Every finding on record at Samaritan Keep Nursing Home Inc

Based on observations, record review, and interviews, the facility failed to ensure residents had the right to a dignified existence for two (2) of two (2) residents (Residents #184 and #257) reviewed. Specifically, Residents #184 and #257 had their side rails removed and there was no documented evidence they were provided with education, a therapy evaluation, side rail alternatives, or an opportunity to discuss their concerns prior to the side rails being removed. This resulted in a decline in bed mobility for Residents #184 and #257. Findings include:The facility policy Bed Rail Use - Side Rails, Assist Rails, Transfer Rails, Bed Enablers, revised 09/03/2025, documented assignment of a bed rail would be considered only after all non-bed rail alternatives are attempted; side rails may only be considered to treat a resident's medical symptoms or as an assistive device to assist with mobility and transfer of residents; the resident/representative will be provided education on the risks versus the benefits of using the device so that the resident/resident representative can make an informed decision. The facility policy Resident Rights, last reviewed 09/12/2025, documented residents had the right to participate in their person-centered care planning and treatment; to reasonable accommodation of needs so long as it did not endanger the health or safety of them or other residents; and to a safe, clean, comfortable and home-like environment that allowed them to be as independent as possible. The facility policy Standard of Care - Activities of Daily Living, revised 01/01/2019, documented each resident would receive and the facility must provide the necessary care and services to attain or maintain the highest possible level of functioning and wellbeing as limited by the individual's recognized pathology and normal aging process; residents would be encouraged to perform bed mobility tasks to the extent they were safely able, in alignment with the care plan; and staff would provide appropriate assistance, including use of adaptive equipment, to prevent avoidable decline and promote maximum functional independence. A 09/03/2025 facility issued letter to families and residents documented all use of bed rails was to be discontinued and staff were trained in alternative safety measures. Additionally, a phone number was provided should anyone have questions or would like to discuss further. 1) Resident #257 had diagnoses including morbid obesity and left side paralysis following a stroke. The 02/26/2026 Minimum Data Set assessment documented the resident had intact cognition; was dependent for rolling left and right and returning to lying on their back in bed; and did not use side rails. The 11/14/2023 Comprehensive Care Plan, revised 09/04/2025, documented the resident required assistance with self-care and mobility related to left side paralysis. Interventions included substantial assistance of two (2) for bed mobility. Prior to the 09/04/2025 revision, the resident required substantial/maximal assistance of one (1) for bed mobility. Bed Rail Evaluations documented the following:-On 03/26/2025 the resident displayed poor bed mobility and bilateral side rails were recommended as an enabler to promote independence.-On 09/04/2025 the resident displayed poor bed mobility and bilateral side rails were not indicated. There was no documented evidence that the resident was informed, educated, offered an alternative, or given the opportunity to voice their concerns prior to their side rails being removed. During an interview on 03/17/2026 at 10:04 AM and 03/19/2026 at 10:02 AM, Resident #257 stated they were upset over the removal of their side rails. They previously had two (2) side rails that helped them reposition themself. No one explained ahead of time the side rails were going to be removed or why. The left side rail allowed them to independently reposition themself, shift their weight, and turn to their left. They stated without that rail they could not move at all. A trapeze was trialed after the rails were removed but it did not help them to roll so they asked that it be removed. During an interview on 03/18/2026 at 1:42 PM, Certified Nurse Aide #23 stated all side rails were taken off last year by administration. They did not recall any discussions or education with the residents prior to their removal. A lot of residents were still unhappy about it. Resident #257 grabbed the side rail with their good hand to help roll themself. At that time, they could document their assistance level as substantial but now, because the resident could no longer help pull themself over, they had to document the resident was dependent. During an interview on 03/19/2026 at 11:23 AM, Certified Nurse Aide #35 stated Resident #257 would grab the side rail to their left to pull and hold themself on their left side. They required minimal assistance to roll to their left when they had the side rail. Now, they had to grab the corner of the headboard to pull themselves over. When they had the trapeze, it did not help them to roll so it was removed. During an interview on 03/19/2026 at 10:52 AM, Licensed Practical Nurse #24 stated in September 2025 maintenance removed all side rails. There were a lot of independent residents that needed something to grab, and their side rails were taken away. Residents and families were very angry, and some were still complaining. Staff were told an alternative to the rails was being worked on and to hold off on therapy evaluations unless there was a decline in function. Resident #257 was able to roll themself to their left with use of the left side rail and minimal assistance of one (1). Without the side rail they now required assistance of two (2) for rolling. The resident had a trapeze, but they did not like it because it was awkward, and it did not help them roll and the resident asked for it to be removed. 2) Resident #184 had diagnoses including right side paralysis and muscle weakness. The 01/22/2026 Minimum Data Set assessment documented the resident had intact cognition; functional impairment on one side of both upper and lower extremities; and required maximum assistance with bed mobility. The 11/14/2023 Comprehensive Care Plan, revised 09/25/2025, documented the resident required assistance with self-care and mobility related tasks. Interventions included substantial/maximal assistance of one (1) for bed mobility. The Bed Rail Evaluations documented the following:-On 08/07/2025 the resident displayed poor bed mobility and bilateral side rails were recommended as an enabler to promote independence.-On 09/04/2025 the resident displayed poor bed mobility and side rails were not indicated. There was no documented evidence the resident was informed, educated, offered an alternative, or given the opportunity to voice their concerns prior to their side rails being removed. The August 2025 certified nurse aide Follow Up Question Report documented the resident required partial assist for rolling left and right in bed most of the time. The certified nurse aide Follow Up Question Report from 09/04/2025-09/30/2025 documented the resident required either substantial assistance or was dependent on rolling left and right in bed most of the time. The certified nurse aide Follow Up Question Report from 03/01/2026-03/19/2026 documented the resident required either substantial assistance or was dependent for rolling left and right in bed most of the time. During an interview on 03/18/2026 at 2:17 PM, Resident #184 stated two (2) maintenance workers removed both of their side rails. No one explained why they were removed, and no alternatives were offered. They used the rail to their right to roll and the one to their left for stability and security when sitting at the edge of the bed. Since the side rail removal, they did not move around in bed as well. They were able to roll to the right by themself but could no longer do so. They talked to Registered Nurse Unit Manager #21, and anyone else who would listen, and was told they were not getting the side rails back. During an interview on 03/19/2026 at 11:23 AM, Certified Nurse Aide #35 stated Resident #184 used the side rails to roll onto their side and to steady themselves when sitting on the edge of the bed. Without the side rails they no longer could pull and hold themself onto their side and when sitting on the bed edge they had to grab at the bed and staff to steady themself. The resident told them they felt like they were losing their independence. The resident previously required assistance of one (1) for bed mobility when they had side rails and now, without the side rails, they required assistance of two (2). During an interview on 03/19/2026 10:52 AM, Licensed Practical Nurse #24 stated Resident #184 was upset over the removal of their side rails because they wanted to be independent but now had nothing to grab. When they had the side rail the resident was able to use the rail effectively with their good hand to pull themself over. During an interview on 03/19/2026 at 1:26 PM, Registered Nurse Unit Manager #21 stated in September 2025 Administration decided the facility would be side rail free and removed all side rails. They thought a letter was sent out regarding the removal. They were not involved in any discussions or education with the residents prior to taking the side rails off. There were no therapy evaluations or alternative options offered prior to the removal and some residents expressed disagreement with the decision. They thought Administration was going to investigate alternative devices, but nothing came of that. They heard Resident #257 was upset about the removal of their rails. The rails helped the resident off load and pull themself up. Resident #257 had a trapeze, but it was a hindrance and was removed. Resident #257 went from assistance of one (1) to two (2) for bed mobility on 09/04/2025. The resident had always required assistance pf one (1) with bed mobility and used the side rail to pull themself over. All residents should have been part of the side rail conversation as it was their home, and they had the right to be informed and involved in their care plan. During an interview on 03/19/2026 at 2:05 PM, Physical Therapist #44 stated their department was told all side rails needed to be removed with the goal to have a transfer bar for those that might need them but that was never rolled out. There were no evaluations or alternatives offered before side rail removal. Side rails provided independence for some residents and when they were removed it affected their independence. Resident #257's side rails were removed because they were not independent with bed mobility. They had a therapy evaluation on 09/09/2025 after the side rails had already been removed. They went from maximum assistance of one (1) with two (2) side rails to maximum assistance of two (2) with no side rails. They thought Resident #184 had one side rail but was unsure if they used the rail or had a therapy evaluation. Resident #257 required substantial to maximum assistance with the side rail and because they were not independent the side rail was removed. During an interview on 03/19/2026 at 3:28 PM, the Director of Nursing stated in September 2025 the decision was made to become a side rail free facility. On 09/03/2025 text notifications, voice notifications and certified letters were sent out to residents and families informing them of the side rail removals. On 09/03/2025, nurse managers were provided with literature with which to educate the residents. The education was verbal and was not documented. The certified letter provided a number to call welcoming any discussions, but there was no time for discussions as the removal of the rails started the same day those notifications went out and the side rails were removed very quickly. They did not think there should have been time allotted for discussion because it was such a big facility and there were only a handful of residents that were upset. At the time the side rails were removed, those residents with side rails had been determined the side rails were appropriate, but there were too many risks, and the side rails were removed. It was easier to remove them all and then reassess if needed. No residents had a decline or required more staff assistance because of side rail removal. Resident #184 was very upset about the removal of their side rails. The resident had always been dependent on bed mobility. Even if the side rails had not made them entirely independent with bed mobility, their ability to assist with their own bed mobility could provide them with a sense of some independence. Residents had the right to an environment that allowed them to be as independent as possible, but the facility looked at safety over independence. 10 New York Codes, Rules and Regulations 415.3(c)(1)(i)

Based on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident (Resident #133) reviewed. Specifically, Resident #133 had a medication cup at their bedside containing one white round pill and one half of a round white pill. There was no documented evidence of assessments and/or physician orders for the residents to safely self-administer medications.Findings included:The facility policy Administration of Medication Guidelines, last reviewed 04/02/2025, documented the nurse was personally responsible for every drug they administered. They stayed with the resident until they swallowed the drug, and medications were not left with the resident, except with a doctor's order.The facility policy Self-Administration of Medications, created 02/18/2026, documented residents who desired to self-administer medication would be allowed to do so under guidelines in the policy. Residents were evaluated for desire and competence to self-medicate, and a licensed nurse completed an evaluation on each resident upon admission, a significant change in condition and/or annually. Results of the evaluation were reviewed by the Interdisciplinary Care team for a team decision to determine the resident's ability to self-medicate, and the decision was documented in the Care Plan. Residents who did not meet the guidelines for self-medication administration were administered their medications by the nurse.Resident #133 had diagnoses including neurocognitive disorder (decline in mental function), Parkinson's disease (progressive neurological disorder), and epilepsy (seizure disorder). The 02/05/2026 Minimum Data Set assessment documented the resident was cognitively intact, had no behavioral symptoms, and was independent for most activities of daily living.The 02/06/2026 Comprehensive Care Plan documented the resident took carbidopa - levodopa (medication used to treat Parkinson's disease). Interventions included to administer medications as ordered by the provider; monitor and document side effects and effectiveness every shift; and document and report adverse reactions which included increased risk of low blood pressure on rising, falls, significant confusion, restlessness, delirium, difficulty walking, nausea, dizziness, hallucinations, agitation.During an observation and interview on 03/15/2026 at 4:48 PM Resident #133 was in their room. There was a medication cup at their bedside containing one white round pill and one half of a round white pill. Resident #133 stated the nurse left it there and they were not sure what the medication was, and they should probably take it. The resident was not sure how long it was there.There was no documented evidence of a medical order for self-medication administration or a self-medication administration assessment.During an interview on 03/15/2026 at 4:50 PM Licensed Practical Nurse #7 stated the medication in the cup in Resident #133's room was levodopa, and they thought the resident had taken the medication. They stated they instructed the resident to take the medication, and they did. They signed the medication as administered at 4:43 PM.During a follow-up interview on 03/19/2026 at 11:00 AM Licensed Practical Nurse #7 stated licensed practical nurses were responsible for medications. They occasionally signed off medications prior to administering them. Resident #133 did not have an order for self-medication administration. They stated they were distracted when they gave Resident #133 their medication and left the room before the resident took them. They did not pay attention, and they should have.During an interview on 03/19/2026 at 11:41AM Registered Nurse Unit Manager #6 stated when nurses passed medication, they expected them to ensure residents swallowed their medications at that time. Medications such as carbidopa - levodopa needed to be taken at a specific time as it was used for seizures. There were no residents on their unit who had orders to self-medicate. They stated medications should not be left at the bedside. 10 New York Codes, Rules, Regulations 415.3(f)(1)(vi)

Based on observation, record review, and interviews, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice for one (1) of one (1) resident (Resident #257) reviewed. Specifically, Resident #257 had a bilevel positive airway pressure machine (non-invasive mechanical ventilator that keeps airway open when sleeping) that was not cleaned per professional standards; was not maintained with water in the reservoir; did not have an order for supplemental oxygen use when used; was not documented as administered on the medication administration record; and there was no documented evidence of ongoing assessment of the resident's respiratory status, response to the therapy, documentation of the equipment settings or when to use the equipment.Findings include:The facility policy CPAP (continuous positive airway pressure) BIPAP (bilevel positive airway pressure) Therapy, revised 06/01/2021, documented the facility would provide bilevel positive airway pressure therapy in accordance with physician orders, manufacturer guidelines, and evidence-based practice to maintain resident safety, respiratory stability, and quality of life; the mask must be taken off daily and cleansed with a wet cloth; and use of bilevel positive airway pressure would be documented on treatment record.The facility policy Oxygen Delivery, revised 06/18/2025, documented an order would be obtained for use of low flow oxygen of one (1) to six (6) liters and oxygen administered by a concentrator would be placed in the treatment administration record.Resident #257 had diagnoses including respiratory failure and obstructive sleep apnea (a condition where sleep is interrupted by abnormal breathing). The 02/26/2026 Minimum Data Set assessment documented the resident had intact cognition; was dependent for most activities of daily living; had shortness of breath with exertion, at rest and when lying flat; and received oxygen therapy and non-invasive mechanical ventilation.The 12/02/2021 Comprehensive Care Plan, revised 12/18/2025 documented the resident required constant oxygen with bilevel positive airway pressure related to respiratory failure. Interventions included monitor for signs of respiratory distress, and oxygen to be bled through bilevel positive airway pressure at five (5) liters a minute (introducing supplemental oxygen into the air stream via an oxygen enrichment port or bleed-in adapter, usually to treat low blood oxygen saturation during sleep apnea treatment).Physician orders documented the following:-On 09/26/2021 check water level in the bilevel positive airway pressure machine every shift.-On 11/13/2023 bilevel positive airway pressure settings 22/18. Order for new bilevel positive airway pressure and all supplies revised.-On 02/07/2024 did the resident have shortness of breath or trouble breathing while lying flat and/or kept the head of their bed elevated/slept in a recliner due to shortness of breath or trouble breathing while lying flat? Document every shift.The physician orders did not document when to use the bilevel positive airway pressure equipment or include directions for oxygen bleed in. Additionally, the administration of the bilevel positive airway pressure and its settings was not being documented.The March 2026 Treatment Administration Record documented the water level in the bilevel positive airway pressure machine was not checked every shift as ordered on 03/01/2026, 03/03/2026, 03/06/2026 - 03/08/2026, 03/09/2026, 03/10/2026, 03/14/2026 and 03/15/2026. The Treatment Administration Record did not document whether the resident had shortness of breath or trouble breathing while lying flat and/or kept the head of their bed elevated/slept in a recliner due to shortness of breath or had trouble breathing while lying flat as ordered on 03/01/2026, 03/03/2026, 03/06/2026- 03/10/2026, 03/14/2026, and 03/15/2026.During an observation and interview on 03/15/2026 at 3:44 PM the water reservoir of the bilevel positive airway pressure machine was empty; the nasal mask had dried brown debris on the inside; and the oxygen concentrator was set at five (5) liters and was piped into the bilevel positive airway pressure tubing. The resident stated they used their bilevel positive airway pressure all the time and the nasal mask was never cleaned.During an observation on 03/16/2026 at 1:53 PM the water reservoir of the bilevel positive airway pressure machine was empty.During an observation on 03/18/2026 at 9:37 AM the resident was using their bilevel positive airway pressure and the oxygen concentrator was piped into the bilevel positive and set at four and a half (4.5) liters.The March 2026 Treatment Administration Record documented Licensed Practical Nurse #20 signed they checked the water level of the bilevel positive airway pressure on 03/16/2026 during the day shift.During an observation and interview on 03/17/2026 10:04 AM the resident's bilevel positive airway pressure machine was filled with clear fluid; the oxygen concentrator was set at four and a half (4.5) liters and was being piped into the bilevel positive airway pressure tubing; and the nasal mask had dried brown debris on the inside. The resident stated they could tell the water reservoir was full as their nares did not feel dry as they had the last couple of days.During an observation on 03/19/2026 at 10:02 AM, the oxygen concentrator was set at four and a half (4.5) liters and was being piped into the bilevel positive airway pressure tubing.During an interview on 03/19/2026 at 1:07 PM, Licensed Practical Nurse #20 stated they were unsure what Resident #257's bilevel positive airway pressure orders were; they did not have to verify the settings were correct; they thought the mask was supposed to be cleaned monthly and did not know who was responsible to do so; and the mask was only changed if broken. They stated they filled the water reservoir with water during the day shift on 03/16/2026 and was unsure why it was empty.During an interview on 03/19/2026 at 12:03 PM, Licensed Practical Nurse #24 stated oxygen required an order and the setting should be checked once a shift. Nursing was responsible for maintaining the correct bilevel positive airway pressure settings and the water reservoir was full. The bilevel positive airway pressure mask was rinsed out weekly with water and replaced if it stopped working or was filthy beyond repair. There was no special respiratory assessment other than checking oxygen levels every shift. Resident #257 used bilevel positive airway pressure all the time and had five (5) liters of oxygen piped into it. Nursing checked the settings, but they did not document the use or the settings. They did not keep any back up supplies for the bilevel positive airway pressure device on hand and if they needed something they would have to call respiratory across the street. During an interview on 03/19/2026 at 1:45 PM, Registered Nurse Unit Manager #21 stated oxygen required an order and they expected the nurses to ensure the settings were correct. They were unsure who was supposed to clean the bilevel positive airway pressure masks or how often. The water reservoir created humidification and should not be dry. They expected the nurses to know what bilevel positive airway pressure and oxygen settings were and they were set correctly. The bilevel positive airway pressure order was not scheduled and therefore not signed for by nursing, but it should be. They were unsure how the effectiveness of the bilevel positive airway pressure was monitored as there was nothing in place other than checking their oxygen level on the night shift. 10 New York Codes, Rules, and Regulations 415.12(k)(6)

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1 was on transmission-based precautions (enhanced barrier precautions) and Certified Nurse Aide #37 did not perform hand hygiene prior to entering the resident's room, emptied the resident's urinary catheter without wearing required personal protective equipment, and did not perform hand hygiene with glove changes. Findings include: The facility policy Enhanced Barrier Precautions, reviewed 03/06/2026, documented any resident with an indwelling medical device such as a urinary catheter was placed on enhanced barrier precautions. Personal protective equipment including gloves and gown was required to be worn during any high contact resident care activities that included care of a urinary catheter. Face protection may also be worn if needed if performing an activity with a risk of splash or spray. Signage was present on the wall outside the resident's room and indicated the type of precaution, the required personal protective equipment, and the high contact resident care activities that required personal protective equipment. The facility's Enhanced Barrier Precaution signage posted on the wall outside the resident room doors documented everyone must clean their hands, before entering and when leaving the room; providers and staff must also wear gloves and a gown for high contact resident care activities including dressing; bathing/ showering; transferring; changing linens; providing hygiene; changing briefs or assisting with toileting; and device care of use of central lines, urinary catheters, feeding tube, tracheostomy; and wound care. The same gown and gloves were not worn for the care of more than one person. Resident #1 had diagnoses including retention of urine. The 01/05/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had moderate cognitive impairment, required substantial/ maximum assistance with most activities of daily living, and had an indwelling urinary catheter. The Comprehensive Care Plan initiated 01/13/2026 documented the resident had a urinary catheter due to urinary retention. Interventions included the catheter was placed prior to admission on [DATE] and the catheter was changed at least monthly, signs and symptoms of urinary tract infection were monitored and reported, and the drainage bag was kept below the level of the bladder. During an observation and interview on 03/17/2026 at 11:11 AM, the wall to the left of the door to Resident #1's room had an enhanced barrier precaution sign posted. Certified Nurse Aide #37 entered Resident #1's room and addressed the resident. They did not perform hand hygiene prior to entering the resident's room. At 11:12 AM, the certified nurse aide stated they had to find alcohol pads as they could not find any in the room. They took their gloves off, disposed of them in the trashcan, and left the room. They stated they did not perform hand hygiene upon exiting the room. At 11:14 AM, Certified Nurse Aide #37 returned to the room and put on gloves. They did not perform hand hygiene prior to entering the room. They closed the door to the resident's room. There was a yellow caddy on the door with gowns and gloves. They entered the resident's bathroom and dumped a graduated cylinder of urine into the toilet. They depressed the flushing mechanism with a gloved hand and rinsed the graduated cylinder. They put a hand towel on the floor and placed the graduated cylinder on the towel. At 11:15 AM, they placed alcohol pads on the towel on the floor. Resident #1 was seated in their recliner to the left of their bed. The certified nurse aide unclamped the tubing to the resident's catheter drainage port and emptied the urine into the graduated cylinder, re-clamped the tubing and wiped the drainage port with an alcohol wipe. At 11:16 AM, they placed the drainage bag in a privacy bag and hung it from the recliner chair. They did not wear a gown when emptying the urinary drainage bag. They measured the urine, entered the bathroom, dumped the urinary drainage and flushed the toilet. At 11:17 AM, the certified nurse aide took both gloves off and put a new glove on their right hand. They did not perform hand hygiene in between the glove change. At 11:18 AM, they picked up the towel from the floor with their gloved right hand and walked halfway down the hallway to a soiled linen bin to discard the towel. They did not perform hand hygiene upon exiting the room. During an interview on 03/17/2026 at 11:19 AM, Certified Nurse Aide #37 stated the yellow caddy had always been on the resident's door and it was there so they could get a gown to put on. They did not put a gown on because they did not think the resident had any sickness. They stated they should have performed hand hygiene before putting on gloves and in between glove changes but it slipped their mind. Hand hygiene was the biggest thing that could break the link of infection, and it kept away germs. They stated based on the enhanced barrier sign, they should have put a gown on. They learned about precautions when they first started but there was no training since then. During an interview on 3/17/2026 at 11:27 AM, Licensed Practical Nurse #34 stated personal protective equipment was only worn with urinary catheter care if a resident had an active infection. They were not sure what enhanced barrier precautions were but there were signs outside the residents' rooms that told them when and what personal protective equipment was required. During an interview on 3/17/2026 at 12:07 PM, Licensed Practical Nurse Assistant Unit Manager #26 stated enhanced barrier precautions were new this year. The Infection Preventionist was working hard on education and staff had badge backers to reference because it was hard to remember it all. Anyone with a medical device was on enhanced barrier precautions and staff were expected to look for the sign and follow the sign. Resident #1 had a urinary catheter and was on enhanced barrier precautions. Wearing gloves did not eliminate the need for hand hygiene. A gown, gloves, mask, and face shield should be worn with catheter care. This protected residents and staff and prevented the spread of infection. During an interview on 03/20/2026 at 9:29 AM, the Infection Preventionist stated hand hygiene should be performed before and after any resident contact. Gloves did not negate the need for hand hygiene, and it was the single most important thing for infection control and preventing the spread of pathogens. Staff were expected to read the signage and follow it every time. If staff performed any high contact activity that included urinary catheter care, they should wear a gown, gloves, and a face shield if there was a splash risk. All staff were educated on enhanced barrier precautions upon hire, annually, and as needed to protect the residents, staff, and prevent the spread of infection. 10 New York Codes, Rules, and Regulations 415.19(a)(b)

