.27(c)(3)(v)(4)

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00347069) during a Standard survey completed on 3/28/25, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for one of one facility reviewed for infection control. Specifically, staff did not utilize enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) during morning care, urinary catheter (foley-a tube inserted into the bladder to drain urine) care, and wound care and staff did not remove their gloves or wash hands after incontinent care was provided and before touching clean items for Resident #19; staff did not use enhanced barrier precautions during administration of intravenous medication through a central line for Residents #396 and #399; staff did not perform hand hygiene in between residents during medication administration and without wearing gloves, instilled eye drops for Resident #108; there was no signage on Resident #444's door that indicated they were on enhanced barrier precautions and staff did not wear a gown during wound care; staff performed urinary incontinent care, did not remove their soiled gloves nor their precaution gown, touched door handles, exited the room, touched the clean linen cart cover and clean linens, then returned to the room and without changing their gloves or performing hand hygiene and completed care for Resident #79. The findings are: The policy titled Infection Prevention and Control Program, last revised 3/21/24, documented the infection prevention and control program was a facility-wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. The elements of the program consisted of coordination/oversight, policies/procedures, enhanced barrier precautions, prevention of infection, and identifying, recording and correcting infection control program incidents. The policy titled Enhanced Barrier Precautions, effective 4/1/24, documented enhanced barrier precautions were used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. Enhanced barrier precautions employ targeted gown and glove use during high contact resident care activities; gloves and gown were applied prior to performing the high contact resident care activity and changed before caring for another resident, face protection may be used if there was a risk of slash or spray. High contact care activities that required the use of gown and gloves included dressing, bathing, transferring, providing hygiene, changing linen and/or briefs, device care (central line, urinary catheter), and wound care. Enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices regardless of multi-drug-resistant organism colonization and remained in place for the duration of their stay or until resolution of the wound or discontinuation of indwelling medical device that placed them at increased risk. Staff were trained prior to caring for residents on enhanced barrier precautions, signs posted on the door or wall outside residents' room and personal protective equipment available outside of residents' room. The policy titled Handwashing/ Hand Hygiene, last revised 4/1/2020, documented all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: when hands are visibly soiled and after contact with a resident with infectious diarrhea. Use an alcohol based hand rub containing at least 62% alcohol, or alternatively soap and water for the following: before and after direct contact with residents, when performing standard and transmission based precautions, before and after touching contaminated personal protective equipment, before and after handling medications, before performing any non-surgical invasive procedures, before and after handling invasive device, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, after contact with a residents intact skin or with blood or body fluids, after handling used dressings, after contact with objects in the immediate vicinity of the resident, after removing gloves, and before and after entering isolation precaution settings. The use of gloves did not replace hand washing/hand hygiene. 1.Resident #19 had diagnosis neuromuscular dysfunction of bladder (condition where nerve damage prevents the bladder from functioning properly, leading to difficulty controlling urination, can result in symptoms of difficulty emptying the bladder) with history of urinary tract infections, and dementia. The Minimum Data Set (a resident assessment tool) dated 2/21/25 documented Resident #19 had moderate cognitive impairment, did not exhibit rejection of care, required partial/moderate assistance to roll from lying on back to left and right side while in bed, and was always incontinent of bowel. The comprehensive care plan dated 7/29/25 documented Resident #19 had potential for infection related to indwelling catheter and history of urinary tract infections, interventions included enhanced barrier precautions, foley catheter care daily and as needed. During an observation on 3/26/25 from 9:12 AM to 9:33 AM, an enhanced barrier precaution sign was on Resident #19's room door that directed staff to wear a gown and gloves during care and there were supplies set up next to the resident's door in the hallway. The following was observed during an observation of AM care, foley care and pressure ulcer treatment care for Resident #19: - Certified Nursing Assistant #4 and Licensed Practical Nurse #7 were observed wearing face masks and they donned (put on) gloves. They did not don a gown to provide care. - Certified Nursing Assistant #4 provided catheter care, bowel incontinence care, and washed the resident's buttocks that had two open areas. They did not remove the soiled gloves, perform hand hygiene and don clean gloves before they placed a clean bed linen pad and a clean brief under the resident. Certified Nursing Assistant #4 removed their soiled gloves, did not wash their hands, and donned a new pair of gloves. Then they provided oral care set up to Resident #19. - While wearing gloves, Certified Nursing Assistant #4 emptied Resident #19's foley catheter bag into a graduate (measuring container), emptied and rinsed the graduate into the toilet, touched the toilet flush handle and the sink faucet handles, removed their gloves and did not wash their hands before donning another pair of gloves. Then they assisted with dressing Resident #19. - During the observed care Licensed Practical Nurse #7 assisted Certified Nurse Aide #4 in positioning the resident and handling soiled linens. Licensed Practical Nurse #7 removed their gloves but did not wash their hands, donned gloves and provided a treatment to Resident #19's left buttocks and coccyx open areas. During an interview on 3/26/25 at 9:34 AM, Certified Nursing Assistant #4 stated Resident #19 was on enhanced barrier precautions because they had an indwelling foley catheter and they should have worn a gown while providing care. They stated they should have removed their gloves and washed their hands after providing incontinent care and before touching any clean items in the room, after draining the foley catheter before touching any handles in the bathroom such as the toilet flush handle and sink faucet handles. They stated they were taught to wash their hands any time they changed their gloves, but they did not because the gloves were too difficult to put on if their hands were damp and stated they did not wash their hands until they have completed all care although they knew they were supposed to. During an interview on 3/28/25 at 8:59 AM, Unit Manager Registered Nurse #5 stated they expected Certified Nursing Assistant #4 and Licensed Practical Nurse #7 to have worn a gown while providing care to Resident #19 because they were on enhanced barrier precautions related to their foley catheter. They stated Certified Nursing Assistant #4 should have changed their gloves and washed their hands at a minimum after peri care/ foley catheter tubing care; after removing feces and providing incontinent care; and they should have removed one glove to facilitate using the toilet flush handle and sink faucets with the ungloved hand for infection control purposes. They stated Licensed Practical Nurse #7 should have changed their gloves and washed their hands before wound care, and between treatment applications to two separate open areas to prevent cross contamination. During an interview on 3/28/25 at 10:35 AM, the Assistant Director of Nursing stated they would have expected Certified Nursing Assistant #4 and Licensed Practical Nurse #7 to have worn a gown while providing care to Resident #19 because they are on enhanced barrier precautions related to their foley catheter. They stated Certified Nursing Assistant #4 should have changed their gloves and washed their hands at a minimum of after peri care/foley catheter tubing care; after removing feces and providing incontinent care; and they should have removed one glove to facilitate using the toilet flush handle and sink faucets with the ungloved hand for infection control purposes. They stated Licensed Practical Nurse #7 should have changed their gloves and washed their hands before wound care, and between treatment applications to two separate open areas to prevent cross contamination. During an interview on 3/28/25 at 4:03 PM Licensed Practical Nurse #7 stated they should have worn a gown while providing care to Resident #19 because they were on enhanced barrier precautions related to having an indwelling foley catheter. They stated they should have changed their gloves and washed hands before wound care, and between treatment applications to two separate open areas to prevent cross contamination. 2. Resident #396 had diagnoses including abscess of the lung with pneumonia, methicillin resistant Staphylococcus aureus (bacteria resistant to multiple antibiotics, making infection harder to treat) infection, and malignant neoplasm (tumor that tends to spread to other parts of the body) of the bronchus or lung. The Minimum Data Set, dated dated dated [DATE] documented Resident #396 was cognitively intact, was understood, understands and received intravenous antibiotics. The comprehensive care plan, dated 3/24/25, documented Resident #396 was at risk for infection related to a port, pneumonia/lung abscess, and pressure ulcer with interventions to administer medications as ordered, vascular access device care as ordered, and to maintain precautions as needed. The medication administration record for March 2025 documented Resident #396 had an order to receive Vancomycin (intravenous antibiotic) 1500 milligram/300 milliliter solution via central line every 12 hours for 10 days for infection. The medication had a check mark on 3/24/25, indicating it had been administered. Resident #399 had diagnoses that included acute and subacute endocarditis, (inflammation of the heart), chronic kidney disease, and bacteremia (bacteria in the bloodstream). The Minimum Data Set, dated dated dated [DATE] documented Resident #399 had moderate cognitive impairment, was understood, understands, and received intravenous antibiotics. Review of active physicians' orders form dated 3/28/25 documented Resident #399 received Ceftriaxone (antibiotic medication) intravenous solution 2 grams/100 milliliters in normal saline once daily for 25 days starting on 3/13/25. During a continuous observation on 3/24/25 at 12:06 PM, Registered Nurse Unit Manager #2 prepared medications to administer to Resident #396 and #399 at the nurse's station. At 12:09 PM they entered Resident #399's room, performed hand hygiene and donned (put on) gloves but did not wear a gown. The Registered Nurse Unit Manager #2 hung a bag containing a clear liquid medication onto the pole beside the resident, cleansed Resident #399's PICC (peripherally inserted central catheter-a catheter that is inserted through a vein and advanced until the tip enters the central venous system) line with an alcohol pad, flushed the port with normal saline, attached the intravenous catheter tubing to the port, and turned on the pump. They exited the room and grabbed another bag from the nurse's station. Registered Nurse Unit Manager #2 entered Resident #396's room at 12:12 PM, performed hand hygiene, applied gloves, hung the bag containing the antibiotic onto the pole, cleansed Resident #396's left chest mediport (a central venous access device) with an alcohol swab, flushed the port with a syringe of normal saline, attached the intravenous catheter tubing to Resident #396's chest port, turned on the pump and exited the room. Both resident's had signage outside of their rooms that indicated they were on enhanced barrier precautions and staff were to wear a gown and gloves during high contact resident care activities. During an interview on 3/24/25 at 12:14 PM, Registered Nurse Unit Manager #2 stated they had just hung the intravenous medications for Resident's #396 and #399. They stated both residents were on enhanced barrier precautions because they were receiving antibiotic medications for infections through an intravenous medical access device so they should have had on gloves, a gown, and a mask, and they had not. Registered Nurse Unit Manager #2 stated it was important to wear gloves, a gown, and a mask while providing care to a resident on enhanced barrier precautions to lower the risk of infection. They stated they were responsible for ensuring all staff on the unit were wearing proper personal protective equipment when providing hands on care to residents on enhanced barrier precautions, including themselves. During an interview on 3/28/25 at 11:16 AM, Medical Director #1 stated if a resident had methicillin resistant staphylococcus aureus or any other contagious bacteria and were on enhanced barrier precautions they would expect the staff caring for them to wear gloves, a gown, and mask when providing hands on care, especially when administering intravenous antibiotic medication. They stated it was important to wear all appropriate personal protective equipment to prevent the spread of infection. They stated the unit manager was responsible for ensuring all staff adhered to the rules on the unit and the Director of Nursing was responsible for monitoring and any follow through needed. During an interview on 3/28/25 at 12:15 PM, Regional Quality Assurance Nurse/Infection Preventionist stated when a resident was on enhanced barrier precautions, they expected all staff to wear gloves, a gown, and a mask when providing care. A resident receiving intravenous antibiotic medication would be on enhanced barrier precautions so the nurse hanging the antibiotic medication should be wearing gloves, a gown, and a mask when administering the medication. They stated the unit manager was responsible for ensuring all staff wore appropriate personal protective equipment when providing care and the Director of Nursing was responsible for follow through. There was a risk of cross contamination and enhanced barrier precautions were needed to prevent the spread of infection. During an interview on 3/28/25 at 1:33 PM, the Director of Nursing/Infection Preventionist stated they expected staff to wear gloves, a gown, and a mask whenever providing any direct care to residents on enhanced barrier precautions. It was important to decrease the risk of transmission. They stated the unit manager was responsible for ensuring all staff wore appropriate personal protective equipment, and the Assistant Director of Nursing and themselves were responsible for any follow through. During an interview on 3/28/25 at 2:31 PM, the [NAME] President of Clinical Services stated staff should wear gloves, a gown, and a mask when providing care to residents on enhanced barrier precautions, especially when administering intravenous medications. They stated it was important to keep the resident safe and help prevent the spread of infection. 3. During a medication administration observation on 3/27/25 at 9:15AM, Licensed Practical Nurse #3 administered oral medications, then without performing hand or donning gloves went into Resident #108's room and administered the resident's oral medications. Licensed Practical Nurse #3 used their ungloved hand to hold the resident's eyelids open and instilled eye drops into both of their eyes. Licensed Practical Nurse #3 then performed hand hygiene. During an interview on 3/27/25 at 9:18AM, Licensed Practical Nurse #3 stated they cross contaminated by not washing or sanitizing their hands in between residents and not putting gloves on to administer the eye drops and was an infection control risk. Licensed Practical Nurse #3 stated they were not thinking. During an interview on 3/28/25 at 1:04PM, the Assistant Director of Nursing stated the safest way that prevented the spread infection was by performing hand hygiene. Licensed Practical Nurse #3 should have washed their hands in between residents, then donned gloves before giving the eye drops, administered the eye drops, removed their gloves and washed their hands for infection control practices. Licensed Practical Nurse #3 should have washed their hands after giving medications regardless. Hand hygiene and wearing gloves protected the residents from the spread of infection. During an interview on 3/28/25 at 1:30PM, the Regional Quality Assurance Nurse/Infection Preventionist stated the lack of hand hygiene in-between residents' medication pass was unacceptable and against the facilities infection control protocol. 4. Resident #444 had diagnoses that included diabetes mellites with a skin ulcer, acute osteomyelitis (infection of the bone) of the left foot, and orthopedic aftercare. The comprehensive care plan dated 3/11/25, documented Resident #444 was alert and oriented and was at risk for impaired skin integrity related to acute osteomyelitis of the left foot and orthopedic aftercare. The resident had an infection related to bacteremia (bacteria in the blood stream) and a wound. Interventions included to administer meds as order and infectious disease consult as needed. Resident #444's physician orders dated 3/28/25 documented an order dated 3/21/25, to cleanse the left foot wound with normal saline, pack wound with 1/2 inch of iodoform packing strip (antiseptic gauze dressing), cover with gauze and kling (flexible, absorbent gauze dressing used to wrap wounds) once a day. The physician orders documented that Resident #444 was on Unasyn (antibiotic) 3 grams intravenously every 6 hours for infection. Review of Unit 1 daily unit report from 3/22/25-3/27/25 did not indicate Resident #444 was to be on enhanced barrier precautions. Review of the facility's Enhanced Barrier Precaution signage provided by Registered Nurse #4 documented that staff were to wear gloves and gown for the following high contact resident care activities: wound care; any skin opening requiring a dressing. During observations on 3/24/25 at 10:14 AM, 3/25/25 at 9:00 AM, 3/25/25 at 1:52 PM, 3/26/25 at 11:59 AM, 3/26/25 at 5:21 PM there was no enhanced barrier precaution signage on Resident #444 door/wall near the entrance to their room. Outside of the resident's room there was a red garbage bin and a three-drawer plastic bin that contained masks, gloves and gowns. During an interview on 3/25/25 at 9:08 AM, Resident #444 stated that staff did not wear gowns while they were doing their treatment to their infected left foot or when they administered their intravenous medication. During a wound care treatment observation on 3/27/25 at 4:31 PM, Licensed Practical Nurse #8 performed hand hygiene and donned gloves prior to the start of Resident #444 left foot diabetic wound treatment. The old dressing on the resident's food was observed to have serosanguinous (blood and serum) drainage on it. Resident #444 diabetic ulcer wound bed appeared to be moist with serous (pale yellow or clear) drainage. Licensed Practical Nurse #8 completed Resident #444's treatment without wearing a gown. During an interview on 3/27/25 at 4:45 PM, Licensed Practical Nurse #8 stated they did not wear a gown during Resident #444's treatment because they could not wear paper gowns. They stated Resident #444 was just on universal precautions and not enhanced barrier precautions because the dressings were not sterile. Licensed Practical Nurse #8 stated if a resident was to be enhanced barrier precautions there would be signage on their door, and it would also be written on the 24-hour report sheet. During an observation and interview on 3/28/25 at 10:52 AM, Registered Nurse #4, Unit Manager stated Resident #444 was on enhance barrier precautions because they had an intravenous line and a draining diabetic ulcer to their foot. After Registered Nurse #4 visualized the outside of Resident #444 room they stated that there was not enhance barrier precaution signage but there should have been. Registered Nurse #4 stated that Licensed Practical Nurse #8 should have worn a gown while performing wound care on Resident #444. During an interview on 3/28/25 at 11:53 AM, the [NAME] President of Clinical Services stated that they expected staff members to utilized enhanced barrier precautions during wound care for a diabetic ulcer. They stated that all residents that were on enhanced barrier precautions were to have green or orange signage outside of their door to alert staff that the resident was on enhanced barrier precautions. They stated they expected Licensed Practical Nurse #8 to wear a gown during Resident #444's treatment and a cloth gown could have been utilized. 5. Resident #79 had diagnoses that included sacral pressure ulcer stage 4 (full thickness tissue loss with exposed bone, tendon or muscle), dementia and hypertension. The Minimum Data Set, dated dated dated [DATE] documented Resident #79 had severe cognitive impairment, sometimes understands, was sometimes understood, and had one stage IV (4) pressure ulcer that was present upon reentry to the facility. The comprehensive care plan revised on 9/17/25, documented Resident #79 had an infection related to the presence of a sacral pressure ulcer stage 4 and osteomyelitis. Interventions included to administer wound treatments as ordered and maintain enhanced barrier precautions as needed. Review of the Wound Assessment and Plan note dated 3/21/25, revealed the Wound Physician documented that Resident #79 had a stage IV sacral pressure ulcer. The wound status was documented as a healing wound with a large amount of drainage. During an AM care observation on 3/27/25 at 9:33 AM, Certified Nurse Aide #10 and Certified Nurse Aide #11 donned (put on) gowns and gloves prior to entering Resident #79 room. Certified Nurse Aide #10 washed and dried Resident #79's peri area (area between the anus and genitalia) with a towel, rolled the resident onto their side with the help of Certified Nurse Aide #11, and washed and dried the resident's buttocks. Resident #79's sacral wound dressing was observed on the incontinent pad and Certified Nurse Aide #10 picked it up with their gloved hand, exited the room, removed their gloves in the hallway, never doffing (taking off) the gown they were wearing. Certified Nurse Aide #10 reentered the resident's room, donned a new pair of gloves but did not perform hand hygiene. Certified Nurse Aide #10 entered Resident #79's bathroom, filled a basin with water and placed it on the resident's bed side table. Certified Nurse Aide #10 did not doff their gloves or gown, touched the door handle with their gloved hand, exited the resident's room, grabbed additional linens off the linen cart, and reentered Resident #79's room. Certified Nurse Aide #10, with the assistance of Certified Nurse Aide #11 rewashed Resident #79's peri area, buttocks and changed the resident's incontinent pad that was wet with urine. Certified Nurse Aide #10 did not doff their gloves or gown, touched the resident's bathroom door to close it, touched the room door handle, exited the resident's room, touched the cover on the linen cart, and removed a hospital gown from the linen cart. Certified Nurse #10 walked back into Resident #79's room with the clean hospital gown to the resident's bedside, turned around, walked back out of the room with the hospital gown still in their gloved hand, put it back onto the linen cart, removed a second hospital gown from the linen cart, and walked back into the resident's room. Wearing the same gloves that they provided peri care with, they dressed the resident in the gown. During an interview on 3/27/25 at 10:01 AM, Certified Nurse Aide #11 stated that Resident #79's AM started off bad from the beginning. They stated that Certified Nurse Aide #10 did not wash their hands prior to starting care, never took their gown off each time they left the resident room and never washed their hands after reentering the resident's room. Certified Nurse Aide #11 stated Resident #79's incontinent pad was saturated with urine prior to changing it. Certified Nurse Aide #11 stated that staff should perform hand hygiene before and after care was provided, at least four times during care and whenever gloves were changed. They stated the purpose of proper hand hygiene was for infection control reasons and so you don't pass stuff around. During an interview on 3/27/25 at 10:41 AM, Certified Nurse Aide #10 stated they broke infection control barriers by exiting Resident #79's room with their gown and gloves on. They stated they touched everything with their gloved hands, and they were not supposed to do that. Certified Nurse Aide #10 stated they removed a hospital gown from the linen cart, went into the resident's room with the gown and then returned the same gown to the linen cart. They stated that they needed to wash their hands before and after care but not in between glove changes. Certified Nurse Aide #10 stated that they should never wear gloves out in a hallway because they were considered dirty. They stated that they were nervous, and they were not even thinking. During an interview on 3/28/25 at 11:01 AM, Registered Nurse #2 stated that staff should perform hand hygiene before care, after care, anytime they were soiled and anytime a staff member changed their gloves. They stated that gowns and gloves should be doffed at the resident's door and thrown in their garbage can prior to leaving the room. Registered Nurse #2 stated that Resident #79 was on enhanced barrier precautions due to having a pressure ulcer to their sacrum and infection control breaches during care could possibly spread infection to other residents. During an interview on 3/28/25 at 11:53 AM, the Assistant Director of Nursing stated that Certified Nurse Aide #10 had broken infection control practices during AM care for Resident #79 when the staff member left the resident room with their gown and dirty gloves on, touched items and put the hospital gown back onto the linen cart. They stated that staff were to remove their gloves and hand sanitize after providing peri care prior to washing other parts of a resident's body. The Assistant Director of Nursing stated the importance of proper hand hygiene and doffing of gloves and gowns prior to exiting a resident room was to prevent the spread of infection especially with a resident who had a wound. During an interview on 03/28/25 at 12:24 PM, the [NAME] President of Clinical Services stated their expectation for appropriate hand hygiene would be staff washed their hands prior to care being started, after the completion of peri care and anytime the staff member was going from a dirty to clean area. They stated that linens should never be returned to the linen carts after it had already been in a resident's room for infection control reasons. 10 NYCRR 415.19(a)(1-3), 415.19(b)(4)

Based on interview, observation, and record review conducted during complaint investigations (NY00348183, NY00338640, NY00335062, NY00347069) conducted during a Standard survey completed on 3/28/2025, the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (3) (Units 1, 2, and 3) of three (3) resident units. Specifically there were issues with dirty floors (Units 1, 2, 3); dirty window curtains in disrepair (Units 2, 3); stained privacy curtains in disrepair (Units 1, 2, 3); window blinds with missing or broken slats (Units 1, 2, 3); walls had chipped paint and spackled areas that were not sanded or painted (Units 1, 2, 3); dirty wall register covers (Units 1, 2, 3); resident's bed had missing molding around the footboard (Unit 3); soiled fall mats (Unit 2): strong urine odors in resident rooms (Units 2, 3); dirty windows (Units 2, 3); spider webs on windows and walls (Unit 3); door threshold was missing (Unit 3); missing or broken tiles in the shower rooms (Units 2, 3); basins and graduated cylinders on the floor in shared bathrooms (Units 2, 3); missing lightbulbs in a wall lamp (Unit 3); broken dresser drawers and an over the bed table soiled with food debris and dried liquid (Unit 3). The findings are: The policy titled Cleaning and Disinfecting Resident's Rooms dated 11/1/2017 documented that resident rooms housekeeping surfaces such as floors and tabletops will be cleaned on a regular basis; environmental surfaces shall be disinfected or cleaned on a regular basis or when visibly soiled; and walls, blinds, and window curtains will be cleaned when these surfaces are visibly contaminated or soiled. The policy titled Cleaning and Disinfecting Environmental Surfaces dated 3/10/2020 documented that environmental surfaces shall be cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled. The job description of a Maintenance Manager documented the manager was to plan, organize, develop, and direct the general and preventative maintenance of the physical plant and grounds as directed by the Administrator, to assure that the facility was maintained according to policy. The job description of a Maintenance Assistant documented the assistant was to implement required maintenance procedures in an efficient, cost-effective manner meeting all federal, state and local requirements while providing a safe environment for residents. The job description of a Housekeeper documented they were to implement required housekeeping procedures in an efficient, cost-effective manner meeting all federal, state, and local requirements while providing a safe environment for residents. Observations on 3/24/2025 between 8:00 AM to 1:00 PM revealed the following: Unit 1 room [ROOM NUMBER] - a four-foot-long section of wall behind headboard of bed, paint chipped and wall with scrapes and gouges exposing drywall; floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - blinds with approximately four broken slats; the bathroom sink was supported by a round, wooden stick approximately three feet long; floor approximately one to two inches wide from the wall with black and brown debris. Unit 2 room [ROOM NUMBER] -the chair rail on the wall was missing an approximately 10-foot section; a six inch long section of baseboard was missing next to the bathroom door; a three foot by three foot area behind the headboard of the bed had chipped paint and gouged wall; the window curtains were mismatched; a strong urine odor in the room; the floor had a one to two inch area from the wall with black and brown debris. Shower Room - tiles missing from the shower wall approximately eight inches by two inches; baseboard and drywall missing from shower wall approximately six inches by six inches exposing bare wood; tiles missing from the floor in front of missing baseboard approximately seven inches by one inch exposing the subfloor; eight foot by one foot area in front of the small shower stall with chipped paint; entire floor approximately one inch to two inches wide from the wall of shower room with black and brown debris. room [ROOM NUMBER] - a six-foot-long fall mat was stuck to the floor with black and brown debris along the edge of the mat; another fall mat was dirty with black and brown debris; the window blind was broken with missing slats; room floor approximately one to two inches wide from the wall with black and brown debris; the wall register cover was dirty with black, white, and grey debris. room [ROOM NUMBER] - the bathroom tile floor was dirty with black and brown debris; an unlabeled, graduated cylinder was on the floor of a shared bathroom; a three by five foot area behind the bed nearest to the bathroom entrance had chipped paint and was scraped; the window blinds had six broken and missing slats; room floor approximately one to two inches wide from the wall with black and brown debris; a towel with brown debris was on the bathroom sink faucet; the wall register covers under the window and in the bathroom were dirty with grey and white debris; there were brown dried liquid spills on the wall register; the window curtains were dirty with black and brown debris; the window curtain rods were broken; the privacy curtains were dirty with multiple white, brown, and pink spots on them. Unit 3 room [ROOM NUMBER] -the floor had multiple white spots; spider webs were on the inside of the window; white and grey debris on the outside of the window. Shower Room - six inch by one-inch missing tile exposed drywall outside of the large shower stall; six 4 inch by 4 inch tiles with black and brown debris along the walls in the large shower stall; rusty handrails in the large shower stall; approximately four foot section of the baseboard was pushed in and exposing bare floor next to the toilet; black and brown debris along the baseboard outside the smaller shower stall approximately four feet long. room [ROOM NUMBER] - window blinds with three broken slats; window curtains with holes in the fabric, missing curtain hooks, and not attached to the curtain rod; entry door threshold missing molding; baseboard molding missing approximately four feet long that exposed spackled drywall that was not sanded or painted; room floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; the wall had an approximately four foot by four foot area next to the window with peeling paint and was stained brown; there were spider webs in the corner of the room next to the window; the entry door threshold was missing. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; approximately six hooks missing from the privacy curtain and hanging from the track; over the bed table with food debris and dried, liquid spills on it; black non-skid strips on the floor next to the bed were worn with approximately 1.5 feet missing; the bathroom floor tiles were dirty with black and brown debris. room [ROOM NUMBER] -two-foot-long missing baseboard with exposed drywall next to the bathroom door; wall lamp had missing bulbs with electric wires exposed and white debris on top of the sconce; the wall register cover was dirty with black, grey and white debris on it. room [ROOM NUMBER] - outside of window with white and grey debris; room floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - strong urine odor in room; room floor approximately one to two inches wide from the wall with black and brown debris; wall register cover with dried brown liquid spills; windows were missing blinds and curtains; bathroom floor tiles with black and brown debris; grey and white debris on the outside of the window. room [ROOM NUMBER] - strong urine smell in the room. room [ROOM NUMBER] - seven-bathroom floor tiles were missing and coming up from the floor; black debris around the toilet; strong urine smell in the bathroom. Unit 3 utility room - baseboard molding coming off the wall next to the utility room approximately one foot long; drywall spackled, not painted or sanded on the wall above the baseboard molding approximately eight inches. Observations on 3/25/2025 between 7:00 AM to 12:00 PM revealed: Unit 1 room [ROOM NUMBER] - window blinds had approximately five broken slats, brown, dried liquid spills on the wall register cover, the privacy curtain was dirty with multiple brown spots; the floor approximately one to two inches wide from the wall with black and brown debris. Unit 2 room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; four privacy curtains were dirty with brown or white stains, were hanging from the ceiling with missing hook attachments that attach to the ceiling; window blinds with approximately five broken slats; the wall register cover under the large window was dirty with brown liquid spills; approximately six feet along the entry door with missing or cracked drywall; a dresser in disrepair with a drawer face missing from the top drawer and a drawer face falling off another drawer. room [ROOM NUMBER] - bathroom floor with black and brown debris along the base of the wall; room floor approximately one to two inches wide from the wall with black and brown debris; three foot by three foot area next to the bed with paint scraped and chipped exposing drywall underneath; approximately four broken slats on the window blinds. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; fall mat had a one-inch gouge and was dirty with black and brown debris; windows were dirty with white and grey debris on the outside. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; seven foot by three-foot area on the wall next to the bed with paint chipped and gouged exposing drywall underneath; unlabeled basin and graduated cylinder in a shared bathroom; wall register cover with black and white debris on it. Unit 3 room [ROOM NUMBER] - soiled linens on the floor; bathroom tiles with black debris on them; chipped paint on the bathroom door. Observations on 3/27/2025 between 7:00 AM to 11:00 AM revealed: Unit 1 room [ROOM NUMBER] - a four-foot-long section of wall behind headboard of bed, paint chipped and wall with scrapes and gouges exposing drywall; floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - window blind blinds still had approximately five broken slats, brown, dried liquid spills on wall register cover, privacy curtain was dirty with multiple brown spots: floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - blinds with approximately four broken slats; the bathroom sink was supported by a round, wooden stick approximately three feet long; floor approximately one to two inches wide from the wall with black and brown debris. Unit 2 room [ROOM NUMBER] - chair rail on wall missing approximately 10-foot section; baseboard missing next to the bathroom door approximately six inches long; three foot by three-foot area behind the headboard of the bed with paint chipped and wall gouged; mismatched window curtains; a strong urine odor in the room; floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; four privacy curtains with brown or white stains, hanging from ceiling with missing hook attachments that attach to the ceiling; window blinds with approximately five broken slats; wall register cover under the large window with brown liquid spills; approximately six feet along the entry door with missing or cracked drywall; a dresser in disrepair with a drawer face missing from the top drawer and a drawer face falling off another drawer. room [ROOM NUMBER] - bathroom floor with black and brown debris along the base of the wall; room floor approximately one to two inches wide from the wall with black and brown debris; three foot by three-foot area next to bed with paint scraped and chipped exposing drywall underneath; approximately four broken slats on the window blinds. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; fall mat with one inch gouge with black and brown debris; windows with white and grey debris on the outside. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; seven foot by three-foot area on the wall next to the bed with paint chipped and gouged exposing drywall underneath; unlabeled basin and graduated cylinder in a shared bathroom; wall register cover with black and white debris on it. Shower Room - tiles missing from shower wall approximately eight inches by two inches; baseboard and drywall missing from shower wall approximately six inches by six inches exposing bare wood; tiles missing from floor in front of missing baseboard approximately seven inches by one inch exposing subfloor; eight foot by one foot area in front of small shower stall with paint chipped; entire floor approximately one inch to two inches wide from the wall of shower room with black and brown debris. room [ROOM NUMBER] - six-foot-long fall mat stuck to the floor with black and brown debris along the edge of the mat; another fall mat with black and brown debris on it; window blind with broken and missing slats; room floor approximately one to two inches wide from the wall with black and brown debris; wall register cover with black, white, and grey debris on it. room [ROOM NUMBER] - bathroom tile floor with black and brown debris; unlabeled graduated cylinder on the floor of a shared bathroom; three by five foot area behind the bed nearest to the bathroom entrance with paint chipped and scraped; approximately six broken and missing slats on the window blinds; room floor approximately one to two inches wide from the wall with black and brown debris; a towel with brown debris on the bathroom sink faucet; wall register cover with grey and white debris under the window and in the bathroom; brown liquid spills on the wall register; window curtains with black and brown debris; window curtain rods broken; privacy curtains with multiple white, brown, and pink spots on them. Unit 3 room [ROOM NUMBER] - floor with multiple white spots; spider webs on the inside of the window; white and grey debris on the outside of the window. Shower Room - six inch by one-inch missing tile exposed drywall outside of the large shower stall; six 4 inch by 4-inch tiles with black and brown debris along the walls in the large shower stall; rusty handrails in the large shower stall; approximately four feet of baseboard pushed in and exposing bare floor next to the toilet; black and brown debris along baseboard outside smaller shower stall approximately four feet long. room [ROOM NUMBER] - approximately three broken slats in the window blinds; window curtains with holes in the fabric, missing curtain hooks, and not attached to the curtain rod; entry door threshold missing molding; baseboard molding missing approximately four feet long exposing spackled drywall that was not sanded or painted; room floor approximately one to two inches wide from the wall with black and brown debris. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; approximately a four foot by four-foot area next to the window with peeling paint and stained brown; spider webs in the corner of the room next to the window; entry door threshold missing. room [ROOM NUMBER] - room floor approximately one to two inches wide from the wall with black and brown debris; approximately six hooks missing from privacy curtain and handing from the track; over the bed table with food debris and dried, liquid spills on it; black non-skid strips next to bed worn with approximately 1.5 feet missing; bathroom floor tiles with black and brown debris. room [ROOM NUMBER] - missing baseboard approximately two feet long exposing drywall next to the bathroom door; wall lamp missing bulbs with electric wires exposed and white debris on top of the sconce; wall register cover with black, grey and white debris on it. room [ROOM NUMBER] - outside window with white and grey debris; room floor approximately one to two inches wide from the wall with black and brown debris. Observations on 3/28/2025 between 7:00 AM to 11:00 AM revealed: Unit 3 room [ROOM NUMBER] - strong urine odor in room; room floor approximately one to two inches wide from the wall with black and brown debris; wall register cover with dried brown liquid spills; windows missing blinds and curtains; bathroom floor tiles with black and brown debris; grey and white debris on the outside of the window. room [ROOM NUMBER] - strong urine odor in the room. room [ROOM NUMBER] - seven-bathroom floor tiles missing and coming up from the floor; black debris around the toilet; strong urine odor in the bathroom. Utility room - baseboard molding coming off the wall next to the utility room approximately one foot; drywall spackled, not painted or sanded on the wall above the baseboard molding approximately eight inches. During an interview on 3/24/2025 at 8:11 AM, Resident #5 stated that the room could be cleaner. They stated that the missing tiles wasn't homelike and they minded. During an interview on 3/24/2025 at 8:52 AM, Resident #396 stated that the bathroom needs to be cleaned more and Housekeeping only sweeps but never mops. During an interview on 3/24/2025 at 11:28 AM, Resident #79 stated that the facility was not clean or homelike. They stated that the floors were disgusting and that the walls needed to be repaired. During an interview on 3/24/2025 at 11:29 AM, Resident #25 stated that it bothered them that the floors were filthy and that their window blinds were broken. During an interview on 3/24/2025 at 12:11 PM, Resident #9 stated that with the broken blinds, the sun shines on their television, they can't watch television, and it bothered them. During an interview on 3/24/2025 at 12:33 PM, Resident #1 stated that staff don't clean the room like they should and the spider webs bothered them. During an interview on 3/25/2025 at 8:44 AM, Resident #47 stated that the floors were dirty and needed to be cleaned. They stated that their house would not be like this. During an interview on 3/25/2025 at 9:02 AM, Resident #444 stated that their room was definitely not homelike. They stated that the window blinds were broken, the walls were crusty, and the wall register was all banged up. During an interview on 3/25/2025 at 11:54 AM, Resident #56 stated that housekeeping did not have enough staff to keep the facility clean. They stated that their room smells awful. During an interview on 3/25/2025 at 12:01 PM, Resident #9 stated that the facility wasn't homelike and needed to be cleaned. During an interview on 3/27/2025 at 8:15 AM, Resident #6 stated that it bothered them that they had broken blinds in the window as the sun would get in their eyes. They stated that it was not homelike. They stated they told staff about the bathroom sink having a wooden stick supporting it, but nothing was ever done. During an interview on 3/27/2025 at 8:44 AM, Resident #19 stated that the curtains are filthy, the floors are filthy, the walls are filthy, the windows are filthy and it bothered them. During an interview on 3/28/2025 at 8:33 AM, Housekeeper #1 stated that the floors were dirty because the facility's floor technician has been out and has not stripped and waxed the floor. They stated if the floors were stripped and waxed it would be easier to maintain and keep the floors clean. They stated they used to have a maintenance book that they would put things that needed repair in resident rooms, but they haven't seen it in a while. They stated that privacy curtains should be taken down and cleaned when they became soiled. They stated that any furniture, walls, doors, window blinds that were in disrepair was the responsibility of the maintenance department. They stated that they only cleaned the inside windows, and that maintenance was responsible for the outside of the windows. They stated that Unit 3 wasn't homelike or clean. During an interview on 3/28/2025 at 9:00 AM with Registered Nurse #2 Unit Manager, they stated that basins and graduated cylinders should be labeled with the resident's name and room number as that can lead to cross contamination. They stated that personal use items should be put away in the resident's drawer after being rinsed and clean. They stated that the floors could be cleaner, and they expected staff to report to them or maintenance if there was an issue with the resident's room. They stated that the building wasn't homelike for the residents. During an interview on 3/28/2025 at 9:55 AM, the Director of Housekeeping stated they expected their housekeepers to clean the resident rooms and to report to maintenance or to them any issues in resident rooms. They stated that maintenance was responsible for stripping and waxing floors and that housekeeping was responsible for keeping the floors clean. They stated that they were responsible to wash privacy curtains, and that maintenance was responsible for replacing privacy curtain. They stated that maintenance is responsible for cleaning the outside of the windows and housekeeping was responsible for cleaning the inside of the windows. They stated that they realized this was the residents' home and the rooms could be cleaner. During an interview on 3/28/2025 at 10:00 AM, the Maintenance Director stated that they were aware of issues in the resident rooms and resident areas. They stated that it was a constant battle to repair things in resident rooms due to the age of the building. They stated that they would expect any staff to report things to maintenance if there was an issue in a resident room or a resident use area. They stated they do weekly rounds in the facility to fix things in resident rooms. They stated they needed to hire an outside company to clean the outside of windows and could not remember when they were last cleaned. They stated they expected housekeeping to clean spider webs in the corners of the rooms. They stated that the floors needed to be stripped, waxed, and then maintained to be kept clean. They stated that it was a constant battle to fix the walls and any water issues. They stated that they could do better in maintaining the building. During an interview on 3/28/2025 at 10:10 AM, the Regional Plant Operations Director stated that they were aware of the window blind issues. They stated that they were going to try different types of window shades to see if they will work better in the long-term care environment. During an interview on 3/28/2025 at 11:11 AM, the Administrator stated that the building could be cleaner. They stated that they expected housekeeping to keep the building clean and that maintenance should repair things. During an interview on 3/28/2025 at 11:44 AM, the [NAME] President of Clinical Services stated that they believed the building could be cleaner. They stated they expected the housekeepers to clean the resident rooms, and that maintenance staff should repair things in resident rooms. 10 NYCRR 415.5(h)(1)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure that each resident was treated 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 (1) (Resident #48) of one (1) reviewed. Specifically, Resident #48 was treated by nursing staff members in an undignified and demeaning manner. The issues involved staff grabbing and yanking the residents clothing to keep them seated; lack of staff intervention when the resident experienced agitation in a common area; transporting the resident facing backwards through the hall; inappropriate use of a staff members foot against the residents face to support their head after a fall; an inappropriate transfer from the floor causing the resident to land on their face; and providing a feeding though the percutaneous endoscopic gastrostomy (PEG) tube (tube feed) in the dining room. The undignified and demeaning care occurred while other residents and nursing staff were in the dining room. Additionally, in the dining room staff members at times sat on tables, lounged in a reclined Geri chair against the wall, were on their cell phones and interacted with each other versus the residents. The finding is: The policy and procedure titled Resident Rights dated 3/1/17 documented employees shall treat all residents with kindness, respect, and dignity. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness and dignity. The policy and procedure titled Quality of Life - Dignity dated 2/2021 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times, treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth, staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedure. Demeaning practices and standards of care that compromise dignity is prohibited, staff shall promote dignity and assist residents as needed. Resident #48 had diagnoses including autistic disorder, dysphagia (difficulty swallowing) with gastrostomy (a surgical opening into the stomach used to deliver nutrition and medications directly, through a feed tube), impulse disorder (a mental health condition where individuals struggle to control their impulses, leading to repetitive behaviors or actions). The Minimum Data Set (a resident assessment tool) dated 1/17/25 documented that Resident #48 was severely cognitively impaired, was rarely/never understood, and rarely/never understands. The resident was dependent on staff for all activities of daily living. The comprehensive care plan provided and identified as current by the [NAME] President of Clinical Services documented: - 2/22/20 Resident #48 had profound mental/medical impairment. Interventions included to approach resident warmly and positively, engage in sensory activities, likes rides in their chair and to go outside. - 1/17/25 Resident #48 was unable to verbally communicate needs, feelings and mood. Interventions included to remove the resident from an environment that appeared to cause anxiety. The undated Care Profile (guide used by staff to provide care) provided by the [NAME] President of Clinical Services and identified as current documented for staff to redirect, provide reassurance, distraction, decrease stimuli, use calm reassuring voice and remove from loud/busy area when Resident #48 was agitated. During an observation on 3/26/25 at 11:44 AM Resident #48 was transported/wheeled facing backwards in their Geri chair from their room through the hallway and into the dining room by Certified Nurse Aide #4. During an investigation regarding an accident concern a review of the video surveillance footage was conducted of the Unit 2 dining room on 3/27/25 at 10:16 AM in the presence of the Administrator and [NAME] President of Clinical Services. The footage was dated 3/24/25 and time stamped from 6:09 PM to 6:51 PM and revealed the following: -6:09 PM - 6:24 PM Resident #48 was sitting in their Geri chair in the dining room while other residents were eating their dinner. Resident #48 was not seated at table; they were agitated, at times flailing their arms, hitting them self in the head and swinging their leg over the arm rest without staff intervention. - 6:27:45 PM and at 6:29:05 Resident #48 attempted to get out of their Geri chair by swinging and dangling their legs over the right arm rest of the chair and leaning forward. Certified Nurse Aide #1 while seated grabbed the back of Resident #48's shirt and pulled them back into the seat of the chair with enough force the resident hit their back on opposite arm rest. Certified Nurse Aide #2 and #3 were in the dining room and in close proximity to Resident #48 and Certified Nurse aide #1. - 6:29:36 PM Resident #48 attempted again to get out of their Geri chair by swinging and dangling their legs over the right arm rest of the chair and leaning forward. Certified Nurse Aide #1 grabbed the back of Resident #48 shirt and pulled them back into the seat of chair hitting their back on the opposite rest. Certified Nurse Aide #2, #3 and #4 were in the dining room in and close proximity to Resident #48 and Certified Nurse aide #1. - 6:29:50 PM through 6:30:22 PM Certified Nurse Aide #1 played with Resident #48's hair using a pen multiple times. Certified Nurse Aides #2, #3 and #4 were in the dining room and in close proximity to Resident #48 and Certified Nurse aide #1. - 6:31:05 PM Resident #48 continued to be agitated/restless, positioned their legs over the right side of the Geri chair arm rest and thrusted forward. Certified Nursed Aide #1 remained seated next to the resident, leaned forward, grabbed the back of Resident #48 shirt and yanked them backward into the Geri chair five (5) times [NAME] with enough force the resident hit their back against the opposite arm rest. -6:31:41 PM Resident #48 leaned slightly forward and Certified Nurse Aide #1 again yanked the resident backward by their shirt. Certified Nurse Aide #2 and #4 were in the dining room and in close proximity to Resident #48 and Certified Nurse Aide #1. -6:32:09 PM Resident #48 positioned their legs over the Geri chair's right arm rest, with their back resting against the back of the chair back. Certified Nurse Aide #1 pulled on Resident's shirt at the shoulder pulling them backward. Certified Nurse Aide #2, #3 and #4 were in the dining room in and in proximity to Resident #48 and Certified Nurse Aide #1. -6:32:50 Resident #48 continued to attempt to get out of their Geri chair by and dangling their legs over the right arm rest of the chair and leaning forward. Certified Nurse Aide #1 grabbed the back of Resident #48 shirt and pulled them back into the seat of the chair again hitting their back on the opposite arm rest. Certified Nurse Aides #2, #3 and #4 were in the dining room in close proximity of Resident #48 and Certified Nurse Aide #1. -6:33:44 PM Licensed Practical Nurse #1 entered, repositioned Resident #48 in the Geri chair and provided a tube feeding in the dining room in plain view of other residents. -6:45:06 PM Resident #48 was rocking themself toward the right side of the Geri chair; Certified Nurse Aide #4 was sitting in the corner next to foot end of the Geri chair; at 6:45:13 PM the resident leaned over the right-side arm rest with their arm dangling and rolled over the side of the chair landing on the floor hitting their head. Certified Nurse Aide #4 got up from the chair as the resident was falling to the floor but did not attempt to stop or soften the residents fall. -At 6:47:56 PM Certified Nurse Aide #2 held the residents head up by placing their foot/sneaker under the resident's forehead until 6:49:01 PM. Instead of using other more appropriate measures such as a pillow/blanket/towel or their hands to support the resident's head. -6:49:58 PM Resident #48 was lifted by their extremities from floor and flopped back into their Geri chair by Certified Nurse Aide #2 and #4, and Licensed Practical Nurse #1. The resident landed on their face in the Geri chair. Registered Nurse Nursing Supervisor #1 was present and observed the transfer. During the time frame as noted in the video surveillance footage Resident #48 was visibly restless, agitated and at times could be seen hitting themselves in the head. The staff members that were present in the dining room did not attempt to assist with repositioning or stop Certified Nurse Aide #1 from yanking the resident back into the chair by their shirt. The staff members did not move the resident to a calmer environment, try distraction, activities, or any other intervention to ease the resident's restlessness and agitation. Also, of note in the video footage staff members at times sat on tables, lounged in a reclined Geri chair against the wall, were on their cell phones and interacting with each other versus the residents. During an interview on 3/27/25 at 10:20 AM, the [NAME] President of Clinical Services stated staff were not compassionate and had no empathy for Resident #48. Staff should have removed Resident #48 from the dining room and transferred them to their low boy bed with mats on the floor for their safety and dignity. The staff members in the dining room should have paid more attention to the residents and their surroundings instead of sitting around or on their cell phones. During an interview on 3/27/25 at 10:20 AM, the Administrator stated they had not viewed the video footage dated 3/24/25 prior to viewing with the surveyor and was unaware of the situation. After they viewed the surveillance video the Administrator stated, staff didn't do anything correct. Certified Nurse Aide #1 should not have pulled on Resident #48's shirt to reposition them back into the chair or used a pen to move their hair. Certified Nurse Aide #2 should not have placed their sneaker/foot under the resident's forehead. At 12:22 PM the Administrator stated Resident #48 should not have had their tube feeding in the dining room in view of others and this violated the resident's rights and was undignified care. They stated they would have expected their staff to promote a more dignified environment. During an interview on 3/27/25 at 1:07 PM, Certified Nurse Aide #1 stated they pulled the back of Resident #48's shirt to keep them from falling out of the Geri chair. They did not attempt to reposition them and ask other staff to assist them in repositioning because Resident #48 always tried to get out of the Geri chair by falling. They stated they do not recall using a pen to sweep through the resident's hair and does not know why they would have done that. They stated they had not had any specialized training on how to better care for Resident #48. They stated they do not believe they acted in an undignified manor towards the resident. During an interview on 3/27/25 at 5:24 PM, Registered Nurse Nursing Supervisor #1 stated they believed Resident #48 required 1:1 supervision during the evening of 3/24/25. They stated they were not aware staff were pulling on Resident #48's shirt to keep them in the Geri chair and used a pen to move the resident's hair. They stated they would have expected all the staff in the dining room to have interacted with the resident. The resident was agitated and should have been transported to their room for a calm and dignified environment. They stated the resident should not have received their tube in the dining room as this violated their rights to dignified care. They stated they directed the staff to lift Resident #48 from the floor to their Geri chair and not get the Hoyer lift because they thought the staff were strong enough. The transfer was a poor transfer, the resident landed awkwardly and it was undignified treatment. During an interview on 3/27/25 at 6:46 PM, Certified Nurse Aide #2 stated they were in the dining room on 3/24/25 and did not observe Certified Nurse Aide #1 pulling Resident #48 back into the Geri chair by using their shirt or using a pen to move the resident's hair. They stated these actions would be undignified. Certified Nurse Aide #2 stated they did not recall the resident being agitated or attempting to get out of the Geri chair. They stated after Resident #48 fell to the floor they placed a clean incontinence brief under the residents face for protection, but the Resident removed the brief under them, so they put their foot under the resident's forehead to prevent the resident from banging their head on the floor. Certified Nurse Aide #2 stated it was undignified treatment. Additionally, they stated they were supposed to use a Hoyer (mechanical) lift to move residents from the floor back to their bed or chair but the Registered Nurse Nursing Supervisor #1 had instructed them to pick up the resident from the floor without using the Hoyer lift and by holding onto the resident's extremities. Certified Nurse Aide #2 stated this was also undignified care. During an interview on 3/27/25 at 7:21 PM, Licensed Practical Nurse #1 stated they should not have provided Resident #48's tube feeding in the dining room because it violated the resident's rights and was undignified. They stated pulling on the back of a resident's shirt to keep them in a chair, and placing a foot under the resident's head after they had fallen to the floor was also undignified. They stated they do not know why they didn't use a Hoyer lift to transfer Resident #48 from the floor back to their Geri chair but they should have for the resident's dignity. During an interview on 3/28/25 at 9:17 AM, Registered Nurse Unit Manager #5 stated they viewed the video surveillance footage dated 3/24/25 from 6:00 PM - 7:00 PM on 3/27/25. They stated it was heartbreaking, sad and embarrassing. Certified Nurse Aide #1 should have asked another staff member to assist them in repositioning the resident appropriately in the Geri chair, instead of pulling on the back of their shirt. It was rough and undignified. Certified Nurse Aide #1 should not have messed around with the resident's hair with a pen. Registered Nurse Unit Manager #5 stated all the staff members (Certified Nurse Aides #2, 3 and #4) should have identified that Resident #48 was agitated and assisted to ensure the resident was removed from the dining room and placed in a calm environment; with one of them staying and providing 1:1 for the resident's safety and dignity. Registered Nurse Unit Manager #5 stated the resident's tube feeding should not have provided in the dining room in view of others as this violated the resident's rights and was undignified. Staff should not be transporting and pulling resident's backwards in Geri chairs, it was undignified. The staff members should have used the Hoyer lift (mechanical lift) to transfer the resident from the floor to their Geri chair. Registered Nurse Unit Manager #5 stated the transfer of Resident #48 was rough, unsafe and undignified. During an interview on 3/28/25 at 10:10 AM, Certified Nurse Aide #4 stated they were in the dining room on 3/24/25 when Resident #48 fell in the dining room. Resident #48 was their assigned resident, and they were on every 15 minute checks. They brought Resident #48 out to the dining room so all the staff could assist in watching them. They stated they did not see the other staff pulling Resident #48's by the back of their shirt to maintain them in the Geri chair or use a pen to move their hair. They stated this would be undignified and they should have been more aware of the interactions with residents and staff. They stated when the resident fell , they did not use the Hoyer lift (mechanical lift), and they should have because it was a difficult and undignified transfer. During an interview on 3/28/25 at 1:15 PM, the Assistant Director of Nursing stated they had viewed the video surveillance footage dated 3/24/25 6:00 PM - 7:00 PM and stated the staff member were highly inappropriate. There were multiple dignity issues such as yanking on Resident #48's shirt to keep the resident in the chair, using a pen through the resident's hair, and picking the resident up from the floor to the Geri chair after they had fallen. They stated staff should have moved Resident #48 to their room for a less stimulating environment. Additionally, transporting a resident backwards and providing a tube feeding in the dining room in view of others violated the resident's rights to a dignified existence. 10NYCRR 415.5 (a)