Based on observations, record review, and interviews, the facility failed to ensure residents received and the facility provided a diet in a form designed to meet individual needs for one (1) of one (1) resident (Resident #241) reviewed. Specifically, Resident #241 received a whole regular brownie instead of a pureed brownie as ordered; and the resident's person-centered Comprehensive Care Plan did not include the ordered altered food consistency. Findings include:The facility policy Altered Consistency-Texture Modified Diet-Dysphagia difficulty swallowing) Management, reviewed 04/02/2025, documented residents received food and fluids in a consistency that was safe, palatable, and met their nutritional needs, in accordance with physician orders, clinical assessment, and regulations of the New York State Department of Health. Texture-modified diets and fluid consistencies were implemented as clinically indicated and reduced the risk of aspiration, choking, and malnutrition, while resident rights and preferences were honored. Food texture level Pureed (Level 1) was homogeneous, cohesive, pudding like foods that required minimal chewing. Dietary services ensured all food and fluids met ordered consistencies and were prepared to maintain safety. After the Speech Language Pathologist's evaluation, diet orders, interventions, and care plans were updated in the electronic medical record. Resident #241 had diagnoses including dementia, pneumonia, and difficulty swallowing. The 01/15/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had moderate cognitive impairment, required supervision or touching assistance with eating, and was on a mechanically altered diet. The Comprehensive Care Plan initiated 05/15/2025 and revised 03/16/2026 documented the resident had impaired swallowing related to impaired movement of solids and liquids from the mouth to the stomach as evidenced by coughing with thin liquids and difficulty chewing solids. Interventions included encouraging the resident to eat in the dining room, diet was provided per order, and thin liquids (no straws). The Comprehensive Care Plan did not document the ordered food texture. The 12/20/2025 physician order documented the resident was to receive a level one (1) pureed texture, regular (thin) consistency diet. The 01/01/2026 Speech Language Pathologist #30 Speech Therapy Evaluation and Plan of Treatment documented the resident tolerated their current diet consistencies of level one (1) solids (pureed)/ thin liquids. The resident had absent mastication (chewing) skills when provided with level (2) mechanical soft food. The recommendation was the current diet consistency was continued. The resident was not appropriate for a diet upgrade. The resident's 03/17/2026 lunch meal ticket documented one (1) mint brownie pureed. During an observation on 03/17/2026 at 1:30 PM, Resident #241 was in the dining room eating their lunch. They were not in reach of any other residents' food items. Their main lunch plate had pureed items. To the right of the lunch plate was a smaller plate with an untouched regular consistency brownie with green frosting. At 1:32 PM, the resident was coughing. Speech Language Pathologist #31 was walking through the dining room and asked the resident if they were ok. After looking at their meal ticket, the Speech Language Pathologist picked up the regular consistency brownie and took it to Food Service Worker #32 and asked them for a pureed brownie. Speech Language Pathologist #31 placed the pureed brownie in front of the resident and told them what it was. During an interview on 03/17/2026 at 1:35 PM, Speech Language Pathologist #31 stated they noticed Resident #241 was coughing so they checked their meal ticket, and saw the resident was on a pureed diet with a regular consistency brownie in front of them. The resident had dementia and had forgotten how to eat. It was important that food consistency was followed as choking was silent and could happen quickly. They did not normally monitor the dining room but just happened to be there at that time. During an interview on 03/17/2026 at 1:41 PM, Certified Nurse Aide #33 stated all food items on the meal ticket were placed on the tray by dietary. After all items were placed on the food tray, the staff who picked up the tray and delivered it also double checked for accuracy that the ticket matched the items on the tray. Sometimes things were missed. Resident #241 was on a pureed diet and should not have a regular consistency brownie. It was important the residents were served the correct items and consistencies to make sure there was not a choking hazard. During an interview on 03/17/2026 at 1:53 PM, Food Service Worker #32 stated when they plated meal items they looked at the meal ticket. There were four (4) food levels. If a ticket called for a pureed brownie, the resident should not receive a regular brownie. The food levels were followed because each resident had different health reasons. If a resident on a pureed diet received whole food, they could choke. It was extremely important the guidelines were followed. They did not recall plating a regular brownie on Resident #241's tray. During an interview on 03/19/2026 at 9:27 AM, Licensed Practical Nurse Assistant Unit Manager #26 stated the food server plated the items listed on the meal ticket and the certified nurse aide also read the ticket so there were two (2) eyes to ensure the resident received the proper diet and consistency. Resident #241 was on a pureed diet and should not have a regular consistency brownie. Orders were expected to be followed, and they did not want the residents to choke or aspirate. During an interview on 03/19/2026 at 10:03 AM, Registered Nurse Unit Manager #21 stated the certified nurse aides read the meal ticket to the server, the server looked at the ticket and placed the items on the tray. The staff member who delivered the meal also checked the accuracy of the ticket. Resident #241 was on a pureed diet and should not have a regular consistency brownie. With so many checks, they were not sure how this could have been missed. Residents were on altered diets for a specific reason, there was a medical order, and that medical order was expected to be followed. During an interview on 03/19/2026 at 10:11 AM, the Food Service Director stated the food server referenced the meal ticket and put the items on the tray. The certified nurse aides ensured the accuracy of the items on the tray to match the meal ticket. There was a two (2) point check. Training was done both through the certified nurse aide training as well food service worker training upon hire. They heard Resident #241 received a regular consistency brownie, and they should not have. Food consistencies were followed for the safety of the resident. 10 New York Codes, Rules, and Regulations 415.14(d)(3)

Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for two (2) of seven (7) medication carts (8th floor and 4th floor medication carts); one (1) of four (4) medication rooms (4th floor medication room); and one (1) of seven (7) treatment carts (3rd floor treatment cart) reviewed. Specifically, one medication cart on the 8th floor was unlocked and unsupervised; one medication cart on the 4th floor contained pre-poured, unlabeled medications; the 4th medication room refrigerator contained an open, undated multi-dose tuberculin purified protein derivative vial; and the 3rd floor treatment cart was unlocked and unattended.Findings included:The facility policy Storage of Medications, last reviewed 02/10/2026 documented medication supply was only accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies were locked when they were not attended by persons with authorized access. Outdated, contaminated, or deteriorated medications were immediately removed from inventory, disposed of according to procedures for medical disposal, and reordered from the pharmacy.The manufacturer recommendation documented a vial of tuberculin purified protein derivative which has been entered and in use for 30 days should be discarded.4th floorDuring an observation and interview on 03/17/2026 at 3:38 PM a 4th floor medication cart top drawer contained two white circular tablets in an unlabeled plastic cup. Licensed Practical Nurse #25 stated a resident was supposed to receive them at 4:00 PM but the resident went to bingo. They should have labeled the cup, but they knew who the medications were for.During an observation and interview on 03/17/2026 at 3:43 PM the 4th floor medication room refrigerator had an open vial of tuberculin purified protein derivative with a dispensed date of 01/20/2025. Licensed Practical Nurse #25 stated any multi-dose vial should be labeled with the open date. They were not sure how long the vial was good for after it was opened.During an interview on 03/17/2026 at 4:02 PM Licensed Practical Nurse Assistant Unit Manager #26 stated multi-dose vials should be dated when opened. They had one vial of tuberculin purified protein derivative on the unit. The solution was good 28 days after it was opened. If there was no date then it needed to be discarded. The solution was used for newly admitted residents, and the unit did have admissions in the last 30 days. They stated medications should not be pre-poured; there was no way to know what the medications were and the medications in the cup should have been discarded and not saved for later. During an interview on 03/19/2026 at 10:03 AM Registered nurse Unit Manager #21 stated if medications were put into a medication cup and the resident was not available the medications should be discarded. It was never appropriate to leave a medication cup with pills in the medication cart for administration later. Tuberculin purified protein derivative vials should be dated when opened and were only good for 30 days. The nurse was expected to check the expiration date prior to administration. The nurse should have discarded the vial and ordered a new one once they saw it had no open date. 8th floorDuring an observation on 03/18/2026 from 12:25 PM-12:35 PM the 8th floor medication cart, located across from room [ROOM NUMBER], was unlocked and unattended. Multiple residents and unlicensed staff walked past the unlocked and unattended medication cart.During an interview on 03/18/2026 at 12:36 Licensed Practical Nurse #18 stated the cart was unlocked and contained medications and should not be unlocked. They stated they walked away and did not realize the cart was unlocked. They were trained on medication storage and knew it was supposed to be locked.During an interview on 03/18/2026 at 1:34 Registered Nurse Unit Manager #19 stated medications carts should be locked for safety of the residents and to prevent medication diversion.3rd floorDuring an observation on 03/18/2026 at 6:59 AM the 3rd floor treatment cart was unlocked and unattended. The cart contained an electric razor, a gait belt, multiple medicated creams, sunscreen, alcohol prep pads, and wound gel. During an interview on 03/18/2026 at 1:43 PM Licensed Practical Nurse #27 stated the treatment cart was supposed to be locked when unattended. They did not do treatments on night shift and did not know why it was unlocked. The unit had residents that wandered, and the treatment cart should be locked for safety reasons.During an interview on 03/19/2026 at 11:41 AM Registered Nurse Unit Manager #6 stated medication carts and treatments carts should be locked when unattended so residents could not get in them. The treatment cart had skin prep, alcohol wipes, antibacterial cream, iodine swabs and normal saline, all potentially dangerous for residents and staff. 10 New York Codes, Rules and Regulations 415.18(d)

Based on observation, record review, and interviews, the facility failed to ensure that a resident who required dialysis (a process that filters blood during kidney failure) received services consistent with professional standards of practice for one (1) of one (1) resident (Resident #13) reviewed. Specifically, Resident #13 received dialysis at a community-based dialysis center, and the facility did not perform ongoing assessments of their condition or monitor for complications before and after dialysis treatments and there was inconsistent communication between the dialysis center and the facility. Findings include: The facility policy Dialysis, revised 03/01/2023, documented communication with the dialysis team would be maintained to ensure quality care of the resident; the purpose of the communication book was to share information/ask questions, not requiring immediate responses with the dialysis center; the unit manager/designee was responsible for writing in the communication book; and the resident would be monitored for such things as signs of fluid retention or dehydration, findings documented, and physician notified as appropriate. Resident #13 had diagnoses including kidney failure. The 02/11/2026 Minimum Data Set assessment documented the resident had intact cognition and received dialysis. The 07/03/2025 Comprehensive Care Plan, revised 08/21/2025, documented the resident needed hemodialysis related to kidney failure. Interventions included monitor intake and output, monitor labs and report to the doctor as needed, and monitor/document/report signs/symptoms of renal insufficiency. There was documented evidence the plan included monitoring pre and post dialysis, checking the dialysis access site, or ongoing communication with the dialysis center. Physician orders documented the following:-An undated order for hemodialysis every Monday, Wednesday, and Friday. -On 08/22/2025 notify the physician if systolic blood pressure (upper number on blood pressure reading) was less than 90 or the heart rate was greater than 110 (beats per minute) every shift. There was no documented evidence blood pressures were checked/monitored every shift as ordered or vital signs were obtained before and after dialysis treatments. The March 2026 Medication Administration Record documented check right chest permacath (access site for dialysis) for bleeding every shift, if bleeding apply pressure and notify physician. The Medication Administration Record documented the permacath was checked every day on all three shifts from 03/01/2026-03/18/2026. During an interview on 03/15/2026 at 5:58 PM, Resident #13 stated when they returned from dialysis no one ever checked their vital signs or looked at their dialysis access site. During an observation on 03/16/2026 at 3:05 PM, the resident returned from dialysis and self-propelled to their room. The resident had a venous access site for dialysis located on their right chest. The site was covered with a dry dressing. Their dialysis binder was in a bag connected to the back of their wheelchair and contained a post dialysis weigh form, a photocopy of their medical order for life sustaining treatment, a face sheet, and a printout of orders effective 02/06/2026. It did not include communication between the facility and the dialysis care center regarding medication administration (initiated, administered, held or discontinued) by the nursing home and/or dialysis facility, physician/treatment orders, laboratory values, vital signs, or dialysis treatment provided and resident's response. During an interview on 03/17/2026 at 1:42 PM, Licensed Practical Nurse #20 stated before sending a resident to dialysis they made sure the resident ate, took their medications and had their dialysis binder containing updated orders with them. They did not have to communicate vital signs, last meal, glucose level, or what medications were taken to the dialysis center. They did not usually get communication sheets or any type of report from the dialysis center unless the resident was sent to the emergency room. If there was no communication from the dialysis center, they assumed everything went smoothly. Taking vital signs before or after going to dialysis was not a requirement. They sent Resident #13 to dialysis on 03/16/2026. They did not check the dialysis binder upon return. The resident verbally reported their post dialysis weight which they documented. They did not recall if they checked to make sure the physician orders were updated before sending the resident. They should have gone with updated orders because the 02/06/2026 orders did not reflect medication orders that had been made since then including changes to their Eliquis (a blood thinner). During an interview on 03/18/2026 at 10:54 AM, Registered Nurse Manager #21 stated the licensed practical nurse assigned to the dialysis resident was responsible for making sure their dialysis binder went with them and contained updated orders; the facility was not required to check pre or post dialysis vital signs; there was not a communication form between the facility and the dialysis center; and the dialysis center performed their own vital signs and weights that were supposed to be documented in the binder. They expected if anything unusual happened while at dialysis then they would receive a phone call from the center but that did not always happen. Because their dialysis residents were alert and oriented, they were able to report if something unusual happened. If a resident had a problem like hypotension during dialysis, then that should be monitored upon their return but there was not a policy outlining that. Resident #13 went to dialysis three (3) times a week and should have updated orders in their binder. 10 New York Codes, Rules and Regulations 415.12(k)

Based on observation, record review, and interviews the facility failed to ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for one (1) of three (3) residents (Resident #281) reviewed. Specifically, Resident #281 was admitted with a Stage 2 (partial thickness skin loss) pressure ulcer and did not have admission orders for wound care.Findings include:The facility policy Wound Care and Pressure Injury Prevention and Treatment, last reviewed 02/11/2026, documented the facility would implement a systemic interdisciplinary process for the prevention, identification, assessment, treatment, and monitoring of wounds and pressure injuries to ensure pressure injuries were prevented and that existing wounds received appropriate and timely treatment. The nurse managers were responsible for performing comprehensive wound and skin assessments, initiating/updating care plans, obtaining and entering provider orders, overseeing wound care practices, participating in wound rounds, and ensuring follow-up on recommendations.Resident #281 had diagnoses including diabetes, muscle weakness, and need for assistance with personal care. The 02/13/2024 admission Minimum Data Set assessment documented the resident had moderate cognitive impairment; was frequently incontinent; required substantial/maximal assistance with personal hygiene and showering/bathing; was dependent with toileting hygiene; did not have unhealed pressure ulcers; and was at risk for pressure ulcers.The 02/08/2024 admission Assessment completed by Registered Nurse Unit Manager #21 documented the resident had redness and a dime size Stage 2 pressure ulcer on their coccyx (tailbone).There was no documented evidence of wound care orders for the coccyx upon admission to the facility.The Comprehensive Care Plan initiated 02/09/2024 and revised 02/21/2024, documented the resident had a potential/actual impairment (Stage 2 pressure injury to coccyx) to skin integrity related to impaired mobility. Interventions included follow facility protocols for treatment of injury, encourage good nutrition and hydration to promote healthier skin, monitor/document size and location of skin injury and report signs and symptoms of infection.The 02/13/2024 Skin Only Evaluation completed by Licensed Practical Nurse #24 documented the resident had a skin issue on their back and coccyx.The 02/13/2024 provider order documented apply foam dressing to the coccyx every day shift every 3 days for protection.The resident did not have wound care orders for 5 days.The 02/16/2024 Registered Nurse Unit Manager #21 progress note documented the resident had a very small Stage 2 pressure ulcer on their coccyx upon admission. Wound care orders were put in place for protection, and the wound healed.The resident was hospitalized from [DATE]-[DATE].The 02/21/2024 admission Assessment completed by Registered Nurse Unit Manager #21 documented the resident had a reopened Stage 2 pressure ulcer on their coccyx.The 02/21/2024 at 12:57 PM physician orders documented resume previous orders. The provider order documented apply foam dressing to the coccyx every day shift every three (3) days for protection was discontinued 02/23/2026.The 02/23/2024 Registered Nurse Unit Manager #21 progress note documented they completed wound rounds with the wound care nurse and the resident's skin was clear at that time.The 02/27/2024 Skin Only Evaluation completed by Licensed Practical Nurse #20 documented the resident had a pressure ulcer on their coccyx.The 03/04/2024 Licensed Practical Nurse #24 progress note documented the resident's family called and complained the resident had an open area on their buttocks. The nurse manager was aware and assessed the resident.There was no documented evidence that the Skin Only Evaluation was completed on 03/05/2026.The 03/05/2024 Licensed Practical Nurse #36 progress note documented the resident refused to be repositioned on their side for an open area on their right buttock.The 03/08/2024 Registered Nurse Unit Manager #21 progress note documented they assessed the resident's coccyx with the wound care nurse. The area was red and had no open areas. The 03/10/2024 provider order documented the following wound care orders. Stage 2 pressure ulcer to the coccyx cleanse with normal saline, pat dry, apply skin prep to the surrounding skin, and cover with foam dressing on the day shift every three (3) days and as needed.The resident did not have wound care orders for the Stage 2 pressure ulcer on their coccyx for 12 days from 02/27/2024-03/10/2024.During an interview on 03/19/2026 at 11:24 AM, Registered Nurse Unit Manager #21 stated when a resident was admitted to the facility they reviewed the hospital paperwork, completed a head-to-toe assessment which included a skin/wound assessment, emailed the wound team so any wounds would be tracked, and notified medical to obtain orders. Resident #281 was admitted on [DATE] with redness and a Stage 2 pressure ulcer on their coccyx. They stated they sent an email to the wound team on 02/08/2026 so they were unsure why the resident was not seen by the team, and they could not recall why there were no wound care orders until 02/13/2024. The resident was readmitted from the hospital on [DATE] with a Stage 2 pressure ulcer on their coccyx. Licensed practical nurses were responsible for completing weekly skin checks. The 02/27/2024 skin check documented a Stage 2 pressure ulcer, so they were unsure why there was no documented registered nurse assessment, wound provider notes, or orders for wound care until 03/10/2024. They stated it was a long time ago and they could not recall why Resident #281's skin and wounds were not monitored appropriately.During an interview on 03/19/2026 at 12:14 PM, Licensed Practical Nurse #20 stated they were responsible for completing weekly skin checks on residents and if they found any issues they notified the registered nurse. They completed the 02/27/2024 skin check on Resident #281 and it appeared the wound was not resolved. They could not recall but thought they may have notified Registered Nurse #21.During an interview on 03/19/2026 at 12:36 PM, Licensed Practical Nurse/Wound Nurse #26 stated they did not see any wound notes or other documentation for Resident #218. If the wound team was notified the resident had a wound, they entered the information into the system for wound tracking. Resident #281's Stage 2 pressure ulcer should not have gone without an ordered treatment for any amount of time and should have been monitored regularly for progression of healing.During an interview on 03/19/2026 at 1:40 PM, the Director of Nursing stated when a resident was admitted the registered nurse was responsible for completing a clinical evaluation for any skin issues. If the resident had a Stage 2 pressure ulcer on admission the provider should have been contacted to obtain orders for a treatment and the wound team notified so they could complete weekly wound rounds to ensure the treatment was effective. Resident #281 should have had a treatment in place for the Stage 2 pressure ulcer as soon as it was identified. 10 New York Codes, Rules and Regulations 415.12(c)(1)

Based on observations and interviews during the survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of four (4) Residents (Resident #197) reviewed. Specifically, Resident #197 had significant weight loss, was not assisted with meals as care planned, and there was no documented evidence a medical provider addressed the resident's weight loss.Findings included:Resident #197 had diagnoses including Alzheimer's disease and abnormal weight loss. The 01/29/2026 quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision/touching assistance with eating, and had a 5% or weight loss in the last month or 10% more in the last 6 months and was not on a physician-prescribed weight-loss regimen.The 08/19/2025 Comprehensive Care Plan, revised 11/18/2025, documented the resident had inadequate oral intake related to decreased appetite and sleeping during meals as evidenced by poor recorded intakes and significant weight loss of 11 pounds in 90 days. The goal was to consume adequate intakes to support a weight goal of 115 pounds, no further weight loss, no skin breakdown, or signs or symptoms of dehydration. Interventions included providing Ensure Plus High Protein (nutritional supplement) with breakfast and evening medication pass daily and weights per provider order. The resident required assistance with self-care and mobility related tasks. Interventions included provide assistance of one staff with extensive verbal cues for encouragement. The Care Card (care instructions) documented the resident required assistance of one with extensive verbal cues for encouragement at meals and if the resident became overwhelmed in the dining room, provide a place to sit outside or the option to eat in their room. The resident's weights documented:- 10/01/2025: 128 pounds- 11/05/2025: 122.4 pounds- 12/03/2025: 119.4 pounds The 12/05/2025 Registered Dietitian #12 progress note documented the resident had a 13% weight loss in the past 180 days. The plan was to continue Ensure Plus High Protein with breakfast and at bedtime. Continue monitoring weekly weights. Staff reported the resident benefitted from encouragement and redirection during meals to promote intake. There was no documented evidence the medical provider was made aware of the resident's weight loss. The resident's weights documented:- 01/07/2026: 114.8 pounds (severe 10.3% loss in 3 months) The 01/30/2025 Registered Dietitian #12 progress note documented the resident had a 10% weight loss in 180 days but weights were stable for 30 days. The resident benefited from staff redirection during meals however continued to be preoccupied with picking at their skin. The plan was to add high protein strawberry milk with all meals and continue to monitor. The 02/04/2026 weight was documented at 115 poundsThe 02/08/2026, Registered Dietitian #12 progress note document the resident received Ensure High Protein at breakfast and at night for snack. They required the assistance/supervision of one staff member with extensive verbal cues provided for encouragement. They had a 10 percent weight loss in the last six months. Interventions included a regular diet with Ensure High Protein at breakfast and evening medication pass and to continue weekly weights.There was no documented evidence the medical provider was made aware of the resident's weight loss. The 03/11/2026 weight was documented at 114.2 pounds. The following observations were made of Resident #197 during dinner service on 03/15/2026:- At 6:04 PM spilling their drink on the table and their hands were shaking.- At 6:07 PM touching their food with their hands and not eating.- At 6:24 PM asleep at the table. They consumed 0-25% of solid food and 75% of the pink milk.- At 6:41 PM a safety aide cleaned the drink spill. No assistance or encouragement was provided.- At 6:52 PM at the table with their eyes closed and their head on their hands. The resident had no additional intake. No assistance or encouragement was provided.- At 7:06 PM Certified Nurse Aide #15 asked the resident if they were done eating and removed their meal tray. The resident consumed 0-25% of the chicken patty and cauliflower, 75% of pink milk, and 100% of the hot beverage. No assistance or encouragement was provided during the meal. The following observations were made of Resident #197 during lunch service on 03/16/2026:- At 1:23 PM the resident was served green beans, rice, strawberry milk, high protein Ensure, ice cream, cut up honey chicken, and Asian vegetables.- From 1:28 PM- 1:38 PM there was no assistance or encouragement provided to the resident.- At 1:48 PM the resident's eyes were closed and they did not consume anymore of the meal.- At 2:09 PM Hospitality aide #16 spoke to the resident and pointed to the Ensure then walked away.- At 2:10 PM the resident's tray was removed.During an interview on 03/19/2026 at 9:00 AM Registered Dietitian #12 stated they provided nursing a list of residents who needed to be weighed; significant weight changes were 5% change in one month, 7.5% change at three months, and 10% change at six months. Resident #197 had significant weight loss and was on supplements. The resident was care planned to receive verbal cues at meals and staff should follow the care plan.During an interview on 03/19/2026 at 9:30 AM Licensed Practical Nurse #18 stated staff reviewed the care plan, and if residents required verbal cues staff should provide cues during meals. Resident #197 did not eat a lot and needed cues and staff should be encouraging them. Staff should tell the nurse if a resident was not eating. They were not aware that the resident was not eating or receiving verbal cues.During an interview on 03/19/2026 at 9:59 AM Registered Nurse Unit Manager #19 stated the care instructions listed the level of assistance required for meals. The registered dietitian sent out an email about significant weight changes to the medical providers. Resident #197 had significant weight changes and required supervision with verbal cues at meals. Staff needed to be in line of sight of the resident and provide encouragement at meals. Staff should tell the nurse if the resident was not eating and offer alternatives. They stated medical had not addressed the resident's weight loss and they had not discussed it with the providers.During an interview on 03/19/2026 at 2:10 PM Nurse Practitioner #8 stated registered dietitians sent them an email discussing significant weight changes. They did not attend the weight meetings. They communicated with the registered dietitian electronically and tried to document the significant weight changes. Weights were reviewed monthly and they expected to be notified of significant weight loss. Resident #197 had significant weight loss six months ago and then stabilized. There was a significant change in December. In an ideal situation they would have requested a re-weight. They did not see any medical notes about the significant weight loss from December. The weight loss was likely progression of dementia. They stated staff should follow the care plan. During an interview on 03/19/2026 at 2:37 PM Certified Nurse Aide #17 stated they reviewed the care instructions to identify the level of assistance residents needed for meals. Supervision/touching assistance meant assisting the resident with eating, guiding their hands, and supervising them. Verbal cues of encouragement at meals were to get them to eat. Resident #197 required verbal cues and sometimes assistance. They did not assist the resident with meals on 03/15/2026 and believed the resident did not eat much. The resident was not on the list to assist with meals. They should have provided verbal cues if they were not eating. 10 New York Codes, Rules and Regulations 415.12(i)1

Based on observations, record review, and interviews the facility failed to provide the necessary services and treatment for indwelling urinary catheter use for two (2) of six (6) residents (Residents #1 and #13) reviewed. Specifically, Resident #1 did not have a provider recommended voiding trial completed; and Resident #13 had an indwelling urinary catheter with a history of bladder infections and did not receive assistance with changing between their urinary collection leg bag (a small, wearable, and discreet receptacle used to collect urine) and a large capacity urinary collection bag. Findings include: The facility policy Foley Catheter, revised 04/21/2015, documented the facility ensured all residents with an alteration in urinary continence had been assessed and provided the interventions that best meet their needs and the physician's order would be checked for an appropriate medical justification. There was no documented policy addressing care and maintenance of an indwelling urinary catheter. 1) Resident #1 had diagnoses including retention of urine. The 01/05/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had moderate cognitive impairment, required substantial/ maximum assistance with most activities of daily living, and had an indwelling urinary catheter (a tube that allows urine to pass out of the body). The Comprehensive Care Plan initiated 01/13/2026 documented the resident had a urinary catheter due to urinary retention. Interventions included the catheter was placed prior to admission on [DATE] and the catheter was changed at least monthly, signs and symptoms of urinary tract infection were monitored and reported, and the drainage bag was kept below the level of the bladder. The 12/30/2025 Hospital Discharge Summary documented the resident had a urinary catheter in place, failed voiding trials during the hospital stay and the plan was to continue the urinary catheter on discharge and a voiding trial could be attempted at the rehabilitation facility and the resident should be referred to urology (medical specialty that focuses on the urinary system) outpatient. The 12/30/2025 Registered Nurse Unit Manager #21's Clinical admission Assessment documented the resident had a new urinary catheter placed at the hospital for urinary retention. The 01/02/2026 Initial History and Physical completed by Physician #4 documented the resident had a urinary catheter in place and had apparently failed three (3) voiding trials at the hospital. The plan was to follow up with urology. There was no documented evidence an appointment for urology follow up was made. The 01/09/2026 physician orders documented the resident had a urinary catheter for urinary retention as needed for obstruction. There was no documented evidence of a physician order for the urinary catheter from 12/30/2025-01/09/2026. The 01/12/2026, 01/14/2026, 01/20/2026, and 01/22/2026 Nurse Practitioner #8 progress notes documented the resident had a urinary catheter. There was no documented plan to address the urinary catheter. The 01/30/2026 physician order documented to remove the urinary catheter one time for a voiding trial. If the resident did not void during the day shift, the urinary catheter would be replaced. The 02/02/2026 Licensed Practical Nurse Assistant Unit Manager #26 progress note documented the resident had their urinary catheter removed a 6:00 AM that morning for a voiding trial. The resident was unable to void after eight (8) hours, and the urinary catheter was replaced. There was no documented evidence Nurse Practitioner #8 was notified of the failed voiding trial. Medical provider progress notes documented: - On 02/13/2026, 02/24/2026, 02/26/2026, 02/27/2026, and 03/02/2026 by Nurse Practitioner #8 the resident had a urinary catheter. There was no documented plan to address the urinary catheter. There was no documented evidence they were aware of a failed voiding trial. -On 03/06/2026 by Physician #4 the resident had a urinary catheter in place. The plan was discussed with the team to attempt a voiding trial and if it failed, consider urology follow up. There was no documented evidence an additional voiding trial was attempted, or a urology appointment was made. The 03/09/2026, 03/10/2026, 03/11/2026, 03/12/2026, 03/13/2026, and 03/17/2026 Nurse Practitioner #8 progress notes documented the resident had a urinary catheter. There was no documented plan to address the urinary catheter. During an observation and interview on 03/15/2026 at 4:20 PM, Resident #1 was seated in their recliner chair in their room. They had a urinary catheter drainage bag hanging off the recliner chair wrapped in a pillowcase. The tubing had straw colored urine in it. The resident stated they had the catheter since they were admitted to the facility. During a follow up interview on 03/17/2026 at 10:03 AM, Resident #1 stated the urinary catheter was placed in the hospital because they could not urinate. The facility removed the catheter once, but they could not urinate, so it was put back in. They had never seen a urologist and they were not informed of any sort of plan for the urinary catheter. During an interview on 03/17/2026 at 12:07 PM, Licensed Practical Nurse Assistant Unit Manager #26 stated if a resident was admitted to the facility without a proper diagnosis for a urinary catheter, a voiding trial was done and if that failed, the resident went to urology for a proper diagnosis. It was important residents went to urology right away because having a urinary catheter put them at high risk for infection or they could lose the ability to urinate on their own. They recalled attempting a voiding trial with Resident #1, but they failed. The medical provider should have been notified of the failed attempt, and it was documented in their progress note if it was done. They were not sure why the resident had not yet gone to urology. Unit Clerk #43 scheduled urology appointments. During an interview on 03/17/2026 at 1:20 PM, Unit Clerk #43 stated they made outside appointments for the residents. Usually, they could get residents in for urology appointments within a couple of weeks. They were not sure why it had taken so long to get Resident #1 to urology, but they stated the resident had an appointment scheduled for 04/27/2026 (4 months after admission). During an interview on 03/19/2026 at 10:03 AM, Registered Nurse Unit Manager #21 stated if a resident was admitted to the facility with a urinary catheter, a voiding trial was attempted within the first couple of weeks. If the voiding trial failed, the catheter was replaced and the resident followed up with urology. The unit clerk made the appointments but they did not document their efforts anywhere so there was no way to prove when they contacted urology for an appointment. A voiding trial required an order; they did not know why the recommended voiding trial on 03/06/2026 was not followed through. Whatever nurse this was communicated to was responsible for entering the order. The medical provider should be notified of the initial failed voiding trial, but the nursing progress note did not indicate that it was done. During a telephone interview on 03/19/2026 at 3:25 PM, Nurse Practitioner #8 stated the facility had a protocol to attempt a voiding trial as soon as possible after admission for removal of a urinary catheter. Residents with catheters had increased risk for urinary tract infections. Resident #1 had voiding trials that failed at the hospital and one at the facility. The resident should have been sent to urology to determine what the problem was. The resident had declined a urology follow up in the past couple of weeks, and the refusals were likely not documented. The resident's family did not want any aggressive measures. They thought the resident was going to expire and the goal was to keep them comfortable, but they did not. Not all cases were black and white but if they were not going to send the resident to urology, they should have documented notes to support that, and nursing should have too. 2) Resident #13 had diagnoses including obstructive uropathy (a condition that blocks the flow of urine), bladder cancer, and bladder infection. The 02/11/2026 Minimum Data Set assessment documented the resident had intact cognition; required moderate assistance with toileting hygiene; and had an indwelling catheter. The 07/15/2025 Comprehensive Care Plan, revised 02/19/2026, documented the resident had an indwelling urinary catheter. Interventions included position catheter bag and tubing below the level of the bladder and change catheter bag per protocol and as needed. Physician orders documented the following: -On 02/05/2026 change the 16 French (catheter size) urinary catheter on the 2nd of each month and as needed. -On 2/01/2026 cefpodoxime proxetil (an antibiotic) oral tablet 100 milligrams give one (1) tablet by mouth three (3) times a day for urinary tract infection for three (3) days. -On 03/19/2026 Bactrim DS (an antibiotic) oral tablet 800-160 milligrams give one (1) tablet by mouth two (2) times a day for urinary tract infection for five (5) days. During an interview on 03/15/2026 at 5:58 PM, Resident #13 stated they had a leg bag and did not change to a large collection bag when going to bed. They did not know they should do so, as no one had ever explained why they should. If it was in their best interest to do so they would. Per manufacturer specifications urinary leg bags generally measure around 10 to 13 inches in length and 3.75 to 5 inches in width and are designed to fit discreetly on the thigh or calf and are held in place with wide fabric straps. When reclined in bed the collection bag does not remain below the level of the bladder. During an interview on 03/17/2026 at 3:36 PM, Certified Nurse Aide #22 stated leg bags were switched to large bags at bedtime. Resident #13 independently switched back and forth between a leg and large collection bag. They did not think the resident wore a leg bag while in bed. During a follow up interview on 03/18/2026 at 9:04 AM, Resident #13 stated they never switched their own bags before as they were told only nursing could do so. During an interview on 03/18/2026 1:42 PM, Certified Nurse Aide #23 stated Resident #13 regularly wore a leg bag when they went to dialysis, kept it on when they returned, and went to bed with it on. They could not switch the bags themself so staff should be offering to do so. They recalled times when they found the resident in the morning in bed still wearing their leg bag. During an interview on 03/18/2026 at 2:06 PM, Licensed Practical Nurse #24 stated leg bags should be switched to large bags when going to bed. If a resident preferred not to do so, there should be documentation that education was provided to the resident. Resident #13 had a history of bladder infections and generally liked to leave the leg bag on most of the time including when in bed. The resident depended on staff to switch the bags. If their preference was to not switch bags there should be documented education on the risks. During an interview on 03/19/2026 at 10:34 AM, Registered Nurse Unit Manager #21 stated leg bags were not ideal when in bed due to the bag not being below the level of the bladder which could impact draining and cause backflow and infection. However, if a resident was alert and oriented and preferred to wear a leg bag to bed, they should be allowed to do so after receiving education on the associated risk. Education should be documented and their preference added to the care plan. Resident #13 had a history of bladder infections. Their bag should be positioned below their bladder and switched from a leg to a large collection bag at night, but they preferred a leg bag. The resident's care plan should document they declined to switch. They were not aware of any documented education provided to the resident regarding the associated risk or any documentation of their declinations. 10 New York Codes, Rules and Regulations 415.12(d)(1)

Based on observations, record review, and interviews, the facility failed to ensure adequate supervision to prevent accidents for one (1) of one (1) resident (Resident #215) reviewed. Specifically, Resident #215's elopement safety interventions of 30 and 60-minute safety checks and wander guard tag checks were not completed as planned/ordered. Findings include:The facility policy Elopement Prevention, revised 01/11/2023, documented the assigned nurse would check the resident every shift to ensure the wander guard tag was in place and had a blinking red light indicating it was functioning properly. The facility policy Elopement - Resident Evaluation for Potential, revised 02/16/2024, documented elopement precautions would be addressed on the care plan, implementing measures as indicated.The facility policy Increased Supervision-Visual Monitoring Checks and 1 to 1, revised 10/11/2021, documented a resident on increased supervision would have a staff person assigned to do a visual check on the resident within consecutive 30 or 60-minute intervals as necessary; interventions would be added to the appropriate care plan; and the assigned staff person was responsible for observing the resident at designated intervals and documenting the observation on the sheet.Resident #215 had diagnoses including dementia. The 07/18/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition; walked up to 150 feet with a walker independently; and used an elopement alarm daily.The 05/24/2024 Comprehensive Care Plan documented the resident was at risk for elopement due to cognitive impairment. Interventions included check placement and function of wander guard every shift.07/24/2024 incident:The 05/24/2024 elopement risk assessment documented the resident was at high risk for elopement.The 06/27/2024 Licensed Practical Nurse #34's progress note documented the resident was started on a trial of 30-minute checks.There was no documented evidence the resident's Comprehensive Care Plan included initiation of 30-minute checks. The undated Summary of Investigation documented on 07/24/2024 at 5:00 AM the resident was found in the basement lobby by an environmental services employee who responded to the sound of the wander guard system's audible alarm. The resident was last seen at 2:00 AM lying in their bed.The 07/24/2024 Observation Record Safety Check form documented 30-minute checks were not documented as being completed from 12:00 AM through 2:30 PM.During an interview on 03/18/2026 at 11:09 AM and 03/19/2026 at 1:18 PM, Registered Nurse Unit Manager #21 stated once a decision to initiate 30 or 60-minutes checks was made, they communicated it to the nurse and the aide assigned to the resident; the care plan and resident care instructions was updated; and safety check sheets initiated and placed either on a clipboard or in a binder and kept in the zone of which the resident's room was located. They were aware Resident #215 was placed on 30-minute checks in June 2024. Those checks should have been on their care plan and resident care instructions, and they were not sure why they were not. On 07/24/2024, when the resident was found in the basement, they were on 30-minute checks. They stated they were unsure when the last check was documented prior to the resident being found in the basement but it should have been between 4:00 AM and 5:00 AM.During an interview on 03/18/2026 at 12:09 PM and 03/19/2026 at 4:00 PM, the Director of Nursing stated if a resident was put on 30 or 60-minute checks it should be added to the care plan and the resident care instructions. The staff member assigned to that resident was responsible for making sure those checks were documented. On 07/24/2024, Resident #215 had a wander guard and was on 60-minute safety checks. They were provided care at 2:00 AM and went back to sleep. At approximately 4:56 AM the wander guard system in the basement alarmed and an environmental service worker found Resident #215 just outside the basement elevator. The safety check sheet was blank until 3:00 PM on 07/24/2024 but should not have been. They were unsure why they had not caught that when they investigated the incident. March 2026:The 05/24/2024 Comprehensive Care Plan, revised 10/27/2025, documented the resident was at risk for elopement due to cognitive impairment. Interventions included check placement and function of wander guard on right ankle every shift and continue 60-minute checks.The 01/23/2026 elopement risk assessments documented the resident was at high risk for elopement.The 08/05/2025 physician order documented to check placement and function of the resident's wander alert device every shift.The March 2026 daily Observation Record Safety Check forms documented 60-minute checks were not signed hourly on the following dates: 03/01/2026- 03/03/2026, 03/06/2026, 03/09/2026, 03/12/2026, 03/13/2026, 03/16/2026, and 03/19/2026. The March 2026 Medication Administration Record documented Licensed Practical Nurse #20 signed for checking the placement and function of the resident's wander guard on 03/17/2026 during the day shift.During an interview on 03/17/2026 at 3:20 PM, Licensed Practical Nurse #20 stated wander guard placement and the presence of a blinking red light, indicating the device was functioning properly, was checked daily. They signed they performed all the resident wander guard checks on 03/17/2026, including Resident #215's, but they did not as they were spread too thin that day. Instead, they relied on the aides to tell them if a wander guard was missing or not flashing. Resident #215 eloped in the past and had a history of removing their wander guard. They should have checked the resident's wander guard. They should have asked their manager to help with the checks, but it did not occur to them to do so. During an interview on 03/19/2026 at 11:33 AM, Certified Nurse Aide #35 stated 30-minute checks were listed on the white board at the nurses' station and thought it would be on the resident care instructions but was not sure. The checks entailed documenting what the resident was doing and the initials of the person performing the check. There should not be any blanks on them, and it was the responsibility of the assigned aide to make sure there were not. Resident #215 was on 60-minute checks. They should have safety check sheets kept in a binder and there should not be any blanks on them. During an interview on 03/19/2026 at 11:54 AM, Licensed Practical Nurse #24 stated safety checks were typically communicated verbally during shift report. It should also be on the care plan and resident care instructions. The aide assigned to that resident was responsible for making sure they were completed. There was no follow-up process in place to monitor the completion of the forms. Resident #215 was high risk for elopement and was on safety checks for elopement. During an interview on 03/18/2026 at 11:09 AM and 03/19/2026 at 1:18 PM, Registered Nurse Unit Manager #21 stated wander guards were checked every shift for a blinking red light which meant it was working properly. That check was documented on the treatment administration record and if the nurses were signing for it, they expected it to be done. If a nurse was too busy to complete, they should report so someone else could be assigned. The safety check sheets were completed by the certified nurse aide assigned to the resident and should not have any blanks. No one monitored the sheets to make sure they were complete. It would be good practice for someone to monitor them, but they had not done so because staff should know what they were supposed to do.During an interview on 03/18/2026 at 12:09 PM and 03/19/2026 at 4:00 PM, the Director of Nursing stated nurses should check placement and function of the wander guards every shift and should not be signing they had done so if they had not. The nurse managers should make sure there were no blanks on the safety check sheets. They did not know why there were blanks on them as they thought the nurse managers were checking them and following up if there was a problem. 10 New York Codes, Rules and Regulations 415.12(h)(1)(2)

Based on record review and interviews during the survey (Complaint #756448), the facility failed to ensure residents were free from abuse and neglect for one (1) of three (3) residents (Residents #3) reviewed. Specifically, on 03/24/2024 at approximately 12:00 AM, Resident #3 was zip tied (a fastener with a locking, self-snagging nylon strap used to secure items) to the able riser (enabler bar) on their bed by Licensed Practical Nurse #7, for approximately 45 minutes to one (1) hour. This resulted in Immediate Jeopardy Past Non-Compliance for Resident #3 and placed all residents at risk for abuse. Findings include:The facility policy Prevention of Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, revised 02/10/2023, documented abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Involuntary seclusion was confinement to his/her room against the resident's will. In addition to orientation, all employees should be in-serviced annually regarding: the appropriate interventions for dealing with aggressive resident behaviors; how to report alleged allegations of abuse, neglect, and misappropriation of resident property; and what constitutes abuse, neglect, and misappropriation of resident property.\Resident #3 had diagnoses including Alzheimer's dementia and Parkinson's (a progressive neurological disorder) disease. The 01/24/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition; did not exhibit behavioral symptoms; and walked independently with supervision. The 01/18/2024 comprehensive care plan documented the resident was an elopement/wandering risk related to disorientation to place, impaired safety awareness, and wandering aimlessly. Interventions included distractions from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book; and identify pattern of wandering. The 01/19/2024 comprehensive care plan documented the resident had a potential psychosocial well-being problem related to their disease process of dementia. Interventions included allowing time to answer questions and to verbalize feelings, perceptions, and fears. The 03/25/2024 facility investigation synopsis completed by the Director of Nursing documented on 03/24/2024 at approximately 12:00 AM, Certified Nurse Aide #4 witnessed Licensed Practical Nurse #7 place a zip tie around Resident #3's right wrist connecting it to the able riser, in the down position, on the resident's bed. Certified Nurse Aide #6 reported they observed Licensed Practical Nurse #7 place a zip tie on Resident #3's right wrist, connecting it to the right side rail which was in the down position. Certified Nurse Aide #6 stated on 03/24/2024, approximately 45 minutes to one (1) hour later, they cut the zip tie off Resident #3's right wrist. Certified Nurse Aide #4 reported the incident to oncoming Licensed Practical Nurse #22 (at 3:00 AM), who reported to Registered Nurse Supervisor #5. Licensed Practical Nurse #22 immediately checked on Resident #3 and noted they did not find any marks on the resident's wrists. Registered Nurse Supervisor #5 immediately assessed Resident #3 who did not sustain any injury as evidenced by no redness, no bruising, and no open areas. During the assessment, there was no evidence of or display of any signs or symptoms of psychological distress. Resident #3 was interviewed at the time of the initial assessment with no recollection of the event. Registered Nurse Supervisor #5 notified the Director of Nursing and immediately placed involved parties on administrative leave pending investigation. Investigation statements included:- The undated statement signed by Certified Nurse Aide #4 documented on 03/23/2024, they ordered food, and it arrived at 11:21 PM, they got their food and ate it. They went around with the linen cart and checked the shower rooms; once they were finished, they went back to the nurse's Station. They heard a commotion, near Resident #3's room where Licensed Practical Nurse #7 and Certified Nurse Aide #6 were. They went to the door to see if they needed assistance and saw Licensed Practical Nurse #7 zip tie Resident #3 to the bedside rail. There was a white zip tie around the resident's wrist and a black one intertwined around the bedrail. They attempted to take a photo, but Licensed Practical Nurse #7 and Certified Nurse Aide #6 were in and out of the room. They started their rounds at 1:00 AM, and that was when Licensed Practical Nurse #7 and Certified Nurse Aide #6 decided they should remove the zip ties.- The undated statement signed by Licensed Practical Nurse #22 documented on 03/24/2024 at 3:00 AM, when they came on shift, they got report from Licensed Practical Nurse #7. After Licensed Practical Nurse #7 left with Certified Nurse Aide #6 at approximately 4:30 AM, Certified Nurse Aide #4 reported that Licensed Practical Nurse #7 had zip tied Resident #3 to their bed earlier in the night. They immediately went to Resident #3's room and checked the wrist and ankles for injuries and found no marks of any kind. They found a black zip tie on the floor under Resident #3's bed, it was zipped together and cut. They went to the nurse's station and found a white zip tie in the garbage that had been zipped together and cut. At about 3:30 AM, Certified Nurse Aide #6 picked up garbage from the floor at the nurse's station and threw it in the trash stating, garbage all over the floor, this was the same trash the white zip tie was gathered from. After redirecting and assisting a resident, Licensed Practical Nurse #22 and Certified Nurse Aide #4 reported the incident to Registered Nurse Supervisor #5.- The undated statement signed by Registered Nurse Supervisor #5 documented on 03/24/2024 at 8:20 AM, it was reported to them by Certified Nurse Aide #4 that they witnessed Licensed Practical Nurse #7 zip tie a resident's left wrist to their bed rail, at approximately 12:00 AM. They documented that Certified Nurse Aide #4 attempted to take a photo of the zip tie in place, but Licensed Practical Nurse #7 and Certified Nurse Aide #6 were in and out of the room. Per Certified Nurse Aide #4, when Certified Nurse Aide #6 noticed Licensed Practical Nurse #22 approaching they quickly picked up the zip tie and tossed it in the trash. Licensed Practical Nurse #22 then collected the zip tie from the trash. After notification of the whole incident, they reported it to the Director of Nursing and assessed the resident. There were no noted injuries to the resident's wrists and no apparent signs of mental or emotional stress. Resident #3 did not recall the incident. - The 03/26/2024 statement signed by Certified Nurse Aide #6 documented they worked half the shift, until 3:00 AM, and left around 4:45 AM. Licensed Practical Nurse #7 went out to smoke, and came back out of character, uncomfortable looking, sweaty, had puffy eyes, and random outbursts. Resident #3 came out of their room earlier in the night, maybe 12:00 AM - 1:00 AM. They saw Resident #3 in the hall by the nurse's station and walked quickly towards them, as they were a fall risk. Licensed Practical Nurse #7 helped Certified Nurse Aide #6 bring Resident #3 back to bed, they left the room when the resident was back in bed. Later, they went back to Resident #3's room. Licensed Practical Nurse #7 was in the room, and Resident #3 was hitting Licensed Practical Nurse #7. They asked if Licensed Practical Nurse #7 needed help and was told no, so they left. Licensed Practical Nurse #7 still looked out of character, possibly stressed. They checked on Resident #3 towards the end of the shift, and the resident was sleeping. There was a sock on their wrist, and a zip tie. They cut it off and placed it on the desk at the nurse's station. Before leaving for the night, they saw Licensed Practical Nurse #7 holding Resident #3's door shut. Resident #3 would turn the handle and Licensed Practical Nurse #7 kept the handle still, not allowing the resident to open the door. Licensed Practical Nurse #7 talked through the door and said [Resident #3], go back to bed. The 03/26/2024 Police Report documented an unlawful restraint possibly used on a resident. It was documented that on 03/24/2024, Resident #3 had a sock placed over their right hand and several plastic zip ties around the hand, restraining the resident to the bed. During an interview on 02/11/2026 at 8:30 AM, the Director of Nursing stated they investigated the incident with Resident #3 on 03/24/2024. All parties were suspended pending investigation.Certified Nurse Aide #6 was terminated for not reporting the incident and Licensed Practical Nurse #7 was terminated due to the found abuse. The incident was reported the same day it was discovered. Based on the investigation, Licensed Practical Nurse #7 was found to have zip tied Resident #3's wrist to the bedrail. They were unsure if it was both wrists or which one. They still had the zip ties from the investigation. The incident occurred on the overnight shift from 3/24/2024 to 3/25/2024. The staff members were suspended on 3/25/2024 in the morning. During a telephone interview on 02/11/2026 at 10:58 AM, Certified Nurse Aide #4 stated there was an incident with Licensed Practical Nurse #7 and Resident #3 on 03/24/2024. Resident #3 had frequent falls from bed, so they had pressure mats that alerted when the resident got out of bed. Licensed Practical Nurse #7 got tired of having to come to the unit and check on the resident, so they stated they were going to give Resident #3 their own personal protective bracelets. They asked Licensed Practical Nurse #7 what that meant and told them it was illegal to restrain the residents. Licensed Practical Nurse #7 and Certified Nurse Aide #6 went into Resident #3's room, they thought they were putting the resident back to bed. They continued their nightly chores of returning clean clothes to the residents' closets. When they went in with Resident #3's clothing they saw the zip ties. Licensed Practical Nurse #7 and Certified Nurse Aide #6 came in right after they left and cut off the ties. Certified Nurse Aide #4 stated they did not have anything to remove the zip ties with at the time. They told the oncoming nurse about the situation. They did not know where the zip ties came from. During a telephone interview on 02/11/2026 at 11:43 AM, Certified Nurse Aide #6 stated Licensed Practical Nurse #7 was not acting normally during that shift on 03/24/2024. They went out for a smoke break, and when they came back their face was red, they were sweating, and just not acting right. Licensed Practical Nurse #7 was getting really upset with Resident #3. The resident kept removing stuff from their closet, leaving their room, up and down moving all night. At the end of the night, Licensed Practical Nurse #7 asked for the scissors they carried. The only time they saw any zip ties was in a package on a cart in the hallway. They were unused in the package from the store. They did not know where they came from. Certified Nurse Aide #6 stated they had no idea about the zip ties and Resident #3 until they came from their shift and was sent to a room on the first floor. They did not know where the ties came from or anything about taking them off. Resident #3 was up a lot that night and Licensed Practical Nurse #7 said they would take care of it. During a telephone interview on 02/12/2026 at 9:39 AM, Licensed Practical Nurse #22 stated they came in for the shift at 2:30 AM on 03/24/2024, and they went to look for Licensed Practical Nurse #7 to get report. Licensed Practical Nurse #7 was acting differently; they were talking fast and very erratic. Licensed Practical Nurse #7 left their shift with Certified Nurse Aide #6. Certified Nurse Aide #4 told Licensed Practical Nurse #22 they had to talk, and told them, Licensed Practical Nurse #7 zip tied Resident #3 to the bed. Licensed Practical Nurse #22 went to Resident #3 and did not see any marks on Resident #3's hands or ankles. They found two (2) zip ties under the bed. Before Certified Nurse Aide #6 left they came to the nurse's station and picked up trash and threw it in the trash bin. Licensed Practical Nurse #22 stated they found an additional used zip tie in the trash after Certified Nurse Aide #6 left. They went with Certified Nurse Aide #4 to Nursing Supervisor #5 to report the situation. During an interview on 02/12/2026 at 10:15 AM, the facility [NAME] President stated it was a terrible situation that occurred. The abuse happened. The facility used to have old hospital beds that needed to have the side rails zip tied down, so the rails were not used inappropriately. Those beds were all removed, so there was no longer a need for zip ties on the units. With the founded abuse, they contacted the police, office of professions, provider, and family of the resident. They completed audits and training for the staff. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)_________________________________________________________________Immediate Jeopardy Past Non-Compliance was identified, and the Administrator on Record was notified on 02/12/2026 at 4:12 PM. The facility provided verification the following corrective actions were completed:-Resident #3 was immediately assessed by a registered nurse for physical and psychological harm; the physician and family were notified, and the resident's care plan was revised to include potential for abuse.- On 03/25/2024, Licensed Practical Nurse #7, and Certified Nurse Aides #4 and #6 were placed on administrative leave pending investigation. Certified Nurse Aide #4 received discipline for timely reporting and received additional education. Licensed Practical Nurse #7 and Certified Nurse Aide #6 were terminated. - On 03/28/2024, the accused Licensed Practical Nurse's actions were reported to the Office of Professions. - On 03/28/2024, the facility-initiated training regarding restraints, dementia care, abuse prevention, identification, and reporting. All training sessions and staff were educated by 04/02/2024.- On 03/29/2024, a full house abuse assessment was conducted on each resident.- On 03/29/2024, the facility-initiated restraint audits for all residents, findings were reported to the Quality Assurance Team.