Based on observation, record review, and interview conducted during the Standard survey completed on 3/28/25, the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for two (2) (Resident #53 and #90) of five (5) residents reviewed for choices. Specifically, Resident #53 missed two scheduled orthopedic consult appointments and Resident #90 was not provided with showers twice a week per their preference. The findings are: The policy titled Quality of Life-Self-Determination dated 9/1/17, documented the facility respects and promotes the right of each resident to exercise his/her autonomy regarding what the resident considers to be important facets of his/her life. Each resident shall be allowed to choose activities, schedules and health care that are consistent with his/her interest, assessments and plans of care, including: bathing schedules, bathing methods and health care scheduling. The policy titled Resident Rights dated 3/1/17, documented federal and state laws guarantee certain basic rights to all residents of the facility. The rights include the residents right to: self-determination; communication with and access to people and services, both inside and outside the facility; be supported by the facility in exercising his/her rights; and be informed of, and participate in, his/her care planning and treatment. The policy titled Bathing/Showering dated 3/1/17, documented the facility would promote person-centered care. A resident will be offered the choice of frequency, days of the week, and location of their shower/bath. 1. Resident #53 had diagnoses including diabetes mellitus, depression and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 2/28/25, documented Resident #53 was cognitively intact, understood and understands and did not have any refusals of care. The comprehensive care plan dated 3/25/25 documented Resident #53 was at risk for alteration in their mood related to depression and anxiety. Interventions included to encourage participation in formulation of care plan, decision-making when able. In the area of care plan preferences and choices the goal was that staff would honor the resident's preferences and choices as able. Review of the undated Care Profile (a guide used by staff to provide care) identified as current by the [NAME] President of Clinical Services, documented Resident #53 was oriented with independent decision making. Review of the Physician's Acute Visit Note dated 10/10/24 at 10:30 AM, revealed the Medical Director documented to schedule with orthopedics for left shoulder pain. Review of the facility's Weekly Medical Appointments Schedule forms dated January 2025 through March 2025 revealed the following: -Resident #53 had an Orthopedic appointment scheduled on 1/27/25 at 8:40 AM with a 7:40 AM pick up time. This was rescheduled to February 23rd with no further explanation. -Resident #53 had an Orthopedic appointment scheduled on 2/24/25 at 11:20 AM with a 10:20 AM pick up time. This was cancelled due to transportation. There was no documented evidence Resident #53 had an Orthopedic appointment scheduled in March 2025. During an interview on 3/24/25 at 12:40 PM, Resident #53 stated they have wanted to see an Orthopedic doctor for their shoulder for over 3 months and believed they had missed three scheduled appointments and did not know why. They stated they wanted their left shoulder assessed as recommended by the Rehabilitation Department Director. During an interview on 3/26/25 at 1:34 PM, the Rehabilitation Department Director stated they recommended Resident #53 to be assessment by an Orthopedic months ago for their left shoulder/left arm discomfort and decreased mobility. They stated they thought Resident #53 went to the appointment, but did not follow up and did not know why they have missed scheduled appointments. During an interview on 3/27/25 at 11:01 AM, the Orthopedic Office scheduler #1 stated Resident #53 had appointments scheduled on 1/27/25 and 2/24/25 to evaluate their left shoulder and it was documented in their computer that Resident #53 did not show up for their appointments. During an interview on 3/27/25 at 5:41 PM, Unit Manager Registered Nurse #5 stated they did not know why Resident #53 did not attend the 1/27/25 Orthopedic appointment and believed the 2/24/25 appointment was cancelled because of a transportation issue. They stated they believed the transportation company was not reliable to get the resident to the scheduled appointments. They stated it was the facility's responsibility to ensure Resident #53 attended their outside consult appointments and it was the resident's choice and right to attend their appointments. During an interview on 3/27/25 at 5:54 PM, the Assistant Director of Nursing stated it was Resident #53's right and choice to have been seen by an Orthopedic for their shoulder and they were not aware Resident #53 had missed two scheduled appointments and it was recommended in October 2024. They stated they expected Resident #53 to have been seen. They stated the transport company used for Resident #53, based on their insurance, was not reliable and the Administrator was aware. During an interview on 3/27/25 at 6:23 PM the Administrator stated it was Resident #53's right and choice to get to their Orthopedic appointment and was not aware Resident #53 had recommendations since October 2024 and would have expected them to have been seen by now. They stated the transportation company used for Resident #53 was related to their insurance and was very unreliable. The Administrator stated it was their responsibility to ensure Resident #53 choices and healthcare needs were met, but they were unable to make the transportation company pick up Resident #53 as scheduled. 2. Resident #90 had diagnoses including central cord syndrome (a spinal cord injury that damages the nerves that control the arms), injury of the vertebral artery (arteries along the bones of the spine) and personal injury from a motor vehicle accident. The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact, understood and understands. The resident did not have any refusals of care, and it was very important to them to choose between a tub bath, bed bath, shower or sponge bath. It was documented that Resident #90 was a maximal assist for showering/bathing. The comprehensive care plan dated 1/3/25 documented Resident #90 had a self-care performance deficit related to activities of daily living and had care plan preferences and choices with an intervention that they preferred to shower twice a week with no time preference. Review of the Care Profile dated 3/28/25, documented Resident #90 was to have a shower twice a week and they were needed substantial assistance with shower/bath. Review of the Bath and Shower Sheet dated March 2025, documented that Resident #90 was to have a shower on Tuesdays and Saturdays 2:00 PM-10:00 PM. On 3/8/25 Certified Nurse Aide #8 documented on the bath sheet that they gave Resident #90 a complete shower with their hair washed and a shave. There were no other notes on the form that a shower was given. During an interview on 3/25/25 at 10:12 AM, Resident #90 stated they had not had a shower in the past three weeks. They stated they got washed up in bed, but they wanted to get into the shower. Resident #90 stated staff stated they cannot get them into the shower because there was not enough staff. Observations on 3/24/25 at 10:03 AM; 3/25/25 at 8:51 AM, 10:17 AM and 2:37 PM; 3/26/25 at 11:16 AM and 5:20 PM; and 3/27/25 at 4:42 PM, revealed Resident #90 had greasy hair. During a further observation and interview on 3/28/25 at 10:10 AM, Resident #90 was up in their wheelchair, hair was washed and combed. They stated the staff just washed them up in bed including their hair. Resident #90 stated staff washed them in bed and not in the shower because it was not their shower day. They stated their shower days were on Tuesdays and Saturdays, and they felt their hair had been greasy all week. During an interview on 3/27/25 at 6:32 PM, Certified Nurse Aide #12 stated they worked both day and evening shifts and were familiar with Resident #90. They stated they did not remember the last time they gave Resident #90 a shower. Certified Nurse Aide #12 stated they worked on 3/25/25 and probably did not get to it or it was too busy to give Resident #90 a shower. Certified Nurse Aide #12 stated that at times there were not enough linens in the facility to give residents showers. They stated it was a resident right to receive a shower as per their preference. During a telephone interview on 3/27/25 at 9:40 PM, Certified Nurse Aide #2 stated they were familiar with Resident #90, and they did not give them a shower on 3/18/25. They stated they normally did not work on Resident #90's unit and was not familiar with where the shower book was. They stated that if they knew Tuesdays were Resident #90's shower day they would have given them one because it was important to give residents showers and to honor their choices for a shower. During a telephone interview on 3/28/25 at 9:27 AM, Certified Nurse Aide #15 stated they worked on 3/22/25 the 2:00 PM - 10:00 PM shift and Resident #90 was scheduled for their shower that evening. They stated they gave the resident a bed bath instead of a shower because they did not have enough linens to give a shower. They stated that if a resident preferred a shower and they got a bed bath instead, their wishes were not being honored. During an interview on 3/28/25 at 10:31 AM, Registered Nurses #4, Unit Manager, stated the staff did not document that Resident #90 had their showers in March except for 3/8/25. They stated that Resident #90 was to get their showers on Tuesdays and Saturdays on the 2:00 PM-10:00 PM shift. Registered Nurse #4 Unit Manager stated that there was enough staff on the 2:00 PM-10:00 PM shift to give showers. They stated that there was a lack of linens in the building at times, staff have given that as a reason they do not provide residents their showers, but there was not an issue with linens on Unit One. Registered Nurse #4 Unit Manager stated that if a resident chooses to have a shower and they were not given one then their wishes were not honored. They stated there was no reason for the residents not to be showered and look presentable. During an interview on 3/28/25 at 11:53 AM, the Assistant Director of Nursing stated staff knew when a resident's shower was by looking that the shower books on the units. They stated certified nurse aides documented on the shower sheet in the book when they provided showers or when a resident refused one along with the floor nurses. Assistant Director of Nursing stated they did not see any documentation in Resident #90's medical record of any shower care refusals. They stated they cannot say Resident #90's wishes were not honored by not receiving a shower because staff have told them the resident refused them. They stated that the facility had an issue with not having enough linens and that could be a reason for Resident #90 not receiving a shower. During an interview on 3/28/25 at 12:24 PM, the [NAME] President of Clinical Services stated they expected residents to receive their showers as they preferred. They stated they were unaware of any linen issues in the facility and that there was enough staff on the 2:00 PM-10:00 PM shift to provide residents showers as scheduled. During an interview on 3/28/25 at 12:47 PM, the Administrator stated that if Resident #90 stated they did not receive their shower in three weeks, they probably did not. They stated they had known residents were not receiving their shower as scheduled was an issue and had requested Registered Nurse #4 Unit Manager to monitor if they were being given. The Administrator stated that depending on what time of the month it was the facility may have had a lack of linens. They stated they have had to order new linens monthly because staff kept throwing them out. The Administrator stated that a lack of linen was not a reason for a resident not to have their showers because they always had disposable cloths available. They stated staff preferred to use wash cloths and towels instead of using the disposable cloths. The Administrator stated if a resident did not get their shower as they preferred, they were not getting what they wanted. 10 NYCRR 415.5 (b)(1-3)

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00365639) during a Standard survey completed on 3/28/25, the facility did not ensure the resident's right to be free from physical restraints imposed for the purposes of discipline or convenience and is not required to treat the residents' medical symptoms for one (Resident #48) of four residents reviewed. Specifically, Resident #48 was physically restrained by a staff member in bed. The finding is: The policy and procedure titled Abuse, Neglect and Exploitation of Residents with a revised date of 2/2023 documented acts of abuse against residents were absolutely prohibited. Abuse includes control of resident's behavior through corporal punishment. Unlawful restraint is intentionally or knowingly using physical or chemical restraints or medication on a care-dependent person. The policy and procedure titled Resident Rights dated 3/1/17 documented Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, and physical or chemical restraints that are not required to treat the resident's symptoms. Review of the undated facility's staff education identified as current titled Prevention of Abuse provided by Regional Educator #1 revealed physical abuse includes aggressive act to control behavior including inappropriately restraining a resident. Resident #48 had diagnoses including autistic disorder, dysphagia (difficulty swallowing) with gastrostomy (a surgical opening into the stomach used to deliver nutrition and medications directly, through a feed tube), epilepsy (seizures disorder), impulse disorder (a mental health condition where individuals struggle to control their impulses, leading to repetitive behaviors that can cause distress or harm, despite negative consequences). The Minimum Data Set (a resident assessment tool) dated 11/29/24 documented that Resident #48 was severely cognitively impaired and was dependent on staff for all activities of daily living. The resident had behavioral symptoms not directed toward others that occurred 4 - 6 days, but less than daily. The comprehensive care plan provided and identified as current by the [NAME] President of Clinical Services documented: -2/22/20 Resident #48 had profound mental/medical impairment. Interventions included to approach resident warmly and positively, engage in sensory activities, likes rides in their chair and to go outside. -4/29/20 falls related to poor safety awareness interventions included resident to have 1:1 caretaker during times of increased agitation/anxiety. -6/1/23 Resident #48 has severe intellectual disabilities, self-harm behaviors, anxiety, autism, depression, insomnia and is treated with psychotropics. Non-pharmacological interventions included 1:1 staff, change in environment, take outside (weather permitting), reduce noise, assist in lying down for rest periods. The undated Care Profile (guide used by staff to provide care) provided by the [NAME] President of Clinical Services and identified as current documented that when Resident #48 was agitated staff should redirect and provide reassurance; use distraction and decrease stimuli; use a calm reassuring voice and remove from the loud/busy area; 15-minute checks at all times and 1:1 caretaker during times of increased agitation/anxiety and may need extra assistance due to mood or behaviors. A reported incident dated 12/25/24 completed by the Administrator documented that incident occurred on 12/21/24 at 8:30 PM and there was no reasonable cause to believe that abuse, neglect or mistreatment occurred. The report documented a staff member saw on the monitor what appeared to be the 1:1 aide (Certified Nurse Aide #13) laying on the resident. Facility's immediate response was to remove Certified Nurse Aide #13 from the 1:1 schedule and was interviewed. The Nursing Home Investigative Report Submission #12407 dated 12/25/24 at 3:39 PM and changed on 12/27/24 at 2:51 PM documented It came to light on 12/24/24 that a charge nurse (Licensed Practical Nurse #1) watched the monitor and recorded on their cell phone the incident of the aide laying across the resident during an increased period of aggression. That nurse did not volunteer, nor did they intervene when they saw what they thought was inappropriate behavior. Review of the facility's investigation file revealed the following: Certified Nurse Aide #13's statement dated 12/22/24 documented they watched Resident #48 from 2:00 PM - 10:00 PM on 12/21/24. The resident started to pull out their feeding tube. They stood up in front of the resident then sat on the edge of the bed and leaned back on to them. Licensed Practical Nurse #6 came into the room and told them they should not have done that, and it was the wrong approach to stop a resident from pulling out their feeding tube. Nursing Supervisor Registered Nurse #7's statement dated 12/27/24 documented they were made aware of the accusations of Certified Nurse Aide #13 long after the supposed incident occurred. The certified nurse aide was sitting on Resident's bed trying to prevent the resident from placing themselves on the floor and/or pulling out their feeding tube. Writer did not visualize Certified Nurse Aide #13 sitting on resident. The investigation file did not contain statements from Licensed Practical Nurses #1 and #6. An undated Investigation Summary signed by the Administrator documented that eventually a copy of the video was obtained. After review of the video and the facts, there was no confirmed abuse, mistreatment or neglect. Certified Nurse Aide #13 was attempting to safeguard the resident but used poor judgement in doing so. A Disciplinary Action Form dated 1/7/25 and signed by the Director of Nursing and Certified Nurse Aide #13, documented Certified Nurse Aide #13 physically restrained Resident #48 against their will. During an interview on 3/26/25 at 4:32 PM, the Administrator stated Certified Nurse Aide #4 informed them days later that there was a video sent to them and other employee's phones, related to the accusations regarding Certified Nurse Aide #13 laying on Resident #48. The Administrator stated they copied the video from Certified Nurse Aides #4's phone to their phone and did not know who else had the video, and did not know who originally took the video. The Administrator stated Licensed Practical Nurse #1 denied taking the video during an interview. They stated, they believe the video doesn't clearly conclude Certified Nurse Aide #13 was physically restraining Resident #48 and terminated Certified Nurse Aide #13 for using poor judgement. Observation of video #1 provided by the Administrator on 3/26/25 at 4:45 PM revealed it was undated and without a time stamp but was identified as the recorded video of Certified Nurse Aide #13 laying on Resident #48. Certified Nurse Aide #13 laid back onto Resident #48 while the resident was in bed; they had their back against Resident #48's abdomen and their left arm was outstretched alongside the resident's right leg. Resident #48 was noted frequently moving their legs and attempting to reposition themselves. At the 32 second mark through the 42 second mark Certified Nurse Aide #13 repositioned their left arm over Resident #48's legs and held the resident into a right-side laying position against the bed mattress. Observation of video #2 provided by the Administrator on 3/26/25 at 4:45 PM revealed it was undated and without a time stamp but was identified as the recorded video #2 of Certified Nurse Aide #13 laying on Resident #48. Video #2 revealed Certified Nurse Aide #13 laid back onto Resident #48 with their back against the resident's abdomen and at the 5 second mark, Certified Nurse Aide #13 got up from laying against Resident #48. During an interview on 3/27/25 at 7:40 PM, Licensed Practical Nurse #1 stated they saw Certified Nurse Aide #13 on the video monitor at the nurse's station laying on Resident #48. They stated they told another Certified Nurse Aide to go to Resident #48's room but did recall who they had directed. They stated they informed Registered Nurse Supervisor #7 as to what they saw. Licensed Practical Nurse #1 stated they believed the actions of Certified Nurse Aide #13 were physically abusive because they restrained them. During an interview on 3/28/25 at 10:10 AM, Certified Nurse Aide #4 stated they received the video on their phone of Certified Nurse Aide #13 restraining Resident #48 in bed, and shared the video with the Administrator on 12/26/24. They stated they do not know when they received the video, or who sent the video because of the type of phone app the sender used. During a telephone interview on 3/28/25 at 11:59 AM, Certified Nurse Aide #13 stated they positioned themselves on the bed with their back up against Resident #48's abdomen to prevent the resident from falling out of bed and pulling on their feeding tube. They had tried using their hands to hold Resident #48 but it was ineffective; so they leaned back onto Resident #48. Certified Nurse Aide #13 stated they knew they were physically restraining Resident #48 and believed it was for the resident's safety. They stated Resident #48 had a lot of behaviors and the had facility never taught them how to specifically provide care to Resident #48. They stated they were trained on abuse, mistreatment, neglect and it covered physical restraint. During a telephone interview on 3/28/25 at 12:19 PM, Nursing Supervisor Registered Nurse #7 stated on 12/21/24 staff (unable to identify who), reported to them that Certified Nurse Aide #13 was laying against Resident #48. They were not informed that staff believed Resident #48 was restrained until the following day 12/22/24, when they were questioned by the Administrator. Certified Nurse Aide #13 had reported to them on 12/21/24 they were trying to prevent Resident #48 from falling out of bed and from pulling out their feeding tube by holding onto the Resident's hands and having their body up against the bed. They denied having laid against Resident #48. Therefore they did not have reason to suspect allegations of abuse and did not contact the Director of Nursing or Administrator on 12/21/24. During an interview on 3/28/24 at 1:15 PM, the Assistant Director of Nursing stated Certified Nurse Aide #13 was terminated for physically restraining Resident #48. During a telephone interview on 3/28/25 at 1:54 PM, the Medical Director stated if an employee was laying back onto a resident to prevent them from falling out of bed or trying to prevent them from pulling on their feeding tube then it would be considered a physical restraint. During a telephone interview on 3/28/25 at 2:00 PM, Licensed Practical Nurse #6 stated when they returned to the unit after their break on 12/21/24 there was a lot of commotion. Licensed Practical Nurse #1 had voiced Certified Nurse Aide #13 was getting aggressive with Resident #48. Licensed Practical Nurse #6 stated they immediately went to the resident's room and Certified Nurse Aide #13 was seated on the bed, but not touching the resident. They stated they were not informed by anyone Certified Nurse Aide #13 was laying on Resident #48. During an interview on 3/28/25 at 2:52 PM, Administrator stated there had not been any specific staff training of how to best care for Resident #48, and in hindsight there should have been. Certified Nurse Aide #13 was terminated for physically restraining Resident #48. 10 NYCRR 415.4 (b)(1)(i)

Based on interviews and record reviews conducted during the Standard Survey completed on 3/28/25, the facility did not provide services consistent with professional standards of quality for one (Resident #444) of 25 residents reviewed. Specifically, Resident #444 did not receive an intravenous medication as ordered by the physician and the physician was not notified of those omissions. The policy and procedure titled administering medication/treatments dated 12/1/17, documented medications shall be administered in a safe and timely manner and as prescribed including any required time frame and state regulations. If the drug is withheld or refused, the licensed nurse administering the medication will document accordingly in the electronic medical record and notify the nursing supervisor. 1. Resident #444 had diagnoses that included diabetes mellites, acute osteomyelitis (infection of the bone) of the left foot, and orthopedic aftercare. The comprehensive care plan dated 3/11/25, documented Resident #444 was alert and oriented. The care plan documented Resident #444 had an infection related to bacteremia (bacteria in the blood stream) and a wound. Intervention included to administer medications as order and infectious disease consult as needed. Review of the Acute Visit note dated 3/17/25 at 7:15 AM, the Medical Director documented Resident #444 underwent a fifth toe amputation on 3/6/25 with positive blood cultures and was started on intravenous medications until 4/17/25. Physician orders dated 3/28/25 documented an order dated 3/11/25 to administer Unasyn (antibiotic) 3 grams intravenously every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM for infection. During an interview on 3/24/25 at 10:14 AM, Resident #444 stated they did not receive their 12:00 AM and 6:00 AM intravenous antibiotic during the night shift. Review of the medication administration record dated 3/1/25-3/26/25 revealed there was no evidence that Resident #444 was administered Unasyn 3 grams via intravenously on 3/24/25 at 12:00 AM and 6:00 AM. Review of the facility staffing sheet for 3/23/25 into 3/24/25 revealed there was no registered nurses scheduled for the 11:00 PM-7:00 AM shift. Review of the nursing progress notes on 3/24/25 revealed no documented evidence that Resident #444 was administered their intravenous medication. Review of Unit 1 daily unit report from 3/22/25-3/27/25 revealed there was no documented evidence that Resident #444 was administered their intravenous antibiotic on 3/24/24 at 12:00 AM and 6:00 AM. During a telephone interview on 3/26/25 at 2:43 PM, Licensed Practical Nurse #4 stated they worked 3/23/25 into 3/24/25 on Unit 1 (one). They stated that Resident #444 was on intravenous medication and they had notified Licensed Practical Nurse Supervisor #5 that Resident #444 needed the medication to be administered. Licensed Practical Nurse #4 stated they did not notify a medical provider the resident was not able to receive their intravenous antibiotic. They stated could not recall if they reported to the oncoming shift that Resident #444 did not receive their (12:00 AM and 6:00 AM) intravenous antibiotics. During a telephone interview on 3/26/25 at 3:03 PM, Licensed Practical Nurse Supervisor #5 stated they were working 3/23/25 into 3/24/25 on the 11:00 PM- 7:00 AM shift as the shift supervisor. They stated they were aware Resident #444 had an intravenous medication scheduled for 12:00 AM and 6:00 AM. Licensed Practical Nurse Supervisor #5 stated on 3/21/25 they had a conversation with Registered Nurse #5 and Registered Nurse #5 had said they would be in on 3/24/25 to administer Resident #444's intravenous medications. However, Registered Nurse #5 never showed up. Licensed Practical Nurse Supervisor #5 stated they did not call Registered Nurse #5 to find why they did not come and they do not call people to come in. Licensed Practical Nurse #5 stated they did not notify the medical provider that Resident #444 was unable to receive their medications. In a follow up telephone interview on 3/26/25 at 4:03 PM, Licensed Practical Nurse #5 stated they did not notify Registered Nurse #4 (the on-coming nurse) the morning of 3/24/25 that they needed to hang Resident #444's 6:00 AM antibiotic. Licensed Practical Nurse Supervisor #5 stated they should have notified someone. During an interview on 3/26/25 at 3:28 PM, Registered Nurse Supervisor # 5 stated they were the registered nurse on-call until 3/23/25 at 7:00 AM and then Registered Nurse #4 took over. Registered Nurse #5 stated they did have a conversation with Licensed Practical Nurse Supervisor #5 on 3/21/25 and Licensed Practical Nurse #5 told them they would have Registered Nurse #1 administer Resident #444's 12:00 AM dose on 3/23/25 prior to them ending their shift and would have Registered Nurse #4 administered the 6:00 AM dose on 3/24/25 upon arrival to work. Registered Nurse #5 stated they had not received any phone calls over that weekend. During an interview on 3/26/25 at 3:37 PM, Registered Nurse #4 stated that no one had told them upon arriving to work on 3/24/25 that Resident #444 needed their 6:00 AM dose of intravenous antibiotic administered. They stated when there was not a registered nurse in the building and one was needed, the on-call registered nurse would have to come in. Registered Nurse #4 stated they were on-call starting 7:00 AM on 3/23/25 and had not received a call to come in to the facility. During an interview on 3/27/25 at 3:51 PM, Registered Nurse #1 stated they worked the 3:00 PM-11:00 PM shift on 3/23/25, and administered Resident #444's 6:00 PM intravenous antibiotic but did not administer the 3/24/25 12:00 AM dose prior to the end of their shift. During a telephone interview on 3/28/25 at 10:40 AM, the Medical Director stated that Resident #444 has a diabetic foot ulcer with bone necrosis (death of cells or tissue) that required surgical intervention, and they were at the facility for intravenous antibiotic treatment. Resident #444 had informed them that they missed their 12:00 AM and 6:00 AM dose of the medication on 3/24/25. Medical Director stated they spoke with Registered Nurse #4 who confirmed the two doses were omitted. They stated they expected the facility to have a registered nurse in the building to avoid this situation. The Medical Director also stated they would have expected to be notified with the first missed dose, and they could have possibly ordered an oral antibiotic to cover the missed doses. During an interview on 3/28/25 at 11:53 AM, the Assistant Director of Nursing stated they expected Registered Nurse #1 to administer the 12:00 AM dose on 3/23/25 at 11:00 PM prior to leaving their shift and Registered Nurse #4 to have administered the 6:00 AM dose when they arrived to work on 3/24/25. The Assistant Director of Nursing stated when the facility did does not have a registered nurse in the building and need one, the licensed practical nurse supervisor was to call the on-call registered nurse. They stated Licensed Practical Nurse #5 should have called the on-call, registered nurse to come to the facility to administer the intravenous medication and/or call the medical provider. During an interview on 3/28/25 at 12:24 PM, the [NAME] President of Clinical Services stated they expected residents to be administered their intravenous medications as ordered. They stated that Licensed Practical Nurses were not allowed to administer intravenous medications via PICC line and there was no registered nurse scheduled on 3/23/25-3/24/25 11:00-7:00 shift. They stated that the Director of Nursing and the Assistant Director of Nursing needed to plan for this. The [NAME] President of Clinical Services stated they expected Licensed Practical Nurse #5 to notify someone above them and notify a medical provider that there was no one in the facility to administer the intravenous medication. During an interview on 3/28/25 at 12:57 PM, the Administrator stated they expected all nurses follow the medical providers orders and if they were not able, they expected Licensed Practical Nurse Supervisor #5 to call someone if they knew the medications were not administered. The Administrator stated they always have a contingency plan for when there was no registered nurse in the building and in this case the contingency plan did not work. 10 NYCRR 415.12

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00335062, NY00338640, and NY00347069) during the Standard survey completed on 3/28/25, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (Resident #82, #19 and #79) of six residents reviewed. Specifically, Resident #82 had long fingernails with brown debris underneath them on multiple observations; Resident #19 had facial hair that they wanted removed and during morning care observation staff did not offer shaving; Resident #79 had disheveled, oily hair on multiple observations and during a morning care observation, staff did not wash their face and underarms, oral care was not provided, hair wasn't washed or combed, and they were not dressed in their personal clothing or transferred out of their bed to a chair. The findings are: The policy titled Activities of Daily Living dated 1/8/25, documented the facility will provide care and services for the following activities of daily living: hygiene-bathing, dressing, grooming and oral care. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good grooming, personal and oral hygiene. The policy titled Bathing/Showering dated 3/1/17, documented the certified nurse aide would trim the non-diabetic resident's fingernails on bath/shower days and the licensed nurse would trim the diabetic resident nails on their assigned shower day. Encourage the resident to bathe themselves and assist as needed. The policy documented be sure the resident's skin is free of soap and then dry the resident from head to toe. The policy documented the resident was to be assisted with dressing and grooming. The policy titled Perineal Care dated 2/1/17, documented the purpose of the procedure was to provide cleanliness and comfort to the resident to prevent infections and skin irritation. The policy documented that equipment, and supplies were to be assembled as needed and place on the bed side stand. The wash basin was to be filled 1/2 with warm water and place at bedside. Wet the washcloth and apply soap the wash the perineal area from front to back and then dry area. Assist the resident onto their side and rinsed the washcloth and apply soap and wash the rectal area. The policy documented to not reuse the same washcloth or water to clean to labia. Rinse and dry the rectum thoroughly. Review of the undated Certified Nursing Assistant job description/competency/evaluation documented Certified Nursing Aides were to assist residents with daily dental, mouth care. They were to provide bath functions as directed, hair care functions, nail care and keep hair on female residents clean shaven (i.e. facial hair, underarms, on legs, etc) as instructed. 1. Resident #82 had diagnoses including dementia, depression and cerebral infarction (a stroke, is a condition where blood flow to the brain is blocked, leading to brain tissue damage). The Minimum Data Set (a resident assessment tool) dated 1/31/25 documented Resident #82 had moderate cognitive impairment and required partial/moderate assistance with shower/bathing including washing, rinsing and drying self and required setup or clean up assistance for personal hygiene. The comprehensive care plan dated 1/24/24 documented Resident #82 had self-care deficit related to dementia and cognitive loss, interventions included establish daily routines, provide consistent caregivers, give one instruction at a time and approach resident warmly and positively. The undated Care Profile (guide used by staff to provide care) provided and identified as current by the [NAME] President of Clinical Services, documented Resident #82 was confused, required moderate assistance to bathe self, including washing, rinsing and drying, and needed setup/clean up assistance to maintain personal hygiene, including combing hair, shaving washing/drying face and hands. Review of Resident #82's Bath & Shower Sheets dated March 2025, documented they preferred bath/showers on Tuesday 6:00AM - 2:00PM and Thursday 2:00PM - 10:00PM. The section regarding if nails were trimmed and cleaned was blank and there was no documented evidence Resident #82's fingernails were trimmed and cleaned 3/1/25 through 3/27/25. During observations on 3/24/25 at 11:36 AM, 3/26/25 at 8:40 AM, 3/27/25 at 9:36 AM and 3/27/25 at 4:00 PM, Resident #82 had long fingernails with brown debris underneath all nails on both hands. During an interview on 3/27/25 at 4:29 PM, Certified Nursing Assistant #12 stated they provided a shower to Resident #82 on 3/25/25 and did not complete the Bath & Shower Sheet because they didn't have time, and they did not provide fingernail care and should have, which included cleaning and trimming their nails. During an observation and interview on 3/27/25 at 4:05 PM, Unit Manager Registered Nurse #5 stated Resident #82's fingernails should be cleaned and trimmed on shower days and as needed. They stated Resident 82's fingernails on both hands were long and dirty with brown debris beneath them. They stated Resident #82 was not a diabetic and expected Certified Nursing Assistant #4 to have provide nail care during AM care that morning, which included cleaning and trimming them. They stated Resident #82's fingernails should have been cleaned and trimmed on their shower days and documented on the Bath & Shower Sheet. Unit Manager Registered Nurse #5 reviewed the Bath & Shower Sheets dated March 2025 and stated the form had a column to check Yes or No if nails were trimmed and clean and there was no documented evidence Resident #82's fingernails were trimmed and cleaned from 3/1/25 through 3/27/25. They stated they would have expected the Bath & Shower Sheets to have been completed by the certified nursing assistants and staff nurses. During an interview on 3/27/25 at 6:06 PM, the Assistant Director of Nursing stated all Certified Nursing Assistants, and Nurses were responsible to ensure resident's fingernails were trimmed and clean. They stated they would have expected the certified nursing assistants assigned to Resident #82 on any shift to have noticed their fingernails to be long with brown debris under them and provided nail care. They stated they would have also expected the medication nurses to have observed the resident's fingernails and ensured they were trimmed and cleaned. They stated they expected the assigned staff for Resident #82 to have completed the Bath & Shower Sheets and stated there was no documented evidence Resident #82 received nail care from 3/1/25 through 3/27/25 and there should be. They stated the Unit Manager was responsible to ensure the staff nurses and certified nursing assistants were providing fingernail care as needed and the Director of Nursing was ultimately responsible to ensure resident care was provided by the nursing staff. During an interview on 3/27/25 at 6:34 PM the Administrator stated they would have expected Resident #82's nail care to have been completed on shower days and as needed for dignity and infection control purposes. 2. Resident #19 had diagnosis dementia, diabetes, and anxiety disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #19 had moderate cognitive impairment, did not exhibit rejection of care, was dependent with shower/bathing self-including washing, rinsing and drying self and required setup or clean up assistance for personal hygiene. The comprehensive care plan dated 1/27/24 documented Resident #19 had decreased activities of daily living, disoriented with short term memory loss with delusions, interventions included establish daily routines, provide consistent caregivers, give one instruction at a time and approach the resident warmly and positively. The undated Care Profile (guide used by staff to provide care) provided and identified by the [NAME] President of Clinical Services as current, documented Resident #19 had agitated mental status with short term memory loss, was dependent for shower/bathing, including washing, rinsing and drying, and setup assistance to maintain personal hygiene, including combing hair, shaving washing/drying face and hands. Review of Resident #19's Bath & Shower Sheets dated March 2025 documented they preferred bath/showers on Monday 6:00AM - 2:00PM and Friday 2:00PM - 10:00PM. The section regarding if the resident was shaved was blank and there was no documented evidence Resident #19 was shaved from 3/1/25 through 3/27/25. During observations on 3/24/25 at 9:51 AM, 3/25/25 at 9:51 AM, 3/26/25 at 8:30 AM and 3/26/25 at 10:00 AM, Resident #19 was observed with facial hair on their upper lip, chin and neck. During an interview on 3/25/25 at 9:51 AM Resident #19 stated the facial hair on their upper lip, chin and neck was not dignified, and they wanted it removed but staff did not shave them. During a morning care observation at 3/26/25 at 9:12 AM, with Certified Nursing Assistant #4 and Licensed Practical Nurse #7 included, washing, dressing, oral care and combing Resident #19's hair. Resident #19 was observed with facial hair on their upper lip and many long whiskers on their chin and neck. Certified Nursing Assistant #4 and Licensed Practical Nurse #7 did not offer to shave and remove Resident #19's facial hair, chin or neck whiskers. During interview on 3/26/25 at 10:00 AM, Resident #19 stated they do not ask staff to shave their facial/chin/neck hair because they believed the staff did not have time and they expected the staff to offer them a shave. They stated the whiskers on their upper lip, chin and neck were undignified and it bothered them. They stated the whiskers were so long they were able to pull the facial chin and neck whiskers with their fingers. During an interview on 3/26/25 at 10:01 AM, Certified Nursing Assistant #4 stated they did not offer to remove Resident #19's facial upper lip, chin and neck whiskers and they should have. During an observation and interview on 3/26/25 at 10:09 AM, Unit Manager Registered Nurse #5 observed Resident #19 and stated they had facial hair on their upper lip and many long whiskers on their chin and neck and would have expected Certified Nursing Assistant #4 to have offered and provided shaving for their dignity. The Unit Manager Registered Nurse #5 reviewed the Bath & Shower Sheets dated March 2025 and stated there was no documented evidence Resident #19 had been shaved from 3/1/25 through 3/26/25 and would have expected the Bath & Shower Sheets to have been completed by the certified nursing assistants and staff nurses. During an interview on 3/28/25 at 10:35 AM, the Assistant Director of Nursing stated they expected Certified Nursing Assistant #4 to have offered Resident #19 shaving during morning care to remove their facial hair for their dignity. 3. Resident #79 had diagnoses that included sacral pressure ulcer stage 4 (full thickness tissue loss with exposed bone, tendon or muscle), dementia and hypertension. The Minimum Data Set, dated dated dated [DATE] documented Resident #79 had severe cognitive impairment, sometimes understands and sometimes understood. The assessment tool documented that Resident #79 was dependent for all activities of daily living. The comprehensive care plan revised on 9/17/25, documented Resident #79 had a self-care deficit and had cognitive loss/dementia related to disorientation to time, place, person and inappropriate verbal responses. Interventions included to establish daily routines with the resident and provided consistent caregivers. Review of the Care Profile (used by staff to guide care) dated 3/27/25, documented Resident #79 was dependent on staff for oral hygiene, toileting hygiene, shower/bathing, dressing, and personal hygiene. During a telephone interview on 3/25/25 at 10:57 AM, Resident #79's family member stated staff did not get the resident out of bed nor dressed in their personal clothing. They stated Resident #79 had personal clothing in their drawers. The family member stated Resident #79's hair looked oily at times when they visited, and the staff did not take them into the shower. During observations on 3/24/25 at 9:44 AM, 3/25/25 at 2:44 PM, 3/26/25 at 8:45 AM and 3/26/25 at 5:15 PM, Resident #79 was observed in bed, wearing a hospital gown. Their hair was disheveled and greasy. During a morning care observation and interview on 3/27/25 at 9:33 AM, Certified Nurse Aide #10 and Certified Nurse Aide #11 donned (put on) gowns and gloves and entered Resident #79's room. Resident #79 was in bed, wearing a hospital gown and their hair was greasy and disheveled. Certified Nurse Aide #10 went into the bathroom, filled a wash basin and placed it on the resident's bed side table. Certified Nurse Aide #10, with the assistance of Certified Nurse Aide #11 washed Resident #79's peri area (area between the anus and genitals), buttocks and changed the resident's incontinent pad that was wet with urine. Certified Nurse Aide #11 instructed Certified Nurse Aide #10 that Resident #79's gown needed to be changed. Certified Nurse Aide #10 walked out of the room, retrieved a hospital gown, reentered the room, and put the clean hospital gown on Resident #79. The CNA did not offer the resident to be dressed in their clothing or look in the resident's drawers or closet for their personal clothing. Certified Nurse Aide #10 and Certified Nurse Aide #11, did not wash the resident's face and underarms, provide oral care, hair hygiene, dress the resident in their personal clothing or get them out of bed. During an interview directly after care, Certified Nurse Aide #10 stated they completed AM care and they did not wash Resident #79's upper torso prior to putting on the new hospital gown because they usually worked the 2:00 PM-10:00 PM shift, and they were so nervous. During an interview on 3/27/25 at 10:01 AM, Certified Nurse Aide #11 stated that Resident #79's AM care started off bad from the beginning. They stated that Certified Nurse Aide #10 did not gather all their supplies, did not fill the basin to wash the resident and washed and dried the resident using the same towel. Certified Nurse Aide #11 stated they were unsure if they could direct Certified Nurse Aide #10 during the care. They stated Certified Nurse Aide #10 only washed Resident #79's peri area and buttocks, but AM care consisted of washing the whole body. Certified Nurse Aide #11 stated Resident #79 had uncombed greasy hair. During an interview on 3/27/25 at 10:41 AM, Certified Nurse Aide #10 stated AM care consists of washing the residents upper and lower body, face and teeth. They stated that they did not complete full AM care for Resident #79 because they were so nervous, but the resident deserved to have full AM care completed. During an interview on 3/28/25 at 11:01 AM, Registered Nurse # 2 Unit Manager, stated that Resident #79 could have been out of bed all week, but the certified nurse aides during the week were unfamiliar with the resident's care. Registered Nurse #2 Unit Manager stated that AM care consisted of washing the resident's face, neck, breast, arms and peri area, changing their clothing, oral care, and combing their hair. They stated that only washing Resident #79's peri area and buttocks was incomplete AM care. They stated Resident #79 always had greasy hair, but the staff could utilize shampoo caps to wash their hair if need be. Registered Nurse #2 Unit Manager stated the importance of complete AM care was for the resident's dignity and infection control. During an interview on 3/28/25 at 11:53 AM, the Assistant Director of Nursing stated complete AM care would be washing the resident's face, brushing their teeth, washing the upper and lower body, dressing and grooming. he Assistant Director of Nursing stated that Certified Nurse Aide #10 did not complete full AM care to Resident #79 on 3/27/25. They stated Certified Nurse Aide #10 was very nervous to be observed, usually did not work the day shift and they missed steps in AM care. The Assistant Director of Nursing stated that the importance of proper AM care on the resident was for dignity and healthiness of those residents. During an interview on 3/28/25 at 12:24 PM, the [NAME] President of Clinical Services stated their expectation for completed AM care would be washing of the resident's face, arms, hands, armpits, breasts, peri area, back and buttocks and that should be completed every morning. They stated that just washing the resident's peri area and buttocks was not completed AM care. 10NYCRR 415.12 (a)(3)

Based on observation, interview, and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (1) (Resident #19) of three (3) residents reviewed. Specifically, staff did not follow physician orders when completing a pressure ulcer treatment. In addition, there was a delay in assessments and notification to the physician regarding a declining skin concern and newly identified pressure ulcer. The finding is: The policy and procedure titled Skin and Wound Care Policy dated 5/10/18 documented, the purpose is to facility the prevention and or treatment of impaired skin integrity, by assessing and planning care immediately upon identification of residents at risk or with existing wounds. To provide skin and wound care protocols for use in determining appropriate interventions. A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage to underlying tissue. Stage 2 pressure ulcer is partial thickness skin loss or blister. Wound Documentation should be measured weekly on a consistent basis, includes stage, size (length, width, and depth) to be measured in centimeters and appearance of the wound bed. Ongoing skin assessment is necessary to detect early signs of pressure damage, accurate documentation is essential for monitoring the progress of the individual and to aiding communication between professionals. Pressure ulcer care included cleansing the pressure ulcer and surrounding skin at the time of each dressing change. The policy and procedure titled Administering Medications/Treatments dated 12/1/17 documented medications and treatments must be administered in accordance with the orders. Resident #19 had diagnosis neuromuscular dysfunction of bladder (condition where nerve damage prevents the bladder from functioning properly), dementia, and diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 2/21/25 documented Resident #19 had moderate cognitive impairment, did not exhibit rejection of care, and required partial/moderate assistance from staff for bed mobility. Additionally, the assessment documented Resident #19 was at risk for developing pressure ulcers, did not have unhealed pressure ulcers, and had moisture associated skin damage (MASD) (general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, heat, wound drainage). The comprehensive care plan dated 4/19/21 documented Resident #19 had moisture associated skin damage to their left buttocks dated 1/24/25 and coccyx documented a resolved date of 3/14/25. Interventions included to apply skin treatment per the physician's order and monitor effectiveness of the treatment. The resident was incontinent of bowel and had a neurogenic bladder. The goal was that the resident would not experience additional break their in skin integrity and was dated 6/25/23. Interventions included the use of an indwelling foley catheter, check and change (for incontinence), and apply skin moisture barrier for each incontinence episode. The undated Care Profile (guide used by staff to provide care) provided by the [NAME] President of Clinical Services and identified as current documented that Resident #19 was at high risk for skin breakdown, and directed staff to check skin with routine care each shift, provide preventive skin care and was dependent for toileting hygiene. The Physician's Order Form dated 3/26/25 documented an order to apply zinc barrier cream daily for prophylaxis (preventative) to the resident's coccyx on the day shift with a start date 3/15/25. In addition, an order to cleanse the left buttock with sterile water then apply zinc barrier cream daily to the wound bed on the day shift with start date 3/21/25. Review of Resident #19's Treatment Administration Record dated March 2025 revealed orders to apply zinc barrier cream daily to the coccyx for prophylaxis on the day shift and cleanse the left buttocks with sterile water and apply zinc barrier cream to wound bed daily on the day shift. Review of Resident #19's Wound Assessment and Plan documented by Wound Physician Consultant #1 revealed the following: - 3/21/25 left buttocks moisture associated skin damage, healing with 100 percent (%) epithelial tissue (a protective layer that covers the body's external surfaces) and measured 1 centimeter (length) x 0.1-centimeter (width) x less than 0.1 centimeter (depth). Treatment order: Cleanse with sterile water, then apply zinc barrier cream every day and as needed. Comments: Irritant contact dermatitis (skin rash) due to fecal, urinary or dual incontinence. - 3/14/25, coccyx moisture associated skin damage healed. At risk for reopening due to incontinence and limited mobility. Treatment order: for prophylaxis, apply zinc barrier cream every day and as needed. Comments: Irritant contact dermatitis due to fecal, urinary or dual incontinence. During an interview on 3/25/25 at 9:22 AM, Resident #19 stated they have an open area on their left buttocks because the staff had to scrub off the zinc barrier cream and now they had to put a bandage over it. During a treatment observation on 3/26/25 at 9:12 AM Certified Nurse Aide #4 assisted the resident with positioning while Licensed Practical Nurse #7 completed the treatment. Resident #19 was noted with two (2) distinct and separate open ulcers. One located in the sacral slit on their coccyx and measured approximately 1.5-centimeters (length) x 0.2 centimeters (width). The second area was beefy red and measured approximately 6 centimeters (length) x 4 centimeters (width) with sporadic superficial open areas within. Licensed Practical Nurse #7 put on gloves and without cleansing the skin and/or ulcers smeared Resident #19's entire left buttocks and coccyx with A&D ointment (a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) using a circular motion covering both open areas and the intact surrounding skin. Licensed Practical Nurse #7 then without changing their gloves and washing their hands, they then applied to the residents entire left buttocks and coccyx zinc barrier cream (mixing the zinc barrier cream and A&D ointment together) again using a circular motion and covering both open ulcers and the intact surrounding skin. Licensed Practical Nurse #7 then applied a border dressing to the left buttock ulcer. During the observation Licensed Practical Nurse #7 stated they believed the areas identified on the left buttocks and sacral crease were both stage 2 pressure ulcers. They stated they were not familiar with Resident #19 and does not know if the ulcers were new areas or declining. Licensed Practical Nurse #7 stated they did not use a cleansing agent to clean the open ulcers prior to applying the A&D and Zinc barrier cream and they should have. During the observation Certified Nurse Aide #4 stated they believe the two areas were identified last week and believed the nurses were aware since the treatment was being done daily. Review of Progress Notes dated 3/1/25 through 3/28/25 revealed there was no documented evidence that staff identified, assessed or notified the physician that Resident #19's the left buttock skin concern was declining, and that a new pressure ulcer had developed on their coccyx as noted during the observation on 3/26/25. Review of 2 [NAME] Daily Unit Report dated 3/26/25 revealed there was no documented evidence that staff identified, assessed or notified the physician that Resident #19's the left buttock skin concern was declining, and that new pressure ulcer had developed on their coccyx as noted during observation on 3/26/25. During an observation on 3/28/25 at 8:36 AM Registered Nurse Unit Manager #5 and Registered Nurse Supervisor #8 assessed Resident #19's buttocks and coccyx, completing wound rounds in absence of Wound Physician Consultant #1. Observation revealed a border foam dressing removed from the left buttocks area; treatment completed as ordered and Registered Nurse Supervisor #8 measured both ulcers: Left buttock 7.5 centimeters (length) x 6 centimeters (width) x 0.1 centimeters (depth) and coccyx 2 centimeters (length) x 0.3 centimeters (wide) x 0.2 centimeters (depth). During an interview on 3/28/25 at 8:48 AM, Registered Nurse Supervisor #8 stated they accompany Wound Physician Consultant #1 on skin rounds and previously described the left buttocks area as a moisture associated skin damage because of the redness with denuded areas like a rash. They stated the area was now identified as a Stage 2 pressure ulcer and the coccyx previously was intact and now was identified as a Stage 2 pressure ulcer. They stated Licensed Practical Nurse #7 should have cleansed the open areas with sterile water and treated each open area separately, (not smearing ointment from intact to open areas) to prevent cross contamination between the pressure ulcers and they should not have applied A&D because it was not ordered. Additionally, they stated applying A&D and Zinc barrier cream to the same areas was mixing two items which was considered compounding a mixture and that was out of the scope of a nurses licensure. They stated they would have expected Licensed Practical Nurse #7 to have notified Registered Nurse Unit Manager #5 of the declining area on the resident's left buttock and the newly identified ulcer on their coccyx. They would have expected the Wound Physician Consultant #1 to have been updated related to the changes in the resident's skin condition. During an interview on 3/28/25 at 9:08 AM, Registered Nurse Unit Manager #5 stated that Licensed Practical Nurse #7 did not notify them of the changes in the resident's skin condition on 3/26/25; they should have so Wound Physician Consultant #1 could have been notified and determined if new orders were needed. Additionally, they would have expected Licensed Practical Nurse #7 to follow the physicians orders. During an interview on 3/28/25 at 10:35 AM, the Assistant Director of Nursing stated they would have expected Licensed Practical Nurse #7 to have followed the physician's orders when completing Resident #19's treatments. Licensed Practical Nurse #7 should have notified Registered Nurse Unit Manager #5 of the declining area and the newly developed pressure ulcer so that Wound Physician Consultant #1 or a provider could determine if new orders were needed. Treatments should be applied separately to open ulcers as not to cross contaminate the wounds and promote healing. During an interview on 3/28/25 at 11:19 AM, Wound Physician Consultant #1 stated Licensed Practical Nurse #7 should have cleansed the open wounds prior to applying a treatment and would have expected them to follow the order as written. They stated they should have been notified on 3/26/25 when a new ulcer was identified and the other area had declined. During an interview on 3/28/25 at 4:03 PM, Licensed Practical Nurse #7 stated they should have read the Treatment Administration Record more closely because A&D and a dressing was not ordered. They should have cleansed the two areas and treated them as separate areas to prevent cross contamination. Licensed Practical Nurse #7 stated they should have notified Registered Nurse Unit Manager #5 that Certified Nurse Aide #4 informed them the pressure ulcer on Resident #19's coccyx was new and the pressure ulcer on their left buttocks had worsened. They stated there was no excuse for their errors and should have done a better job for the resident, by maintaining infection control practices and to promote healing of the pressure ulcers. 10NYCRR 415.12 (c)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (1) (Resident #48) of five (5) reviewed for accidents. Specifically, staff did not remove Resident #48 from the common area/dining room to a lesser stimulating environment as care planned when they had increased agitation and the resident fell out of their Geri chair (specialized chair designed for elderly or disabled individuals), hitting their head on the floor; staff inappropriately transferred the resident from the floor back into their chair and the resident landed on their face. Additionally, care plan interventions were not revised after the resident fell on [DATE]. The finding is: The policy titled Accidents and Incidents - Investigating and Reporting revised 12/10/21 documented the facility will ensure that the residents environment remains as free from accident hazards as is possible while providing adequate supervision and assistive devices to prevent accidents. Interventions will be updated as needed when evaluating the effectiveness of the interventions consistent with the resident's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident. The policy titled Care Plans, Comprehensive Person-Centered dated 10/1/23 documented a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents' conditions change. Resident #48 had diagnoses including autistic disorder, dysphagia (difficulty swallowing) with gastrostomy (a surgical opening into the stomach used to deliver nutrition and medications directly, through a feed tube), and impulse disorder (a mental health condition where individuals struggle to control their impulses, leading to repetitive behaviors or actions). The Minimum Data Set (a resident assessment tool) dated 1/17/25 documented that Resident #48 was severely cognitively impaired, was rarely/never understood, and rarely/never understands. The resident was dependent on staff for all activities of daily living and has fallen with injury. The comprehensive care plan for Resident #48, provided and identified as current by the [NAME] President of Clinical Services, documented the following: -4/29/20, falls related to poor safety awareness, possible sensory overload due to autistic disorder. Intervention included 15-minute checks for all shifts, to have 1:1 caretaker during times of increased agitation/anxiety, and staff were to remove the resident from common areas during periods of high traffic/loudness/busyness. -6/1/23, severe intellectual disabilities, self-harm behaviors, anxiety, autism, depression, insomnia and was treated with psychotropics. Interventions included non-pharmaceutical interventions, 1:1 at times, change environment, take outside (weather permitting), reduce noise, assist in laying down for a rest period. -6/7/23, poor safety awareness and possible sensory overload due to autistic disorder. Interventions included encourage the resident to be returned to bed when restless in the geri chair as needed, 1:1 caretaker during times of increased agitation/anxiety, staff to remove resident from common areas during periods of high traffic/loudness/busyness. There is no documented evidence the care plan was revised after the resident's fall on 3/24/25. The undated Care Profile (guide used by staff to provide care) provided and identified as current by the [NAME] President of Clinical Services documented for staff to redirect, provide reassurance, distraction, decrease stimuli, use calm reassuring voice and remove from loud/busy area when Resident #48 was agitated. The Incident Report dated 3/19/25 at 12:10 PM, the Unit Manager Registered Nurse #5 documented Resident #48 had an unwitnessed fall on the floor at 12:10 PM in the 2nd floor (common area) dining room in front of the nurses station. Was found lying on their right side in the fetal position and was placed back into their Geri chair via Hoyer lift, neuro checks were initiated. The Incident Report dated 3/24/25 at 6:30 PM, the Nursing Supervisor Registered Nurse #1 documented they arrived to find the resident in a right laying position (on floor) next to their geri chair. Staff were present at the time of the fall, staff member assigned 1:1 was present but said they turned away for a second and the resident had fallen. Review of the staff statement dated 3/24/25, revealed Certified Nursing Assistant #4 documented they were sitting right next to resident, and looked down for two seconds when the resident jumped out of the chair. They couldn't catch the resident in time. Supervisor was called. The resident was on 15 min checks and had increased agitation since the shift started. Review of a progress note dated 3/24/25 documented, Resident #48 had an unpredictable movement while in geri chair causing them to slide from it before staff monitoring for 1:1 could prevent it. No visible injuries or signs of pain on assessment. Following the assessment, the resident was transferred to the Geri chair without issue and 1:1 continued to be provided. The facility's video footage dated 3/24/25 time stamped from 6:09 PM to 6:51 PM of the Unit 2 common area/dining room was viewed on 3/27/25 at 10:16 AM with the Administrator and [NAME] President of Clinical Services present. The video revealed Resident #48 attempted to get out of their Geri chair multiple times. Staff members Certified Nursing Assistants #1, #2, #3 and #4, and Licensed Practical Nurse #1 were in the common area/dining room at various times and did not remove the resident and transport them to a less busy environment to decrease stimuli. They did not provide redirection, reposition the resident's extremities to maintain them within the seat of the Geri chair, did not provide any distraction to maintain a safe environment and Resident #48 fell from their chair hitting their head on the floor. During an interview on 3/27/25 at 10:20 AM, the [NAME] President of Clinical Services stated staff should have removed Resident #48 from the common area/dining room and transported them to their low boy bed with mats on the floor for their safety. During an interview on 3/27/25 at 10:20 AM, the Administrator stated they had not viewed the video of 3/24/25 and did not know about the incident. They stated the staff did not do anything they should have, and the resident fell . They would have expected the staff to remove the resident from the common area/dining room to a less busy environment to promote a calm environment for their safety and maintain a 1:1 to ensure their safety. During an interview on 3/27/25 at 5:24 PM, Nursing Supervisor Registered Nurse #1 stated they believed Resident #48 was a 1:1 supervision the evening of 3/24/25 and would have expected all the staff identified in the dining room to have interacted with the resident, identify that the resident was agitated and transport them to their room for a calm environment for their safety. They stated they directed the staff to lift the resident from the floor to the geri chair and not get the Hoyer lift because they thought the staff were strong enough and they didn't assist because they had a bad back, but during the transfer from the floor to the chair it was a poor transfer and the resident landed awkwardly in the geri chair and the transfer was unsafe. They stated they had not received any specific training how to care for Resident #48 and believe they should for the Resident's safety. They stated after Resident #48 fell on to the floor neuro checks should have been completed. They stated they did not fill out a form or write an order for the neuro checks and did not know if they were done. During an interview on 3/27/25 at 6:46 PM, Certified Nursing Assistant #2 stated they were not the primary care giver for Resident #48 and didn't know what their care plan interventions were to promote a safe environment. They stated they were supposed to use a Hoyer lift to lift residents from the floor to the chair for their safety and they had not because the Nursing Supervisor Registered Nurse #1 instructed them to pick up the resident from the floor to the geri chair by holding onto the resident's extremities. They stated it was a dangerous and unsafe transfer because of the resident's spastic movements. They stated they had not received any specific training how to care for Resident #48 and believed they should for the resident's safety. During an interview on 3/27/25 at 7:21 PM, Licensed Practical Nurse #1 stated they worked as the staff nurse when Resident #48 fell and the identified Certified Nursing Assistants #1, #2, #3, and #4 should have done more for Resident #48 to prevent them from falling out of the Geri chair but did not know what they should have done. They stated they did not know the resident's care plan interventions for the resident's safety or behaviors. Licensed