Based on record review and interviews during the abbreviated surveys (NY00308228 and NY00322916) the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported to the New York State Department of Health as required. Specifically, Resident #2 sustained a fracture from a transfer with a mechanical lift and Resident #3 eloped (exited, undetected by staff) to a non-resident area and the incidents were not reported as required. Findings include: The Accident and Incident Investigating and Reporting policy revised 10/18/2022 documented: - any alleged violation of abuse, mistreatment, neglect, injuries of unknown origin, or misappropriation of resident's property will be reported to the New York State Department of Health if and when the reasonable cause threshold has been achieved. - The policy references included the 2016 New York State Department of Health Nursing Home Incident Reporting Manual. The New York State Department of Health Nursing Home Incident Reporting Manual dated 8/2016 documented the following incidents are reportable: a resident in a non-resident area, if the resident was found in a potentially hazardous non-resident area and an incident or accident related to entrapment or use of equipment. 1) Resident #2 had diagnoses including anemia, anxiety disorder, and difficulty walking. The 8/1/2023 Minimum Data Set assessment documented the resident had intact cognitive function and no falls since the last assessment. The 8/22/2023 physical therapist #15's note documented the resident had shown improvement with mobility. Care plan recommendations included transfer with the sit-to-stand mechanical lift with assistance of 2 staff. The 8/28/2023 facility investigation summary signed by the former Administrator and former Director of Nursing documented: - on 8/27/2023 at approximately 6:45 PM, certified nurse aides #3 and 6 were transferring Resident #2 utilizing the sit-to-stand lift per their care plan. According to staff interviews, the legs to the sit-to-stand became jammed under the wheelchair they were transferring Resident #2 from. While certified nurse aides #3 and 6 were getting the sit-to-stand machine released from under the wheelchair chair, the resident became anxious and removed their hands from the machine causing them to slide down with the sling still in place. This caused the resident to be in a standing position pushing their shoulders upward. Certified nurse aides #3 and 6 lowered the resident to the floor and notified registered nurse Supervisor #2. - Registered nurse Supervisor #2 completed an assessment on Resident #2 and Resident #2 had complaints of left shoulder pain which resolved approximately 30 minutes later with no apparent injuries. - Resident #2 had complaints of pain again to the left shoulder later in the shift. The physician was notified and an order for an x-ray was obtained. A left clavicle fracture was identified. - It was concluded there was no evidence of abuse, neglect or mistreatment. The facility determined the facts did not meet reasonable cause threshold for reporting as defined by the New York State Department of Health regulations. Resident #2 was lowered to the floor by the certified nurse aides with no care plan violations identified. The radiology report dated 8/28/2023 documented the indication for radiography of the left shoulder was a recent fall and the impression was oblique fracture of the left clavicle. There was no documented evidence the facility reported the resident sustained a fracture related to use of equipment to the New York State Department of Health. During an interview with licensed practical nurse #1 on 3/20/2024 at 11:30 AM, they stated on 8/27/2023, Resident #2 was calling out. The nurse arrived and saw the resident up in the sling on the sit-to-stand lift and the machine was stuck and could not be moved. The only option was to lower the resident to the floor onto their stomach, as there was no room to turn them. The resident complained of pain in their arm while they were on the floor. During an interview with certified nurse aide #3 on 3/20/2024 at 1:05 PM, they stated when they went to transfer the resident from their wheelchair to bed, the sit-to-stand lift got stuck under the resident's wheelchair when they went to pull it back, the resident began yelling and let go of the machine, causing their feet to be misplaced and unable to be corrected. The resident was lowered to the floor by certified nurse aides #3 and 6 while licensed practical nurse #1 pulled the machine back. The resident had to be lowered face down to the floor, as there was no room to turn the resident or move the sit-to-stand and wheelchair. The resident's wheelchair was positioned next to the head of the bed, with the lift in front of the resident, so that when lifted, the resident would pivot to the bed. The closet and cabinets were on other side of the wheelchair and machine, and there was no room to swing the lift or the resident's wheelchair around. During a telephone interview with certified nurse aide #6 on 3/25/2024 at 1:33 PM, they stated when transferring the resident, the sit-to-stand got stuck under their electric wheelchair, which had a large footrest. The resident moved during the transfer and their feet were not positioned correctly, then they let go of the lift and were hanging in the lift. The aides had to lower the resident to the floor, and the resident was hollering about pain in their shoulder. During a telephone interview with the Director of Nursing on 4/1/2024 at 2:44 PM, they stated they were not in the role of Director of Nursing when Resident #2 sustained the fracture following the incident on 8/27/2023. They stated the facility utilized the New York State Department of Health Nursing Home Incident Reporting Manual to determine if an incident was reportable. The Director of Nursing was not certain if the incident was reportable as they did not complete an investigation. They were unable to state the reason the former Director of Nursing did not report the incident since it involved an injury with equipment use. 2) Resident #3 had diagnoses including dementia with other behavioral disturbance, anxiety disorder, and repeated falls. The 11/10/2022 Minimum Data Set assessment documented the resident had severe cognitive impairment and did not exhibit behaviors of wandering. The 11/8/2022 Elopement Evaluation documented the resident had a history of or attempted to leave the facility without informing staff. The resident did not wander, did not express a verbal desire to go home, or did not stay near an exit. The 11/8/2022 at 4:06 PM AM, nursing progress note entered by registered nurse #10 documented the resident had no recent attempts to leave the unit, was attending off unit activities with monitoring, scored 1 (low) on the elopement risk evaluation, and will be trialed off the wander alert device at this time. Door alarms were in place at the exits to the unit during this trial period. The 11/16/2022 at 6:37 AM, nursing progress note entered by licensed practical nurse #9 documented the resident was carrying their catheter bag, looking for a way out of the unit. They would not let staff do their finger stick (blood sugar monitoring) stating they did not have time for that, they were looking for the kids to take them home, they tried a couple of times, then walked up the hall. The comprehensive care plan, updated 11/23/2022, documented the resident was at risk to wander related to dementia with behaviors. Interventions included: identify a pattern of wandering, intervene as appropriate; distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book. There were no documented interventions related to the use of the wander alert device, the trial period of cessation of the device, or any new interventions to address the resident's exit-seeking behavior. The 12/30/2022 at 10:53 PM nursing progress note entered by licensed practical nurse #11 documented the resident got on the service elevator and went to the 8th floor diet kitchen and was returned by staff (the resident resided on the 3rd floor). There was no documented incident report completed when the resident left the unit undetected by staff and accessed a a non-resident area on 12/30/2022. There was no documented evidence the facility reported the resident was found in a non-resident area to the New York State Department of Health. During a telephone interview with licensed practical nurse #14 on 3/25/2024 at 1:07 PM, they stated the resident had behaviors of wandering and trying to find snacks. On 12/30/2022, the resident got onto the service elevator and went to another floor. The service elevator was next to the other elevators on the unit. The difference was the service elevator had a rear door that opened to the kitchens on the units. The only other means to get into the kitchen was entering a code on the door from the hallway. The kitchen and service elevator were not for resident access. The licensed practical nurse could not recall if an incident report was completed as a result of the resident getting into the kitchen on another unit. During a telephone interview with the Director of Nursing on 4/1/2024 at 2:44 PM, they stated they were not in the role of Director of Nursing when Resident #3 left the unit on 12/30/2022. They were unaware of an incident report or of the reason the incident was not reported to the New York State Department of Health. They stated the service elevator and kitchen were not resident areas and based on the New York State Department of Health Nursing Home Incident Reporting Manual, the incident was reportable. 10NYCRR415.4 (b) (2)

44838 48675 Based on observation, record review, and interview during the recertification survey conducted 2/26/2024-3/1/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 7 of 7 residents (Resident #33, #103, #212, #124, #75, #68, and #92) reviewed. Specifically, Resident #33 did not have pressure relief for their heels as planned and Residents #33, #103, #212, #124, #75, #68, and #92 had air mattresses (a specialty mattress that provides air flow to relieve pressure) in use that were not monitored for functioning. Findings include: The facility policy Skin Care Program dated 5/2023 documented the Interdisciplinary Team would evaluate the need for additional pressure relieving support surfaces and/or pressure relieving devices based on the resident's assessment. Pressure reduction included a therapeutic mattress that would be utilized on beds as indicated/needed. 1) Resident #33 had diagnoses including Alzheimer's disease, left femur (thigh bone) fracture, and reduced mobility. The 12/21/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, required substantial/maximal assistance for bed mobility, was at risk for pressure ulcers, had 1 unstageable deep tissue injury (pressure induced soft tissue damage with purple or maroon discoloration to intact skin), and had a pressure reducing device for their chair and bed. The revised 2/3/2023 comprehensive care plan documented the resident had potential for impaired skin integrity related to their diagnoses of dementia, advanced age, and multiple comorbidities. Interventions included a heel elevator cushion (elevates the lower legs to eliminate pressure to the heels) while in bed to relieve pressure from heels, use caution during transfers and bed mobility, keep skin clean and dry, and keep hands and body parts dry from excessive moisture. The revised 1/2/2024 comprehensive care plan documented the resident had a suspected deep tissue pressure injury to the left heel. Interventions included follow facility policies/protocols for prevention/treatment of skin breakdown, monitor and report loose dressings to treatment nurse, and to administer treatments as ordered and monitor for effectiveness. The care plan did not include the use of a specialty mattress. The undated care instructions (Kardex) documented the resident needed substantial/maximal assistance with bed mobility and a heel elevator cushion while in bed to relieve pressure to the heels. The 2/22/2024 wound care flow sheet completed by wound care licensed practical nurse #2 documented the resident's left heel deep tissue injury measured 1 centimeter by 0.5 centimeters, had no drainage, and the wound bed was purple. The current treatment was to cover the wound with silicone foam adhesive heel border every 3 days and as needed. The preventative actions section was left blank. Resident #33 was observed: - on 2/26/2024 at 10:08 AM, lying in bed on their back, their heels were resting directly on the air mattress, and their heel elevator cushion was in the recliner chair. The air mattress was on, set to alternate, and set to comfort level 4. - on 2/26/2024 at 11:10 AM, lying in bed on their back their heels were resting directly on the air mattress, and their heel elevator cushion was in the recliner chair. - on 2/28/2024 at 10:50 AM, lying in bed on their back their heels were resting directly on the air mattress, and their heel elevator cushion was on the floor next to the left side of the bed. The air mattress was on, set to alternate, and set to comfort level 4. - on 2/28/2024 at 11:26 AM, lying in bed on their back the heel elevator cushion was under their knees, and their heels were resting directly on the air mattress. The 2/2024 treatment administration record did not include instructions for monitoring the air mattress to ensure it was on and functioning. During an interview on 2/29/2024 at 12:08 PM, certified nurse aide #20 stated they had Resident #33 on their assignment during the day shift on 2/26/2024. Resident #33 had a pressure ulcer on their heel that had healed and recently returned. They had a heel elevator cushion in their room that was supposed to be used while they were in bed and had an air mattress. They stated they did not touch the settings on the mattress, and it would alarm if it was not working properly. They stated they forgot to use the heel elevator cushion while caring for the resident because they used to be reminded by the big bandage on Resident #33's left foot that was not there anymore. They stated heels were a pressure point, so it was important to use the heel cushion so Resident #33's heels would not rub on the mattress and cause their pressure ulcer to get worse. During an interview on 2/29/2024 at 1:54 PM, registered nurse Unit Manager #21 stated if a resident had a pressure ulcer, the interdisciplinary team and wound nurse would discuss what pressure relieving devices were best. If a heel elevator cushion or air mattress was being implemented, it was put in the care plan for all staff to see. They stated Resident #33 had a deep tissue injury on their left heel that recently returned, and they were care planned to use a heel elevator cushion while in bed. They stated if the heel elevator cushion was not used as planned, Resident #33's deep tissue injury could worsen and eventually open. They stated Resident #33 was on an alternating air mattress and it was not in their care plan. They were unsure who determined the settings on the air mattress, unsure what comfort level 4 meant, and they would have to ask someone else for clarification. During a follow up interview on 3/1/2024 at 9:10 AM, registered nurse Unit Manager #21 stated air mattress settings were based on the resident's weight. They were unsure if an air mattress needed a physician order, but they knew it had to be put in Resident #33's care plan. They stated all staff were responsible for checking to make sure an air mattress was functioning properly. During an interview on 3/1/2024 at 8:44 AM, licensed practical nurse #22 stated if a resident had a pressure ulcer the therapy department and wound nurse would determine what pressure relieving devices would be appropriate like an air mattress, heel elevator cushion, or foot booties. All devices should be put in the care plan so all staff would know how to properly care for the resident. They stated they had seen Resident #33 kick their heel elevator cushion off the bed in the past, but they were on 30-minute checks so the certified nurse aide should have noticed the cushion was not in use or not properly positioned and fixed it. It was important to use the heel elevator cushion as planned so Resident #33 did not have more skin breakdown from their heels resting on the mattress. Resident #33 received an air mattress when they returned from the hospital a few months ago because they were not ambulatory. The settings on the bed were based on the resident's weight but they were not sure what the 1-5 comfort settings meant. The shift nurse was responsible for monitoring the mattress to make sure it was on and functioning properly. They used to work on the 7th floor and some residents had orders to check the air mattress to ensure it was on and they had to document it in the treatment administration record every shift. During an interview on 3/1/2024 at 9:25 AM, certified nurse aide #23 stated Resident #33 had a wound on their left ankle or heel and had an air mattress and a heel elevator cushion. They stated they provided care to Resident #33 on 2/28/2024 during the day shift and saw the heel elevator cushion in their care plan and thought the air mattress should have been in it too. They stated they remembered putting the heel elevator cushion under Resident #33's legs when they assisted them into bed, but they were not aware it was on the floor or not positioned properly. They stated it was important to use the heel elevator cushion and to place it properly so Resident #33 did not get further skin breakdown on their heels. During an interview on 3/1/2024 at 10:05 AM, the maintenance supervisor stated there were 5 comfort settings on the air mattresses. Comfort setting 1 being the softest and comfort setting 5 being the firmest. When new pumps came in, they were responsible for setting them up, installing them on the beds, and making sure the mattress was functioning properly. They had older mattress models that had the same settings, but they had an adjustment knob rather than buttons. They stated nursing adjusted the air mattress settings and maintenance staff did not touch or change them. During an interview on 3/1/2024 at 11:01 AM, the Assistant Director of Nursing stated the settings on the air mattress were based on the resident's comfort level, and usually started at the lowest setting (level 1), and then gradually increased. The air mattress settings would not be documented in the care plan or in a physician order because they could change frequently based on the resident's current comfort level/pain. They stated all nurses assessed pain levels so any nurse could change the mattress settings based on their findings. All staff members were responsible for ensuring air mattresses were functioning properly and turned on, and it was not a specific staff members responsibility. They expected staff to use the Resident #33's heel elevator cushion as planned. The Unit Manager was responsible for monitoring the unit to ensure pressure relieving devices were being implemented. If a heel elevator cushion was not used correctly or at all it could cause further skin breakdown for Resident #33. 2) Resident #124 had diagnoses including dementia and functional quadriplegia (inability to move due to a medical condition). The 12/28/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, upper and lower extremity functional limitations, was dependent on staff for activities of daily living, was at risk for pressure ulcers, and had a pressure reducing device for their chair and bed. The revised 11/13/2023 comprehensive care plan documented the resident had an unstageable pressure injury to the right heel, potential for further impaired skin integrity related to impaired cognition, impaired mobility, and functional quadriplegia. Interventions included changing positions every 2 hours, toileting every 2 hours, ensure treatments were done as ordered, and use of a pressure relieving cushion when using the wheelchair or recliner. The care plan did not include the use of an air mattress. Resident #124 was observed lying in bed with the air mattress on and set to comfort level 5, auto firm, and the green light was on indicating low pressure at the following times: -on 2/26/2024 at 12:18 PM. -on 2/29/2024 at 4:54 PM. -on 3/1/2024 at 8:45 AM. The 2/2024 treatment administration record did not include instructions for monitoring the air mattress to ensure it was on and functioning. During an interview on 3/1/2024 at 9:02 AM, certified nurse aide #30 stated Resident #124 was the only resident on the unit with an air mattress. They were unsure who determined the need for an air mattress or who was responsible for the settings. They did not check the mattress settings, they only made sure the air mattress was on. They stated they had never seen it listed on the care instructions (Kardex) and did not have to document on it, but they would tell the nurse if it was not on because air mattresses were important for healing pressure areas. During an interview on 3/1/2024 at 9:06 AM, licensed practical nurse #33 stated a registered nurse would determine if a resident needed an air mattress to prevent pressure ulcers or help with pressure relief. The registered nurse would then talk to the physician to get an order, put in a work order, and maintenance would set it up. They were unsure who determined the mattress settings, but they thought it was the registered nurse or physician. The order would usually go on the treatment administration record to notify the licensed practical nurse to check the function of the air mattress. They stated Resident #124 did not have a physician order for the air mattress so they would not know to check it, if it was not turned on, or not working properly to relieve pressure. 3) Resident #212 had diagnoses including spinal stenosis (narrowing of the spaces of the spine), diabetes, and morbid obesity. The 1/25/2024 Minimum Data Set assessment documented the resident was cognitively intact, was dependent on staff for bed mobility, had upper and lower extremity functional impairment, had a pressure reducing device for their chair and bed, and had 1 unstageable pressure ulcer. The revised 2/6/2024 comprehensive care plan documented the resident had unstageable pressure injury to the peri-rectal area and potential for pressure ulcer development related to immobility and history of pressure ulcers. Interventions included follow facility policies/protocols for prevention/treatment of skin breakdown, administer treatments as ordered and monitor for effectiveness, required a pressure relieving cushion for the chair, and an alternating air mattress. The 2/2024 treatment administration record did not include instructions for monitoring the air mattress to ensure it was on and functioning. During an observation on 3/1/2024 at 9:22 AM, the residents air mattress was on, and the setting dial was on auto 3/4 of the way between soft towards firm. During an interview on 3/1/2024 at 9:25 AM, licensed practical nurse/wound nurse #2 stated alternating air mattresses were mainly used for residents who had pressure ulcers, but all their mattresses had some form of pressure reduction. Air mattress settings were based on the resident's weight. They stated all staff should check the air mattresses because if they were not set correctly or not functioning properly, they would not promote healing or aide with pressure relief. 10NYCRR 415.12(c)(1)

Based on record review and interview during the recertification survey conducted 2/26/2024 -3/1/2024, the facility did not ensure a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet a resident's medical and nursing needs for 1 of 1 resident (Resident #7) reviewed. Specifically, Resident #7 had a wedge positioning pillow (a wedge-shaped pillow used to aid with positioning) tucked under their fitted bedsheet that was not included on their comprehensive person-centered care plan. Findings include: The facility's policy Comprehensive Care Plan revised 10/2023 documented the comprehensive care plan would include measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs. The care plan would be individualized for each resident. All disciplines were responsible for reviewing the plan of care, documenting goals, interventions, monitoring notes, and updating as needed. The facility's policy Positioning and Positioning Device revised 12/2018 documented positioning devices would be utilized to assist with proper positioning of residents. The nursing department would ensure proper positioning of each resident to maintain maximum level of function and comfort. Devices that were approved included wedge cushions for chairs, side rails, lap cushion, and bed wedges. Resident #7 was admitted to the facility with diagnosis including epilepsy (seizure disorder), Parkinson's disease (a progressive neurological disorder), and repeated falls. The 12/14/2023 Minimum Data Set Assessment documented the resident had severely impaired cognition, had impairment in function to both upper extremities, was dependent with rolling left to right, moving from a seated to lying position, and with chair/ bed transfers, and did not use restraints. The 12/12/2023 Restrictive Device assessment documented the resident had impaired memory, decreased safety awareness, was cooperative, was dependent with transfers and mobility, had no history of falls in the last 90 days, no restrictive devices were attempted to date, and no restrictive devices were currently required. The revised 2/21/2023 comprehensive care plan for falls documented the resident's bed was against the wall to assist with bed boundary awareness. On 1/9/2024, the care plan documented the resident would have a low bed against the wall with a fall mat on the floor next to the bed. There was no documented evidence a wedge positioning pillow was used. During an observation on 2/26/2024 at 12:27 PM the resident was lying in their bed with a wedge positioning pillow tucked under their fitted bedsheet on the left-hand side with their bed against the wall and a fall mat on the floor. During an observation on 2/28/24 12:13 PM, certified nurse aides #34 and #35 transferred the resident from their chair to their bed using a mechanical left. At 12:19 PM, certified nurse aide #35 removed the wedge positioning pillow from beneath the fitted bedsheet and placed it in the resident's chair. The certified nurse aides continued to transfer the resident to their bed and certified nurse aide #34 provided care to the resident. At 12:33 PM, the wedge positioning pillow was observed tucked under the resident's fitted bedsheet, their bed was against the wall, and there was a fall mat on the floor on the left side of the bed. At 12:34 PM, certified nurse aide #30 entered the resident's room and asked certified nurse aide #34 if they needed assistance. Certified nurse aide #30 exited the room and stated the wedge positioning pillow was used to prevent rolling as the resident was a fall risk. At 2:21 PM and 4:49 PM, the resident was observed lying in bed with the wedge positioning pillow tucked under their fitted bedsheet with their bed against the wall and a fall mat on the floor on the left side of the bed. During an observation on 2/29/24 at 9:16 AM, the resident was observed lying in bed with a wedge positioning pillow tucked under their fitted bedsheet, their bed was against the wall, and a fall mat was on the floor on the left side of their bed. During an interview on 2/29/2024 at 9:17 AM certified nurse aide #34 stated they were assigned to resident #7 yesterday and today. They looked at the care plan everyday as things could change. The care plan listed items such as fall mats and any mobility devices. They stated the resident did have a wedge positioning pillow for their bed and thought therapy would have to approve the use of the device. When they reviewed the resident's care plan, they did not see the wedge positioning pillow listed. They stated the wedge positioning pillow could prevent a resident from getting out of bed and should only be used if they were care planned for safety reasons. During an interview on 2/29/2024 at 9:57 AM licensed practical nurse #36 stated wedge positioning pillow use was determined by a therapy assessment. Typically, the wedges were used for positioning, but they should be listed on the resident's care plan. If the resident was not assessed and it was not listed on the care plan the wedge positioning pillow should not be used. They reviewed the resident's care plan and medical orders and did not see wedge positioning pillows listed. During an interview on 2/29/2024 at 10:17 AM registered nurse Unit Manager #29 stated staff reviewed the resident's care plans daily as things could change. The care plan also listed any safety devices and level of care the resident required. Wedge positioning pillows should also be documented on the care plan and nursing staff could place the wedge positioning pillows as needed without a medical order or therapy assessment as they were used to aide with pressure prevention and positioning. Resident #7 was totally dependent on staff to provide care. Their wedge positioning pillow was used to aide with bed mobility. During an interview on 2/29/2024 at 11:45 AM the Director of Therapy stated the wedge positioning pillows were kept in the therapy department, but nursing staff could obtain them as needed. They did not think the wedge positioning device needed to be on the resident's care plan. They stated Resident #7 was recently evaluated for chair mobility due to restlessness and not for bed mobility. The wedge positioning pillow should only be used for pressure relief or for bed positioning and should not be used for fall prevention, as anything that restricted movement could be a restraint. When they reviewed the resident's care plan, they did not see a wedge positioning pillow listed. During a follow up interview on 2/29/2024 at 12:20 PM registered nurse Unit Manager #29 stated the resident did not have any pressure areas at this time, was at low risk for falls, the therapy department would complete a restraint assessment if needed, and care plans were reviewed quarterly, annually, and as needed. During an interview on 2/29/2024 at 1:52 PM the Director of Nursing stated wedge positioning pillows were used for offloading pressure areas and for comfort. Any nurse could put it on a resident's bed to prevent skin breakdown and a therapy evaluation and medical order was not needed. The wedge positioning pillow would not show up on the certified nurse aide care instructions, but it should be listed on the comprehensive care plan. 10NYCRR 415.11(c)(2)(ii)

Based on observation, record review, and interview during the recertification and abbreviated (NY00322441) surveys conducted 2/26/2024-3/1/2024, the facility did not ensure each resident received adequate supervision to prevent accidents for 2 of 9 residents (Residents #4 and #162) reviewed. Specifically, Resident #4 was care planned to be out of bed for meals with use of specific swallowing strategies and was left in bed unsupervised during a meal; Resident #162 had a diagnosis of dysphagia (difficulty swallowing) with aspiration precautions and was observed eating meals alone in their room. Findings include: The facility policy Assistance with Meals last reviewed 9/2023, documented residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who need assistance will be assisted with attention to safety, comfort, and dignity. The facility policy Aspiration Policy and Procedure last revised 6/2023 documented encourage chewing and swallowing during oral intake. Suction was to be readily available at bedside during meals. The resident's head of bed was to always be elevated to 30 degrees, except during meals to elevate the head of the bed to 90 degrees. Sitting position was to be maintained for at least 30 minutes after meal. The policy did not include meal supervision requirements for aspiration precautions. 1) Resident #162 had diagnoses of oropharyngeal phase dysphagia (difficulty initiating swallowing), acute respiratory failure with hypoxia (low oxygen levels), and severe protein calorie malnutrition. The 11/23/2023 admission Minimum Data Set assessment documented the resident had moderate cognitive impairment, eating ability was not attempted due to a medical condition or safety concern, did not have a swallowing disorder, had unplanned weight loss, and had a feeding tube. The comprehensive care plan initiated 11/27/2023 documented the resident was at risk for weight loss and inadequate oral intake related to dysphagia. Interventions included head of bed elevated at least 30 degrees during and after feeding for at least 30 minutes. Interventions initiated 2/6/2024 documented aspiration precautions, pleasure feedings: pureed solids and nectar thick cup sips. The 2/5/2024 speech language pathologist #14 progress note documented a bedside swallow evaluation to determine safest and least restrictive diet, feeding tube was the main source of nutrition, tray notes to include pleasure feedings of pureed solids and nectar thick cup sips, and aspiration precautions. Physician orders documented: - on 2/6/2024 keep head of bed elevated at all times at 30 degrees, aspiration precautions. - on 2/7/2024 may have pleasure feedings, pureed diet, nectar thick fluids every shift. The 2/15/2024 physician #7 progress note documented the resident had dysphagia, was on tube feedings with suspected chronic aspiration, and had aspiration pneumonia. A 2/16/2024 at 1:35 PM a licensed practical nurse #1 progress note documented the resident was on Augmentin (antibiotic) for mild pneumonia. Resident #162 was observed: - on 2/27/24 at 1:26 PM, in bed with their lunch tray at their bedside. The resident stated had not assisted them with eating. - on 2/28/24 from 12:53 PM to 1:14 PM, in bed with a lunch tray. The resident was feeding themselves pureed fruit with a spoon. No staff was observed checking on the resident or assisting them with lunch. During an interview on 2/28/2024 at 1:44 PM, the Director of Therapy stated a resident on aspiration precautions should have nursing responsible for monitoring them at least every shift, and meals should be in the dining room or supervised. A resident with a diagnosis of oropharyngeal dysphagia (swallowing disorder) that was on pureed pleasure feedings should be supervised or in the dining room for eating. During an interview on 2/29/2024 at 10:36 AM, speech and language pathologist #14 stated assessments were done on residents with dysphagia related concerns, to make sure they had the safest and least restrictive diet in place. Diet restrictions and interventions were done on an individualized basis. A resident with aspiration precautions should be encouraged to eat in the dining room with supervision. Residents with aspiration precautions were at risk for aspiration pneumonia It was the responsibility of staff to keep the residents safe and that was why recommendations were made. During an interview on 2/29/2024 at 11:01 AM, certified nurse aide #41 stated resident care information was on the Kardex (care instructions) in the electronic medical record and included information regarding assistance levels for activities of daily living. A resident on choking hazards and aspiration precautions should be in the dining room for meals. Certified nurse aides walked through the unit during meals to check on residents in their rooms. If a resident required supervision during meals, they should be in sight of staff. Resident #162 had a pureed diet because of difficulty swallowing, should be checked on frequently or at least every 30 minutes during meals. During an interview on 2/29/2024 at 11:21 AM, licensed practical nurse Unit Manager #2 stated resident care information was found in the computer in the Kardex or on the care plan. Information included mobility, level of assistance, and diet. An aspiration precaution care plan included keeping the head of bed elevated and encouraging meals to be eaten in the dining room. If a resident on aspiration precautions wanted to eat in their room, they should have supervision. Aspiration could lead to pneumonia or death. Staff should check on residents eating in their rooms during mealtimes. During an interview on 2/29/2024 at 11:35 AM, certified nurse aide #40 stated some residents were able to eat in their rooms, but staff tried to encourage them to go to the dining room. If they refused, they could eat in their room if they were not a choking risk. Some residents had to be supervised during mealtimes. Aspiration precautions meant the resident's head of bed was elevated at least 45 degrees and they required supervision while eating. Resident #162 was on aspiration precautions and should not eat in their room alone. They should be checked on every 10 to 15 minutes minimally. The risk of aspiration could be the possibility of choking. There was no specific certified nurse aide assigned to round the unit during meals. 2) Resident #4 had diagnoses including dementia, history of recurrent pneumonia, and gastroesophageal reflux disease. The 11/16/2023 comprehensive Minimum Data Set assessment documented the resident had intact cognition, required set up assistance for eating, had no weight loss, and received a mechanically altered diet. The 2/13/2023 physician orders documented a regular diet, advanced mechanical altered texture, and thin consistency liquids. The 6/29/2023 speech language pathologist #14 discharge summary for dates of service 6/26/2023-6/29/2023 documented the resident had achieved the highest practical level. They had been provided dysphagia management with compensatory strategies. Recommendations on discharge from therapy included a diet of mechanical soft textures, and thin liquids with encouragement to use chin tuck maneuver (swallowing strategy) during thin liquid intake. The 8/18/2023 comprehensive care plan documented all meals were to be supervised out of bed in the dining room due to high aspiration risk, and chin tuck with swallowing liquids was to be used. The 2/17/2024 dietary aide #26 quarterly nutrition note documented tray card notes specified to remind the resident to tuck chin while drinking. Additional interventions included meals in the dining room. The 2/29/2024 Kardex (care instructions) documented supervision of 1 for eating, and chin tuck with swallowing liquids. During an observation on 2/27/2024 at 1:15 PM, the resident was set up with a lunch tray on the overbed table in their room. The resident was in bed with the head of the bed elevated. The resident's meal ticket stated they needed reminders to tuck chin when drinking thin liquids. There was no staff supervision, cueing, or assistance provided. During an interview on 2/29/2024 at 1:28 PM, certified nurse aide #39 stated supervision with eating meant the resident should be watched while eating to provide encouragement and physical assistance if needed. They should not be left alone in their room during meals. Resident #4 was not in the dining room on Tuesday for lunch, as the aide must not have gotten them up. They stated they did not know the exact purpose of chin tuck techniques and thought it was a safety strategy. During an interview on 2/29/2024 at 1:49 PM, licensed practical nurse #38 stated some residents could eat in their room depending on their diet order and level of assistance needed. Anyone who had altered consistencies should not eat alone in their room. A resident requiring supervision must have visual supervision during mealtime. [NAME] tuck was a swallowing strategy to prevent choking or aspiration. Resident #4 should not be alone in their room with their lunch tray. Sometimes the resident wanted to stay in bed, but they should not get their meal tray while alone in their room. During an interview on 2/29/2024 at 2:10 PM, certified nurse aide #37 stated resident specific care information was in the electronic medical record on the Kardex. If the Kardex stated supervision was needed for eating, this meant the resident may need encouragement, may be at risk for choking, and needed to be watched. [NAME] tuck with liquids was used to prevent choking and the resident should be watched. Resident #4 ate alone in their room. Certified nurse aide #37 was not aware Resident #4 was at risk for choking or required supervision. During an interview on 2/29/2024 at 4:56 PM, the Assistant Director of Nursing stated resident specific care was found on the Kardex and was used as a reference to provide care for residents safely. The resident care plan could also be found in the electronic medical record. Both items contained information regarding resident's assistance needed for activities of daily living. Supervision for eating meant the resident should be in view during meals on an individualized basis. Aspiration precautions meant the resident's head of bed was to be elevated. If a resident on aspiration precautions refused to come to the dining room, safety modifications should be in place such as frequent checks. The risk of aspiration included possible pneumonia or death. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interview during the recertification and abbreviated (NY00302726, NY00316052, NY00322441) surveys conducted 2/26/2024- 3/1/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 8 residents (Residents #638 and #109) reviewed. Specifically, Resident #638 was not assisted with meals and Resident #109 was observed with unwanted facial hair. Findings include: The facility policy Standard of Care-Activities of Daily Living reviewed 11/6/2023 documented residents maintained adequate nutrition and adequate intake of each meal by encouraging, cueing, prompting, and feeding as needed. Residents were assisted to keep clean, neat, and well-groomed including shaving. Shaving was provided on shower days and as needed. 1) Resident #638 was admitted to the facility with diagnoses including Parkinson's (a progressive neurological disorder), generalized anxiety disorder, and dementia. The admission Minimum Data Set assessment had not yet been completed. The comprehensive care plan initiated 2/23/2024 documented the resident required assistance with self-care that included eating set up assistance of 1 and adequate nutrition was encouraged. The resident had impaired cognitive function and thought process related to dementia and needed cueing, reorientation, and supervision. Progress notes documented: - On 2/23/2024 by registered dietitian #27, the resident had increased nutrient needs related to increased demand as evidenced by recent COVID/pneumonia and increased skin risk. Interventions were to monitor intakes and weekly weights. The goal was to consume adequate calories, protein, and fluids. - On 2/23/2024-2/25/2024 by licensed practical nurse #17, the resident ate all meals in their room. - On 2/26/2024 by licensed practical nurse Unit Manager # 18, the resident ate all meals in their room. - On 2/27/2024 by licensed practical nurse #9, the resident ate all their meals in their room and required assistance. - On 2/27/2024 by certified occupational therapy assistant #16, the resident was in bed with untouched breakfast and consumed breakfast items with encouragement throughout. They spoke with licensed practical nurse Unit Manager #18 regarding getting the resident out of bed for meals for increased intake. - On 2/28/2024 by licensed practical nurse #17, the resident ate lunch in their recliner in their room. - On 2/29/2024 by licensed practical nurse Unit Manager #18, the resident required verbal ques and encouragement with their meals. - On 2/29/2024 by certified occupational therapy assistant #16, the resident needed maximum encouragement during meals as they were easily distracted. The February 2024 Resident #638 meal consumption log documented: - On 2/26/2024- 25% of breakfast, refused lunch and dinner - On 2/27/2024- 25% of breakfast, 50% of lunch, and 25% of dinner - On 2/28/2024- refused breakfast, lunch, and dinner - On 2/29/2024- 25% of breakfast, 50% of lunch and no documented evidence dinner was consumed. Resident #638's weight record documented: - On 2/25/2024, 129.3 pounds - On 2/28/2024, 127 pounds (2.3 pound/ 1.78% weight loss in 3 days) During an observation on 2/26/2024 at 10:17 AM, Resident #638 was sleeping in their bed with a breakfast tray in front of them with only a few bites taken. There was no staff present for assistance or encouragement. At 1:30 PM, the resident was sleeping in bed with an untouched lunch tray in front of them and no staff was present for assistance or encouragement. At 1:43 PM, the resident was still sleeping with an untouched lunch tray in front of them. During an interview on 2/26/2024 at 12:03 PM Resident #638's home health aide visitor stated they were upset when they walked in the resident's room and saw the resident in bed asleep with a fork in their hand. They had only eaten a couple of bites. They stated the resident did better when seated at a table and ate that way at home. During an observation on 2/27/2024 at 8:55 AM, the resident was sitting up in their bed with their eyes closed with an untouched breakfast tray in front of them. There was no staff present for assistance or encouragement. During a follow up interview on 2/27/2024 at 1:33 PM the resident's home health aide visitor stated the resident had always eaten meals and did very well with encouragement. During an observation on 2/28/2024 at 9:08 AM, the resident was sitting up in bed sleeping with an untouched breakfast tray in front of them. There was no staff present for assistance or encouragement. During an observation on 2/29/2024 at 8:34 AM, Resident #638 was seated in their wheelchair in the dining room and certified nurse aide #15 fed the resident their breakfast. The resident ate most of their breakfast. At 1:28 PM, certified nurse aide #15 fed the resident lunch. During an interview on 3/1/2024 at 9:02 AM, certified nurse aide #15 stated Resident #638 was listed as set-up assistance of 1 but they fed the resident in the dining room on 2/29/2024 for breakfast and lunch. The resident was very slow with eating and sometimes needed more assistance. The resident was not eating well in their room because they were very anxious and needed encouragement. They did not know why the resident was not always in the dining room because they ate much better with encouragement or assistance. It was important the appropriate level of assistance was provided with eating to meet a resident's basic needs and if they were not provided with the appropriate level of assistance they could decline. If they noticed the resident was not eating, they assisted the resident as it was important to eat three meals a day for body nourishment. They stated the resident had lost two pounds in just a couple of days. During an interview on 3/1/2024 at 9:11 AM, licensed practical nurse Unit Manager #18 stated certified nurse aides referenced the care plan at the beginning of each shift and knew the level of assistance needed. If a resident required more assistance, they should report it to them and they would request an additional evaluation from therapy. The resident required set up with meals and a lot of encouragement for consumption. If a resident did not eat three meals a day, they could become malnourished and lose weight. They were not aware that the resident ate very little or not at all from 2/26/2024-2/28/2024. The resident was sleeping through meals, and they expected staff to report that. They would have had the resident consume all meals in the dining room for encouragement sooner if they were aware. During an interview on 3/1/2024 at 9:29 AM, the Director of Therapy stated Resident #638 was seen by occupational therapy on 2/27/2024 and 2/29/2024 for meal observation and it was noted they needed encouragement and redirection. If a resident was not eating, they should be re-evaluated. Resident #638 should only eat in their room if they had frequent monitoring, and the dining room was more appropriate for frequent encouragement. It was important residents received the appropriate assistance to ensure adequate intake. 2) Resident #109 had diagnoses including dementia. The 2/6/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had impaired range of motion in both arms, and was totally dependent for personal hygiene. The 1/25/2024 updated comprehensive care plan documented the resident had dementia and required assistance with activities of daily living. Interventions included toilet every 2-3 hours, dependent on 1 for toileting, maximum assistance of 1 with dressing upper and lower body/tub/shower bath/oral hygiene. The 2/28/2024 care instructions documented maximal assistance of 1 with bathing, dressing, and personal hygiene. The undated unit shower schedule documented the resident was to receive a tub bath/shower every Monday on the evening shift. During an observation on 2/26/2024 at 10:24 AM, Resident #109 was sitting in a wheelchair in the unit dining room. The resident had approximately 1/8 inch long facial hair on their chin. During a telephone interview on 2/26/24 at 4:44 PM, the resident's family member stated the resident was to receive a bath every Tuesday. The resident had noticeable facial hair on 2/25/2024 when they visited, and this upset the family. During observations on 2/27/2024 at 8:01 AM and 2/28/2024 at 9:28 AM, Resident #109 was sitting in a wheelchair in the unit dining room watching TV. The resident had approximately 1/8 inch long facial hair on their chin. During an observation on 2/29/2024 at 9:25 AM, Resident #109 was lying in bed wearing a hospital gown and had approximately 1/8 inch long facial hair on their chin. During an interview on 2/29/2024 at 2:41 PM, certified nurse aide #4 stated they were assigned to the resident on 2/27/2024. Residents should be shaved whenever facial hair was noticeable and on shower days. Every resident was scheduled for a shower/tub bath weekly. Staff should have noticed the resident needed to be shaved during their bath on Monday evening. The aide performed basic hygiene the morning of 2/27/2024 and did not notice the facial hair. During an interview on 3/1/2024 at 9:55 AM, licensed practical nurse #5 stated resident specific care was listed in each resident's care instructions. The unit nurses were responsible to ensure resident care was done. Residents should be shaved during showers/baths or when noticed by staff. Long facial hair should be shaved for dignity purposes. During an interview on 3/1/2024 at 10:39 AM, registered nurse Unit Manager #6 stated staff should check resident facial hair when performing care. Residents should be shaved during their showers and as needed. It was a dignity issue if they had long facial hair unless the resident refused shaving or wanted facial hair. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interview during the recertification survey conducted 2/26/2024-3/1/2024, the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion and proper positioning for 2 of 4 residents (Residents #166 and #124) reviewed. Specifically, Resident #166 did not have bilateral hand splints in place as ordered and planned and Resident #124 did not have hand splints in place as planned. Findings include: The facility policy Rehab-Splints/Upper Extremities dated 1/2019 documented the occupational therapy evaluation and recommendation would be documented in the medical record. The splint would be fitted to the resident and issued on the unit. The care plan would be updated, a wearing schedule would be provided to the resident, and the nursing staff would be educated regarding application and use. Nursing would contact occupational therapy anytime the resident was no longer wearing the splint for any reason and would be re-evaluated if the splint would be necessary and appropriate recommendations were made. Static splints were used for protection of weak muscles from overstretching and prevent their antagonists from contracting. 1)Resident #166 had diagnoses including dementia with psychotic disturbance and functional quadriplegia (paralysis of all 4 limbs). The 2/8/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, was dependent for activities of daily living, non-ambulatory, and had impairment in function to upper and lower extremities on both sides. The comprehensive care plan initiated 6/2/2021 and revised 12/4/2023 documented the resident had risk for falls related to impaired mobility with interventions initiated on 12/12/2022 for a right hand splint. The care plan initiated 11/3/2023, documented the resident required assistance with self-care and mobility related tasks. Interventions included putting on bilateral palm guards (hand splints) at morning care, and taking off at evening care, and gentle range of motion stretching of both hands to prevent further contractures. The certified nurse aide care card outlined the interventions as special instructions. The 8/9/2023 physician #7 order documented to make sure certified nurse aides washed and dried the resident's hands and applied hand splints in morning care, and removed, washed, and dried resident's hands with evening care, to be done every morning and at bedtime. The 2/2024 Medication Administration Record documented make sure certified nurse aide washed and dried resident's hands and applied hand splints in the morning, and removed, washed, and dried resident's hands with evening care, to be done every morning and at bedtime and was signed as completed on 2/26/2024 and 2/27/2024 by licensed practical nurse #12, and on 2/28/2024 by licensed practical nurse #9. Resident #166 was observed with both hands contracted and folded over their stomach without hand splints: - On 2/26/2024 at 11:26 AM in the dining room - On 2/26/2024 at 2:27 PM, in their room - On 2/27/2024 at 8:55 AM and 12:23 PM, in the dining room - On 2/27/2024 at 11:25 AM, in their room - On 2/28/2024 at 8:49 AM, 10:57 AM, and 11:29 AM, in the dining room. During an interview on 2/27/2024 at 1:06 PM, Resident #166's family stated the resident's hands had been contracted for a while, and they had hand splints placed on their hands sometimes. They stated during their visit on this day there were no hand splints on the resident. They last saw them on the resident a few weeks ago. During an observation on 2/28/2024 at 10:58 AM, there was a hand splint on the windowsill in Resident #166's room. During an interview on 2/28/2024 at 11:01 AM, certified nurse aide #8 stated Resident #166 had hand splints for their hand contractures and should be wearing them all the time except for sleeping, washing, and eating. Without the hand splints the resident's contractures could worsen or their fingernails could cause an open area from pressing against the skin. Certified nurse aides were responsible for placing the hand splints, but everyone should be aware of their placement. Not wearing the hand splints could have a negative effect on the resident's quality of life, especially if they got an infection from open areas. During an interview on 2/28/24 at 11:31 AM, licensed practical nurse #9 stated that a check mark on the medication administration documented the task was completed. The check mark for hand splints for Resident #166 documented the hand splints were in place. The certified nurse aides that provided morning care for Resident #166 were washing the resident's hand when the nurse left the room that morning. The hand splints were not in place when they left the resident's room. The licensed practical nurse stated the certified nurse aides stated they would be on, so they signed the medication administration record as complete. Sometimes they would check for themselves to ensure they were on, other times they asked the certified nurse aides if they completed the task instead. During a follow up interview on 2/28/2024 at 1:54 PM, licensed practical nurse #9 stated without the splints the resident could get more contractures and skin breakdown. Certified nurse aides were responsible for the application of the splint as a task, and the licensed practical nurses were responsible for ensuring the splints were in place. During an interview on 2/28/2024 at 2:30 PM, certified nurse aide #10 stated Resident #166 had hand contractures to both hands and certified nurse aides were responsible for applying the splints. Without the splints the resident could injure themselves. Certified nurse aide #10 stated they helped place the hand splints on Resident #166 just before lunch on 2/28/2024. During an interview on 2/29/2024 at 9:41 AM, registered nurse Unit Manager #11 stated Resident #166 used hand splints on both hands after morning care. The licensed practical nurses documented placement of the splints on the electronic medication administration record. A check mark with initials on the medication administration record documented the task was completed and by whom. Without the splints the contractures could get worse, and the splints kept the resident's nails off their palms. The resident was more comfortable with the splints on due to the contact of the fingers on their palm. The lack of splints use could negatively affect the resident's quality of life. During an interview on 2/29/2024 at 2:25 PM, licensed practical nurse #12 stated that the check marks on the medication administration record documented the task was completed. The letters under the check mark documented who completed the task. On 2/26/2024 and 2/27/2024 they asked the certified nurse aides if they placed the splints and washed and dried the resident's hands after morning care and they checked and initialed the medication administration record. During an interview on 3/1/2024 at 9:28 AM, the Director of Nursing stated the expectation was the splints were used according to the therapy recommendations. The nurse managers would add the recommendations to the care plan for the residents. If the medication administration record documented the splints were in place, the expectation was that the nurse saw the splints on the resident. 2) Resident #124 was admitted with diagnosis of muscle weakness and functional quadriplegia (paralysis of all 4 limbs). The 12/28/2023 Minimum Data Set Assessment documented the resident had severely impaired cognition, did not reject care, had impairments to both sides of their upper and lower extremities, was dependent on staff for all activities of daily living, and had no pressure injuries. The 10/17/2023 comprehensive care plan documented the resident required assistance with self-care and mobility related tasks. Interventions included a left palm guard with finger separators on at all times as tolerated aside from meals and care. The 10/17/2023, occupational therapy discharge summary documented the caregivers were educated on the proper use of the palmar guard with finger separators to decrease left hand contracture (shortening of muscles) symptoms. The 11/2/2024 physician orders documented occupational therapy to evaluate and treat left hand contractures. The February 2023 Treatment Administration Record did not include the left palm guard with finger separators. The undated certified nurse aide care instructions did not include the left palm guard with finger separators. On 2/20/2024, licensed practical nurse #42 documented the resident's skin was examined. They had a left-hand brace, and the device was removed, and site was inspected. The resident was observed without their left palm guard with finger separators on: - On 2/26/24 at 2:51 PM. - On 2/27/24 at 3:10 PM. - On 2/28/2024 at 9:15 AM, 11:35 AM, 4:49 PM, and 5:11 PM. During an interview on 2/28/2024 at 5:11 PM certified nurse aide #30 stated Resident #124 had a contracted hand and had a device that was to be placed into their hand to help prevent it from closing. The resident did not have the device in their hand at this time. They had been assigned to the resident for the day shift and they thought another certified nurse aide had placed the palm guard in the resident's hands when they took their break. They stated all staff should check the care plan prior to providing care or assistance. They did not observe the device in the resident's hand on the day shift and did not tell anyone it was not applied. If staff was unable to find the device or the resident refused the device, they should let a nurse know. They stated the device was currently on the windowsill. During an interview on 2/29/2024 at 9:57 AM licensed practical nurse #36 stated certified nurse aides applied any devices such as palm guards. Palm guards were important to aide with the prevention of worsening contractures. If a resident refused or staff could not find the device a nurse should be made aware, and it should be documented the resident refused or the device was missing. They stated they were not notified on 2/28/2024 that Resident #124 did not have their palm guard applied. There was nowhere for the nurse to document the palm guard was applied. During an interview on 2/29/2024 at 10:17 AM registered nurse Unit Manager #29 stated they expected staff to review the resident's care plan prior to providing care. If a resident required a palm guard, it was listed on the care plan and staff should make sure the resident had it on to aide with contracture management. If the resident refused or the palm guard could not be found staff should alert the nurse. Resident #124 was care planned to wear a palm guard, but there was no place for certified nurse aides to document if the resident wore it or refused it and there was also no place for the nurse to document on the device. During an interview on 2/29/2024 at 11:45 AM, the Director of Therapy stated residents were assessed by therapy for contracture management. If a therapist determined the resident required a palm guard, they would add it to the care plan and expected staff to apply the device. If a resident refused the device or the device was missing staff should alert the nurse and therapy should also be notified. Therapy would evaluate the resident if they were refusing it or provide a new device. It was important for the resident to wear the device for contracture management. 10NYCRR415.12(e)(2)

Based on record review and interview during the recertification and abbreviated surveys (NY00316052) conducted 2/26/2024-3/1/2024 the facility did not ensure residents were free of significant medication errors for 1 of 3 residents (Resident #21) reviewed. Specifically, Resident #21's medications were crushed, combined, and administered all at once through their gastrostomy tube (feeding tube). Additionally, prednisone (corticosteroid) was ordered to be given orally and was given via the gastrostomy tube. Finding include: The 2009 American Society for Parenteral and Enteral Nutrition The Enteral Nutrition Practice Recommendations guide documented each drug should be administered separately through a feeding tube diluting the drugs as appropriate. The medications should be flushed before, between and after each administration. Avoid mixing two or more medications together, whether solid or liquid formulations, as this can create a new unknown entity with an unpredictable release and bioavailability. The facility policy Administration of Medication Guidelines revised 12/18/2023 documented the medication nurse would question drug orders that were unclear or appeared incorrect. The drug label was read at least 3 times. Before administering any drug, the 6 rights of medication administration were reviewed, which included the right route. Resident #21 had diagnoses including gastrostomy (feeding tube placed in the stomach), oropharyngeal dysphagia (difficulty swallowing), and malnutrition. The 12/14/2023 Minimum Data Set assessment documented the resident had intact cognition, required supervision for eating, had a gastrostomy feeding tube, had a mechanically altered diet, and received greater than 50% of calories and 500 milliliters or more of fluid intake via the gastrostomy tube. Resident #21's physician orders documented: - 5/19/2023 flush gastrostomy tube with 60 milliliters of water before and after each as needed medication pass; - 5/19/2023 Risperidone (antipsychotic) 0.5 milligrams give 1 tab twice a day via gastrostomy for bipolarism; - 5/20/2023 Folic acid (nutritional supplement) 1 milligram give 1 tab via gastrostomy tube daily for anemia; - 5/27/2023 Otezla 30 milligrams give 1 tab via gastrostomy twice a day for rheumatoid arthritis, may crush per physician; - 6/12/2023 Lamotrigine 100 milligrams give 1/2 tab via gastrostomy twice a day for bipolar; - 6/29/2023 regular diet pureed texture with honey consistency liquids; - 7/17/2023 Tylenol (pain/fever reducer)325 milligrams give 2 tabs via gastrostomy 3 times a day for neck pain; - 8/17/2023 Senna-S (laxative) 8.6 milligrams give 2 tabs via gastrostomy daily for constipation; - 8/17/2023 iron sulfate elixir (nutritional supplement) 220 milligrams/5 milliliters give 7.4 milliliters via gastrostomy twice a day for supplement; - 10/11/2023 prednisone (corticosteroid) 2.5 milligrams give 1 tab by mouth daily for rheumatoid arthritis; - 10/12/2023 famotidine (acid controller) 20 milligrams give 1 tab via gastrostomy daily for gastroesophageal reflux disease; - 10/27/2023 flush gastrostomy tube with 120 milliliters of water before and after each medication pass; and - 12/4/2023 amoxicillin (antibiotic) 875 milligrams give 1 tab twice a day for right knee infection for an additional 2 months until 3/30/2024. The 11/10/2023 updated comprehensive care plan documented the resident had swallowing difficulties and interventions included pureed solids and honey thickened liquids, please administer medications as ordered by physician, enteral nutrition and water flushes as ordered, supervise pleasure feedings, enteral feeding independent of water flushes, and monitor medications for side effects and effectiveness. During an observation on 2/27/2024 at 9:11 AM, licensed practical nurse #24 crushed, mixed with water, and administered the following medications all at once via Resident #21's gastrostomy tube: - Risperidone 0.5 milligrams 1 tab; - Folic acid 1 milligrams 1 tab; - Otezla 30 milligrams 1 tab; - Lamotrigine 100 milligrams 1/2 tab; - Tylenol 325 milligrams 2 tabs; - Senna-S 8.6 milligrams 2 tabs; - iron sulfate elixir 220 milligrams/5 milliliters gave 7.4 milliliters; - prednisone 2.5 milligrams 1 tab (order was to administer by mouth); - famotidine 20 milligrams 1 tab; and - amoxicillin 875 milligrams 1 tab. The nurse flushed the gastrostomy tube with 120 milliliters of water before and after administering the medications. During an interview on 3/1/2024 at 9:21 AM, licensed practical nurse #24 stated medications were to be given as ordered and Resident #21 received their medications via gastrostomy tube. The prednisone had the order to give orally but the nurse thought it was to be given via tube. The nurse stated that one of the 6 rights of medication administration was to give via the right route. The prednisone was not given the right route as the nurse did not catch that it was to be given by mouth and assumed that it was to be given by tube as all the other tablets were given that way. The nurse stated that per best practice, there should have been an order to give the medications all at once unless this was contraindicated. The resident did not have an order to give all the medications at once together. The nurse stated they were never told by the facility to give each medication separately. They were not aware of concerns with crushing the prednisone and administering it via gastrostomy tube. During an interview on 3/1/2024 at 9:36 AM at 10:28 AM, registered nurse Manager #6 stated the resident had an order to give the prednisone orally. The prednisone was ordered a few months ago and somehow must have had the wrong route entered and missed with each monthly check. Gastrostomy medications were to be given individually unless the physician ordered that it was ok to give them together at once. There were no negative results or contraindications for the medications to be given together or the prednisone to be crushed. Medication nurses received competencies during orientation and the Manager had not yet done any further competencies for current staff. During an interview on 3/1/2024 at 11:51 AM, nurse practitioner #25 stated there were no issues with Resident #21 being given all their medications at once and the prednisone being crushed and given via gastrostomy. Resident #21 was able to swallow pureed foods and thickened fluids but preferred their medications be given via gastrostomy. The nurse practitioner stated they originally ordered the prednisone to be given via gastrostomy and did not know how it became entered to be given orally. 10NYCRR 415.12(m)(2)