Practical Nurse #1 reviewed the resident's comprehensive care plan and stated the staff should have ensured Resident #48 was removed from the common area / dining room and transported to a calm environment to decrease their agitation. They stated they should have used a Hoyer lift to move Resident #48 from the floor to the Geri chair for their safety as it was a very unsafe transfer. They stated they had not received any specific training how to care for Resident #48 and believe they should have for the Resident's safety. They stated they thought they completed neuro checks after Resident #48 fell but did not recall how often they were done and was unable to find the neuro check form. During an interview on 3/28/25 at 9:17 AM, the Unit Manager Registered Nurse #5 stated they saw the video footage of 3/24/25 from 6:00 PM to 7:00 PM and stated they would have expected Certified Nursing Assistants #1, #2, #3 and #4, and Licensed Practical Nurse #1 to have followed the resident's care plan by removing Resident #48 from the common area/ dining room and transported them to their room or a calm environment to decrease the resident's anxiety and for their safety. They stated the staff should have used a Hoyer lift to move Resident #48 from the floor to the Geri chair for their safety as it was a very unsafe transfer related to the resident's spastic movements. They stated the resident's fall from the Geri chair to the floor was preventable and would have expected Certified Nursing Assistant #4 to have positioned themselves on the resident's right side within arm's reach to prevent them from falling out of the Geri chair. They stated there were no additional interventions on the care plan after Resident #48's fall on 3/24/25 and would have expected the Nursing Supervisor Registered Nurse #1, who completed the Accident/Incident form, to have developed a new intervention for Resident #48's safety. During an interview on 3/28/25 at 10:10 AM, Certified Nursing Assistant #4 stated they were the primary care giver for Resident #48 on 3/24/25 and stated Resident #48 was anxious and frequently moved in their Geri chair in their room and were on every 15-minute checks. Certified Nursing Assistant #4 stated they called the staffing coordinator at approximately 2:00 PM on 3/24/25 asking for an additional staff member to provide a 1:1 for Resident #48 and they were told one of the Certified Nursing Assistants working on the unit would need to be the 1:1. Certified Nursing Assistant #4 stated Certified Nursing Assistants #1, #2 and #3 would not accept being a 1:1 and they (Certified Nurse Aide #4) did not feel comfortable or safe to provide 1:1 for Resident #48 because their movements. They stated they transported Resident #48 from their room to the common area/dining room so all staff could watch Resident #48 for their safety. They stated they should have been more attentive to Resident #48, should have followed the plan of care and removed them from the common area/dining room and placed them in their room for a calm environment to decrease their agitation and should have used a Hoyer lift to move Resident #48 from the floor to the Geri chair for the resident's safety as it was a very unsafe transfer related to the resident's spastic movements and they landed on their face in the Geri chair. They stated they told the Administrator in the past (unable to provide dates) that no one wanted to care for Resident #48 because of their behaviors and difficulty managing and providing care to them. They stated they had not received any specific training on how to care for Resident #48 and believed they should for the resident's safety. During an interview on 3/28/25 at 11:33 AM, the Rehabilitation Director #1 stated they had not received a therapy referral request for Resident #48's positioning since 12/17/24 and that was related to a wound on their ear. They stated they would have expected to have received a referral for each identified fall, 3/19/25 (fall from Geri chair in common area / dining room), 3/22/25 (fall in Resident's room) and 3/24/25 (fall from Geri chair in common area / dining room); especially if they were falling from the Geri chair to determine if there were additional interventions that could be put into place. During an interview on 3/28/25 at 1:15 PM, the Assistant Director of Nursing stated they viewed the video footage dated 3/24/25 from 6:00 PM to 7:00 PM and stated the staff should have followed the plan of care and transported Resident #48 to their room for a less stimulating environment, would have expected Certified Nursing Assistant #4 to have positioned herself in a manner next to Resident #48 to prevent them from falling out of the Geri chair and would have expect the staff to utilize the Hoyer lift to transfer Resident #48 from the floor to the Geri chair for the resident's safety. They stated they would have expected staff to provide redirection, reposition the resident's extremities to maintain within the seat of the Geri chair and they did not provide any distraction to maintain resident in a safe environment. They stated it's been over a year since they provided verbal education to the staff on how to care for Resident #48 and they did not have any documented evidence there was any specific training provided to the staff on how to care for Resident #48 and they believed there should be related to their behaviors and autism. They stated if Certified Nursing Assistant #4 believed Resident #48 required to be a 1:1 for their safety they should have contacted them or the Administrator or followed the Staffing Coordinator's suggestion and provided the 1:1 in the resident's room. The Assistant Director of Nursing stated there should be a new care plan intervention for each fall and there was not an intervention for 3/24/25 and therapy should have been requested to complete a positioning evaluation on 3/19/25 and 3/24/25 since the resident had fallen from the Geri chair in the common area/dining room both times. They stated the staff did not follow the care plan and provide a safe environment. They stated neuro checks should have been completed after the resident fell on [DATE] and have been documented in the resident's medical record. During an interview on 3/28/25 at 1:54 PM, the Medical Director stated Resident #48 was high risk for falls and the staff should be more vigilant in monitoring the resident and sitting close to them in a position to ensure they were safe. They would have expected Certified Nursing Assistant #4 to have positioned themselves in a manner to prevent the resident from falling out of the Geri chair and would have expected neuro checks to have been completed to monitor for any changes. During an interview on 3/28/25 at 2:52 PM, the Administrator stated there had not been any specific education training of how to take care of Resident #48 to their staff and in hindsight there should have been. They stated they would have expected any of the staff members identified in the 3/24/25 video footage, Certified Nursing Assistants #1, #2, #3, #4 and Licensed Practical Nurse #1 to have followed Resident #48's plan of care and moved them to a less stimulating environment. They stated they were not aware Certified Nursing Assistant #4 requested Resident #48 to be a 1:1 related to their agitation and anxiety and movements in the Geri chair, and they should have maintained them in their room with a 1:1. They stated they would have expected their staff to collectively maintain a safe environment for Resident #48. They stated the staff should have used the Hoyer lift to move the resident from the floor to the Geri chair for resident safety, completed neuro checks and have documented evidence it was done to ensure changes were being monitored. The nursing supervisor should have provided additional care plan interventions and requested Therapy to complete a positioning evaluation on 3/19/25 and 3/24/25 since the resident had fallen from the Geri chair in the common area/dining room both times. They stated since the staff had not followed the plan of care, they did not provide a safe environment. 10NYCRR 415.12(h)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 3/28/25, the facility did not ensure that 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 two (Resident #13 and #19) of three residents reviewed. Specifically, infection control practices were not maintained when caring for residents with an indwelling foley catheter. Resident #13's foley catheter drainage bag (used to collect urine) was observed on the floor and Resident #19's foley catheter drainage bag was improperly emptied. Additionally, the comprehensive care plan was not developed to include the use of an indwelling foley catheter and the Minimum Data Set ( a resident assessment tool) was coded inaccurately (#13). The findings are: The policy and procedure titled Urinary Catheter Care dated 8/2022 documented use aseptic technique (a method used to prevent contamination with microorganisms) when handling or manipulating the drainage system and be sure the catheter tubing and drainage bag are kept off the floor. The policy and procedure titled Care Plans, Comprehensive Person-Centered dated 10/2023 documented the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, builds on the resident's strengths and reflects currently recognized standards of practice for problem areas and conditions. 1. Resident #13 had diagnoses including benign prostatic hyperplasia (enlarged prostate), obstructive uropathy (obstruction of the urinary tract), urinary retention and urinary tract infection. The Minimum Data Set, dated dated dated [DATE] documented Resident #13 was understood, understands and was cognitively intact. The Minimum Data Set documented there was no indwelling catheter, but Resident #13's urinary continence was not rated due to a catheter, ostomy, or no urine output for the seven-day look back period. The physician's order form dated 3/27/25 documented orders to change the foley catheter every month, change continuous drainage bag as needed for soiling, cloudiness, leaking or odor with any foley catheter change, and irrigate foley catheter every shift as needed with 100 milliliters (ml- a unit of measurement) normal saline and had a start date of 3/3/25. The comprehensive care plan dated 1/12/25 documented Resident #13 had an alteration in elimination due to diagnosis of benign prostatic hyperplasia and obstructive uropathy but did not include the resident had an indwelling foley catheter. Review of the Medical Director's progress note dated 3/12/25 documented Resident #13 was ordered an antibiotic for an acute urinary tract infection. During intermittent observations on 3/24/25 between 9:21 AM and 12:55 PM, Resident #13's foley catheter drainage bag was lying flat directly on the floor without a barrier. The urine in the drainage bag was cloudy and pale. During an observation on 3/26/25 at 11:19 AM, Resident #13's foley catheter drainage bag and approximately 12 of tubing were laying directly on the floor, next to the bed without a barrier. The urine in the drainage bag was amber in color and cloudy. At 12:54 PM, Resident #13's foley catheter drainage bag and approximately 12 of tubing were still laying directly on the floor next to the bed. During an observation and interview on 3/26/25 at 1:12 PM, Certified Nurse Aide #8 stated the drainage bag was on the floor and should not be because that was illegal. They stated that by illegal they meant that would be a problem with infection control and it was something they would let the Licensed Practical Nurse know about. Certified Nurse Aide #8 stated they were not sure how long the urinary drainage bag was on the floor, but it was probably there because Resident #13 took it out of the privacy bag and tossed it on the floor. Certified Nurse Aide #8 was observed to question Resident #13 why they tossed their drainage bag onto the floor and Resident #13 responded by stating they did not throw the drainage bag on the floor. Resident #13 stated the urinary drainage bag probably falls out of the blue privacy bag when they raised and lowered their bed. During an interview on 3/26/25 at 2:37 PM, Licensed Practical Nurse #3 stated occasionally, they have seen Resident #13's foley catheter drainage bag on the floor. They thought that Resident #13 might tug on the drainage bag when they were moving in bed and that was how it kept ending up on the floor. Licensed Practical Nurse #3 stated Resident #13 does not currently have a urinary tract infection that they were aware of, but they had just completed antibiotics for a urinary tract infection on 3/12/25. They stated the foley drainage bag should not touch the floor for infection control reasons. During an interview on 3/28/25 at 10:24 AM, Registered Nurse #6 Minimum Data Set Coordinator stated Resident #13 has had an indwelling foley catheter and the most recent Minimum Data Set was coded incorrectly. They stated that it should have been entered that Resident #13 had an indwelling catheter to reflect the type of care they were receiving During a telephone interview on 3/28/25 at 10:34 AM, the Medical Director stated Resident #13 was admitted to the facility with an indwelling foley catheter and that placed them at a high risk for urinary tract infections. They expected staff to monitor the drainage bag and keep it off the floor. During an interview on 3/28/25 at 10:49 AM, the Regional Quality Assurance Nurse/Infection Preventionist stated nursing staff should check the location of the foley drainage bag more often to make sure it was not on the floor. They stated the drainage bag should not have been on the floor because of germs, contamination and infection. During an interview on 3/28/25 at 10:59 AM, Registered Nurse Unit Manager #4 stated the staff have commented that when Resident #13 moves about the drainage bag falls out of the privacy bag, and they should have put something in place to prevent that from happening. They stated anyone who saw the foley drainage bag was responsible to make sure the drainage bag was not on the floor, including certified nurse aides, licensed practical nurses, and supervisors. Registered Nurse #4 Unit Manager stated the foley catheter was not on Resident #13's care plan, but should have been, and they were responsible for putting it on the care plan. During an interview on 3/28/25 at 12:12 PM, the Assistant Director of Nursing stated foley drainage bags should never be exposed or on the floor because it was both a dignity and infection control issue. The Assistant Director of Nursing stated the unit manager was responsible for the care plans and the foley catheter should have been on the care plan because that was a part of Resident #13's treatment. During an interview on 3/28/25 at 11:59 AM, the [NAME] President of Clinical Services stated if the nursing staff was aware the urinary drainage bag was coming out of the privacy bag then they should have put an intervention in place to keep it from falling out. The Minimum Data Set should have included the use of the indwelling foley catheter for accuracy of information and the Minimum Data Set Coordinator was responsible. 2. Resident #19 had diagnoses of neuromuscular dysfunction of bladder (condition where nerve damage prevents the bladder from functioning properly) with history of urinary tract infections, dementia, and diabetes mellitus. The Minimum Data Set, dated dated dated [DATE] documented Resident #19 had moderate cognitive impairment, did not exhibit rejection of care and had an indwelling foley catheter. The comprehensive care plan dated 4/19/21 documented Resident #19 had neurogenic bladder and included the use of an indwelling foley catheter. During a morning care observation on 3/26/25 at 9:12 AM Certified Nursing Assistant #4 provided fecal incontinence care for Resident #19. After fecal incontinence care they changed their gloves but did not wash their hands prior putting on new gloves and emptying the urinary catheter drainage bag. Additionally, Certified Nurse Aide #4 emptied the drainage bag into a graduate container without cleansing the drainage port prior to and after emptying the urine from the drainage bag. During an interview on 3/26/25 at 9:34 AM, Certified Nurse Aide #4 stated they should have washed their hands after removing their gloves prior to emptying Resident #19's foley catheter drainage bag and stated they should have used an alcohol wipe to clean the drainage bag port before and after draining the urine into the graduate container for infection control purposes. During an interview on 3/28/25 at 9:08 AM, Registered Nurse Unit Manager #5 stated Certified Nurse Aide #4 should have washed their hands between changing their gloves and before providing catheter care. Also, Certified Nurse Aide #4 should have cleansed the foley drainage bag port with an alcohol wipe before and after draining the urine from the drainage bag for infection control purposes. During an interview on 3/28/25 at 10:35 AM, the Assistant Director of Nursing stated Certified Nurse Aide #4 should have washed their hands between changing their gloves before they provided catheter care. The urinary drainage bag port should have been cleaned with an alcohol wipe before and after draining the urine from the drainage bag for infection control purposes. 10NYCRR 415.12(d)(1)

Based on interview and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure that the pharmacist reported irregularities to the attending physician and the facility's Medical Director, and the Director of Nursing, and that these reports were acted upon for two (Residents #25 and #75) of five residents reviewed for drug regimen reviews. Specifically, the Consultant Pharmacist did not report a gradual dose reduction for a psychotropic medication had not been attempted at least annually per the facility protocols (#25). In addition, the Consultant Pharmacist recommendations on 10/17/24 and 12/5/24 were not acted upon (#75). The findings are: The policy and procedure titled, Coordination of Consultant Pharmacist Monthly Review and Recommendations revised 11/28/2017, documented the facility will ensure that all pharmacist recommendations are coordinated with the Physician and nursing services timely and appropriate actions and follow up actions occurs to ensure each resident receives the necessary care as recommended by the Pharmacy Consultant. The Consultant Pharmacist will e-mail the completed reports to the Director of Nursing and Administrator on the same day reports are completed. The Director of Nursing will ensure any irregularities are immediately addressed with the Physician to ensure immediate action is taken. The Director of Nursing will ensure all follow up action is addressed timely within thirty days prior to the next scheduled pharmacy review. A copy of all resident drug regimen reviews will be maintained in a binder in the Director of Nursing office with supporting documentation attached as evidence that the recommendations and follow up action occurred. The Consultant Pharmacist will review the binder monthly to ensure all Physician and nursing recommendations have been addressed timely. The policy titled Tapering Medications and Gradual Dose Reduction dated 11/1/2029 documented that all medications are considered for possible tapering. The policy documented that attempted tapering of psychopharmalogical (medication for mental diagnoses) medications shall be considered a way to determine if the resident can benefit from a lower or less frequent dose. The policy documented that within the first year of an initiation of a psychopharmalogical medication, the facility will attempt to taper the medication during at least two separate quarters with one month between attempts unless medically contraindicated. The policy documented after the first year, tapering of the psychopharmalogical medication shall be attempted annually. 1. Resident #25 had a diagnosis of general anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 1/3/25 documented the resident was cognitively intact, understood by others, and understands others. The Minimum Data Set documented that the resident was on an antidepressant. The comprehensive care plan dated 2/24/24 documented Resident 25 had an altered mood state and had the potential for side effects related to psychotropic (relating to medications that affect a person's mental state) medication use. Physician orders dated 2/5/24 to 12/30/24 documented an order for escitalopram oxalate (an antidepressant that also treats generalized anxiety disorder), 10 milligrams, 1 tablet by mouth daily. The medication administration record dated 3/4/24 to 3/28/25 documented that Resident #25 received escitalopram oxalate, 10 milligrams by mouth daily as ordered. Review of the monthly medication regimen review dated from 1/16/24 to 3/12/25 revealed there were no recommendations from the pharmacist consultant for a gradual dose reduction for escitalopram or that a gradual dose reduction would be medically contraindicated. Review of the interdisciplinary progress notes dated 3/2/24 to 3/24/25 revealed there were no progress notes written for a gradual dose reduction attempt of escitalopram 10 milligrams or that a gradual dose reduction would be medically contraindicated. During an interview on 3/28/25 at 10:51 AM, the Medical Director stated they expected the Consultant Pharmacist to inform them if a resident had been on an antidepressant for a year. They stated that it was up to them, not the Consultant Pharmacist to make the determination if a resident needed to have a gradual dose reduction or not. During an interview on 3/28/25 at 11:11 AM, the Administrator stated that they believe it was up to the resident to decide if they wanted to stop a medication. During an interview on 3/28/25 at 11:44 AM, the [NAME] President of Clinical Services stated they would expect the Consultant Pharmacist to bring any irregularities or, if a resident had been on a medication for a long time, to the physician's attention. They stated it was up to the physician to make the determination if there should be a gradual dose reduction or if the medication should be kept the same. During an interview on 3/28/25 at 1:18 PM, Consultant Pharmacist #2, stated it would be unethical for them to recommend a gradual dose reduction for medications for a resident who was on an antidepressant for generalized anxiety disorder. They stated they do not document in the progress notes that they opposed a gradual dose reduction. They stated they only make notations if they reviewed a medication and if there were any irregularities. They stated they would have not done a medication regimen review for a gradual dose reduction for the antidepressant. 2. Resident #75 had diagnoses which included hyperlipidemia (high cholesterol), anxiety, and dementia. The Minimum Data Set, dated dated dated [DATE] documented that Resident #75 was moderately cognitively impaired, sometimes understands, and sometimes understood. The comprehensive care plan dated 4/25/23 (identified as current) documented Resident #75 used nine or more medications and had hyperlipidemia. The planned interventions included but not limited to: assess for side effects of medications; physician to attempt to reduce the number of medications; monthly medication review by the Physician and Pharmacy Consultant and monitor labs as ordered. Review of the interdisciplinary progress notes dated 10/17/24 and 12/5/24, Consultant Pharmacist #1 documented irregularities were identified and to see the report. The Consultant Pharmacist's Medication Regimen Review dated 10/17/24 documented an irregularity and recommended to consider discontinuing the medication Thiamine (Vitamin B-1). The provider agreed, signed, and wrote to discontinue the thiamine. The Consultant Pharmacist's Medication Regimen Review dated 12/5/24 documented to consider ordering a Lipid profile (blood test for cholesterol), HbA1C (glycated hemoglobin)- (blood test for sugar levels in the body) due to a risk of diabetes. The provider agreed and signed the recommendation. The Physician's Order Form as of 3/26/25 documented an active physician's order for Vitamin B-1 oral tablet 100 milligrams (Thiamine HCL) one tablet by mouth daily. The start date was 4/13/23. There was no physician's order to discontinue the Vitamin B-1 per the Consultant Pharmacists' recommendations on 10/17/24. There was no physician's order for the recommended lipid profile, and the HbA1C (glycated hemoglobin) per the 12/5/24 Consultant Pharmacist recommendations. Review of the October 2024 through March 2025 Medication Administration Records revealed that Resident #75 received Vitamin B-1 oral tablet 100 milligrams (Thiamine HCL) one tablet by mouth daily. Review of Resident #75's electronic medical record from December 2024 through March 2025 revealed there were no laboratory diagnostic test results for the lipid profile and HbA1C (glycated hemoglobin) until 3/14/25. During a telephone interview on 3/27/25 at 4:40 PM, Consultant Pharmacist #1 stated they emailed recommendations to the Assistant Director of Nursing, Director of Nursing, the Medical Director and the Administrator after their reviews on 10/17/24 and 12/5/24. The answered regimens were not in front of them during their reviews. The Director of Nursing printed them and distributed the recommendations to the Unit Managers and the originals were kept in a binder in the Director of Nursing's office. Consultant Pharmacist #1 stated they followed up on previous reviews by auditing a random sample but not all of them, and that process was ineffective. Resident #75 should not have received the Vitamin B-1 since the provider wrote to discontinue it and an order should have been written. The requested lipid profile, and HbA1C (glycated hemoglobin) was recommended again on 3/12/25 after the Consultant Pharmacist #1 discovered that it was not done from 12/5/24 and would have expected it to be completed on the next lab day or during the next scheduled lab draw in February. During an interview on 3/28/25 at 9:02 AM, Registered Nurse Unit Manager #5 stated the medication regimen reviews were placed in the providers folder. Once the provider agreed or disagreed, they would input the physician's order into the computer and Unit Clerk #2 filled out a laboratory requisition and logged it into the lab book on the unit. Registered Nurse #5 Unit Manager stated they had no evidence they had reviewed the medication regimen reviews from 10/17/24 and 12/5/24. They should have been taken care of immediately after the provider agreed. Unit Clerk # 2 should have completed a lab requisition form, documented in the logbook and the blood work should have been drawn on the next lab day. Labs were drawn every Monday, Wednesday, and Friday. Registered Nurse Unit Manager #5 stated the missed Vitamin B-1 was their mistake. During an interview on 3/28/25 at 10:59 AM, the Medical Director stated Registered Nurse Unit Manager #5 should have immediately addressed and changed the physician order in the electronic medical record and discontinued the Vitamin B-1 on 10/17/24 after the provider agreed. The labs should have been ordered for the next lab day. During an interview on 3/28/25 at 12:49 PM, Unit Clerk #2 stated the lab order was not logged into the lab logbook in October 2024, therefore the blood work was not drawn, and it should have been. During a telephone interview on 3/28/25 at 1:48 PM, Director of Nursing #1 stated providers reviewed recommendations within twenty-four hours or within two days when not in the building. Once reviewed they would have expected Registered Nurse Unit Manager #5 to have changed the physician's order in the computer to discontinue the medication, order the labs and write a detailed progress note as to the order changes. 10 NYCRR 415.18(c)(2)

Based on observation, interview, and record review conducted during the Standard survey, completed on 3/28/25, the facility did not provide or obtain dental services to meet the resident's needs for one (Resident #74) of one resident reviewed. Specifically, there was a lack of timely follow - up on dental recommendations for extractions (removal of teeth). The finding is: The policy titled Dental Services, last revised 1/26/2020, documented routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. The Director of Nursing or their designee was responsible for notifying social services of a resident's need for dental services and coordinating appointments with Medical Records/ Unit Clerks. Social Services personnel would be responsible for assisting the resident in making dental appointments and transportation arrangements as necessary whenever an outside dentist was requested. All dental services were recorded in the resident's medical record. The Medical Records Department/ Unit Clerks would schedule and track resident dental appointments as per required and recommend visits in the medical appointment tickler tracking system document. The policy titled Consultants, last revised 12/2009, documented the facility may use as needed outside resources to furnish specific services to residents and to the facility. Consultant services may be utilized for medical and dental services. A written, signed, and dated agreement was maintained for each consultant. Consultant provided the Administrator with written, dated, and signed reports of each consultation visit. These included any recommendations, plans for implementation of recommendations, findings and plans for continued assessments. The facility retained professional and administrative responsibility for all services provided by consultants. Resident #74 had diagnoses including multiple sclerosis (chronic disease of the brain and spinal cord that disrupts the nerve signals causing a variety of symptoms), anxiety, and depression. The Minimum Data Set (a resident assessment tool) dated 1/3/25 documented Resident #74 was cognitively intact, was understood, understands. The comprehensive care plan dated 5/11/23 documented Resident #74 had their own teeth and a deficit in grooming related to poor dentition. Interventions included to assist with mouth care, dental consult annually or as needed, and to examine oral cavity and assess for presence of lesions, broken or missing teeth, decaying teeth, inflammation of gums, bleeding, and provide hygiene every shift and as needed. Review of dental consult notes revealed the following: 10/28/24 it was documented Resident #74 was referred for extraction of tooth #14 so that they could receive an upper denture and lower partial. It was documented they were asymptomatic but reported difficulty eating without upper teeth. 11/25/24 it was documented Resident #74 had not had an appointment made yet for extraction of tooth #14. 2/17/25 it was documented Resident #74 had not had an appointment made yet for extraction of tooth #14 and had complaints of pain in tooth #3 and #5. They were added to referral for extraction as well. 3/17/25 it was documented Resident #74 had not had an appointment made yet, it had now been over 90 days since the original referral was made. Review of nursing progress notes dated 10/28/24 to 3/26/25 revealed Resident #74 did not have a follow up dental appointment made until 3/26/25. During an observation and interview on 3/24/25 at 11:15 AM Resident #74 stated they saw Dentist #1 a couple months ago who said they were going to set up an appointment for some teeth to be removed so they could have dentures made because it had been somewhat difficult to eat. Resident #74 opened their mouth and pointed to area in mouth teeth needed to be extracted. The resident had poor dentition (oral care) and missing teeth. They stated they had not had any follow up dental appointments and had not heard anything regarding an appointment. During an interview on 3/26/25 at 9:20 PM, Unit Clerk #1 stated dental consults were given to Medical Records who then gave it to the Registered Nurse Unit Managers for review. If there was a new referral, the Registered Nurse would call to set up an appointment. If it was a routine follow up appointment, the Unit Clerk would set up next needed appointment or any needed follow up care after the initial appointment was made. Unit Clerk #1 stated, to their knowledge, Resident #74 had not had any dental referrals that required further appointments. During an interview on 3/26/25 at 9:22 AM, the Director of Medical Records stated they received the dental consults and scanned them into the residents computerized medical records. They did not review the consults for completion or look to see if the consult documented any recommendations. They stated the Unit Manager was responsible for ensuring all recommendations were reviewed and carried out. The Director of Medical Records stated they were unaware of any recommendations/referrals made for Resident #74 from the dentist for an outside appointment to have teeth extracted. During an interview on 3/26/25 at 9:26 AM, Registered Nurse Unit Manager #1 stated Dentist #1's exam notes and recommendations were documented on a paper form and the form was sent to the (dental company used by facility). The dental company in turn sends the consults to the Administrator, who distributes them to the Unit Managers for review and follow through. They stated the process for dental referrals had not been used correctly, as the dentist was giving their referrals for the residents directly to Medical Records who just scanned them into the residents medical chart. There was no nurse reviewing the consults, so referrals and appointments were not being made. Registered Nurse Unit Manager #1 stated recently (in March) Dentist #1 had been in the facility and gave Resident #74's referral directly to them to have the three teeth extracted. They were unaware of any dental referrals for Resident #74 prior to that and they were unaware the resident had experienced trouble eating and pain. During an interview on 3/26/25 at 11:06 AM, Resident #74 stated they had some tooth pain in November 2024 that lasted about three weeks, and it affected their ability to eat at times but was relieved by their scheduled pain medication. During an interview on 3/28/25 at 11:08 AM, Medical Director #1 stated if a resident required tooth extractions, they would have expected staff to update them, especially if pain was involved. Medical Director #1 stated they were never made aware Resident #74 had tooth pain in November 2024, or that there was a referral for tooth extractions. They stated they were made aware at the beginning of March that Resident #74 had a referral for teeth to be extracted. The Unit Manager was responsible for ensuring all dental recommendations were reviewed, addressed, and carried out. During an interview on 3/28/25 at 1:20 PM, the Administrator stated there had been a systems error leading to dental recommendations not being reviewed or addressed. The dental recommendations were being sent directly to Medical Records, so they were not being reviewed by nursing staff and recommendations were not followed. They stated they expected all dental recommendations to be reviewed in a timely manner so that any appointments could be made. Resident #74 should not have had to wait more than 90 days for a referral to have been made for tooth extractions. During an interview on 3/28/25 at 1:33 PM, the Director of Nursing #1 stated they expected all dental recommendations to be followed and for an appointment to have been made for Resident #74 once the referral for tooth extractions was received from Dentist #1 in November 2024. They stated, 90 days was far too long to wait for an appointment to be made for tooth extractions. It was important to follow through with recommendations because Resident #74 had difficulty eating and had pain for a short time. During an interview on 3/28/25 at 3:18 PM, Dentist #1 stated they expected all dental recommendations to be followed through with. Any outside services needed should be coordinated by the facility and appointments made timely. They stated they made referrals, but it fell on the facility to meet the further dental needs of each resident. 10 NYCRR 415.17 (a-d)