Based on observation, interview, and record review during the recertification survey conducted 2/26/2024-3/1/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection for 1 of 3 residents (Residents #92) reviewed. Specifically, Resident #92's wound care was completed by licensed practical nurse #1 without performing appropriate hand hygiene and precautions to prevent contamination of the wound and clean supplies. Findings include: The facility policy Wound Care last reviewed/revised 1/2018, documented the procedure included to use a disposable cloth (paper towel is adequate) to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Wash and dry hands thoroughly. Put on exam gloves and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves. Wash wound and peri wound per order. Remove gloves, wash hands, and reapply gloves. Apply treatments as indicated. Apply dressing per order. Remove disposable gloves and discard into designated container. Wash and dry hands thoroughly. Resident #92 had diagnoses of Alzheimer's dementia, peripheral vascular disease, and generalized edema. The Minimum Data Set assessment for significant change on 1/24/2024 documented severely impaired cognition, no behaviors, resident had one unstageable pressure ulcer, pressure reducing device for bed and chair, and pressure ulcer care in place. The 1/31/2024 physician order documented to cleanse both sacral (area at base of spine) superficial open area and left buttock break in skin with normal saline, gently pat dry, and apply fresh sacral foam dressing to cover both areas every other day and as needed. Apply skin prep (skin protectant) to both heels every dayshift for skin protection. Left heel skin prep to deep tissue injury (localized tissue damage from pressure), then cleanse with normal saline, gently pat dry, and cover with heel foam dressing daily and as needed. During a wound care observation on 2/28/24 at 10:38 AM with licensed practical nurse #1 the dressing supplies were on the overbed table without a barrier. The resident's protective boots were removed, and a towel was placed underneath the resident's heels. There was a left heel dressing in place dated 2/27/2024. Licensed practical nurse #1 performed hand hygiene and put on clean gloves. The old dressing was removed, and skin prep was applied to the left heel. The left heel had a posterior open area approximately dime sized with surrounding red skin. The area was cleansed with normal saline, patted dry, and a heel dressing was placed and dated 2/28/2024. Licensed practical nurse #1 applied skin prep to the intact right heel. Licensed practical nurse #1 did not perform hand hygiene or glove change in between removal of the left heel dressing and completion of treatments to both heels. Licensed practical nurse #1 then removed their gloves and performed hand hygiene. The resident was assisted with repositioning and incontinence care, and the sacral dressing dated 2/27/2024 was removed. Licensed practical nurse #1 performed hand hygiene and put on clean gloves. The placed the dressing supplies on the bed sheet without a barrier and the open areas to the sacrum and left buttock were cleansed with normal saline, patted dry, and dressings were dated and placed. During an interview on 2/28/24 at 11:03 AM, licensed practical nurse #1 stated after removal of the left heel dressing, they visualized the area, cleansed the wound, patted it dry, and applied skin prep and a new dressing. They did not remember if they performed hand hygiene and glove change after removing the old dressing. They stated when going from a dirty dressing to a clean dressing they should perform hand hygiene and change gloves to prevent spreading germs or infection. They should wash their hands and change gloves between any separate areas needing treatment to prevent spreading germs from one area to another. Dressing supplies should not be placed on bed sheets as it was not considered a clean surface. There may be germs present on bed linens that should not get on clean dressing supplies. During an interview on 2/28/24 at 11:22 AM, licensed practical nurse Unit Manager #2 stated they were a Certified Wound Care Associate. They performed wound care and assessed wounds throughout the building with a registered nurse once weekly. Any dressing change should begin with hand washing and then application of gloves. After removal of the dirty dressing, the nurse should remove gloves, perform hand hygiene, and put on new gloves before the wound was cleansed and a new dressing placed. If there was more than one wound, hand hygiene and clean gloves should be done before going to the next wound. This was important to prevent cross contamination. Dirty gloves should not be worn for placing a clean dressing. A barrier should be placed on the bedside stand to set dressing supplies. Dressing supplies should not be placed directly on the bed as there may be germs present, which could contaminate the wound. During an interview on 2/29/24 at 4:48 PM, the Assistant Director of Nursing/Infection Control Practitioner stated that setup for a dressing change included hand hygiene and setting supplies on a barrier on the bedside table. Clean gloves should be worn to remove old dressings and then removed and discarded. The nurse should then repeat hand hygiene and put on clean gloves before cleansing a wound and applying the treatment. Hand hygiene should always be performed, and clean gloves applied in between body parts. This helped prevent germs from spreading into the wound or from wound to wound. Clean supplies should not be laid directly on the bed, due to possible germs that could contaminate the wound. 10NYCRR 415.19(b)(1)

Based on observation, interview, and record review during the abbreviated and extended surveys (NY00319112 and NY00294178), the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 3 residents reviewed (Residents #1, 2, and 3). Specifically, Residents #1, #2, and #3 were reportedly found by staff engaging in sexual activity, indicative of inadequate supervision of these residents with impaired cognition who reside on a secured unit. On three separate occasions, Resident #1 was found to be engaging in sexual acts with 2 other residents (Residents #2 and 3). Appropriate supervision interventions were not put in place to prevent recurrence, resident care plans were not updated or were not updated timely, and staff were not trained to prevent recurrence or how to provide appropriate supervision. On 7/18/2023, while onsite, a surveyor observed an unsupervised wandering resident on the secured unit enter Resident #1's room. This failure to provide adequate supervision places at risk the 38 residents of the secured unit who lacked decision making capacity. This resulted in the likelihood of actual harm and immediate jeopardy for Residents #1, 2 and 3 and the potential to affect all residents in the facility with dementia who wander and require supervision. Findings include: The facility's 1:1 Supervision policy, initiated on 10/2021 and revised on 10/2022, documented 1:1 was to provide for the safety and welfare of the residents at the facility when it was determined that less intensive supervision was not sufficient to ensure the safety of a resident. 1:1 could be done based on the discretion of the Director of Nursing (DON), Administrator, or medical provider. A 1:1 sitter would be guided by the following evaluation criteria including violent or sexual behaviors. The facility's policy Supervision Behavioral Guideline dated 12/2/2019 documented it was the responsibility of each staff member to ensure the safest environment for the residents who had been determined to need continual observation. The staff were to report any episodes of increased behaviors that posed a risk to themselves or others to the licensed nurse. A registered nurse (RN) would assess and make the determination for immediate interventions of 1:1 or 15-minute checks. The RN would place the resident on the appropriate level of observation and document the actions on the 24-hour report. Documentation for 1:1 supervision was at a minimum of every hour, 15-minute checks would be documented every 15 minutes, and the form would be turned in every shift. The licensed nurse would review the form, document an interdisciplinary note, and document on the 24 hour report. The Assessment and Evaluation policy dated 12/2/2019 documented the facility would provide evaluations by licensed nurses. The licensed nurse would complete the evaluation based upon direct observation and would place the assessment in the medical record. The forms included a risk indicator for sexually and physically aggressive behaviors. The policy did not document when the assessment was to be completed. Resident #1 had diagnosis including dementia and depression. The 5/5/2022 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, delusions, exhibited behavioral symptoms not directed towards others on 1-3 days of the past 7 days, and wandered on 1-3 days of the past 7 days. The resident was independent with most activities of daily living (ADL) and required supervision and oversight while walking in the corridor. Resident #1's comprehensive care plan (CCP), initiated on 1/31/2022, documented Resident #1 was at risk for being a victim of physical, verbal, or sexual abuse related to dementia and the resident would be free from harm. A revision on 2/7/2022, documented Resident #1 was a wander risk and had wandering behaviors. Resident #2 had diagnoses including dementia and depression. The 2/10/2022 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, did not have behavioral symptoms, and required supervision with oversight when ambulating in the room or corridor. The MDS did not document the resident wandered. Resident #2's CCP, initiated on 10/28/2021, documented Resident #2 was to be supervised while ambulating in the hallway, had verbal and physical behaviors, wandered aimlessly at times, and had the potential for resident-to-resident verbal, physical and sexual altercations. The CCP further documented when Resident #2 kissed other residents it was a gesture of affection and there was no sexual intent. Staff were to offer snacks, staff to be educated on behaviors, and help Resident #2 find their room and redirect them if in someone else's room. Revisions to Resident #2's CCP documented on 2/22/2022, the resident would frequently kiss other residents and staff members' hands as a gesture of affection and had no sexual intent in those instances. New interventions of 30-minute behavior checks were added. Incident #1 Residents #1 and 2 The 4/11/2022 facility investigation at 8:30 PM, documented Resident #1 was witnessed with Resident #2, lying in Resident #1's bed with their clothing off from the waist down. Resident #1 had their genitalia in their hand that was not erect. Assessments were completed, 1:1 was initiated, the facility investigated, and the incident was reported to New_York State Department of Health (NYS DOH) as required. Resident #1's nursing progress notes documented on 4/11/22 at 8:11 AM, Resident #1's room was changed from 612 to 611 (different room on the same unit). Resident #1's CCP was revised on 4/19/2022 and documented Resident #1 had a history of lying in bed with peer residents. The resident became confused the peers resembled their spouse. When the resident experienced an increase in behaviors, staff were to provide diversional activities and if a peer wandered in their room they were to be redirected. Safety checks were to be done as needed. A revision to the CCP on 5/26/2022 documented Resident #1 may show affection by holding hands and kissing others on the cheek (not specified whether this behavior was directed towards staff or resident). An additional update on 6/30/2022, documented if a peer was lying in Resident #1's bed, assist the resident out of the bed. Incident #2 Residents #1 and 2 The undated facility investigation summary conclusion by Director of Nursing (DON) #1 documented on 7/21/2022 at approximately 9:45 PM, licensed practical nurse (LPN) #4 witnessed Resident #1 on top of Resident #2 in Resident #1's bed. Both residents did not have clothing on from the waist down. Resident #1 had their genitals in their hand and LPN #4 did not see vaginal penetration. Resident #1 was last observed in the dining room at 8:45 PM and Resident #2 was last seen in the unit dining room just prior to the incident. The residents were separated, head to toe assessments were completed, and no notable injuries near the peri area, groin, or thighs were found. The (unidentified) nurse practitioner (NP) was called, and no new orders were obtained. Residents #1 and 2 were spoken to about their inappropriate behaviors and 1:1 was implemented for Resident #2. Staff were educated on frequent checks and monitoring residents for change in mentation or emotional state and the CCPs were reviewed. On 7/22/2022, Resident #2 was moved to another unit and both residents would be reviewed by the interdisciplinary behavioral team. Their behaviors would be discussed weekly until no longer necessary. The report documented the staff believed Resident #1 thought Resident #2 was their spouse, Resident #2 had a history of attempting to kiss other residents, and Resident #1 may have thought Resident #2's behavior was consensual. Resident #1's 7/2022 Resident Care Record (RCR, care instructions) documented the resident was alert with confusion, had behaviors of showing affection by hand holding and kissing other residents on the cheek. No approaches for those behaviors were documented. Resident #2's 7/2022 RCR documented the resident became upset after family visits and had verbal and physical aggression towards agitated residents. The approaches included redirection and 1:1 interactions. Resident #2's 7/2022 Medication Administration Record (MAR) documented starting on 6/30/2022 if a resident was on safety checks, ensure the CNA documented and completed these at the end of each shift three times daily. There was no documented evidence provided by the facility for safety checks or 1-1 being completed by a CNA. There was no documented evidence Residents #1 and 2's CCP were updated to include the incident or documentation of a plan to provide supervision to the residents. The 7/22/2022 nurse practitioner (NP) #12's progress note for Resident #2 documented they saw the resident for inappropriate sexual behavior. Resident #2 entered Resident #1's room and when the residents were found, it appeared there was no penetration. The residents were separated. The exam did not find redness, swelling, or bruising with Resident #2. Resident #2 had dementia and did not recollect the encounter. This was the second time Residents #1 and 2 had a sexual encounter. Resident #2 would be moved to another floor. Resident #2's 7/21/2022, 1:1 check form provided by the facility was not readable to include the full version of the form. The facility was unable to provide a readable form. Documentation showed Resident #2 was not provided 1:1 from 6:00 AM to 2:30 PM on 7/22/2022. Incident #3 Residents #1 and 3 Resident #1's Risk Indicator for Sexually and Physically Aggressive Behaviors dated 4/19/2023 documented the resident had dementia with frustration, did not have sexual aggression, had physical aggression in the past 6 months, and was usually stationary. The resident did not hold hands, kiss, or hug others. No other evaluations were completed before or after that date. Resident #1's 6/15/2023 MDS assessment documented the resident had severe cognitive impairment, exhibited behavioral symptoms not directed towards others on 1-3 of the past 7 days seven days, and did not wander. The resident was independent with most ADL and required supervision while walking in the room and corridor. Resident #3 had diagnosis including dementia and depression. The 4/13/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, was independent with most ADL and required supervision while walking in the corridor. The MDS did not document the resident wandered. Resident #3's CCP, initiated on 10/26/2021, documented Resident #3 had dementia, wandered aimlessly, and had the potential for sexual altercations. Intervention included redirection if found wandering or in someone else's space. Resident #3's nursing note dated 6/26/2023 documented Resident #3 was found in bed with another resident in the other resident's room. An assessment was completed without injuries, the medical provider and family were notified, and 1:1 was initiated. The unsigned and undated 6/26/2023 facility investigation summary documented: - CNA #14 reported to LPN #32 that Residents #1 and 3 were having intercourse in Resident #1's room. The residents were immediately separated. Registered nurse Supervisor (RNS) #33 was notified and an investigation was initiated. - Resident #3 was assessed without injury or apparent distress. DON #11 and the Administrator interviewed Resident #3 and they were unable to recall the event related to cognitive impairment. - Resident #1 was assessed without injury and did not show signs of distress. - Staff interviews revealed CNA #14 searched for Resident #3 to provide care at approximately 8:30 PM and CNAs #34 and 14 found Residents #1 and 3 in Resident #1's room. Resident #3 had no clothing on from the waist down and Resident #1 was unclothed. CNA #34 reported Resident #1 immediately pulled backwards and stood up. - The facility's investigation summary further documented the staff member's events differed slightly, neither staff were able to state if penetration occurred. - NP #13 assessed Resident #1 and 3 after the incidents and telepsychology (telephone consult) was completed for Resident #1 and 3 by NP # 12 with new orders on 6/30/2023 for medication changes. - The plan included a 1:1 sitter for Resident #3, the CCPs were updated and reviewed for both residents, and the residents were placed on behavioral team meeting. Resident #3's 1:1 form dated 6/27/2023 documented supervision began on 6/27/2023 at 6:00 AM (the day after the incident). There was no documentation 1:1 supervision was initiated on 6/26/2023. The forms further documented 1:1 was provided to Resident #3 on 6/27/2023, 6/28/2023, and 6/29/2023. There was no further documentation that 1:1 was completed for Resident #3 after 6/29/2023. During an interview on 7/18/2023 at 10:17 AM, CNA #7 stated supervision was defined as watching a resident while they were in the hallway until the resident reached their destination. They stated they watched residents the best that they could based on staffing levels. Resident #1 was alert with confusion. They thought the resident was independent with transfers and ambulation, and they did not think Resident #1 had supervision or monitoring in place before or after the incidents on 7/21/2022 or 6/26/2023. The incident in 7/2022 involved Residents #1 and 2 having a sexual encounter. Resident #2 was assigned 1:1 after the incident until they moved to another unit and Resident #1 was not provided additional supervision. Resident #3 was confused, wandered, and was flirtatious with those of the opposite sex. Resident #3 often sat in the dining room and was to be supervised when ambulating. Resident #1 had a few incidents with other residents on different shifts and Resident #1 usually walked other residents to their rooms. On 6/27/2023, CNA #7 stated they came into work at 2:30 AM, found out about the incident on 6/26/2023 and was assigned to Resident #3's 1:1 until 6:00 AM. They worked the day shift on 6/27/2023 and after 6:00 AM they did not do any more 1:1 for Resident #3 after 6:00 AM. During an interview on 7/18/2023 at 1:40 PM RN #8 stated in the past, they were responsible to ensure the CCPs were initiated and changed with nursing interventions. In 1/2023, a change occurred, and they did not know who updated the CCPs after 1/2023. At the present time, they did not make any changes to the CCPs following an incident unless directed to do so by Administration. RN #8 stated supervision was defined as having their eyes on someone. The 4/2022 incident investigation between Residents #1 and 2 was completed and the facility believed Resident #1 thought Resident #2 was their spouse. The CCP was adjusted, Resident #2 was put on 1:1 checks, and they were unable to locate any safety check documentation for Residents #1 or 2. After the 7/21/2022 incident, Resident #2 was moved to another unit and Resident #1 did not have any added supervision. RN #8 stated they had not reviewed Resident #1's CCP since it was updated by the DON after the incident on 6/23/2023. They were not sure what the resident's CCP meant when it documented supervision in the corridor and they believed Residents #1 and 2 were independent. If residents were independent, they did not require supervision. RN #8 stated Administration did most of the investigation into that incident. The incident on 6/2023 between Residents #1 and 3 occurred during the night shift and they learned of the incident the following morning. Resident #3 had 1:1 in place and there was no added supervision in place for Resident #1 the following day. Administration completed the investigation and RN #8 was directed to follow up with a medication review with the medical provider for both residents. The Administrator determined Resident #3 was the aggressor and was placed on 1:1 and Resident #1 did not need additional supervision. Resident #1 liked to go to the dining room to get coffee and Resident #3 was very social and liked to wander on the unit. During an interview on 7/18/2023 at 2:20 PM, LPN #9 stated supervision was defined as watching a resident all the time. Resident #1 was alert with occasional confusion and had dementia. Resident #1 was not on any additional supervision, but they did kind of watch the resident and documented on what the resident was doing. They were aware of Resident #1's previous sexual behaviors. During an interview on 7/18/2023 at 2:22 PM, social worker #10 stated Resident #1 hung out and was friendly. The social worker stated they were aware of the incidents with Residents #1, 2 and 3 and stated when an incident happened, they followed up with the family. They also checked on the residents' emotional status. They visited Residents #1 and 2 after the incident on 7/21/2022 and neither resident remembered what happened. They called the families the day after the incident on 6/26/2023 and made them aware. The plan was to separate and monitor the residents as much as possible often and they thought it was documented on the care plan. They stated they were not involved in any part of the care plans for Residents #1, 2, or 3. During a subsequent with social worker #10 on 7/18/2023 at 3:22 PM, they stated after an incident, the interdisciplinary team including nursing, social work, activities, and therapy met if needed to determine what preventative measures were to be put in place to ensure the incident did not happen again. This occurred with the incident with Residents #1 and 2 on 4/2022. The plan for prevention was a room changes as Residents #1 and 2's rooms were next to each other. On 7/21/2022, Resident #2 was moved to another unit following the second incident. Following Residents #1 and 3's incident, Resident #3 had 1:1 in place and Resident #1 did not have additional supervision put in place. Resident #3 was considered the aggressor as Resident #3 was in Resident #1's room. They were not sure what interventions were initiated for Resident #1 other than a medication change. They did not update any information in the CCP. During an interview on 7/19/2023 at 11:24 PM, DON #11 stated supervision for 1:1 required staff to always have direct sight of the residents. Residents who wandered and had dementia received distant supervision, periodic supervision, and monitoring Staff would not be with a resident all the time and that would be documented on the CCP. The CCPs were completed by the interdisciplinary team. The nurses initiate the CCP, and updates were done with the whole team. After an incident, the team discussed the incident in morning report and whoever had time, completed the updates to the CCP. They expected the CCP to be updated or revised after incidents however stated, it may take a couple of days before it was completed. Behavioral monitoring charting was documented in the progress notes and not anywhere else. They were not aware of Resident #1's sexual inappropriate behavior until the incident in 6/2023 and could not speak to the prior incidents as they were not working at the facility at the time they occurred. Resident #1's CCP was reviewed, and DON #11 defined the supervision on the CCP as monitoring the resident while ambulating in the hallway and room with an indirect line of site monitoring. They were notified by telephone on 6/26/2023 of the incident between Residents #1 and 3. The RNS obtained basic statements so the facility could rule out harm. Residents #1 and 3 were in bed with each other, not clothed, and they were assessed without injury. Resident #3 was placed on 1:1 and Resident #1 was redirected to their room. No other interventions were put in place for Resident #1. Documentation for 1:1 was in the progress notes and there was a form that was not consistently used. The policy stated staff were to document as needed. If Resident #2 was having behaviors or wandering and had 1:1 monitoring in place, they expected documentation on the form. If no documentation was on the 1:1 form, then Resident 2 had no behaviors when the 1:1 was provided. The nursing progress notes would have a daily note that 1:1 was provided. If the form was missing documentation for 2 shifts, they felt no behaviors occurred. Resident #1 did not have additional supervision put in place as they felt the Resident #1 was not the aggressor as Resident #3 went to Resident #1's room. No changes to Resident #1's CCP were made other than the medication changes, preferences, and redirection for Resident #1. Resident #3's CCP was updated on 6/26/2023 and documented medication changes, redirection, and activities were added. No additional supervision was put in place for Resident #2 after the 1:1 was discontinued. They did not feel added supervision was appropriate as there were no further behaviors after the incident. They stated the 1:1 form provided by the facility was not readable due to the original form being cut off. During an interview on 7/19/2023 at 1:03 PM, NP #12 stated Residents #1 and 3 had dementia and did not have capacity to consent to sexual encounters. Resident #1 wandered, and Resident #3 was very active and socialized with members of the same sex. They were aware of the sexual behaviors with Residents #1 and 3 and could not state what interventions should have been put in place after the incident. They made medication changes for both residents that were initiated on 6/30/2023. They stated they added a medication that lowered sexual urges. t During an interview on 7/19/2023 at 1:15 PM, NP #13 stated Residents #1, 2, and 3 did not have capacity to consent to sexual encounters related to dementia. NP #13 stated following the incidents some form of supervision should have been provided for the residents. During an interview on 7/25/2023 at 1:34 PM, CNA # 14 stated supervision was defined as watching a resident and ensuring they had their needs met. Safety checks were completed for some residents and were done every half hour. If the resident had safety checks it would be documented in the RCR. Resident #3 did not need any safety checks prior to the incident on 6/26/2023 and there was no documentation in the system for them to be done. They took care of Resident #3 on 6/26/2023. Resident #1 did not have safety checks or supervision in place that they were made aware of. Resident #3 was independent with ambulation and did not require supervision while ambulating. If a resident required supervision with ambulation, they thought staff were to watch them when they ambulated in the hallway but was not sure. On 6/26/2023, they last observed Resident #3 around 7:45 to 8 PM at the nurse's station. When they went to look for Resident #3 later (time unknown) to provide care, Resident #3 was not a t the nurse's station. CNA #14 found Resident #3 in Resident#1's room. They were in bed with their clothes off. Resident #1 was on top of Resident #3. Resident #1 pulled away from Resident #3 and CNA #14 observed penetration. They left and closed the door, and immediately told the nurse, who came to the room and separated the residents. No supervision was put in place that night for Residents #1 or 3. They returned the following evening and Resident #3 was on 1:1. During an interview on 7/26/2023 at 3:30 PM, the Administrator stated supervision was individualized per the CCP. The minimum standard expected was that all residents were supervised, with eyes on them, every 2 hours unless otherwise care planned. The facility had an old form for safety checks and if safety checks were to be completed, they would be documented on the CCP. Nursing staff were responsible to complete incident/accident investigations. The interdisciplinary team meeting was done after incidents and if CCP changes were required they would be made. They were not at the facility for the 4/2022 or 7/2022 incidents. CCP interventions for Resident #3 included 1:1 following the 6/26/2023 incident as they found Resident #3 to be the aggressor due to their previous behaviors and Resident #3 being found in Resident #1's room. They believed the 1:1 was continuous for Resident #3 and did not remember how long the resident was on 1:1. Medications changes were made for Residents #1 and 3 and the CCPs were updated with redirection or different approaches. After that was implemented, 1:1 was discontinued. They were not aware the 1:1 form was not documented as completed. They stated if a temporary 1:1 was initiated that may not be added to the CCP. The CCP was not updated as they determined the interventions were adequate at that time. They did not believe additional supervision was needed for Resident #1 as they determined Resident #1 was not the aggressor. During an interview on 8/8/2023 at 9:36 AM, the Medical Director stated Residents #1 or 3 were not their assigned residents however they were made aware of the situation involving them after Department of Health (DOH) became involved. Residents #1 and 3 had cognitive impairment and were not able to consent. They were not aware Resident #1 had previous inappropriate sexual behaviors, they would have wanted to be made aware, as they could have possibly identified a pattern and offered suggestions for interventions. They stated they would have wanted some form of supervision put in place to ensure other residents would be safe and they expected the CCP and RCR to have the same interventions regarding supervision. They felt some form of abuse did occur with Resident #1 and 3. 10 NYCRR 415.12(h)(2) --------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified, and the facility Administrator was notified on 7/19/2023 at 5:03 PM. Immediate Jeopardy was removed on 7/22/2023 at 1:48 PM, based on the following corrective actions taken: - All 38 residents on Unit 6 were evaluated for risk potential to be a victim of abuse and risk to be an abuser on 7/20/2023. - A safety aide on Unit 6 was assigned and provides continuous unit supervision and rounding until care plans for residents at risk can be updated. - The 2 residents on Unit 6 determined to be at high risk for potential abuser were placed on 1:1 supervision on 7/21/2023 until follow up with psychiatry was completed. - Resident #1 was evaluated by psychiatry on 7/21/2023 and removed from 1:1 and placed on standard of care monitoring, which consists of safety aide rounding every 30 minutes in all areas of the unit. - Resident #3 was evaluated by psychiatry on 7/21/2023 and 1:1 will continue until follow up with psychiatry related to supervision needs. - The IDT met on 7/21/2023 and was provided education by the DON and Administrator related to Residents #1 and 3, care plans reviewed, interventions, and implementation. - 100% of staff working on Unit 6th floor as of 7/22/2023 at 9:00 AM have been educated by the DON, Administrator or Nursing Supervisor on the plan of care for Residents #1 and 3. - 100% of staff working in the facility as of 7/22/2023 at 11:30 AM have been educated by the DON, Administrator, or Nursing Supervisor on the Resident to Resident Risk Evaluation Tool and new policies, as well as what procedure to follow until policy is developed. - On 7/22/2023, 3 LPNs, 4 CNAs, 2 dietary staff, and 1 housekeeper were interviewed (on 4 floors) and reported they had received education related to at risk behaviors, supervision, and reporting of resident behaviors.

Based on observation, record review, and interview during the abbreviated and extended surveys (NY00294178 and NY00319112), the facility failed to provide the appropriate treatment and services to attain and or maintain his or her highest practicable physical, mental, and psychosocial well-being for residents diagnosed with dementia for 1 of 5 residents (Resident #5) reviewed. Specifically, Resident #5 had severe dysphagia (swallowing difficulty), was on thickened liquids and puree diet consistency, wandered on the unit and ingested thin liquids resulting in aspiration pneumonia (inhalation of food/fluids into the lungs). Following an incident of wandering and ingesting thin liquids on 5/18/2023, nursing progress notes documented the resident was wandering, obtaining, and drinking thin fluids and/or eating regular consistency foods on 12 occasions between 5/25/2023 and 7/14/2023. There was no documented evidence of medical or speech therapy evaluation following the multiple incidents of ingesting thin liquids or regular consistency foods. The resident's care plan remained unchanged, and the facility did not address or implement new interventions and/or provide supervision to prevent Resident #5 from obtaining and ingesting food or drinks that were not the proper consistency. This resulted in the likelihood of actual harm and immediate jeopardy for Resident #5 and the potential to affect all residents in the facility with dementia who wander and require modified-consistency diets. Findings include: The Food and Fluids Consistency Modifications policy revised 8/2016 documented residents will have food and fluid consistency ordered by a qualified medical provider. The facility did not have a policy related to dementia care. Resident #5 had diagnoses including dementia, diabetes, and dysphagia (difficulty swallowing). The 5/5/2023 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and exhibited physical, verbal, and wandering behaviors. The resident had a swallowing disorder with symptoms of coughing or choking during meals. The comprehensive care plan (CCP) initiated 3/4/2022 and revised 4/3/2023 documented the resident required assistance with activities of daily living (ADLs) and mobility and needed ambulation with supervision and self-feeding with supervision in the dining room. The resident had trouble remembering at times due to dementia and needed close observation and evaluation of cognitive abilities. The resident was at risk for wandering and interventions included structured activities, offer frequent snacks as the resident was known to look in kitchenette for preferred food items and make easily accessible, distract from wandering with pleasant diversions, and identify pattern of wandering to determine if purposeful, seeking something, exit-seeking. On 4/18/2023, Speech Language Pathologist (SLP) #18 documented the resident had a swallow evaluation and was recommended for nectar thick liquids. The 4/18/2023 physician's order documented the resident's diet was mechanically altered consistency and nectar thick fluids. The SLP Evaluation and Plan of Treatment by SLP #18 on 4/20/2023 documented the resident was seen for increased coughing while eating and drinking. Recommendations included level 2 solids (soft moistened foods) and nectar thick liquids. The resident was at risk for aspiration (inhalation of food/fluids into the lungs), aspiration pneumonia, and choking. On 5/18/2023 at 10:14 PM, licensed practical nurse (LPN) #9's progress note documented the resident was wandering around tables in the dining room during supper. After dinner, the resident was coughing and shivering, and the Supervisor assessed the resident. New orders were received for a chest x-ray, antibiotics, and an inhaler 4 times per day for 4 days. The 5/19/2023 nurse practitioner (NP) #12's progress note documented the resident was reported to have ingested thin liquids, was coughing, choking, and developed a temperature of 100.1 Fahrenheit (F) with white blood count (WBC) of 12.1 (normal range 4.5-11). The chest x-ray was normal. The antibiotic was extended to 3 days and breathing treatment extended to 7 days. A repeat chest x-ray and blood work will be ordered for 5/21/2023. The resident's representative from Adult Protective Services (APS) was made aware of the elevated temperature and possible aspiration. The physician's orders documented on 5/18/2023, an inhaler and one dose of an antibiotic were ordered The physician's orders documented on 5/19/2023, an antibiotic was ordered for 2 more days, and the inhaler continued for coughing for 7 days. The physician's orders documented on 5/22/2023, an antibiotic was ordered for an upper respiratory infection for 5 days. The 5/21/2023 chest x-ray documented a small area of atelectasis (collapsed lung tissue) or infiltrate (spots on lungs that identify infection). The 5/23/2023 Modified Barium Swallow (swallow evaluation) documented the resident was referred to determine safe diet consistency. The resident was known to drink from the sink and take water from the medication cart. The resident was found with severe oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or throat) and was recommended for a pureed solid diet with pudding thick liquids (the thickest consistency liquids). The 5/24/2023 physician's order documented honey thick liquids and puree solids. The CCP, revised 5/24/2023, documented the resident was non-compliant with dietary recommendations and placed themselves at risk for potential health concerns related to dementia. Interventions included staff will attempt to redirect if making poor decisions regarding diet recommendations, staff will be educated on adverse effects this resident may endure if they do not follow their diet recommendations. The 5/25/2023 at 2:04 PM, registered nurse (RN) Manager #8's progress note documented the resident continued to drink from the faucet. All attempts to re-educate and redirect the resident were unsuccessful. There was no documented evidence of an assessment by medical provider or SLP following the resident drinking from the faucet on 5/25/2023. The 5/25/2023 letter to Adult Protective Services (APS) written by NP #12 documented Resident #5 has been drinking water from the sink in [their] room because [they] are refusing thickened liquids. [They] aspirated on water from [their] room on 5/14/23 (actually 5/18/23) and required antibiotic treatment. On 5/29/2023 at 4:31 PM and 5/30/2023 at 4:24 PM, RN Manager #8 documented in progress notes the resident continued to drink from the faucet. All attempts at redirection and education were unsuccessful. The 6/1/2023 at 11:20 PM, licensed practical nurse (LPN) #6's progress note documented the resident was wandering and invading space, and drinking water out of other residents' sinks. The 6/2/23 at 4:54 PM, LPN #35's progress note documented the resident went into the dining room and was taking other residents' food and thin liquids and shoving their mouth full, refusing to remove it when requested. The resident was also drinking water from their sink. Redirection was unsuccessful and the resident became agitated and aggressive. The 6/2/23 at 11:01 PM, LPN #6's progress note documented the resident was found stealing food and drinks from other residents in the dining room. The resident was found taking paper cups, filling with regular water from the sink, and drinking it. Verbal support and redirection were provided with no effect. There was no documented evidence the resident was assessed by a medical provider or the SLP following the 5/29, 5/30, 6/1, and 6/2/2023 incidents when they were found ingesting thin liquids and other residents' food. There were no new documented interventions to address the resident's behaviors of seeking and ingesting foods and fluids of improper consistency. The 6/11/23 at 10:58 PM, LPN #6's progress note documented resident was found taking thin fluid drinks out of the bins on the counter for tray pass. The resident became agitated with redirection to sit and when given honey thickened fluids in place of thin fluids they had already began to drink. The 6/12/2023 and 6/19/2023 NP #12's progress notes documented the resident has been seen by staff drinking water from the sink. The resident had a swallow evaluation that recommended pudding thick beverages. Due to severe dysphagia and recommendations by radiology and SLP, it was not recommended to change to thin fluids. The 6/20/2023 at 10:57 PM, LPN #6's progress note documented the resident was drinking water from faucet by placing their head under the faucet. Staff redirected the resident with little effect. There was no documented evidence the resident was assessed by a medical provider or the SLP following ingestion of thin liquids on 6/20/2023. The 6/22/2023 at 9:51 PM LPN #36's progress note documented the resident was wandering and drinking from others' drinks and began coughing. The resident was drinking from faucets and became agitated when confronted. The 6/23/2023 at 9:40 PM, LPN #6's progress note documented the resident was in another room found eating a brownie and drinking regular fluids. The resident was educated it was not safe to eat brownies, they became agitated and was redirected to their room. There was no documented evidence the resident was assessed by a medical provider or the SLP following ingestion of solid food and thin liquids on 6/22/2023 and 6/23/2023. The 7/14/23 at 2:21 PM, LPN #35's progress note documented the resident was taking food, popcorn, chips, and cookies and drinking water from the medication cart pitcher, taking from rooms and off tables in the dining room. The NP was notified. The Resident Care Instructions (RCR, care instructions) as of 7/22/2023 documented the resident was on a pureed diet with honey thickened liquid. The resident was to be encouraged to have meals out of bed and in the dining room. The resident fed themself with supervision while in the dining room. Interventions for behaviors included: explain or reinforce why the behavior was inappropriate; intervene as necessary to protect the rights and safety of others; remove from situation and take to alternate location as needed; and praise progress or improvement in behavior. Resident #5 was observed on 7/25/2023 at 1:16 PM, in the dining room with pureed food and 2 honey thickened drinks in a cup; the resident drank both drinks independently by the end of the meal; no coughing was observed; and at 2:50 PM, walking in and out of other resident rooms, down the hall, and then into their own room. During an interview on 7/25/2023 at 1:55 PM, certified nurse aide (CNA) #7 stated Resident #5 sought out food and drinks as they did not like their pureed food and honey thickened liquids. The resident sought water from sinks in other residents' rooms and would take drinks from the tray line in the dining room. The RCRs did not state the resident sought food and drinks that they could not have and did not include interventions to address the behavior. During an interview on 7/25/2023 at 2:10 PM, CNA #15 stated they never offered Resident #5 any drinks outside of meals. The resident did not like honey thick fluids and pureed food and tried to get food from other residents. The CNA had been told by other staff the resident also drank water from faucets. The CNA stated they tried to stop the resident when they did it, and there were usually 3 CNAs on the unit, so they did not watch the resident all the time. The CNA stated they were unaware of any specific interventions aside from just stopping the resident from taking food or drinks when staff observed it. During an interview with CNA #16 on 7/25/2023 at 2:15 PM, they stated Resident #5 wandered all day and sometimes tried to get drinks from faucets or other residents' trays. The CNA stated the resident will take a drink of appropriate consistency if offered and they did not know of any specific interventions to address the resident's behaviors of seeking food or fluids and trying to ingest them. During an interview with CNA #17 on 7/25/2023 at 2:35 PM they stated the resident regularly made attempts to take food and drinks of regular consistency and had caught the resident on multiple occasions drinking from a water faucet. The resident usually coughed when they drank from the faucet or had other thin liquids. The CNA observed the resident drinking from the faucet 2 days ago and reported it to a nurse. The CNA was unaware of any specific care planned interventions to address the resident's behaviors and stated they would offer a drink of appropriate consistency. They had CNA care sheets for directions and there was no information related to the resident's behaviors. During an interview with NP #13 on 7/25/2023 at 3:52 PM, they stated they were not the primary provider for Resident #5 and had some familiarity with the resident. NP #12 was the primary provider and currently unavailable. NP #12 ordered a chest x-ray and antibiotics on 5/19/2023, they also ordered a urine culture, which was negative. The chest x-ray was repeated on 5/22/2023 and had indications of pneumonia, which could have resulted from the ingesting thin liquids. NP #13 ordered the antibiotic on 5/22/2023 for an upper respiratory infection. In reviewing Resident #5's record, NP #13 stated based on the information, everything pointed to aspiration pneumonia. During an interview with SLP #18 on 7/28/2023 at 10:18 AM, they stated Resident #5 had severe dysphagia and was at very high risk of aspiration. The 5/23/2023 swallow evaluation resulted in recommendations for pudding thick liquids due to the resident's severe risk. The resident was placed on honey thick liquids and pureed solids for the least restrictive diet. If the resident ingested liquids or food that was not their ordered consistency, they should be assessed or evaluated with monitoring for symptoms of aspiration. If the resident ingested any food or liquid outside their recommended diet, they were at severe risk of aspiration, or the resident could choke to death upon ingestion. The resident had dementia and redirection and education were not effective with the resident when they attempted to take food or fluids that were not safe. During a telephone interview with LPN #35 on 8/1/2023 at 9:45 AM, they stated they observed Resident #5 taking food and drinks on 2 or 3 occasions. The resident often tried to drink from faucets or take food or drinks from other trays in the dining room, usually after meals. LPN #35 responded by asking dietary staff to clean the tables in the dining room right after meals, and offered the resident thickened drinks they preferred such as cola or lemon water. The resident became agitated when they were redirected and education on safety was not effective. On 6/2/2023, LPN #35 observed the resident with food in their mouth and was unable to remove it. They could not recall if they notified a supervisor, and the unit had no Unit Manager at the time. LPN #35 stated they would have communicated the incident with the full time LPN on days (LPN #6) and other staff and was uncertain if it was documented. During a telephone interview on 8/1/2023 at 10:19 AM, LPN #36 stated the resident had behaviors of drinking from the faucet and taking items from other residents' trays in the dining room. They observed the resident ingesting thin liquids on one occasion and stated they notified a supervisor. The unit had no Unit Manager at that time and the LPN was unaware of any care plan interventions to address the behavior. The LPN was aware the resident previously choked and became ill from aspiration, per their shift-to-shift reports. Redirection and education were not effective with the resident, as they had dementia and became aggressive when redirected. The resident accepted a thickened drink when offered. During a telephone interview on 8/2/2023 at 9:52 AM, NP #12 stated when they assessed the resident on 5/19/2023, the resident had rhonchi sounds (gurgling or bubbling sounds caused by fluid or secretions in the airways), and NP #12 ordered antibiotics and was informed by staff the resident had ingested water from their sink. The 5/21/2023 chest x-ray confirmed pneumonia. NP #12 stated they could not say for certain the pneumonia resulted from the resident ingesting water as they were found to be at risk for aspiration on any consistency food or fluid in a subsequent swallow evaluation (on 5/23/2023). NP #12 wrote a letter to APS on 5/25/2023 related to the resident's condition and stated it appeared as if the resident aspirated from ingesting water. When the resident continued to be found ingesting foods and drinks that were not their ordered consistency, they should have been assessed to ensure their lungs were clear and have follow-up monitoring as it may take a couple of days for symptoms to appear. The resident had dementia and was not able to understand the risks of ingesting food or drinks that were not the proper consistency and required supervision to ensure they did not. Education was not effective with the resident, rather distractions, diversions, and offers of appropriate consistency food or drinks were more effective. During a telephone interview with RN Manager #8 on 8/3/2023 at 1135 AM, they stated they were responsible for care planning and updates. The RN Manager was aware of Resident #5's behaviors of seeking food and fluids that were not appropriate for their recommended diet. The RN Manager verbally communicated with staff related to the resident's behaviors and did not document specific interventions for the behaviors. They stated care plans should be more specific to targeted behaviors and they were unaware of a policy or guidance related to dementia care. When the resident continued to ingest food or fluids that were not the proper consistency, the RN Manager expected staff to notify a supervisor, complete an assessment, have follow up assessments from the medical provider as needed, and review and update the care plan. The assessments should be documented in the resident's record following incidents of ingesting food or fluids of improper consistency. During an interview on 8/8/2023 at 9:36 AM the Medical Director stated Resident #5 had cognitive impairment and a specialized diet and redirection and reeducation was not a very good solution for a resident with dementia who repeatedly continued with the same behaviors. Staff should implement other interventions to prevent the resident's behaviors and agreed the resident would be at risk for choking. They expected some form of supervision be in place to prevent the behaviors from reoccurring. 10 NYCRR 415.12 ______________________________________________________________________________ Immediate Jeopardy was identified, and the facility Administrator was notified on 7/26/2023 at 3:52 PM. Immediate Jeopardy was removed on 7/27/2023 prior to survey exit based on the following corrective actions taken: - Resident #1 was placed on 1:1 supervision. - The facility identified 33 residents with a diagnosis of dementia, who were ambulatory, and received an altered consistency diet. - The 33 residents were assessed for potential non-compliance with their ordered diets. - Resident #5 was the only resident identified at risk of non-compliance. - Resident #5's care plan was updated. - 100 % of nursing staff working on 7/27/2023 were educated to notify a supervisor or unit manager if a resident was non-compliant with their altered consistency diet. Remaining nursing staff were to be educated upon arrival, prior to the start of their shift. - Nursing supervisors and managers were educated to complete an RN assessment when the inaccurate diet consistency was consumed to rule out signs/symptoms of aspiration and to notify the medical provider. The IDT will review the care plan and update with interventions to discourage intake of food and fluid consistency that was not recommended. - Interviews were completed on 7/28/2023 to determine compliance with staff training and education including 4 LPNs, 4 CNAs, and the SLP.

Based on record review and interview conducted during the abbreviated survey (NY 585), it was determined for 6 of 8 residents reviewed for abuse (Residents #4, 5, 6, 7, 8, and 9), the facility did not ensure residents had the right to be free from abuse. Specifically, Resident #5 had multiple incidents of physical aggression towards other residents including Residents 6, 7, 8, and 9, and the facility did not ensure interventions were implemented to prevent abuse. The interventions in place to prevent abuse were not re-evaluated when Resident #5 continued to have incidents with other residents, resulting in Resident #5 entering Resident #4's room and injuring her. This resulted in actual harm to Resident #4 that is not immediate jeopardy. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition per the 5/4/2017 Minimum Data Set (MDS) was severely impaired. The 4/20/2017 social worker #14's progress note documented the resident was at the facility from 4/11/2017 to 4/13/2017, and his spouse took him home. She was not able to manage him at home so he returned to the facility on [DATE] for long term care. Nursing progress notes documented: - on 4/21/2017, the resident was anxious, agitated, verbally aggressive, and slammed doors on the unit. He was not re-directable and was very aggressive getting into other resident's faces. - On 4/22/2017, the resident was aggressive with 2 residents and verbally aggressive with a certified nurse aide (CNA), and an order was obtained for as needed [MEDICATION NAME] (sedative). The 4/23/2017 admission history and physical documented the resident had behaviors that the family was unable to manage at home related to dementia and a head injury 6 weeks ago. The resident received [MEDICATION NAME] (anti-psychotic medication) and that was to continue. Incident reports documented on 4/25/2017, the resident slapped Resident #7 on the right arm and on 4/26/2017, the resident slapped his roommate's arm (Resident #8) to wake him up as he thought Resident #8 was in his bed. The 4/27/2017 nursing progress note documented the resident was aggressive, constantly wandering from room to room, and was very easily agitated. The comprehensive care plan (CCP), initiated on 4/28/2017, documented the resident wandered into other residents' rooms and was inappropriate with them. The plan included 15 minute checks, redirect, and to provide 1:1 when the behavior occurred. The 5/2/2017 at 3:40 PM, LPN's progress note documented the resident was arguing with a male resident and threatened him. The 5/3/2017 incident report documented Resident #9 was found on the floor outside of her room and upon review of the video camera footage, it was determined Resident #5 pushed Resident #9 down. After the incident, Resident #5 stated he thought Resident #9 was in his room and he wanted her to leave. The 5/4/2017 at 12:26 AM, LPN #7's progress note documented the resident was found in another resident's room and staff needed to monitor his whereabouts. On 5/4/2017, the CCP was revised and documented the resident had behaviors. The plan included assessing causes of the resident's wandering; allowing the resident to express his feelings; checking the resident's whereabouts every 30 minutes, and to use a door alarm. On 5/4/2017, RN Manager #6 added to the 4/25, 4/26, and 5/3/2017 incident reports that the plan to prevent further incidents included moving the resident to a private room and placing him on 15 minute checks. The CCP was not updated to reflect the change from 30 minute to 15 minute checks. The 5/5/2017 nursing progress note documented the resident was yelling at staff and a resident and raised his fist to punch a CNA. Incident reports documented: - On 5/6/2017 at 8:30 PM, Residents #5 and 6 were in a room screaming at one another; Resident #6 stated she was beaten up, and Resident #6's clavicle was red. - On 5/6/2017 at 10 PM, Resident #5 wandered out of his room, was not re-directable, and tried to enter another resident's room. CNA #8 tried to intervene and the resident punched her full force in the jaw. The 5/7/2017 LPN #10's progress note documented beginning at 11 AM that day, the resident was placed on 1:1 per the Administrator. The resident needed constant redirection, had angry outbursts, and was to be given plastic utensils as he threatened to stab others. Nursing progress notes documented: - On 5/8/2017, RN Manager #6 noted the resident became the most upset when he wandered into other residents' rooms and thought those residents were in his room. The resident was on 1:1 at that time. - On 5/9/2017, the resident threatened to beat up the nurse. - On 5/10/2017 at 3:15 AM, the resident was found in another resident's room standing in the doorway. There was no further explanation of this event or documentation of whether he remained on 1:1. - On 5/11/2017, LPN #7 documented at 4:57 AM, the resident was on 15 minute checks with a door alarm on the night shift and was found in the hallway twice that shift. - On 5/11/2017 2:05 PM, RN Manager #6 documented the resident was on 1:1 while awake and 15 minute checks at night with a door alarm. The nursing progress notes contained no explanation as to how the decision was made to discontinue 1:1 for the resident at night. - On 5/15/2017 at 2:44 PM, LPN #11 documented at 2:44 PM, the resident had an altercation with another resident over the weekend and the physician was updated. There was no further information in the medical record about the altercation and when asked for an incident report, the facility was unable to provide one. - On 5/16/2017, LPN #11 documented the resident had an increase in physically aggressive behaviors. - On 5/17/2017 at 2:24 AM, LPN #7 documented the resident's door alarm was not turned on and she found him in the hallway. The resident said a lady was in his bed and if anyone was in his room he would throw them out. LPN #7 documented there was no one in the resident's room at that time and she turned his door alarm on. The 5/2017 Medication Administration Record [REDACTED]. The 5/19/2017 social worker #14's progress note documented the resident had a a 1:1 sitter 24 hours per day as he had agitation and struck out at residents and staff (The social worker's documentation of the resident's plan was not consistent with RN Manager #6 who documented 1:1 was discontinued at night on 5/11/2017). The mood and behavior report documented on 5/20/2017 at 1:34 AM, the resident exhibited behaviors of cursing, hitting, slapping, shaking his fist at others, insulting others, interrupting others, teasing, threatening, verbal and physical aggression, yelling, hitting, grabbing, and persistent anger. The 5/20/2017 incident report documented at 1:40 AM, Resident #4 was found on the floor in her room bleeding from her head. Resident #4 sustained a hematoma to the right temple with bruising to the jawline, shoulder, elbow, and knee. The DON at the time of the incident, documented after watching the video camera footage, the facility determined that Resident #5 entered Resident #4's room prior to her being found on the floor; Resident #5 had behaviors and had been on 15 minute checks that were increased to 1:1 monitoring. Resident #5 was not on 1:1 at the time of the incident, and Resident #5 was out of his room for 6 minutes with no staff responding to his door alarm. Resident #5 was placed back on 1:1 after the incident and staff were reminded to respond to his alarm immediately and to ensure staff cover for one another if breaks were taken. The investigation included statements from 2 staff members working on the unit on 5/20/2017 and the RN Supervisor including: - LPN #12's statement documented she was off the unit at break when the incident occurred but prior to the incident, the resident was aggressive towards CNA #16 so she tried to give him [MEDICATION NAME] without success. She called the Supervisor who got the resident to take the [MEDICATION NAME]. (The resident's 5/2017 MAR indicated [REDACTED]. - CNA #13's statement documented she heard the resident's door alarm sounding when she was in another resident's room. The investigation did not include a statement from CNA #16, who was also working at the time of the incident. - RN Supervisor #18's statement was dated 5/25/2017 and documented when she got to the unit on 5/20/2017, Resident #4 was on the floor, she was not aware Resident #5 had been in the room, and she assessed Resident #4 for a fall from bed and sent her to the hospital. She documented she was not aware Resident #5 was involved in the incident until the next day when someone reviewed the video camera footage and told her. The 5/20/2017 nursing progress note for Resident #4 documented she had bruises to the right side of the face, right shoulder, right knee, and an open area to the right forehead. The 5/20/2017 LPN #10's progress notes documented at 9:30 AM, the resident was yelling at the safety aide and threatening to harm anyone and at 2 PM, he was physically aggressive with safety aide. RN Manager #6's progress note dated 5/23/2017 at 10:03 AM, documented the resident was on 1:1 and that was discontinued at night on 5/16/2017 as medications were increased that day. After 5/16/2017, he remained on 1:1 during the day and 15 minute checks at night with a door alarm. After his agitated episode on the night of 5/19/2017 into the morning of 5/20/2017, he was placed back on 1:1 (This note was inconsistent with her note written on 5/11/2017 when she documented 1:1 at night was discontinued on that date). On 11/3/2017, the surveyor requested from the facility in writing any documentation related to 15 minute checks or 1:1 monitoring done for the resident from admission to present and on 11/6/2017, the facility provided the surveyor with copies of forms used to document 15 minute checks on the resident. No documentation of 1:1 monitoring was provided by the facility. On 11/30/2017 at 12:26 PM, CNA #15 stated in an interview: - in 4/2017 and 5/2017, the resident had behaviors including waking into other residents' rooms, being very aggressive, yelling at other residents to get out of his bed, and he did not do well with redirection. - The resident would get up in the middle of the night, approach staff, and punch or hit them for no reason. - One night, she followed the resident into another resident's room and he slammed the door in her face. She opened the door and followed him into the room because she was scared he would hurt the other resident who was bedbound. She stated this was before they believed that he pulled Resident #4 out of her bed. - The night they thought the resident pulled Resident #4 out of her bed, he was not on 1:1 and she did not know why. She would find out at the beginning of the shift if the resident was on 1:1 as it would be written on the communication board. She thought the decision to take him off 1:1 was made by the Unit Manager. - CNA #15 stated when the resident was on 1:1 they also referred to that as door duty and that meant someone needed to sit outside his door the entire shift and monitor his whereabouts. - When the resident was given a door alarm, it agitated him more. He did not like the alarm sound and the staff did not want to set the alarm off at night because if it woke the resident up, it would trigger more behaviors. She stated the staff would walk on the opposite side of the hall from the resident's room and would not go in his room on the night shift so they did not set the alarm off. On 11/30/2017 at 1:27 PM, CNA #17 stated in an interview, on 5/6/2017, she heard Resident #6 yelling and when she got to her, Resident #5 was touching Resident #6's neck, Resident #6's neck was red, and Resident #6 said Resident #5 was beating her up. She stated it took herself and the safety aide to physically remove Resident #5 from the area of Resident #6. CNA #17 stated Resident #5 pulled Resident #4 out of bed and during that time period, Resident #5 thought every room was his and he wandered from room to room and yelled at residents to get out of his room. She stated she did 1:1 with the resident a few times and when she did, she was supposed to sit outside his room and monitor the door and then stay with him if he left his room. She stated this was difficult because his behavior was scary and there were times that she ran from him when he chased her because he would punch, kick, and hit for no reason. On 12/1/2017 at 12:31 PM, LPN #7 stated in an interview, in 4/2017 and 5/2017, the resident would turn violent very quickly. At times he was on 1:1 on the night shift and at other times he was not. LPN #7 stated in 5/2017 on the night shift, the resident would wander from room to room and yell at the residents in those rooms that they were in his room. She stated there were times when she found him in other residents' rooms and he would be mad because he thought those residents were in his room. She stated there were also times when she she found his door alarm turned off. She stated the staff would turn it off and go into the room and then forget to turn it back on when they left. She stated the staff did this because they did not want the alarm to sound when they entered as they did not want to wake the resident up. On 12/4/2017 at 12:50 PM, CNA #16 stated in an interview, she was working when the facility believed that Resident #5 pulled Resident #4 out of her bed. She stated herself and CNA #13 were doing second rounds at around 1 AM and saw Resident #5 in the hall. She stated they were told if the resident was up, they needed to watch him so CNA #13 approached him and he charged her. She also tried to approach him and he charged her too so they told LPN #12. She thought LPN #12 and the Supervisor medicated the resident but her and CNA #13 went back to taking care of other residents when the nurses responded so she did not know for sure. She stated at around 1:20 AM, herself and CNA #13 found Resident #4 on the floor, lying face down, and bleeding from either her head or nose. She stated when they found Resident #4, Resident #5 was already back in his room so she did not know Resident #5 as in Resident #4's room until someone reviewed the video camera footage and she did not think the resident had a door alarm at the time of the incident. She stated there were times the resident was on 1:1 and the purpose of the 1:1 was for someone to stay with him at all times and make sure he did not go into any other residents' rooms. On 12/6/2017 at 9:12 AM, during a telephone conversation with the DON, the surveyor requested the facility's policy on 1:1 monitoring. The DON stated she did not know if the facility had a policy for 1:1 monitoring and stated she would find out. On 12/7/2017 at 11:10 AM, the Administrator's Administrative Assistant sent an email to the surveyor which documented she was sending the requested information including the policies that the facility had. A policy for 1:1 monitoring was not included. On 12/7/2017 at 11 AM, RN Manager #6 stated in an interview: - when the resident was admitted to the facility in 4/2017, he was very behavioral. One minute he would swing at staff, yell, and threaten, and the next minute, he would apologize. - In 5/2017, the resident's aggression increased and at the end of 5/2017, he went to the hospital for about a month and had his medications adjusted. - The resident was on 1:1 in 4/2017, was taken off 1:1 in 5/2017, and went back on 1:1 after he went into Resident #4's room and they thought he pulled her out of bed. - Resident #4 could not move on her own, roll over, or fall out of bed on her own, so they determined when Resident #5 was in her room, he must have pulled her out of bed. - She was not aware of any other times Resident #5 went into other residents' rooms and threatened them or thought they were in his room. - When the resident was taken off 1:1 at night on 5/11/2017, the decision was made by the behavioral team and she was part of that team. She stated documentation of the team meeting was her 5/11/2017 nursing progress note and there was no further documentation. She stated she did not remember the discussion surrounding the decision to discontinue the resident's 1:1 at night. - She did not know why the night shift nurse documented in the early morning of 5/11/2017, that 1:1 at night was discontinued. She stated that note was written before the behavioral team met and may have been due to lack of staff to provide 1:1 that shift. - She did not know why she documented in a progress note on 5/23/2017 that 1:1 at night was discontinued on 5/16/2017 when it was discontinued on 5/11/2017 by the behavioral team. - The behavioral team met on Thursdays and would have reviewed the resident's plan and incidents from 5/12/2017 to 5/17/2017 at the 5/18/2017 meeting. She did not know if there were any changes to the resident's plan of care at that time. - She never heard any reports of staff finding Resident #5's door alarm turned off but was aware of another issue with the alarm. She stated the alarm the resident had sounded once, and did not continue to sound until someone responded to it. She stated they determined this was an issue, and before the resident returned to the facility from the hospital in 6/2017, they replaced his alarm with one that that sounded continuously until someone responded to it. On 12/12/2017 at 1:05 PM, the attending physician stated in an interview, Resident #5 was admitted to the facility from the hospital, went home for a few days, and when his spouse could not manage him at home, he was returned to the facility. He was aware of the resident's behaviors at the time of admission and the behaviors included agitation, aggression, and wandering. The physician stated the resident's behaviors were challenging because one minute he was pleasant and the next minute, he was very aggressive. He stated he had only witnessed the resident in a pleasant state but received reports from the staff about the resident's behaviors and aggression. He stated the facility set standards for supervising residents and would implement those standards based on incidents. He stated he did not write orders for 1:1 or to discontinue 1:1 and would be updated after those changes were made. He stated he was not part of the facility's behavioral team but would be updated after the meetings with any areas of concern. He stated he was notified Resident #4 went to the emergency roiagnom on [DATE] and he saw her 5 days after the incident and she had a head contusion, abrasion on her head, and multiple bruises. He stated Resident #4 could not remember the incident and when he saw her 5 days after, the investigation was still in progress and he did not know what happened. He did not believe that Resident #4 could roll or fall out of bed on her own but he was not notified when the facility investigation was completed and did not know the outcome. He stated after the incident on 5/20/2017, he had the psychiatrist see Resident #4 a few times and later on, he was transferred to the hospital and was there for about a month. On 12/15/2017 at 11:25 AM, social worker #14 stated in an interview, he did know where he got the information from when he wrote the 5/19/2017 progress note. He stated if he wrote a note documenting the resident was on 1:1 then that was his understanding and he could have gotten the information from the behavioral team, morning report, or from the unit staff. He stated he did not recall any specifics about the resident's plan for 1:1 and could not say whether the resident was on 1:1 when the incident occurred with Resident #4 on 5/20/2017 or whether the incident prompted the resident to be placed back on 1:1. 10NYCRR 415.4(b)