Based on interview and record review conducted during the Standard survey completed on 3/28/25, 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, employees that worked in the facility and were subject to the New York State Nurse Aide Registry Verification, were not reviewed through the New York State Nurse Aide Registry prior to their employment as required. This affected three (Employee #1, Activities Aide, Employee #8, Dietary Aide, and Employee #9, Dietary Aide) of seven employees that worked in the facility and were subject to the New York State Nurse Aide Registry Verification, that were not reviewed through the New York State Nurse Aide Registry prior to their employment as required. The findings are: Review of the policy and procedure titled: Abuse, Neglect and Exploitation of Residents with a reviewed date of 2/2023 documented: It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free form verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property. Residents will not be subjected to abuse by anyone, including but not limited to, staff, other residents, consultants, volunteers, contractors, and staff from other agencies, family members, legal guardians, resident representatives, friends or other individuals. Such acts, when proven to have been committed by an employee, are cause for dismissal and possible criminal prosecution. Comprehensive polices and procedures have been developed to aid the facility in the prevention of abuse, neglect, exploitation, mistreatment or mistreatment of property of the residents. Procedure: Screening (Refer to policies: Nurse Aide Registry and Criminal Background Checks.) Certified Nursing Assistant (CNA) Registry is contacted to confirm the aides' enrollment and status on the registry. Review of the policy and procedure titled: Nurse Aide Registry dated 2/17/18 documented: The Department of Health (DOH) requires validation of Certified Nurse Assistants (CNAs) for all nurse assistants employed by the facility. This validation includes verification of the absence of any findings or convictions of abuse. In addition, all other employees are screened for abuse through the nurse aide registry prior to employment. Employment at the facility will be contingent upon a favorable report from the state nurse aide registry. Verifications can be obtained through the state Department of Health (DOH). The Human Resource Department will verify the name and/ or Certified Nurse Assistant (CAN) Certification number of the applicant through the state Nurse Aide Registry, prior to employment. All employees (licensed and non-licensed) will be screened through the New York State Nurse Aide Registry. Employment will be contingent upon a favorable report from the state Nurse Aide Registry. Any employee whose record shows abuse findings or convictions may not be hired. Reports received will be maintained in the employee's personnel file. 1a. During an interview on 3/25/25 at 2:55 PM the Human Resources Generalist (Authorized Person for Criminal History Record Check) stated Employee #1 was hired to work at the facility as an Activities Aide on 11/25/24. Review of the employee file for Employee #1 revealed the employee was hired on 11/25/24 as an Activities Aide and the file contained a Nurse Aide Registry Verification report for the employee that was dated 11/27/24. Review of timecard reports for Employee #1 revealed the employee worked in the facility on: -11/25/24 from 3:00 PM to 7:00 PM. -11/26/24 from 3:00 PM to 7:00 PM. Employee #1 worked in the facility for two days prior to the facility conducting a Nurse Aide Registry Verification report for the employee. Review of the undated Activities Aide Job Description documented: The Activities Aide will assist with the planning and development of the activity's programs, as assigned by the Director of Activities, and will assist carrying out this Facility's overall activities programs, as scheduled. Facilitation of such programs will include efforts by the Activities Aide to make available to all residents, cognitive and sensory stimulation, entertainment, opportunities for active exercise and creative expression that meets basic social, sensory and spiritual needs; subject to written restrictions and limitations as may be ordered by the physician. Minimum Qualifications: Must possess the ability to deal tactfully with coworkers, residents, family members, visitors, government personnel and the general public. Responsibilities: -Carries out activities programs which provide for spiritual, emotional, physical, and intellectual, and sensory needs of the resident population. -Is responsible for leading group and individual activity programs. -Will provide meaningful sensory/ environmental stimulation, encourage social interaction and provide emotional support and cognitive stimulation during the course of facilitating programs. -Will make resident aware of activity option, encourage participation and/ or facilitate resident opportunities for pursuit of individualized leisure interests that are within the resident's cognitive and/or physical capabilities. -Will accommodate the special needs of cognitively impaired residents, and provide support and assistance to the residents, as needed to ensure sensory/ social stimulation within each resident's capacity to receive and/ or capability to be involved. -Will be responsible for recording resident attendance in activities programs. - As assigned by the Director of Activities, the Activities Worker will be responsible for required documentation, such as initial/ annual resident assessments and quarterly progress notes. 1b. During an interview on 3/25/25 at 3:58 PM the Human Resources Generalist (Authorized Person for Criminal History Record Check) stated Employee #8 was hired to work at the facility as Dietary Aide on 4/24/24. The Human Resources Generalist further stated the facility did not have any documentation that a Nurse Aide Registry Verification report had been conducted for Employee #8. During an interview on 3/27/25 at 10:39 AM the Food Service Director stated Dietary Aides delivered and picked up food carts and trays to the First, Second and Third floors/ units and restocked nourishments in the nourishment rooms on the First, Second, and Third floors/ units. During an interview on 3/27/25 at 12:36 PM the Human Resources Generalist stated they had spoken with the Directors of the facility's departments and the Administrator, and the Directors of the departments and the Administrator did not have any other documentation for any of the employee's Nurse Aide Registry Verification reports. Review of the employee file for Employee #8 revealed the employee was hired on 4/24/24 as a Dietary Aide and the file did not contain documentation that a Nurse Aide Registry Verification report had been conducted for the employee. Review of timecard reports for Employee #8 revealed the employee worked in the facility on: -4/24/24 from 11:00 AM to 11:55 AM. -4/25/24 from 7:00 AM to 7:56 PM. -4/26/24 from 6:30 AM to 7:58 PM. -4/27/24 from 6:30 AM to 4:37 PM. -4/28/24 from 6:01 AM to 3:11 PM. -4/30/24 from 5:58 AM to 2:30 PM. -5/1/24 from 6:30 AM to 7: 00 PM. -5/2/24 from 6:58 AM to 3:08 PM. -5/3/24 from 7:30 AM to 4:45 PM. -5/6/24 from 6:30 AM to 4:30 PM. -5/7/24 from 6:32 AM to 4:36 PM. -5/9/24 from 6:38 AM to 7:10 PM. -5/10/24 from 6:28 AM to 4:17 PM. -5/13/24 from 10:56 AM to 8:00 PM. -5/14/24 from 6:52 PM to 4:17 PM. -5/15/24 from 6:52 AM to 7:34 PM. -5/16/24 from 7:15 PM to 8:01 PM. -5/17/24 from 7:10 AM to 3:34 PM. -5/18/24 from 7:22 AM to 6:18 PM. -5/21/24 from 7:11 AM to 3:50 PM. -5/23/24 from 7:32 AM to 6:42 PM. -5/24/24 from 7:10 AM to 3:31 PM. -5/27/24 8:02 AM to 10:15 AM. Employee #8 worked in the facility for 23 days and the facility did not have documentation that a Nurse Aide Registry Verification report had been conducted prior to the date the employee started working at the facility. Review of the undated Dietary Aide Job Description/ Competency/ Evaluation (Annual and Probationary) form documented: Personnel Functions: Report all complaints and grievances made by residents. Specific job functions: -Assist in serving meals as necessary and on a timely basis. -Deliver food carts, trays from carts, trays, etc., and take to dishwashing area. -Prepare and deliver snacks, etc., as instructed. Safety: -Uses appropriate lifting devices to ensure resident and staff safety. Customer Service and Resident Rights: -Interact/ communicate with residents, staff, and visitors in a courteous manner. -Keeps all resident and employee information confidential. -Reports actions detrimental to resident welfare to Manager or Supervisor on duty. Working Conditions: -Is involved with residents, personnel, visitors, government agencies/ personnel, etc., under all conditions and circumstances. -Is subject to hostile and emotionally upset residents, family members, personnel, and visitors. Specific Requirements: -Must possess the ability to deal tactfully with personnel, resident, family members, visitors, government agencies/ personnel, and the general public. -Must have patience, tact, and cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents. 1c. During an interview on 3/25/25 at 4:15 PM the Human Resources Generalist (Authorized Person for Criminal History Record Check) stated Employee #9 was hired to work at the facility as Dietary Aide on 8/21/24. During an interview on 3/27/25 at 10:39 AM the Food Service Director stated Dietary Aides delivered and picked up food carts and trays to the First, Second and Third floors/ units and restocked nourishments in the nourishment rooms on the First, Second, and Third floors/ units. During an interview on 3/27/25 at 12:36 PM the Human Resources Generalist stated they had spoken with the Directors of the facility's departments and the Administrator, and the Directors of the departments and the Administrator did not have any other documentation for any of the employee's Nurse Aide Registry Verification reports. Review of the employee file for Employee #9 revealed the employee was hired on 8/21/24 as a Dietary Aide and the file contained a Nurse Aide Registry Verification report for the employee that was dated 10/4/24. Review of timecard reports for Employee #9 revealed the employee worked in the facility on: -8/21/24 from 11:00 AM to 3:00 PM. -9/16/24 from 6:00 AM to 2:00 PM. -9/17/24 from 6:00 AM to 2:00 PM. -9/21/24 from 6:00 AM to 2:00 PM. -9/22/24 from 6:00 AM to 2:00 PM. -9/23/24 from 6:00 AM to 2:18 PM. -9/24/24 from 6:00 AM to 2:00 PM. Employee #9 worked in the facility for seven days prior to the facility conducting a Nurse Aide Registry Verification report for the employee. 10 NYCRR 415.4(b)

Based on observation, interview, and record review conducted during an Abbreviated survey (#NY 918), completed on [DATE], the facility failed to have an environment free of accident hazards and adequate supervision for one (Resident #1) of three residents reviewed. Specifically, on [DATE] at 9:17 AM Resident #1 identified as moderately cognitively impaired, requiring supervision and a rolling walker for ambulation was found by staff, outside the building in the courtyard-directly below resident room #306, lying face down on the ground deceased . Resident #1 was last seen on [DATE] at 6:00 PM in the dining room by Licensed Practical Nurse (LPN) #1. Through interview Certified Nurse Aide (CNA) #1 stated that after passing meal trays, the CNA#1 realized the unit was cold, and identified the window in resident room #306 was open. The CNA #1 stated the window was opened wider than normal and closed the window and did not report it to anybody. An interview with Director of Nursing (DON) stated that after looking at the facility's security cameras, with the Administrator, they did not observe the resident go out the exit doors. After interviewing the staff, the presumption is that the resident went through the open window in room #306 and fell to the ground. In [DATE], the resident reported suicidal ideation to their daughter and a wander guard was placed and 15-minute checks were initiated. Continued noncompliance was observed by Nursing Home Surveillance Staff on [DATE], at 10:20 AM when a window in resident room #316 was propped open with a tissue box, did not have an appropriate stop and could be fully opened approximately 2 feet. At 1:48 PM, surveillance staff it was further observed that windows in resident rooms #215 and #218 did not have appropriate window stops installed and could be fully opened. This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to Resident #1 with the likelihood of harm and immediate risk to the health and safety of 4 residents with wandering behaviors. The findings are: The facility policy and procedure (P&P) titled Prevention of Elopement and Wandering Protocol dated [DATE] documented the facility will maximize safe resident ambulation for those with the potential for exiting the facility unassisted or undetected, will implement safety measures in at least restrictive environment to ensure the safety of all wandering residents, and will utilize and maintain electronic safety devices to assist staff in monitoring residents who exhibit wandering/exit seeking behaviors. Indicators of wandering or elopement behavior include the history of or new onset of entering other resident's rooms, history of wandering or elopement, and mobile residents who have difficulty with way finding. 1. Resident #1 had diagnoses including major depressive disorder, anxiety disorder, [CONDITION(S)], and history of suicidal ideation. The Minimum Data Set (MDS-resident assessment tool) dated [DATE] documented Resident #1 was moderately cognitively impaired, sometimes understood and understands. Resident #1 required supervision and a rolling walker for ambulation. Review of the Care plan Report dated [DATE] documented Resident #1 had a history of wandering on the unit and was deficient in mobility with a tendency to forget the roller walker. Initial interventions included 15-minute checks and initiate the wander guard system. The wander guard system was discontinued on [DATE]. There was no date of when the 15-minute checks were discontinued. Review of the Closet Care Plan updated [DATE] documented Resident #1 walked with supervision, and a roller walker to all facility destinations, and had a tendency to forget their walker. Review of the hospital History and Physical dated [DATE] documented Resident #1 had previous history of suicidal attempt. Review of the Progress Note dated [DATE] at 9:54 AM by LPN #4 documented after Resident #1 talked to their daughter on the phone. The daughter spoke to LPN #4 and was concerned about Resident #1's safety as Resident #1 stated they wanted to kill themself. The nurse spoke with Resident #1 and denied that they wanted to harm themselves. The Supervisor was notified, and 15-minute checks were initiated to ensure the residents safety. There was no documented evidence medical providers were notified of Resident #1's comments made to their daughter regarding wanting to harm themself or that a psychiatric evaluation was requested. Review of the MD progress Notes dated [DATE] through [DATE] revealed there was no documented evidence that the MD was notified of safety concerns regarding Resident #1's comments made to their daughter regarding wanting to harm themselves. Additionally, there was no documented evidence that a psychiatric evaluation was recommended or ordered. Review of the Safety/Visual Observation Checks documented Resident #1 was on 30-minute checks from [DATE] through [DATE] for wandering off the unit. 15-minute checks from [DATE] through [DATE] for telling their daughter they want to kill themselves/suicidal ideations. Review of the Progress Note by the DON dated [DATE] at 3:45 PM documented writer notified at approximately 9:17 AM Resident #1 was unable to be located on the unit (3rd Floor). The resident was located outside in the courtyard on the west side of the building. A Registered Nurse (RN) assessment was unable to be accurately completed, the resident had multiple scratches on their lower extremities, knees and left lateral leg, discolored area. Resident #1's face on the right side was discolored. Unable to obtain a pulse. 911 was called, several attempts were made to call the daughter. Medical Doctor (MD) updated that resident was without respirations and without a pulse. Resident expired. Review of the Occurrence Report by the DON dated [DATE] at 9:17 AM documented Resident #1 was observed on the ground in the prone position (face down) on the right side of their face outside in the courtyard on the west side of the building beneath the window. Visual assessment completed. Pooled blood was noted near the head of the resident and scratches were noted to the back of Resident #1's left leg. Resident was deceased . Medical and family were notified. Per the National Weather Service outside temperatures in the area on [DATE] -[DATE] was ,d+[DATE] degrees Fahrenheit. Review of facility staff written (CNAs #1, #3, #4, LPN #2 and RN #1, #2) statements that worked on Resident #1's unit between the evening shift (2:00 PM-10:00 PM/3:00 PM-11:00 PM) on [DATE] and the night shift (10:00 PM-6:00 AM/11PM-7AM) on [DATE] provided by the facility documented they all had not seen Resident #1 on their entire shifts. During an observation and interview on [DATE] at 9:50 AM, the Administrator showed the surveyor the location outside where Resident #1 was found. The Administrator stated Resident #1 was found on the ground between the building and the [NAME] row of bushes. The surveyor observed the building directly above where Resident #1 was found. There were three windows which were identified by the Administrator as resident rooms #106, 206 and 306. During an interview on [DATE] at 11:15 AM, the Director of Maintenance stated maintenance staff had checked all the doors and windows yesterday [DATE] after they found Resident #1 outside. The Director of Maintenance stated that in resident room #306, the bolt that prevented the window from opening more than 6 inches was not in the proper placement and was found lying on the windowsill screwed back together. The Director of Maintenance stated they (the facility) thought this was the window Resident #1 fell out of. Review of the video footage from [DATE] to [DATE] with the Administrator present, Resident #1 was last seen on video at 5:29 PM walking down the West Unit hallway on the third floor towards room #306. The video view was limited and only showed Resident #1 walk past the first three doors on the left as the camera was not angled down the entire hallway. During an interview at the time of the video viewing on [DATE] at 11:00 AM the Administrator stated, they had watched the entire video several times and Resident #1 was not seen to walk back towards the camera/nurses' station between 5:29 PM on [DATE] to 9:00 AM on [DATE] when the facility missing resident protocol was initiated. During an interview on [DATE] at 12:15 AM, the DON stated, I haven't really come to a conclusion yet. I looked at the cameras with the Administrator and I did not see Resident #1 go out any of the doors. After interviewing the staff, the presumption would be Resident #1 got out of the window in room #306. During a telephone interview on [DATE] at 1:50 PM, CNA #1 stated they were working on the 3rd Floor West hallway on [DATE] during the evening shift. After helping pass the dinner trays on the 3rd Floor East Side, CNA #1 went back to check on the West Side and noticed the hallway was cold. CNA #1 thought that the window at the end of the hallway was open, as on other occasions they have found it open. When CNA #1 got to the window it was shut, but still felt a breeze. CNA #1 stated they looked to the left and saw the window in room #306 was open. CNA #1 stated the window was opened wider than normal but could not state exactly how far it was opened. CNA #1 stated they glanced out the window, didn't see anything and then shut the window. CNA #1 stated that Resident #4 who resided in room #306 was not in there when they closed the window. CNA #1 further stated they did not say anything to anyone about the window being open. During an interview on [DATE] at 3:10 PM, LPN #1 stated on [DATE] they last saw Resident #1 sitting in the corner in the dining room at approximately 6:00 PM wearing a hospital gown as though they were going to bed after dinner. During an interview on [DATE] at 3:25 PM, CNA #2 (assigned to Resident #1) stated on [DATE] they had left Resident #1's dinner tray in their room on the East Unit and picked the tray up later which had been uneaten. Resident #1 was not observed in their room at that time. CNA #2 stated they did report to LPN #1 that the resident's dinner meal was uneaten. During interviews on [DATE] and [DATE] between 10:30 AM and 8:00 PM facility staff (CNA #1, #3, #4, #5, LPN #2 and RN #1, #2) that worked between the evening shift (2:00 PM-10:00 PM/3:00 PM-11:00 PM) on [DATE] and the night shift (10:00 PM-6:00 AM/11PM-7AM) on [DATE] all stated that they had not seen Resident #1. LPN #1 stated they last saw Resident #1 at 6:00 PM in the dining room. CNA # 2 last saw Resident #1 at 4:30 PM, the resident was coming off the elevator from smoking. During an interview on [DATE] at 7:02 PM, the Regional Director of Nursing stated the facility did not have a policy regarding daily visual checks on residents. I would think they should be doing this as it is a standard of practice across the board, checking the residents when coming on shift and throughout the shift. 2. Review of attestation signed and dated [DATE] by the Administrator documented that they had the building services staff conduct a full window audit to ensure all latches and locks were in place at approximately 10:30 on [DATE]. Findings resulted in all other windows to be secured. Review of the resident Wander Guard list dated [DATE] provided by the Administrator documented residents in room #314P (private), #315E (bed 1), #316W (window), and #319W were all considered at risk for wandering and utilized wander guard bracelets. During an observation on the 3rd Floor East Unit [DATE] at 10:20 AM, the window in resident room #316 was propped open with a tissue box. The window was able to be fully opened, at least 2 feet and had no appropriate safety stops. During an observation and interview on [DATE] at 1:38 PM with Director of Maintenance and the facility Administrator, the Director of Maintenance stated they did not check the windows on [DATE] and that maintenance staff (Maintenance Worker #1 and #2) completed the checks. The surveyor, Director of Maintenance and the Administrator went to resident room #316. The window was still propped open with a tissue box. The Maintenance Director and the Administrator assessed the window, the Director of Maintenance stated the window could be fully opened (slides up and down) because it can be wiggled past the screw to open it. The Administrator stated that the window was damaged. During an observation on the 2nd Floor East Unit on [DATE] between 1:48 PM and 1:51 PM the windows in resident rooms #215 and #218 did not have window stops and could be fully opened at least 2 feet. During an observation and interview on [DATE] at at 2:36 PM, Maintenance Worker #1 checked the window in resident room #215 and stated that the window had no screen and opened a good 2 feet wide. Maintenance Worker #1 stated when they put the screw in the left side of the window frame, they missed the hole that would have locked the window down. During an interview on [DATE] at 2:39 PM, Maintenance Worker #1 stated resident room #218's window was checked yesterday ([DATE]). During an observation at the time of the interview Maintenance Worker #1 rechecked the window in room #218, the right side of the window had a bolt in place and was only able to open 6 inches. The left side of the window fully opened to approximately 2 feet wide. At that time the Maintenance Worker #1 stated they didn't know the left side of the window even opened. During an interview on [DATE] at 6:35 PM, the Administrator stated not all the doors to the outside on the first floor and basement have cameras. The only doors with cameras were the front door, the door by the elevators, and the door back by the kitchen. However, all the doors on the first floor and in basement are armed with the wander guard system, need a code to open and will sound an alarm without the code. During an interview on [DATE] at 3:38 PM, the Administrator stated the facility does not have a specific facility policy and procedure regarding the checking of doors and windows. 415.12(h)(1)(2)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint # NY 166) completed on 1/13/21, the facility did not ensure the resident's right to be free from abuse for one (Resident #1) of three residents reviewed for physical abuse. Specifically, the residents' plan of care guide documented Resident #1 required total assistance of two staff for toileting and activities of daily living (ADL - personal hygiene, bathing, grooming). Certified Nursing Assistant (CNA) #1 did not implement the care plan and provided incontinent care independently. Immediately after CNA #1 provided incontinent care, Resident #1 was found bleeding from the mouth with a laceration to the lower lip, a missing lower tooth, a bruise under the chin, and a swollen, tender nose. Resident #1 was sent to the hospital for evaluation and treatment and returned to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm that is not immediate jeopardy. The finding is: Review of the facility P&P titled Prevention/ Prohibition of Abuse, Neglect, Mistreatment, Exploitation, Injury of Unknown Sources and Misappropriation of Property revision dated 11/01/2019 documented the following: - Our residents have the right to be free from abuse. - Abuse: willful infliction of injury, unreasonable confinement, intimidation of punishment with resulting physical harm or pain or mental anguish or deprivation of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This includes resident to resident, staff to resident, family/visitor to resident that is likely to cause harm or causes harm. - Physical Abuse: hitting, slapping, pinching, kicking, shoving, bumping, and sexual molestation etc. It also includes controlling behavior through corporal punishment. This includes staff to resident, family/ visitor to resident and resident to resident in an aggressive act including inappropriate physical contact that causes harm or likely to cause harm. - Reasonable Cause: means that upon a review of the circumstances, there is sufficient evidence for a person to believe that physical abuse, mistreatment, or neglect has occurred. Circumstances that may lead to a reasonable cause conclusion may include but are not limited to a statement that physical abuse, mistreatment or neglect has occurred. The presence of a physical condition (such as a bruise) that is inconsistent with the resident history of course of treatment. - All employees shall be trained in this abuse prohibition policy and procedure during new employee orientation and annually thereafter. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 12/16/20 documented Resident #1 had severe cognitive impairment. The MDS documented physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), and verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others), occurred daily during the assessment period. Additionally, the MDS documented the rejection of care daily, and total assistance of two staff members for bed mobility, toileting, and personal hygiene. Review of an untitled facility document dated 12/22/20, identified by the facility as the CNA care guide (used by staff to provide care) summary of level assistance for specific resident), revealed Resident #1 required total assistance of 2 staff members for toileting and ADL's. The facility Incident/ Accident Report dated 12/28/20 completed by the Assistant Director of Nursing (ADON) documented the following: - ADON was notified at 5:30 AM of serious injuries of unknown origin for Resident # 1 and found resident in room with multiple injuries on face. - Bruise under chin approximately 2cm (centimeter) x (by) 2cm. - Nose was swollen and tender to touch. - 0.5cm x 0.5cm opening in bottom lip. - Missing tooth. - Attending Physician ordered Resident #1 be sent to the hospital for evaluation. Review of a handwritten statement signed, and dated December 28, 2020 by CNA #1 documented the following: - Incident happened at approximately 5:30 AM. CNA #1 went into Resident #1's room to provide incontinent care. CNA #1 provided care without assistance as Licensed Practical Nurse (LPN) #1 was assisting other residents. Resident #1 was combative during the care, swinging punches at CNA #1. CNA #1 restrained Resident #1's fists against Resident #1's chest. Resident #1 swung again when CNA #1 released the resident's fists. The momentum from releasing the fist caused Resident #1 to strike themselves. When Resident #1 stopped hitting themself, CNA #1 forcibly turned Resident #1 onto their left side to complete incontinent care. CNA #1 then noticed Resident #1 was bleeding and reported the bleeding to the ADON and LPN #1. - The facility investigation concluded that there was cause to believe resident abuse, mistreatment or neglect/injury of unknown origin regarding Resident #1 had occurred. The hospital ED (emergency department) Provider Report dated 12/28/20 documented the following: - Procedures: Laceration repair (sutures) with conscious sedation (drug induced depression of consciousness). - Lab/ Imaging Results: Bilateral acute nasal fractures. Fracture of left condylar process of mandible (jaw). During a telephone interview on 1/13/21 at 9:40 AM, CNA #1 stated LPN #1 was assisting other residents when CNA #1 went into Resident #1's room to provide incontinent care. CNA #1 stated Resident #1 required 2-person assist with hands on care secondary to Resident #1's history of verbal and physically aggressive behaviors. CNA #1 stated Resident #1 was yelling out and attempted to punch the CNA. CNA #1 stated he restrained Resident #1's arm by holding the resident's fist against the resident's chest. When CNA #1 released Resident #1's fist, the momentum from releasing the fist caused Resident #1 to strike themself. CNA #1 then turned the resident onto their left side to complete incontinent care, noticed the resident was bleeding from their mouth, and reported the bleeding to the ADON and LPN #1. During an interview on 1/11/21 at 5:56 AM, LPN #1 stated Resident #1 required the assistance of 2 staff with all ADL's. LPN #1 stated he, CNA #1, and the ADON were on the unit at the time of the incident. LPN #1 offered to assist with the care of Resident #1 if needed. LPN #1 stated CNA #1 did not request assistance with Resident #1. During an interview on 1/11/21 at 10:24 AM, the ADON stated she and LPN #1 were providing care to other residents on the unit at the time of the incident and CNA #1 did not request assistance with Resident #1. During an interview on 1/12/21 at 9:51 AM, the Director of Nursing (DON) stated Resident #1 required the assistance of 2 staff members with all ADL's secondary to the resident's history of combative behaviors, and it was expected that all staff follow the care plan for both the resident and staff safety. In addition, the DON stated CNA #1 had caused harm to Resident #1. During an interview on 1/12/21 at 10:30 AM, the Administrator stated CNA #1 caused harm to Resident #1 by taking Resident #1's own hand to hit themself in the face causing multiple injuries. During an interview on 1/12/21 at 10:40 AM, Resident #1's Attending Physician who is also the facility Medical Director, stated Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 415.4(b)(l)(i)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 763) completed on 9/15/16, the facility did not ensure that each resident receives the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. One (Resident #1) of three residents reviewed for quality of care had issues. Specifically, the resident with a history of [MEDICAL CONDITION] ([MEDICAL CONDITION]-blood clots in the veins) did not receive the Physician ordered [MEDICATION NAME] ([MEDICATION NAME] - anticoagulant medication used to prevent blood from clotting) upon admission on 4/22/16. On 4/24/16 at approximately 9:00 PM the resident's right foot was noted to be cool to touch with ecchymosis (purplish patch caused by blood under the skin) and mild throbbing; the Physician ordered an arterial Doppler (a diagnostic test to evaluate blood circulation) that was not done until the morning of 4/25/16. During this time there was a lack of ongoing monitoring and assessment of the resident's right foot from 4/24/16 at 9:00 PM through 4/25/16 at 8:00 AM when the resident's right foot was noted to be blue/black, with no detectable pulse and cold to the touch. On 4/25/15 the resident was sent to the hospital with a [DIAGNOSES REDACTED]. This resulted in actual harm that is not immediate jeopardy. The findings is: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary dated 4/22/16 revealed the resident has a history of Factor V Leiden Deficiency (a genetic disorder of blood clotting that causes an increase in clotting with a tendency to form dangerous, abnormal blood clots). The medications ordered upon discharge included [MEDICATION NAME] 2.5 milligrams (mg) every Monday and Friday and [MEDICATION NAME] 5 mg every Sunday, Tuesday, Wednesday, Thursday and Saturday. The INR (International normalizing ratio-standardized normalized blood coagulating values) dated 4/22/16 revealed results of 2.02 (range 2-3). Review of the hospital Medication Profile for Last Administered Dose (of medication) revealed that the last dose of [MEDICATION NAME] 4 mg administered in the hospital was on 4/21/16 at 8:20 PM. Review of the admission Physician order [REDACTED]. In addition, PT([MEDICATION NAME] time/partial [MEDICAL CONDITION] time-blood clotting studies) /INR laboratory (lab) work was ordered however there were no dates specified. Review of the facility Medication Administration Record [REDACTED]. The 23, and 24th doses of [MEDICATION NAME] were initialed as given. Review of the Admission Nursing assessment dated [DATE] at 5:00 PM revealed 1+ [MEDICAL CONDITION] (swelling caused by excess fluid accumulation) bilateral lower extremities. Skin intact. Review of the facility History and Physical (H&P) examination completed by the Physician dated 4/24/16 revealed the resident had 2 + non-[MEDICAL CONDITION] of the lower extremities. The plan for the [MEDICAL CONDITION] included [MEDICATION NAME] and [MEDICATION NAME] (diuretic-medications that promotes excretion of urine). The H&P exam also noted the resident has Leiden Factor V for which [MEDICATION NAME] is ordered. Review of a Nursing Progress Note dated 4/24/16 at 5:00 PM written by the Licensed Practical Nurse (LPN) #1 documented that the resident's right foot was noted to be ecchymotic and cool to touch from toes to the ankle with a faint distal pulse. The patient complained of mild throbbing 2 on a pain scale (out of 10). The note documented that the Physician was notified with a new order. Review of a physician's orders [REDACTED].#1 revealed an order for [REDACTED]. Review of Nursing Progress Notes dated 4/25/16 revealed the following; - 11-7 written by LPN #2 revealed the resident complained of pain and was medicated one time with a positive effect. The right foot is cyanotic and cool to the touch. -11 PM - 7 AM written by the Registered Nurse (RN) Supervisor revealed the resident was resting quietly on 11-7, right foot remains cyanotic and cool to the touch. The resident was expressing no pain or discomfort. -8:00 AM written by the Unit Manager-Rehab (RN #1) revealed the right foot was noted to be blue/black with no detectable pulse, cold to touch. The resident was scheduled for an arterial Doppler this AM. The Physician was notified and we will prepare to send the resident out to the ER (emergency room ) for evaluation. The resident complained of pain 6/10 and was medicated per order with effects pending. The resident was sent to the ER via ambulance at 8:40 AM. There was a lack of ongoing monitoring and assessment of the resident's right foot between 4/24/16 at 9:00 PM through 4/25/16 at 8:00 AM when the resident's right foot was noted to be blue/black, with no detectable pulse and cold to the touch. Review of the Resident Transfer Form dated 4/25/16 completed by RN #3 revealed that yesterday eve the nurse reported the right foot was ecchymotic, [MEDICAL CONDITION] and cold. An arterial Doppler was ordered. There was no pedal pulse via palpation. The resident complained of pain to the area and was medicated with 15 mg of [MEDICATION NAME](narcotic pain medication). The resident's finger stick blood sugar before breakfast was 46 (normal 60-120) at 7:15 AM and was up to 137 with OJ (orange juice) -all insulin products were held. Review of the Arterial Doppler of the Lower Extremities results dated 4/25/16 revealed In a limited exam based on wave form analysis there is moderate to severe decrease in perfusion at the ankle level as well as to the great toe right and left secondary to multiple level occlusive disease. Review of a Physician note dated 4/25/16 regarding 4/24/16 revealed that he received a call from the staff nurse at 9:00 PM stating that the patient had a bluish discoloration of her feet and resident had pulses bilaterally. There was no unusual severe pain associated with this. Arterial Dopplers were requested however were not able to be done until early this morning at which time the color of the foot had become a lot deeper and the pulse was not readily palpable by the Unit Coordinator. The note revealed that the Physician requested the resident be sent to the hospital immediately for further evaluation and management. Review of the ED (Emergency Department) RN note dated 4/25/16 at approximately 9:35 AM revealed the resident presented from the nursing home with right foot swollen, eccymotic with toes black, cool to touch no palpable pedal pulse unable to hear pedal pulse with Doppler. PT results 4.14 Review of the ED MD (medical doctor) note dated 4/25/16 at approximately 9:48 AM revealed that the patient presented with right foot pain and discoloration. The onset was 12 hours ago. The right foot is cold and blue. The resident stated that yesterday she had some pain in the foot. She alerted individuals at the nursing home but there was no action taken at that time. The Impression is arterial occlusion, cyanosis, foot pain and swelling. After speaking with the vascular surgeon at another hospital the plan was for the resident to be immediately transferred to the other ED for further evaluation and treatment. Review of the hospital Operative Note dated 4/28/16 revealed that the resident presented with a non-viable ischemic (condition of restricted blood to an area) limb several days ago. After reversal of coagulopathy (a condition in which the blood's ability to clot is impaired) and medical optimization a right above the knee amputation was performed on 4/28/16. During a telephone interview on 8/23/16 at approximately 2:00 PM the11:00 PM - 7:00 AM RN Supervisor stated that on 4/25/16 he checked on the resident between 12:30 AM and 1:00 AM. He stated that the resident's right foot was cyanotic and cool to the touch. The resident denied pain or discomfort at the time. He stated that he does not remember if he assessed the resident's pedal pulse at that time. The RN Supervisor stated that he checked on the resident between 3:30 AM - 4:00 AM and does not remember if he assessed the resident's foot at that time but stated that the resident had no pain. During an interview on 8/23/16 at approximately 11:00 AM, RN #1 stated that she worked on 4/25/16 from 7:00 AM to 3:00 PM. She stated that she does not recall the details of the report given to her by the night shift staff regarding the resident. RN #1 stated that she does not recall details of the resident's condition other than what is documented in her 4/25/16 note. She stated that she notified the Physician of the condition of the resident's right foot and he ordered the resident be sent to the hospital. During interview on 8/23/16 at approximately 3:00 PM, the Director of Nursing (DON) stated that the medication [MEDICATION NAME] is available in the facility's Emergency Medication Kit. The DON stated that she would expect the nurse to utilize the emergency kit for the medication if it had not yet been delivered by pharmacy or to call the Physician for further instructions. During a telephone interview on 9/13/16 at approximately 1:15 PM the Physician stated that he assessed the resident early on 4/24/16 and the resident had 2+ non-[MEDICAL CONDITION]. He stated that he believes he felt a pedal pulse however it is sometimes difficult to feel a pulse when there is [MEDICAL CONDITION]. The Physician stated that he was informed by a staff nurse on 4/24/16 in the evening of the condition of the resident's right foot. He did not feel it was an urgent situation at that point because he was informed that the resident had a pulse. He ordered an arterial Doppler study that was supposed to be done as soon as possible however the ultrasound company did not send a technician until the next morning. The Physician stated that he informed the nurse that the resident required frequent monitoring of the right foot. The Physician stated that he would consider sending the resident to the hospital if the following symptoms were present: increased pain in the foot, the foot was pale or deep blue in color, or if the foot was cold. The Physician stated that he was not informed of the condition of the resident's foot the second time until 4/25/16 at approximately 7:00 AM when the right foot had deteriorated. The Physician stated that it would have been better if the staff had notified him of the condition of the resident's foot earlier during the night shift and that he is available all night. In summary, there was a lack of ongoing monitoring and assessment of the condition of the resident's right foot from 4/24/16 at approximately 9:00 PM through 4/25/16 at approximately 8:00 AM. The resident's right foot had deteriorated resulting in an arterial occlusion and an above the knee amputation of the right leg. 415.12

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 814) completed on 9/15/16, the facility did not ensure that residents are free from significant medication errors. One (Resident #2) of three residents reviewed for medication errors had issues involving an oral diabetic medication (lowers blood sugar levels) given after the medication was discontinued on 6/3/16 and was administered to the resident in error from 7/1/16 through 7/31/16 (except for 7/3, 7/6 and 7/10/16) and 8/1/16 through 8/21/16. The resident had hypoglycemic (low blood sugar) episodes on 8/21, 8/22 and 8/23/16 and required hospital treatment for [REDACTED]. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #2 with [DIAGNOSES REDACTED]. Review of the hospital Discharge Medication List dated 6/3/16 revealed orders to discontinue Glimepiride ([MEDICATION NAME]) (diabetic medication used to lower blood sugar) 2 milligram (mg) tablet once daily. Review of the Medication Administration Record (MAR) for June 2016 revealed Glimepiride 2 mg once daily at 9:00 AM was discontinued on 6/3/16. Review of Monthly Physician order [REDACTED].#2 dated 6/7/16 revealed an order Glimepiride 2 mg tablet once a day at 9:00 AM. Review of a Resident Transfer Summary dated 6/28/16 written by RN #2 revealed the resident was sent to the hospital for a change in his level of consciousness. Review of a hospital Discharge Summary dated 6/30/16 revealed the resident was admitted on [DATE] and discharged back to the facility on [DATE] after treatment for [REDACTED]. Review of the hospital Discharge Medication List dated 6/30/16 revealed orders for [MEDICATION NAME] (iron supplement) 325 mg 1 by mouth twice a day. The discharge orders did not include Glimepiride. Review of the Physician order [REDACTED].#2 on 6/30/16 revealed orders for [MEDICATION NAME] (supplemental protein) 1 packet in 6 ounces (oz) of water BID (twice a day), [MEDICATION NAME] 325 mg 1 by mouth BID (administration times are not designated on the orders). The orders also included Rainbow Coverage (dose of insulin therapybased on blood glucose results) at 7:30 AM, 11:30 AM, 4:30 PM and 8:30 PM. The orders did not include the medication Glimepiride. Further review of the MAR for July 2016 included (in error) to administer Glimepiride 2 mg by mouth was initialed as given at 2:00 PM every day in July except on 7/3, 7/6 and 7/10/16. The MAR that was printed from the Pharmacy indicated the administration time for the medication as 9:00 AM. The time of 9:00 AM was crossed out on the MAR and handwritten in as 2:00 PM. Further review of the MAR for July 2016 revealed Rainbow Coverage was administered 70 out of approximately 124 opportunities with blood glucose results that ranged from 80-400. In addition to the transcription error, per the Nursing 2015 Drug Handbook administration instructions revealed take Glimepiride by mouth with the first meal of the day. Review of the Physician order [REDACTED].#2 on 8/2/16, revealed orders including [MEDICATION NAME] 325 mg 1 by mouth BID at 9:00 AM and 5:00 PM, sliding scale insulin coverage at 7:30 AM, 11:30 AM. 4:30 PM and 8:30 PM; and orders for Glimiperide 2 mg every day at 2:00 PM (the Glimepiride order was handwritten on the orders, not printed by the pharmacy). Review of the MAR for August 2016 revealed Glimepiride 2 mg was initialed as administered every day at 2:00 PM from 8/1 through 8/21/16. In addition, the MAR revealed that [MEDICATION NAME] 1 packet and [MEDICATION NAME] 325 mg tablet were initialed as administered every day at 2:00 PM and 5:00 PM (three hours apart). Further review of the MAR for August 2016 from 8/1 through 8/23/16 revealed that Rainbow Coverage insulin was administered 47 out of approximately 92 opportunities with blood glucose results that ranged from 40-396. Review of a Nursing Progress Note dated 8/21/16 at 6:00 PM written by LPN #3 revealed the Physician ordered to give the resident [MEDICATION NAME] (injection to elevate blood sugar) 1 mg now due to accu-check (fingerstick-sample of blood to determine glucose level) of 47 (normal 60-120.)The note documents that the resident was alert and confused and numerous attempts to offer liquids and solids were spit out continuously. The injection was given and the accu-check result increased to 205. No further signs and symptoms were noted. The accu-check at 9:30 PM was 146. Review of a Physician Telephone Order by Physician #1 dated 8/21/16 at 6:00 PM revealed an order to give [MEDICATION NAME] 1 mg now and to discontinue Glimepiride 2 mg by mouth every day. Review of the MAR for August 2016 revealed the Glimepiride was last given on 8/21/16 at 2:00 PM then discontinued the same day. Per the Nursing 2015 Drug Handbook Glimepiride's onset is 1 hour, it peaks in 2-3 hours with a duration of greater than 24 hours in the system. Review of a Nursing Progress Note dated 8/22/16 at 5:00 AM written by the LPN #3 revealed the resident was foaming at the mouth with an altered mental status, FS (fingerstick) was 56. [MEDICATION NAME] given, respirations were easy and the resident was responding slow. Review of a Nursing Progress Note dated 8/22/16 at 8:15 AM written by RN #2 revealed the resident was not responding per usual. FS was 46. Physician was updated on the resident's condition with a new order to send the resident to the ER (emergency room ) for evaluation. At 3:00 PM the resident returned from the ER with no recommendations. The resident was alert and responding, the skin was warm and dry. Review of a Nursing Progress Note dated 8/22/16 at 8:00 PM written by LPN #4 revealed the resident was very confused, yelling out and not making sense. FS was 43. The resident would not drink and kept foaming at the mouth and then snoring completely asleep. 1 ml (milliliter) [MEDICATION NAME] pen given, 10 minutes later FS was 68 and after another 10 minutes FS was 84, the resident was able to speak and became alert. Review of a Nursing Progress Note dated 8/23/16 at 5:10 AM and 5:20 AM written by LPN #5 revealed the resident had FS of 40, 70 and 84. Physician was notified and the resident was sent to the hospital for evaluation. Review of a Nursing Progress Note dated 8/23/16 at 11:00 PM written by LPN #3 revealed the resident returned from the hospital with a [DIAGNOSES REDACTED]. During an interview on 8/30/16 at approximately 11:30 AM, RN #2 stated that she was not aware of any medication errors regarding the resident's Glimepiride. RN #2 stated that the resident had been on the medication a long time but she would look into it. During a follow up telephone interview on 9/14/16 at approximately 10:30 AM, RN #2 stated that she did not change the administration times of Glimepiride to 2:00 PM and did not know why it was changed. In addition, RN #2 did not change the administration times of the [MEDICATION NAME] packet or the [MEDICATION NAME] tablets to 2:00 PM and 5:00 PM and did not know why it they were changed. During an interview on 8/30/16 at approximately 2:00 PM, the Director of Nursing (DON) stated that the day shift nurses split up the MARs to review them but the night shift nurses are ultimately responsible to check the MARs against the Physician orders [REDACTED]. The DON stated that there is no written facility policy for the nightly medication checks. During an interview on 8/30/16 at approximately 2:45 PM, Physician #1 stated that after speaking to the nurse on 8/21/16 she learned that the resident was on Glimepiride and Physician #1 discontinued it. Physician #1 stated that the resident was not supposed to receive Glimepiride at all during the months of July or August. She stated that the resident was only supposed to be on Rainbow Coverage since the resident was a labile diabetic and did not need the Glimepiride. During a telephone interview on 9/13/16 at 2:30 PM, LPN #6 stated that the 11:00 PM - 7:00 AM shift nurses do the medication checks each night and check the MARs against any new Physician orders [REDACTED]. The night nurse initials the MAR under 11-7 med check QD (everyday) to show that the medication check was done. LPN #6 also stated that at the end of each month the night shift nurse checks the newly printed MARs sent from pharmacy against the Physician orders [REDACTED]. LPN #6 was not aware of any medication discrepancies related to the resident's Glimepiride. Review of the MARs for July and August 2016 revealed the11-7 med checks are initialed as done every night for both months. In summary, the resident received the medication Glimepiride in error from 7/1/16 - 7/31/16 (except for 7/3, 7/6 and 7/10/16) and 8/1/16 through 8/21/16. The resident had hypoglycemic episodes on 8/21, 8/22 and 8/23/16. 415.12 (m)(2)

Based on record review and staff interview, the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly. One (Resident #123) of three residents reviewed for a significant change in condition resulting in hospitalization had an issue involving the lack of timely physician notification of a resident's low blood pressures and continued bleeding with blood clots. Resident #123 had abnormal blood coagulation (complex process by which blood forms clots) levels with low blood pressures and bleeding for 3 shifts. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #123 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is moderately impaired in daily decision making and received anticoagulant (medications to prevent blood from clotting) injections every day since admission. Review of the hospital Discharge Summary dated 3/1/11 revealed the resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. During the hospital stay, the resident received [MEDICATION NAME] (injectable anticoagulant therapy) 40 milligrams (mg) SQ (subcutaneous - injection beneath the skin) once a day and [MEDICATION NAME] (oral anticoagulant therapy) 3 mg once a day. The Discharge Summary documented that the daily dose of [MEDICATION NAME] was increased from 3 mg to 4 mg starting on 3/1/11 and "continued monitoring of PT ([MEDICATION NAME] time)/INR (international normalizing ratio) (PT/INR are blood tests to monitor the clotting time of blood) is necessary to maintain a therapeutic level between 2 to 3. Until that level is achieved, she (the resident) should continue to receive [MEDICATION NAME]". The Physician recommended the PT/INR be drawn in 2 days from discharge and "frequently thereafter". Review of a hospital laboratory report dated 3/1/11 revealed the PT level was 16.0 (normal 9.8 seconds to 14.0 seconds) and the INR was 1.4 (therapeutic range for oral anticoagulant therapy is 2.0 to 3.0 for [MEDICATION NAME] or treatment of [REDACTED]. Review of Admission Physician order [REDACTED]. - [MEDICATION NAME] 4 mg by mouth daily for [MEDICAL CONDITION] - [MEDICATION NAME] 40 mg SQ daily for [MEDICAL CONDITION] - [MEDICATION NAME] (blood pressure medication) 25 mg twice a day for hypertension - BP (blood pressure) every shift for 7 days, - PT/INR daily for 2 days, then 2 times per week, a CBC (complete blood count), CMP (comprehensive metabolic profile), and a TSH ([MEDICAL CONDITION] stimulating hormone - blood test to determine [MEDICAL CONDITION] function). Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The [MEDICATION NAME] was scheduled to be administered twice a day at 9:00 AM and 5:00 PM. Review of a History & Physical, signed by the Nurse Practitioner (NP), dated 3/1/11 revealed the resident's BP was 118/78 (normal) and heart rate was 70 (average 80). The NP documented a plan for PT/INR monitoring and [MEDICATION NAME]/[MEDICATION NAME] as scheduled. The NP documented that the resident was also on [MEDICATION NAME] 25 mg twice a day for hypertension and the BP was well controlled. Review of an untitled comprehensive care plan (CCP) dated 3/2/11 revealed the resident was identified at risk for bleeding/bruising due to anticoagulant therapy with a [DIAGNOSES REDACTED]. CCP approaches included obtaining "labs (laboratory tests) per MD (Medical Doctor) orders, MD to review, "monitor for s/s (signs and symptoms) of bleeding/bruising" such as bleeding gums, stools - observe for a change in color, visible blood, purpura (red or purple discolorations of the skin), emesis (vomiting) - blood; and update MD as needed. Review of laboratory reports dated 3/3/11 revealed results for the following blood tests that were obtained on 3/2/11: - PT - 20.4 - INR - 1.9 - Hemoglobin (Hgb - protein in red blood cells that carry oxygen) - 10.9 G/DL (normal 11.7 to 15.5) - Hematocrit (Hct - the proportion of total blood volume that is comprised of red blood cells) - 32.8 percent (normal 35.0 to 45.0) - BUN (blood urea nitrogen - blood test to determine kidney function and hydration status - 17 (normal 7 to 25 MG/DL) - Creatinine (blood test to determine kidney function) - 1.0 (normal 0.63 to 1.22 MG/DL) Review of the entire medical record revealed no documented evidence that a PT or INR was obtained on 3/3/11 and then twice a week as ordered by the Physician on 3/1/11. Review of a physician progress notes [REDACTED]. physician progress notes [REDACTED]. A Nursing Progress Note written by RN #4, on 3/21/11 at 3:00 PM documented that the resident had "bleeding from bottom" at 11:00 AM and the MD was notified, "no new order, monitor". At 12:40 PM, RN #4 documented there was a small amount of bleeding, an ABD (abdominal pad - thick absorbent dressing) was applied and the MD was notified. Review of an untimed Nursing Progress Note, written by the Registered Nurse (RN #2) Nursing Supervisor, dated 3/21/11 revealed "MD visit today" and Stools for OB (occult blood - blood in the feces that is not visibly apparent) x 3 ordered. Review of a Physician's Progress Note dated 3/21/11 revealed the resident was seen by the Physician for an "acute evaluation" because blood was observed in the toilet when the resident went to the bathroom. The Physician (MD #1 - Medical Doctor) documented that the resident's BP was 128/74, pulse was 68 and advised staff to continue the [MEDICATION NAME] 25 mg twice a day as prescribed. The Physician documented that the resident was examined but no bleeding was found. The Physician advised staff to obtain a urinanalysis because the resident had another episode of bleeding. The Physician also documented that the resident receives [MEDICATION NAME] 4 mg tablet once a day and [MEDICATION NAME] 40 mg once a day for [MEDICAL CONDITION] (prevention). The Physician did not document whether she was aware that the last PT/INR was obtained on 3/2/11 and there was no PT/INR done on 3/3/11 or twice a week from 3/4/11 through 3/21/11. Review of an untimed Physician's Telephone Order dated 3/21/11 revealed an order to obtain an INR in the AM and an INR every Monday and Thursday. Interview with MD #1 on 5/2/11 at 3:55 PM revealed she was notified by RN #1 on 3/21/11 that fresh blood was observed in the toilet after Resident #123 went to the bathroom. MD #1 stated that MD #2 performed a physical exam on the resident (on 3/21/11) and found no vaginal or rectal bleeding at that time. MD #1 stated she ordered stools for OB x 3 and to obtain an INR in the AM and an INR every Monday and Thursday. MD #1 stated that the order to obtain a PT/INR every day for 2 days then 2 times per week is a standard order for anyone on anticoagulant therapy and it should have been done. MD #1 stated she did not know that only one PT/INR had been obtained between 3/1/11 and when she saw the resident on 3/21/11. MD #1 stated that she does not look at residents' blood work because the nurses are to notify her of abnormal labs "as per the protocol". MD #1 stated that since she was not called, she assumed the labs were within normal limits. A Nursing Progress Note written by the RN (#1) Nursing Supervisor dated 3/21/11 at 6:30 PM, documented that the resident continued to have a small to moderate amount of blood when she had a BM (bowel movement) and that the stool for OB #1 was positive for blood. RN #1 documented that the resident was "on [MEDICATION NAME]. Stat PT/INR in AM and 2 x/weekly per policy. VSS (vital signs stable)". Review of the Resident Care Record for the 3:00 PM to 11:00 PM shift on 3/21/11 revealed the resident's BP was 90/56 at an unidentified time during the shift. Additional review of the 3/21/11 Nursing Progress Notes revealed there was no further nursing documentation for the 3:00 PM to 11:00 PM shift and no documented evidence that the resident's BP was rechecked. Review of a Nursing Progress Note, written by a Licensed Practical Nurse (LPN #5), dated 3/22/11 at 2:45 AM revealed there were "Bruises on the resident's right outer calf and ankle". A Nursing Progress Note written by LPN #4 at 5:45 AM documented that a CNA reported the resident was bleeding, the resident had a BP of 167/59 and the NP (Nurse Practitioner) was notified. (Interview with the Director of Nursing (DON) on 5/3/11 at approximately 10:00 AM revealed a Physician Assistant (PA #2) was on call on 3/22/11 at 5:45 AM, not the NP.) Review of a Physician's Telephone Order dated 3/22/11 at 5:45 AM revealed an order to "hold the [MEDICATION NAME] and [MEDICATION NAME] and report the PT/INR to the MD on call. Additional review of a Nursing Progress Notes dated 3/22/11 revealed the following: - At 8:00 AM, LPN #3 documented the resident had vaginal bleeding and that approximately 1/2 of a flat bed pan was full. LPN #3 documented that the resident had a B/P of 88/52 (low BP) and that [MEDICATION NAME], and [MEDICATION NAME] were held. - At 9:30 AM, LPN #3 documented that the resident passed a 6 inch (") blood clot. - At 11:00 AM, LPN #3 documented the resident had bleeding in her brief - "small amount at present, PT/INR drawn earlier; noted bruising at right calf, right ankle and top of foot, light in color". - At 2:00 PM, LPN #3 documented the resident had a moderate vaginal blood flow with a 6" plus blood clot. Review of a laboratory report dated 3/22/11 revealed the PT level reported to the facility at 1:48 PM was > (greater than) 169 and the INR was > 14.0 with a notation that the exact value could not be calculated due to the elevated PT > 169. Review of a Physician's Telephone Order dated 3/22/11 at 2:35 PM revealed an order for [REDACTED]. Additional review of Nursing Progress Notes and the 24 Hour Shift Report for the 7:00 AM to 3:00 PM shift on 3/22/11 revealed no documented evidence that the resident's BP was monitored following the BP of 88/52 at 9:00 AM. During an interview on 5/2/11 at 3:55 PM, MD #1 stated she was not on call on 3/22/11 and did not know that Resident #123 was still bleeding with large clots or that the resident's BP was very low. In addition, MD #1 stated she did not know about the elevated PT/INR nor did she give the order for the Vitamin K because if she had been called, she would have asked a lot more questions regarding the condition of the resident. MD #1 stated she signed the Vitamin K, order the next time she was in the facility, even though she did not give the Telephone Order. During an interview on 5/3/11 at 2:30 PM, Physician Assistant (PA #1) stated that she was not notified on 3/22/11 of the resident's condition or the blood work results because she would have remembered a PT of 169 or an INR >14 and would have asked a lot of questions. PA #1 stated she would have sent the resident to the hospital immediately for an evaluation with the issues that the resident presented. Review of a Nursing Progress Note, written by RN #3, dated 3/22/11 at 10:45 PM revealed "vaginal bleeding continued" with a 2" blood clot during the shift. RN #3 documented the B/P was 78/42 (low BP), "Bed rest, will continue to monitor. Held [MEDICATION NAME], BP too low". Review of the 3/11 MAR indicated [REDACTED]. Additional review of Nursing Progress Notes and the 24 Hour Shift Report for the 3:00 PM to 11:00 PM shift on 3/22/11 revealed no documented evidence that the resident's BP was monitored following the BP of 78/42 at 5:00 PM or that the Physician was notified of the low BP and continued bleeding. During an interview on 5/2/11 at 3:55 PM, MD #1 stated the nurse should have rechecked the resident's low BP every 15 minutes and if the second BP was not higher, the nurse should have called the on-call Physician. MD #1 stated if she had been notified of the resident's condition on 3/22/11, she would have sent the resident to the hospital immediately to be evaluated. MD #1 also stated the lack of obtaining the PT/INR as per the physician orders [REDACTED]. During an interview on 5/3/11 at 1:30 PM, MD #2 reviewed the medical information available regarding Resident #123's BP, bleeding, and PT/INR results and stated the resident should have been sent out 3/22/11 during the 7:00 AM to 3:00 PM shift. MD #2 stated "any licensed professional would have and should have sent this resident to the hospital immediately unless they are dumb". A Nursing Progress Note, written by LPN #5, dated 3/23/11 at 2:07 AM documented "vaginal bleeding continues, no clots noted at this time". Review of the Resident Care Record for the 11:00 PM to 7:00 AM shift from 3/22/11 to 3/23/11 revealed the resident's BP was 94/50. There were no additional BPs documented for the 11:00 PM to 7:00 AM shift and no evidence that the Physician was notified regarding the resident's condition. Review of a Nursing Progress Note, written by RN #4, dated 3/23/11 at 8:40 AM revealed the resident's BP was 108/60, there was a small amount of bleeding at the vagina and MD notified. The RN documented that the resident had rebound tenderness and a right abdominal mass. At 10:00 AM, RN #4 documented that the BP was 122/50, and that the resident refused breakfast and all medications. The RN also documented the resident was sent to the hospital at 10:10 AM. Review of an Acute Physician Visit Note dated 3/23/11 revealed MD #1 saw the resident due to "continued bleeding from 3/21/11". MD #1 documented that on 3/22/11 "it was then realized that she (the resident) was getting [MEDICATION NAME] and [MEDICATION NAME]. A PT/INR was obtained and was abnormal". The resident was given Vitamin K and the [MEDICATION NAME] and [MEDICATION NAME] were put on hold. On examination, the resident was noted to have continued bleeding. MD #1 documented a plan to transfer the resident to the hospital for an "acute problem evaluation". An untimed Nursing Progress Note, written by the Nursing Supervisor (RN #1) dated 3/23/11 documented that Resident #123 was admitted to the hospital at 1:00 PM and was in the ICU (Intensive Care Unit) with a [DIAGNOSES REDACTED]. Review of the hospital History and Physical dated 3/23/11 revealed the resident was noted in the emergency room "to have a marked drop in her hemoglobin" with a level of 4.2 (normal 12.0 to 16.0) and a CT Scan (computerized tomography - diagnostic medical imaging) of the abdomen showed a large hemorrhagic (massive, difficult to control bleeding) mass in the pelvis which is suspicious of a bleed. The Physician documented that the resident had gross hematuria (bloody urine). The Physician documented that the resident was admitted to the hospital with [REDACTED]. Review of hospital laboratory reports dated 3/23/11 revealed the following: - Hemaglobin - 4.2 - CL (critically low) - Hematocrit - 12.0 - CL - BUN - 53 - Creatinine - 5.6 - The urinalysis showed a large amount of blood Review of admission orders [REDACTED]. The Physician ordered [MEDICAL CONDITION] of 2 units of FFP (fresh frozen plasma - the fluid portion of blood that contains clotting a factors, used for patient's who are actively bleeding) and 4 units of PRBC (packed red blood cells). Review of a Transfusion Record dated 3/23/11 revealed the resident received a total of 4 units of packed red blood cells and 4 units of thawed plasma. Review of a facility policy and procedure entitled Change In a Resident's Condition or Status with a revision date of 7/27/10 revealed the nurse is to notify the resident's attending Physician when there is a change in the resident's physical, mental or psychosocial status or when deemed necessary or appropriate in the best interest of the resident. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. Interview with the Director of Nursing (DON) on 5/3/11 at approximately 10:00 AM revealed the nurse on duty on 3/21/11 for the 3:00 PM to 11:00 PM shift should have notified the Physician of the resident's low BP per the facility policy and procedure for Blood Pressure Monitoring. The DON stated the nurses should call the MD for "any systolic (the upper BP number, measures the pressure exerted by circulating blood on the blood vessels) less than 90 or diastolic (the lower BP number, measures the blood pressure when the heart is resting) less than 60, and the nurses are well aware of this". The DON stated the nurses should have called the MD immediately on 3/22/11 during the day shift to ask the MD for guidance and the nurses should have also called her, but did not. Interview with the 3:00 PM to 11:00 PM shift RN (#1) Nursing Supervisor, on 5/2/11 at 5:20 PM revealed she did not know that the resident was bleeding or the amount she was bleeding on 3/22/11, but thought it was "just hematuria". RN #1 Supervisor stated she did not read the 24 Hour Shift Report or the Supervisor's Report and RN #2 ADON who was the Supervisor/Unit Manager on 3/22/11 did not give her a verbal report. RN #1 Supervisor stated she did know that the resident's "BP was low". RN #1 stated she did not notify the MD of the continued bleeding or the low BPs and if she "had known, I (she) would have called the MD and sent this resident out to the hospital immediately". During an interview on 5/2/11 at 6:00 PM, RN #2/ADON stated she was not informed by LPN #3 on 3/22/11 that the resident continued to bleed with "half of a flat bedpan full" with a 6" plus blood clot and a BP of 88/52 or she would have called the MD immediately. During an interview on 5/2/11 at 7:00 PM, RN #3 who worked the 3:00 PM to 11:00 PM on 3/22/11 stated that LPN #3 did tell her during report on 3/22/11 that the resident was bleeding with blood clots and LPN #3 stated that the MD was aware of the resident's condition. RN #3 stated that she did make the 3:00 PM to 11:00 PM Nursing Supervisor aware that the resident continued to bleed and that the resident's BP was low. During an interview with the DON and Administrator on 5/3/11 at 3:30 PM, the DON stated "the nurses missed it" and they should have sent the resident out immediately to the hospital. "The nurses did not do what they were supposed to do starting with the missed PT/INRs through not notifying the physician of the continued bleeding with clots and the low BPs". During an interview on 5/5/11 at 9:00 AM, PA #2 stated the medical personnel who was called for the Vitamin K order could not have known of the bleeding and low blood pressures because they would have sent the resident out to the hospital. 415.3(e)(2)(ii)(b)

Based on record review and staff interview, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care for two (Residents #90, 123) of 20 residents reviewed for quality of care. Resident #123 received two anticoagulant medications (blood thinning medications that stop blood from clotting) and did not have therapeutic blood monitoring done as ordered by the physician. The resident experienced bleeding with blood clots and had a low blood pressure. There was a lack of ongoing monitoring of the resident's blood pressures for 3 nursing shifts and there was a delay in treatment of [REDACTED]. This resulted in actual harm that is not immediate jeopardy for Resident #123. Resident #90 receives [MEDICAL TREATMENT] three times per week. There was a lack of complete, consistent communication with the [MEDICAL TREATMENT] center and lack of documented evidence that the condition of the [MEDICAL TREATMENT] was consistently monitored from 3/1/11 through 5/4/11. Resident #90 had no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #123 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is moderately impaired in daily decision making and received anticoagulant (medications to prevent blood from clotting) injections every day since admission. a). Review of the hospital Discharge Summary dated 3/1/11 revealed the resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. During the hospital stay, the resident received [MEDICATION NAME] (injectable anticoagulant therapy) 40 milligrams (mg) SQ (subcutaneous - injection beneath the skin) once a day and [MEDICATION NAME] (oral anticoagulant therapy) 3 mg once a day. The Discharge Summary documented that the daily dose of [MEDICATION NAME] was increased from 3 mg to 4 mg starting on 3/1/11 and "continued monitoring of PT ([MEDICATION NAME] time)/INR (international normalizing ratio) (PT/INR are blood tests to monitor the clotting time of blood) is necessary to maintain a therapeutic level between 2 to 3. Until that level is achieved, she (the resident) should continue to receive [MEDICATION NAME]". The Physician recommended the PT/INR be drawn in 2 days from discharge and "frequently thereafter". Review of a hospital laboratory report dated 3/1/11 revealed the PT level was 16.0 (normal 9.8 seconds to 14.0 seconds) and the INR was 1.4 (therapeutic range for oral anticoagulant therapy is 2.0 to 3.0 for [MEDICATION NAME] or treatment of [REDACTED]. Review of Admission Physician order [REDACTED]. - [MEDICATION NAME] 4 mg by mouth daily for [MEDICAL CONDITION] - [MEDICATION NAME] 40 mg SQ daily for [MEDICAL CONDITION] - [MEDICATION NAME] (blood pressure medication) 25 mg twice a day for hypertension - BP (blood pressure) every shift for 7 days, - PT/INR daily for 2 days, then 2 times per week, a CBC (complete blood count), CMP (comprehensive metabolic profile), and a TSH ([MEDICAL CONDITION] stimulating hormone - blood test to determine [MEDICAL CONDITION] function). Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The [MEDICATION NAME] was scheduled to be administered twice a day at 9:00 AM and 5:00 PM. Review of a History & Physical, signed by the Nurse Practitioner (NP), dated 3/1/11 revealed the resident's BP was 118/78 (normal) and heart rate was 70 (average 80). The NP documented a plan for PT/INR monitoring and [MEDICATION NAME]/[MEDICATION NAME] as scheduled. The NP documented that the resident was also on [MEDICATION NAME] 25 mg twice a day for hypertension and the BP was well controlled. Review of an untitled comprehensive care plan (CCP) dated 3/2/11 revealed the resident was identified at risk for bleeding/bruising due to anticoagulant therapy with a [DIAGNOSES REDACTED]. CCP approaches included obtaining "labs (laboratory tests) per MD (Medical Doctor) orders, MD to review, "monitor for s/s (signs and symptoms) of bleeding/bruising" such as bleeding gums, stools - observe for a change in color, visible blood, purpura (red or purple discolorations of the skin), emesis (vomiting) - blood; and update MD as needed. Review of laboratory reports dated 3/3/11 revealed results for the following blood tests that were obtained on 3/2/11: - PT - 20.4 - INR - 1.9 - Hemoglobin (Hgb - protein in red blood cells that carry oxygen) - 10.9 G/DL (normal 11.7 to 15.5) - Hematocrit (Hct - the proportion of total blood volume that is comprised of red blood cells) - 32.8 percent (normal 35.0 to 45.0) - BUN (blood urea nitrogen - blood test to determine kidney function and hydration status - 17 (normal 7 to 25 MG/DL) - Creatinine (blood test to determine kidney function) - 1.0 (normal 0.63 to 1.22 MG/DL) Review of the entire medical record revealed no documented evidence that a PT or INR was obtained on 3/3/11 and then twice a week as ordered by the Physician on 3/1/11. Review of a policy and procedure (P&P) entitled Medical Orders dated 4/23/11 revealed routine labs will be added to the Unit Secretary's scheduling book. A P&P entitled Laboratory Orders and Transcription dated 1/25/08 revealed the Unit Secretary/Nurse will check new physician orders [REDACTED]. If the lab work is routine (weekly, monthly, etc.), enter into the lab book and on the resident's individual lab tracking form. The Physician/NP will be notified of any significant abnormal lab values based on guidelines determined by the Medical Director. Copies of all lab reports are forwarded to the Physician for review. All lab reports are reviewed, initialed and dated by the Nursing Supervisor/Unit Manager or Nurse and Physician/Nurse Practitioner prior to filing by the Unit Secretary. Interviews with the Director of Nursing (DON) on 5/2/11 at 4:40 PM, 5/3/11 at approximately 10:00 AM and on 5/5/11 at approximately 2:00 PM revealed she was not aware of the situation involving Resident #123's missed lab work or subsequent hospitalization until the surveyor brought it to her attention, so there was no investigation initiated for this incident. The DON stated they used to review the circumstances involving residents who were sent to the hospital, but have since stopped. The DON stated the process for blood work is that the physician writes the admission orders [REDACTED]. The Unit Secretary then makes out the lab slip and fills in the Lab Schedule sheet for the labs ordered. If the resident is admitted to the facility during the evening shift or on a weekend when the Unit Secretary is not at the facility then the nurse that admits the resident is expected to make out the requisition for the next lab. The DON stated it is the responsibility of the Nurse Manager of the unit to follow up to ensure that labs are scheduled as ordered. The DON stated that Resident #123 missed approximately five PT/INR lab draws. Interview with the Unit Secretary on 5/2/11 at 6:30 PM revealed she writes up the Lab Schedule sheet for new admissions, with the standard labs for CBC, CMP, and TSH scheduled. The Unit Secretary stated she wrote the order for the CBC, CMP, and TSH on the Lab Schedule sheet for Resident #123. The Unit Secretary explained that she did not enter the order for the PT/INR daily for 2 days then twice a week because the resident was admitted in the evening and she had already left for the day. The Unit Secretary stated that the nurses know that if a resident is admitted when she is not there, the nurses are to add any blood work other than the standard CBC, CMP, TSH to the Lab Schedule sheet. The Unit Secretary stated that she "does not go back to check if the labs were scheduled as per the MD orders". Interview with LPN #2 on 5/3/11 at 5:30 PM revealed she was on duty on 3/1/11 when the resident was admitted to the facility on the evening shift. LPN #2 stated she took off the admission orders [REDACTED]. LPN #2 stated the Unit Secretary was supposed to place the scheduled labs on the Lab Schedule sheet. LPN #2 stated that the nurses write the labs that are ordered for the next day on the Laboratory Collections Log and that the Unit Secretary or the Nurse Manager follow through and write any scheduled labs on the resident's Lab Schedule sheet. Interview with the ADON/RN #2 on 5/5/11 at 1:40 PM revealed she did not know that it was her responsibility, when she was the Nurse Manager, to check residents' Lab Schedule sheets for accuracy with the MD orders. b). Review of a physician progress notes [REDACTED]. physician progress notes [REDACTED]. A Nursing Progress Note written by RN #4, on 3/21/11 at 3:00 PM documented that the resident had "bleeding from bottom" at 11:00 AM and the MD was notified, "no new order, monitor". At 12:40 PM, RN #4 documented there was a small amount of bleeding, an ABD (abdominal pad - thick absorbent dressing) was applied and the MD was notified. Review of an untimed Nursing Progress Note, written by the Registered Nurse (RN #2) Nursing Supervisor, dated 3/21/11 revealed "MD visit today" and Stools for OB (occult blood - blood in the feces that is not visibly apparent) x 3 ordered. Review of a Physician's Progress Note dated 3/21/11 revealed the resident was seen by the Physician for an "acute evaluation" because blood was observed in the toilet when the resident went to the bathroom. The Physician (MD #1 - Medical Doctor) documented that the resident's BP was 128/74, pulse was 68 and advised staff to continue the [MEDICATION NAME] 25 mg twice a day as prescribed. The Physician documented that the resident was examined but no bleeding was found. The Physician advised staff to obtain a urinanalysis because the resident had another episode of bleeding. The Physician also documented that the resident receives [MEDICATION NAME] 4 mg tablet once a day and [MEDICATION NAME] 40 mg once a day for [MEDICAL CONDITION] (prevention). The Physician did not document whether she was aware that the last PT/INR was obtained on 3/2/11 and there was no PT/INR done on 3/3/11 or twice a week from 3/4/11 through 3/21/11. Review of an untimed Physician's Telephone Order dated 3/21/11 revealed an order to obtain an INR in the AM and an INR every Monday and Thursday. Interview with MD #1 on 5/2/11 at 3:55 PM revealed she was notified by RN #1 on 3/21/11 that fresh blood was observed in the toilet after Resident #123 went to the bathroom. MD #1 stated that MD #2 performed a physical exam on the resident (on 3/21/11) and found no vaginal or rectal bleeding at that time. MD #1 stated that the order to obtain a PT/INR every day for 2 days then 2 times per week is a standard order for anyone on anticoagulant therapy and it should have been done. MD #1 stated she did not know that only one PT/INR had been obtained between 3/1/11 and when she saw the resident on 3/21/11. MD #1 stated that she does not look at residents' blood work because the nurses are to notify her of abnormal labs "as per the protocol". MD #1 stated that since she was not called, she assumed the labs were within normal limits. A Nursing Progress Note written by the RN (#1) Nursing Supervisor dated 3/21/11 at 6:30 PM, documented that the resident continued to have a small to moderate amount of blood when she had a BM (bowel movement) and that the stool for OB #1 was positive for blood. RN #1 documented that the resident was "on [MEDICATION NAME]. Stat PT/INR in AM and 2 x/weekly per policy. VSS (vital signs stable)". Review of the Resident Care Record for the 3:00 PM to 11:00 PM shift on 3/21/11 revealed the resident's BP was 90/56 at an unidentified time during the shift. Additional review of the 3/21/11 Nursing Progress Notes revealed there was no further nursing documentation for the 3:00 PM to 11:00 PM shift and no documented evidence that the resident's BP was rechecked. Review of a Nursing Progress Note, written by a Licensed Practical Nurse (LPN #5), dated 3/22/11 at 2:45 AM revealed there were "Bruises on the resident's right outer calf and ankle". A Nursing Progress Note written by LPN #4 at 5:45 AM documented that a CNA reported the resident was bleeding, the resident had a BP of 167/59 and the NP (Nurse Practitioner) was notified. (Interview with the Director of Nursing (DON) on 5/3/11 at approximately 10:00 AM revealed a Physician Assistant (PA #2) was on call on 3/22/11 at 5:45 AM, not the NP.) Review of a Physician's Telephone Order dated 3/22/11 at 5:45 AM revealed an order to "hold the [MEDICATION NAME] and [MEDICATION NAME] and report the PT/INR to the MD on call. Additional review of a Nursing Progress Notes dated 3/22/11 revealed the following: - At 8:00 AM, LPN #3 documented the resident had vaginal bleeding and that approximately 1/2 of a flat bed pan was full. LPN #3 documented that the resident had a B/P of 88/52 (low BP) and that [MEDICATION NAME], and [MEDICATION NAME] were held. - At 9:30 AM, LPN #3 documented that the resident passed a 6 inch (") blood clot. - At 11:00 AM, LPN #3 documented the resident had bleeding in her brief - "small amount at present, PT/INR drawn earlier; noted bruising at right calf, right ankle and top of foot, light in color". - At 2:00 PM, LPN #3 documented the resident had a moderate vaginal blood flow with a 6" plus blood clot. Review of a laboratory report dated 3/22/11 revealed the PT level reported to the facility at 1:48 PM was > (greater than) 169 and the INR was > 14.0 with a notation that the exact value could not be calculated due to the elevated PT > 169. Review of a Physician's Telephone Order dated 3/22/11 at 2:35 PM revealed an order for [REDACTED]. Additional review of Nursing Progress Notes and the 24 Hour Shift Report for the 7:00 AM to 3:00 PM shift on 3/22/11 revealed no documented evidence that the resident's BP was monitored following the BP of 88/52 at 9:00 AM. During an interview on 5/2/11 at 3:55 PM, MD #1 stated she was not on call on 3/22/11 and did not know that Resident #123 was still bleeding with large clots or that the resident's BP was very low. In addition, MD #1 stated she did not know about the elevated PT/INR nor did she give the order for the Vitamin K because if she had been called, she would have asked a lot more questions regarding the condition of the resident. MD #1 stated she signed the Vitamin K, order the next time she was in the facility, even though she did not give the Telephone Order. During an interview on 5/3/11 at 2:30 PM, Physician Assistant (PA #1) stated that she was not notified on 3/22/11 of the resident's condition or the blood work results because she would have remembered a PT of 169 or an INR >14 and would have asked a lot of questions. PA #1 stated she would have sent the resident to the hospital immediately for an evaluation with the issues that the resident presented. Review of a Supervisor's Report dated 3/22/11 revealed Resident #123 had vaginal bleeding; [MEDICATION NAME] and [MEDICATION NAME] were on hold: Stool OB+ (positive); Vitamin K 10 mg given at 2:45 PM, no complaints of pain, and bruise LLE (left lower extremity). Interview with the 3:00 PM to 11:00 PM shift RN (#1) Nursing Supervisor, on 5/2/11 at 5:20 PM revealed she did not know that the resident was bleeding or the amount she was bleeding on 3/22/11, but thought it was "just hematuria". The RN (#)1 Nursing Supervisor stated she did not read the 24 Hour Shift Report or the Supervisor's Report and RN #2, who was the Supervisor/Unit Manager for the day shift on 3/22/11, did not give her a verbal report. RN #1 Supervisor stated she did know that the resident's "BP was low". RN #1 stated she did not notify the MD of the continued bleeding or the low BPs and if she "had known, I (she) would have called the MD and sent this resident out to the hospital immediately". Review of a Nursing Progress Note, written by RN #3, dated 3/22/11 at 10:45 PM revealed "vaginal bleeding continued" with a 2" blood clot during the shift. RN #3 documented the B/P was 78/42 (low BP), "Bed rest, will continue to monitor. Held [MEDICATION NAME], BP too low". Review of the 3/11 MAR indicated [REDACTED]. Additional review of Nursing Progress Notes and the 24 Hour Shift Report for the 3:00 PM to 11:00 PM shift on 3/22/11 revealed no documented evidence that the resident's BP was monitored following the BP of 78/42 at 5:00 PM or that the Physician was notified of the low BP and continued bleeding. Review of a facility P&P entitled Blood Pressure Monitoring Guidelines dated 11/5/10 revealed when irregularities in a resident's blood pressure occur, the blood pressure will be checked more frequently. During an interview on 5/2/11 at 3:55 PM, MD #1 stated the nurse should have rechecked the resident's low BP every 15 minutes and if the second BP was not higher, the nurse should have called the on-call Physician. MD #1 stated if she had been notified of the resident's condition on 3/22/11, she would have sent the resident to the hospital immediately to be evaluated. MD #1 also stated the lack of obtaining the PT/INR as per the physician orders [REDACTED]. During an interview on 5/3/11 at 1:30 PM, MD #2 stated it is standard policy for a resident admitted on anticoagulants to have a PT/INR obtained daily for two days and then twice weekly thereafter. MD #2 reviewed the medical information available regarding Resident #123's BP, bleeding, and PT/INR results and stated the resident should have been sent out 3/22/11 during the 7:00 AM to 3:00 PM shift. MD #2 stated "any licensed professional would have and should have sent this resident to the hospital immediately unless they are dumb". A Nursing Progress Note, written by LPN #5, dated 3/23/11 at 2:07 AM documented "vaginal bleeding continues, no clots noted at this time". Review of the Resident Care Record for the 11:00 PM to 7:00 AM shift from 3/22/11 to 3/23/11 revealed the resident's BP was 94/50. There were no additional BPs documented for the 11:00 PM to 7:00 AM shift and no evidence that the Physician was notified regarding the resident's condition. Review of a Nursing Progress Note, written by RN #4, dated 3/23/11 at 8:40 AM revealed the resident's BP was 108/60, there was a small amount of bleeding at the vagina and MD notified. The RN documented that the resident had rebound tenderness and a right abdominal mass. At 10:00 AM, RN #4 documented that the BP was 122/50, and that the resident refused breakfast and all medications. The RN also documented the resident was sent to the hospital at 10:10 AM. Review of an Acute Physician Visit Note dated 3/23/11 revealed MD #1 saw the resident due to "continued bleeding from 3/21/11". MD #1 documented that on 3/22/11 "it was then realized that she (the resident) was getting [MEDICATION NAME] and [MEDICATION NAME]. A PT/INR was obtained and was abnormal". The resident was given Vitamin K and the [MEDICATION NAME] and [MEDICATION NAME] were put on hold. On examination, the resident was noted to have continued bleeding. MD #1 documented a plan to transfer the resident to the hospital for an "acute problem evaluation". An untimed Nursing Progress Note, written by the Nursing Supervisor (RN #1) dated 3/23/11 documented that Resident #123 was admitted to the hospital at 1:00 PM and was in the ICU (Intensive Care Unit) with a [DIAGNOSES REDACTED]. Review of the hospital History and Physical dated 3/23/11 revealed the resident was noted in the emergency room "to have a marked drop in her hemoglobin" with a level of 4.2 (normal 12.0 to 16.0) and a CT Scan (computerized tomography - diagnostic medical imaging) of the abdomen showed a large hemorrhagic (massive, difficult to control bleeding) mass in the pelvis which is suspicious of a bleed. The Physician documented that the resident had gross hematuria (bloody urine). The Physician documented that the resident was admitted to the hospital with [REDACTED]. Review of hospital laboratory reports dated 3/23/11 revealed the following: - Hemaglobin - 4.2 - CL (critically low) - Hematocrit - 12.0 - CL - BUN - 53 - Creatinine - 5.6 - The urinalysis showed a large amount of blood Review of admission orders [REDACTED]. The Physician ordered [MEDICAL CONDITION] of 2 units of FFP (fresh frozen plasma - the fluid portion of blood that contains clotting a factors, used for patient's who are actively bleeding) and 4 units of PRBC (packed red blood cells). Review of a Transfusion Record dated 3/23/11 revealed the resident received a total of 4 units of packed red blood cells and 4 units of thawed plasma. Review of a facility policy and procedure entitled Change In a Resident's Condition or Status with a revision date of 7/27/10 revealed the nurse is to notify the resident's attending Physician when there is a change in the resident's physical, mental or psychosocial status or when deemed necessary or appropriate in the best interest of the resident. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. Interview with the Director of Nursing (DON) on 5/3/11 at approximately 10:00 AM revealed the nurse on duty on 3/21/11 for the 3:00 PM to 11:00 PM shift should have notified the Physician of the resident's low BP per the facility policy and procedure for Blood Pressure Monitoring. The DON stated the nurses should call the MD for "any systolic (the upper BP number, measures the pressure exerted by circulating blood on the blood vessels) less than 90 or diastolic (the lower BP number, measures the blood pressure when the heart is resting) less than 60, and the nurses are well aware of this". The DON stated the nurses should have called the MD immediately on 3/22/11 during the day shift to ask the MD for guidance and the nurses should have also called her, but did not. During an interview on 5/2/11 at 6:00 PM, RN #2 who is currently the ADON, stated she was the RN Supervisor/Nurse Manager on Resident #123's unit in 3/11. The ADON stated she had the MD see the resident on 3/21/11 because the resident was bleeding. The ADON also stated that she was not informed by LPN #3 on 3/22/11 that the resident continued to bleed with "half of a flat bedpan full" with a 6" plus blood clot and a BP of 88/52 or she would have called the MD immediately. The ADON (RN #2) explained that she called the Physician Assistant (PA #1) that was on call with the results of the PT/INR on 3/22/11. The ADON stated that PA #1 did not return the call, so she called MD #1. The ADON stated MD #1 gave her the verbal order to give the Vitamin K 10 mg. The ADON also stated when she received the critical PT/INR lab results and the order for Vitamin K on 3/22/11, she should have gone to assess the resident, but did not. If she had assessed the resident on 3/22/11, she would have sent the resident to the hospital immediately. During an interview on 5/2/11 at 7:00 PM, RN #3 who worked the 3:00 PM to 11:00 PM on 3/22/11 stated that LPN #3 did tell her during report on 3/22/11 that the resident was bleeding with blood clots and LPN #3 stated that the MD was aware of the resident's condition. RN #3 stated that she did make the 3:00 PM to 11:00 PM Nursing Supervisor aware that the resident continued to bleed and that the resident's BP was low. During an interview with the DON and Administrator on 5/3/11 at 3:30 PM, the DON stated "the nurses missed it" and they should have sent the resident out immediately to the hospital. "The nurses did not do what they were supposed to do starting with the missed PT/INRs through not notifying the physician of the continued bleeding with clots and the low BPs". During an interview on 5/5/11 at 9:00 AM, PA #2 stated the medical personnel who was called for the Vitamin K order could not have known of the bleeding and low blood pressures because they would have sent the resident out to the hospital. 2. Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident is cognitively intact, is understood and understands and receives [MEDICAL TREATMENT]. Interview with the LPN (#6) Nurse Manager on 4/27/11 at 9:00 AM revealed the resident has an AV (arterio venous) shunt (a surgical implanted device to create an artificial connection between an artery and vein) in his right arm and he goes to [MEDICAL TREATMENT] three times per week on Mondays, Wednesdays and Fridays. The LPN Nurse Manager stated that the resident leaves the facility around 2:00 PM and returns at approximately 7:00 PM. Review of the untitled comprehensive care plan dated 3/14/11 revealed the resident receives [MEDICAL TREATMENT] with approaches to obtain vital signs per policy, medications as ordered, monitor labs as ordered, monitor [MEDICAL CONDITION], fluid restrictions as ordered, I & O (intake and output), dietary consult as needed, notify MD (medical doctor) as needed, and coordinate care with [MEDICAL TREATMENT]. There was a lack of documented evidence of a plan to monitor the AV shunt site for bruit and thrill or to monitor the site for bleeding, swelling, redness, tenderness or complaints of pain. There were no directions regarding what to do if the resident returned from [MEDICAL TREATMENT] with a dressing on the AV Shunt site. Review of physician's orders [REDACTED]. arm once a day, by an RN only. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of MAR's dated 4/11 through 5/4/11 revealed the RN monitored the bruit and thrill on the day shift prior to the resident leaving for [MEDICAL TREATMENT]. There was a lack of documented evidence the resident's AV shunt site was monitored for bleeding, the presence of a bruit and thrill, redness, tenderness, swelling, or complaints of pain when the resident returned from [MEDICAL TREATMENT]. Review of Nursing Progress Notes dated 3/1/11 to 5/4/11 revealed no documented evidence that the bruit and thrill were monitored or that the AV Shunt site was consistently assessed for bleeding, swelling, redness, tenderness, or complaints of pain. The resident attended [MEDICAL TREATMENT] 29 times during this time period. Review of Outpatient Visit Reports for [MEDICAL TREATMENT] dated 2/28/11 through 5/2/11 revealed the [MEDICAL TREATMENT] Center returned 13 communication forms to the facility following [MEDICAL TREATMENT] and 3 forms contained no communication from the [MEDICAL TREATMENT] center. Review of 10 of the 13 forms sent by the [MEDICAL TREATMENT] Center revealed the forms did not document whether the resident was returning with a dressing over the AV shunt site and they did not include any instructions to the nurse at the facility regarding the resident. There was a lack of complete and consistent communication with the [MEDICAL TREATMENT] Center regarding the resident's care. Review of a facility policy and procedure (P&P) entitled Care of Residents On [MEDICAL TREATMENT] with a review dated of 11/5/10 revealed the following: - Pre-[MEDICAL TREATMENT] - Nurses are to check and monitor the shunt site for redness and/or swelling as ordered by the [MEDICAL TREATMENT] center and confirmed by the primary physician and record findings. The Registered Nurse will check the bruit and thrill daily. Nurses are not to change the dressings unless specifically ordered. Observe resident for s/s of infection, dehydration, and/or [MEDICAL CONDITION]. Report findings to the primary physician as appropriate. - Post-[MEDICAL TREATMENT] - Nurses are to check and record VS (vital signs), weight and other parameters as ordered by the physician. Check and monitor insertion site for condition of skin and catheter. Do not change dressings or address the catheter unless specifically ordered. Monitor for complications associated with [MEDICAL TREATMENT] treatment and report any problems/changes in resident's status to the physician as indicated. The P&P did not include a procedure for the nurses to monitor the resident and the AV shunt site after [MEDICAL TREATMENT] for signs and symptoms of bleeding, tenderness, swelling, redness, bruit/thrill or for complaints of pain. During an interview with the LPN (#6) Nurse Manager and the LPN (#7) Medication Nurse on 5/4/11 at 9:30 AM, the LPN Nurse manager stated that the resident returns from [MEDICAL TREATMENT] approximately 5:30 PM or up to 7:00 PM usually with a dressing on his shunt site but sometimes he returns with no dressing. The LPN Medication Nurse stated she has seen the dressing still on the resident the next morning but does not know who takes the dressing off. The LPN Nurse Manager stated she did not know: who monitors the resident's shunt site upon his return from [MEDICAL TREATMENT]; who takes off the dressing; or what the nurses were to observe the resident's shunt site for when he returned from [MEDICAL TREATMENT]. The LPN Nurse Manager stated there is a problem with the communication from [MEDICAL TREATMENT], "sometimes the resident returns without any information at all or the nurses at [MEDICAL TREATMENT] do not fill out the communication form and it is blank when the form is returned". The LPN Nurse Manager stated "usually it is blank". The Nurse Manager stated she has been calling the [MEDICAL TREATMENT] unit since March to obtain copies of the resident's blood work and information but the [MEDICAL TREATMENT] unit did not send any blood work until 4/29/11 when they faxed several month's worth. The Nurse Manager stated she reviewed the bloodwork results when she received them from [MEDICAL TREATMENT] on 4/29/11 and the resident's "labs are off, so maybe that is why the resident has not been feeling well". Interview with the DON on 5/4/11 at 9:45 AM revealed the nurses check the bruit and thrill on the day shift before the resident leaves for [MEDICAL TREATMENT]. The DON stated that the nurses should be checking the AV shunt site when the resident returns. 415.12