Based on record review and interview conducted during an abbreviated survey (Complaint #NY 000), it was determined for 1 of 5 residents (Resident #1) reviewed for neglect, the facility did not operationalize written policies and procedures regarding abuse/neglect, insulin administration to include transcribing and clarifying physician orders, monitoring of staff as planned for restriction of duties, and providing appropriate oversight for newly hired LPNs. Specifically, the facility did not protect Resident #1, who was insulin dependent, from receiving an excessive dose of [MEDICATION NAME] (short-acting insulin) which caused [DIAGNOSES REDACTED] (low blood sugar) for which hospital care was needed.This resulted in actual harm that is not immediate jeopardy. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The physician orders [REDACTED]." A printed copy of a facility policy titled "Insulin: Sliding Scale Protocol" effective 6/2005 and last revised 7/2008 documented the sliding scale as <100 FSBS give 0 units, 101-150 give 2 units, 151-200 give 4 units, 201-250 give 6 units, 251-300 give 8 units, 301-350 give 10 units, 351-400 give 12 units, >400 give 14 units and recheck in 2 hours if FSBS >400 call the prescriber. The 8/22/2014 EMAR (electronic medication administration record) documented the [MEDICATION NAME] order was incorrectly entered into the medical record as "[MEDICATION NAME] (Insulin [MEDICATION NAME]) Solution 100 units/ml: Inject 100 Units SQ 3 times per day before meals at 0630, 1130, 1630 for DM. Document Regular [MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]/Humalog SS AC: Give insulin per sliding scale <100=0 units and give insulin per SS 101-150=2 units and give insulin per SS 151-200=4 units and give insulin per SS 201-250=6 units and give insulin per SS 251-300=8 units and give insulin per SS 301-350=10 units and give insulin per SS 351-400=12 units and give insulin per SS>400=14 units and recheck FSBS in 2 hours if FSBS >400 and call prescriber if recheck FSBS >400." Review of the EMAR from 8/22-9/2/2014 documented nine different LPNs correctly administered [MEDICATION NAME]to the resident according to the sliding scale parameters contained within the order. The resident's documented blood sugars ranged from a low of 50 to a high of 280 during this time period and the units of [MEDICATION NAME] administered ranged from 0 to 6 units. There is no documented evidence that licensed nursing staff contacted the physician to clarify the order to inject an excessive dose of 100 units of insulin. The EMAR documented on 9/2/2014 at 6:13 AM LPN #1 injected the resident with "routine insulin per MD order." Nursing progress notes dated 9/2/2014 documented the resident received insulin at 6:30 AM, FSBS was 72 afterward, peanut butter and jelly sandwich, orange juice and other nourishments were provided, physician and family contacted and the resident was sent to the hospital at approximately 7 AM. Written statements from LPNs #1, 2 and 12 were obtained by the facility. LPNs #1 and 2 documented that LPN #1 drew up 100 units of [MEDICATION NAME] insulin, handed it to LPN #2 who administered it. LPN #12, who was working as a CNA (certified nurse aide), began getting morning blood sugars and stated Resident #1's blood sugar needed to be obtained at which point LPN #2 recognized the medication error and informed LPN #1 of the error. The hospital admission history and physical dated 9/2/2014 documented the resident was admitted with iatrogenic (caused by medical care) [DIAGNOSES REDACTED] (low blood sugar)when she was injected with 100 units of [MEDICATION NAME] Insulin at 6:20 AM. The resident's blood sugar upon admission was 40 and she remained hypoglycemic after 3 doses of D 50. At the time of the dictation the resident was switched over to a 10 % [MEDICATION NAME] intravenous with the plan set for her to remain at the hospital for observation and hourly blood sugar monitoring until her blood sugar remained above 120 for two consecutive checks, then the IV would be discontinued and she would need to maintain a blood sugar of at least 120 for two additional checks and then return to her nursing home. The discharge summary documented the resident's first blood sugar above 120 occurred at 3:48 PM on 9/2/2014. She was discharged back to the nursing home on 9/3/2014 at approximately 9:44 AM. On 10/3/2014 at 2 PM the Minimum Data Set Specialist/Computer Trainer/LPN was interviewed. She stated staff must double click on insulin orders to see the entire order including the sliding scale. LPN #1 was interviewed on 10/17/2014 at 9:40 AM and stated she; -clicked on the drop down box on the EMAR once so she did not see the complete order for the resident's [MEDICATION NAME] order, she only saw "give [MEDICATION NAME] Insulin 100 Units Subcutaneous" and missed the sliding scale portion of the order; -initially thought 100 units was a large dose but she was interrupted when a resident on the unit fell and she never went back to re-check the order again and drew up the 100 units; -handed the syringe which contained 100 units of [MEDICATION NAME] to LPN #2 and directed LPN #2 to administer it to the resident at about 6:20 AM; and -returned to the medication cart and LPN #2 told her of the medication error, they each looked at the order and realized they missed the sliding scale. LPN #2 was interviewed on 10/10/2014 at 9:45 AM. She stated; -on the morning of 9/2/2014 at approximately 6:30 AM LPN #1 handed her a syringe and told her it was insulin and directed her to give it to Resident #1 which she did; -she noticed the insulin syringe was totally full which indicated it was 100 units but she did not check the resident's orders or blood sugar and administered the insulin; -she assumed because it was such a large dose that she had given a long acting insulin for which this dose did not seem unusual to her; and -after she gave the resident the insulin she offered to help LPN #12 who was checking resident blood sugars; -LPN #12 told her to check the blood sugar of 2-3 residents which included Resident #1, who needed to be checked first due to the sliding scale, at which point she realized a medication error had occurred; and -immediately checked Resident #1's insulin order and saw that it was [MEDICATION NAME], a short acting insulin, so she informed LPN #1, gave the resident orange juice and peanut butter and jelly sandwich after her blood sugar reading was 72, LPN #1 notified the physician who ordered that the resident be sent out to the hospital. LPN #12 was interviewed on 10/3/2014 at 9:45 AM and stated; -on the night of 9/1/2014 she was working as a CNA on Unit 8 with one other CNA, LPNs #1 and 2 and a sitter; -she had worked on the unit multiple times and was familiar with the residents and unit routines; -LPN #1 had not frequently worked on the unit; -between 1 to 2 AM a resident became upset and exhibited some combative behaviors and LPN #1 "could not handle it" and called RN #9 for help; -she went to the nurses' station at 6:15 AM and prepared to start morning blood glucose finger sticks and told LPN #2 that she would get the finger stick done on Resident #1 and LPN #2 stated she already gave the resident Insulin; -LPN #2 stated that LPN #1 handed her the resident's Insulin and told her to give it; -LPN #2 told her she thought it looked like "a lot of Insulin"; -she told LPN #2 that "you never give a medication you have not prepared"; and -she told LPN #2 to call RN #9 because she knew the resident would need hospital care. During interview of the DON (Director of Nursing) on 10/3/2014 at 9:30 AM she acknowledged a transcription error occurred, remained in the EMAR and staff injected an excessive dose of insulin. She stated multiple issues combined and created a "perfect storm." MONITORING OF NURSES WITH PERFORMANCE ISSUES The personnel file of LPN #1 documented the following; -verbal warning issued 4/14/2014 due to seriousness of false documentation and risks by not completing treatment (dressing change) as ordered. Resident and staff slipped in a pool of blood from an undressed wound. LPN #1 was educated that she needed to not document care unless it was provided. The warning was signed by LPN #1 and RN #3; -written warning issued 7/17/2014 when LPN #1 failed to give a medication stocked in Omnicell and failed to follow the five rights of medication administration related to the "right time." LPN #1 was expected to contact the Nursing Supervisor to request medication from Omnicell and if available will administer and if not will contact pharmacy. The warning was signed by LPN #1 and RN #3 with the notation "discussed on 8/15/2014 due to employee out for 2 weeks, RN out for 2 days and employee working on other units;" and -final written warning in lieu of suspension issued 8/22/2014 and signed by LPN #1 and RN #3. LPN #1 administered 3 different medications to residents that were incorrect dosages and in all 3 cases a lower dose than the ordered dose was administered. Also, a dose of antibiotic was not given to 1 resident. LPN #1 was to make no further medication errors and participate in a 90 day action plan to include read and sign medication administration policy, read online education regarding medication administration, re-orient with another nurse as determined by LPN #3 and DON, do not float or pick up extra shifts on other units during 90 day action plan and 3 observed medication pass audits (1 each month) during the 90 day action plan. Attached to this final written warning is a document with handwritten notes between the DON and RN #3 which documented that the 90 day plan would not start until 9/18/2014. The facility policy titled "Abuse Prohibition/Reporting Policy last reviewed 05/2006 documented; -Administration of the facility shall prohibit abuse/neglect.... and by identifying and investigating al potential cases to protect residents; -staff behavior will be closely monitored by other staff; -any inappropriate behavior is promptly addressed; -Licensed nurses and/or Nurse Managers/Supervisors will intervene in situations where direct caregivers are having difficulty; and -when the signs of burnout/stress and frustration are present, they will be addressed. Nursing Supervisor RN #9 was interviewed on 10/3/2014 at 11:15 AM. She stated; -she was aware LPN #1 had made medication errors and would be getting some education regarding medication administration; -LPN #1 told her she was still working double shifts, passing medications and floating to other units; -she did not know that LPN #2 was scheduled for orientation on the night of 9/1/2014 until she made rounds on the unit at 2 AM on 9/2/2014; -LPN #1 did not notify her that there was an orientee working with her; -when she became aware of the assignment of LPNs #1 and 2 working together, she did not intervene because she did not want to bother RN #3 to the time of day; -she had not received any notification from the facility regarding the schedules of orientees and who the designated preceptors were; and -she was aware that LPN #1 was working a double shift on 9/1/2014. Unit Manager RN #3 was interviewed on 10/3/2014 at noon. She stated: -she had provided LPN #1 a Record of Final Written Warning in lieu of suspension dated 8/22/2014 that documented LPN #1 was not supposed to float or work any extra shifts during the 90 day action plan; -there were no formal notifications to other nursing officials regarding the restrictions placed on LPN #1; -she verbally told RN #10 of the restrictions placed on LPN #1; -LPN #2 was scheduled by RN #11; -during the 90 day action plan she wanted to have LPN #1 reorient with a "seasoned nurse" but this was delayed because such staff were not available. In the interim, LPN #1 was supposed to stay on her primary unit where RN #3 could provide oversight; -she works the day shift only and LPN #1 worked day and evening shifts; -LPN #1 was allowed to continue to pass medications; and -following the Record of Final Written Warning of 8/22/2014 and prior to this case on 9/2/2014, she allowed LPN #1 to work 3 shifts (on Unit 7) off her primary unit, contrary to the 90 day action plan, because the shifts were scheduled prior to putting the plan in place. LPN #2 was interviewed on 10/10/2014 at 9:45 AM. She stated; -she was still on orientation when she presented to work the 11 PM to 7 AM shift on 9/1/2014; -9/1/2014 was her first shift on Unit 8; -she was not scheduled to work with LPN #1, but the LPN she was scheduled with did not want to work a "double" shift; -this was the first time she worked with LPN #1 and LPN #1 presented to Unit 8 between 11:30 PM and 12:00 AM after she completed her shift on another unit; -she was unaware which LPNs were preceptors; -during the night shift of 09/1/2014, LPN #1 had poured/drawn up multiple medications for various residents and handed those medications to her and she administered them; -she did not document the medication administrations for the night shift of 9/1/2014, LPN #1 documented them; -LPN #1 drew up/poured the medications and directed her to administer the medications; -she had been taught in school only to give medications she had poured/drew up herself but did not practice this way at this nursing home because she "was working with staff that had been trained to orient new nurses so i thought that this was the way it was done."; and -she was informed by RN #11 that she has completed orientation as of 10/3/2014. LPN #1 was interviewed on 10/17/2014 at 9:40 AM and stated she: -received formal counseling in August 2014 and was not supposed to float to other units or work extra shifts; -was told by her Unit Manager RN #3 that if she was asked to work extra shifts or to float to other units and had difficulty saying no, she was to tell the Nursing Supervisor to call her (RN #3); -worked the evening shift on 9/1/2014 and during that shift a LPN called and asked if she would work the night shift on Unit 8 for her because she was too tired to work a double shift; -wanted the extra shift for the money so she called RN #9 and asked if it was okay for her to work a double shift and float to Unit 8; -could not recall if it was the LPN or RN #9 but one of them notified her it was okay to work the additional shift; -was surprised when she received permission (to work an extra shift and float to another unit) and when she arrived to the unit she thought LPN #2 was a CNA; -when LPN #2 informed her she was an LPN orientee, she decided to provide orientation in the same manner it had been provided to her; -contacted the Nursing Supervisor RN #9 regarding the presence of the orientee but she did not pick up the call; -drew up/poured medications for 6-7 residents and then passed them to LPN #2 to administer; -did not supervise or observe LPN #2 administer any medications and LPN #2 did not question this process; -signed for all the medications including those that LPN #2 administered; and -was not aware giving medications to another person to administer is not standard practice and that signing she gave medications she did not administer could be deemed falsification of the medical record. During interview with the DON on 10/3/2014 at 9:30 AM she stated that the orientation process with the nurses involved in this incident had been "sloppy" and was "not supposed to work that way." She stated that there was a lack of supervisory oversight, RN #9 did not know the staff in the building and did not know the capacity in which they were working, and there was no mechanism in place to ensure RN #9 was informed of the status of the staff. ACCURACY OF ORDERS The physician orders [REDACTED]." The 8/22/2014 EMAR (electronic medication administration record) documented the [MEDICATION NAME] order was incorrectly entered into the medical record as "[MEDICATION NAME] (Insulin [MEDICATION NAME]) Solution 100 units/ml: Inject 100 Units SQ 3 times per day before meals at 0630, 1130, 1630 for DM. Document Regular [MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]/Humalog SS AC: Give insulin per sliding scale......" Facility policies titled " Night, Nurse Assignments For" last reviewed 8/2011 and "Physician Orders, Transcribing Of" last reviewed 1/2013 documented that orders will be transcribed accurately and a two step accuracy review process ("red line") was in place. The telephone physician orders [REDACTED].#8 and the orders were re-checked and signed as accurate by LPN #13. Review of the EMAR from 8/22-9/2/2014 documented nine different LPNs correctly administered [MEDICATION NAME]to the resident according to the sliding scale parameters contained within the order. There is no documented evidence that staff contacted the physician. The resident's documented blood sugars ranged from a low of 50 to a high of 280 during this time period and the units of [MEDICATION NAME] administered ranged from 0 to 6 units. There is no documented evidence that licensed nursing staff contacted the physician to clarify the order for an excessive amount of insulin (100 units) to be injected 3 times a day. During interview with LPN #8 on 10/10/2014 at 1 PM she stated she should have clicked "give as directed" in the EMAR and not "inject." She stated she had never transcribed an insulin order by herself prior to this date. She stated she would never administer 100 units of insulin. LPN #13 was interviewed on 10/10/2014 at 12:40 PM and stated she was supposed to confirm the accuracy of the EMAR entries made by LPN #8 as a part of the facility's two LPN verification process. She stated that when she reviewed the resident's EMAR for accuracy on 8/22/2014 she did not notice the order included "inject 100 units." She stated after the events of 9/2/2014 she re-reviewed the order of 8/22/2014 and noticed the transcription error. She stated she would never administer a dose of 100 units of insulin. During interview with LPN #12 (10/3/2014 at 9:45 AM) she stated she administered insulin to Resident #1 during the prior night (early morning of 9/1/2014) and used the sliding scale parameters despite the documented portion "inject 100 units." She stated she recognized the "inject 100 units" part of the order as a transcription error, considered it to be a dose she "would never give", did not have time to address it and informed the LPN on the next shift of the error. NYCRR 415.4 (b)

Based on interviews and record reviews conducted during the abbreviated survey (Complaint #NY 00), it was determined for 1 of 5 (Resident #1) residents reviewed for a significant medication error, the facility did not ensure the facility was administered in a manner that enabled residents to maintain the highest practicable physical well-being. Specifically, for Resident #1, who was administered an excessive dose of insulin, the facility did not ensure a Licensed Practical Nurse (LPN) was monitored as planned for restriction of duties; did not ensure an insulin order was clarified for administration of an excessive dose; and did not obtain a fasting blood sugar level prior to administering insulin. In addition, the facility delayed implementation of a 90 day action plan for LPN #1, who was known to have had significant medication errors and then allowed LPN #1 to provide orientation to LPN #2 (new employee). This resulted in actual harm that was not immediate jeopardy. Findings include: See F226 See F333 Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The physician orders [REDACTED]." The 8/22/2014 EMAR (electronic medication administration record) documented the [MEDICATION NAME] order was incorrectly entered into the medical record as "[MEDICATION NAME] (Insulin [MEDICATION NAME]) Solution 100 units/ml: Inject 100 Units SQ 3 times per day before meals at 0630, 1130, 1630 for DM. Document Regular [MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]/Humalog SS AC: Give insulin per sliding scale <100=0 units and give insulin per SS 101-150=2 units and give insulin per SS 151-200=4 units and give insulin per SS 201-250=6 units and give insulin per SS 251-300=8 units and give insulin per SS 301-350=10 units and give insulin per SS 351-400=12 units and give insulin per SS>400=14 units and recheck FSBS in 2 hours if FSBS >400 and call prescriber if recheck FSBS >400." Review of the EMAR from 8/22-9/2/2014 documented nine different LPNs administered [MEDICATION NAME]to the resident according to the sliding scale parameters contained within the order. The resident's documented blood sugars ranged from a low of 50 to a high of 280 during this time period and the units of [MEDICATION NAME] administered ranged from 0 to 6 units. There is no documented evidence that licensed nursing staff contacted the physician to clarify the order which documented to inject an excessive dose of 100 units of [MEDICATION NAME] insulin. Nursing progress notes dated 9/2/2014 documented the resident received insulin at 6:30 AM, FSBS was 72 afterward, peanut butter and jelly sandwich, orange juice and other nourishments were provided, MD and family contacted and the resident was sent to the hospital at approximately 7 AM. MONITORING OF NURSE WITH PERFORMANCE ISSUES The personnel file of LPN #1 documented 3 warnings, dated 4/14/2014, 7/17/2014 and 8/22/2014 for numerous medication and treatment errors. LPN #1 was to make no further medication errors and participate in a 90 day action plan to include; read and sign medication administration policy; read online education regarding medication administration; re-orient with another nurse as determined by LPN #3 and DON; do not float or pick up extra shifts on other units during 90 day action plan and 3 observed medication pass audits (1 each month) during the 90 day action plan. Attached to this final written warning is a document with handwritten notes between the DON and RN #3 which documented that the 90 day plan would not start until 9/18/2014. RN Nursing Supervisor #9 (10/3/2014 at 11:15 AM) and Nurse Manager RN #3 (10/3/2014 at noon) were interviewed and stated that LPN #1 was allowed to continue to pass medication, work outside of the Record of Final Written Warning of 8/22/2014 when RN Manager allowed LPN #1 to work 3 shifts (on Unit 7) off her primary unit,planned corrective action was delayed by several weeks because experienced staff were not available and the nursing officials were not aware LPN #1's performance issues/restrictions. LPN #1 was interviewed on 10/17/2014 at 9:40 AM. She stated she; had received formal counseling in August 2014 and was not supposed to float to other units or work extra shifts; had not attended the facility's preceptor training and was not a designated preceptor; drew up/poured medications for 6-7 residents and then passed them to LPN #2 to administer; signed for all the medications including those that LPN #2 administered; and was not aware giving medications to another person to administer is not standard practice and that signing she gave medications she did not administer could be deemed falsification of the medical record. During interview with the DON on 10/3/2014 at 9:30 AM she stated that the orientation process with the nurses involved in this incident had been "sloppy" and was "not supposed to work that way." She stated that there was a lack of supervisory oversight, RN #9 did not know the staff in the building and did not know the capacity in which they were working, and there was no mechanism in place to ensure RN #9 was informed of the status of the staff. The facility Administrator was interviewed on 11/4/2014 at 9 AM. He stated he has been at the facility two years. When he joined the facility he had all policies and procedures reviewed by the facility's medical group so he was comfortable that the policies documented acceptable standards. He stated he was unaware of the practice issues with LPN #1 or problems in the facility with orientation of new nursing staff. NYCRR 415.26

Based on record reviews and interviews conducted during the abbreviated survey (#NY 000), it was determined for 1 of 5 residents (Resident #1) reviewed for insulin administration, the facility did not ensure residents were free of significant medication errors. Specifically, for Resident #1, multiple licensed nursing staff recognized an insulin order which noted to inject an excessive dose of short acting insulin ([MEDICATION NAME]) and did not clarify the order with the physician; two licensed practical nurses (LPNs) did not obtain Resident #1's fasting blood sugar level as ordered prior to administering insulin, and in additon, the facility's electronic medication administration record (EMAR) had the capability of putting in the excessive dose of insulin on Resident #1's EMAR. Subsequently, Resident #1 received 100 units (an excessive dose) of [MEDICATION NAME] which caused [DIAGNOSES REDACTED] (low blood sugar) for which hospital care was needed.This resulted in actual harm that is not immediate jeopardy. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The physician orders [REDACTED]." A printed copy of a facility policy titled "Insulin: Sliding Scale Protocol" effective 6/2005 and last revised 7/2008 documented the sliding scale as <100 FSBS give 0 units, 101-150 give 2 units, 151-200 give 4 units, 201-250 give 6 units, 251-300 give 8 units, 301-350 give 10 units, 351-400 give 12 units, >400 give 14 units and recheck in 2 hours if FSBS >400 call the prescriber. The 8/22/2014 EMAR (electronic medication administration record) documented the [MEDICATION NAME] order was incorrectly entered into the medical record as "[MEDICATION NAME] (Insulin [MEDICATION NAME]) Solution 100 units/ml: Inject 100 Units SQ 3 times per day before meals at 0630, 1130, 1630 for DM. Document Regular [MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]/Humalog SS AC: Give insulin per sliding scale ..." Review of the EMAR from 8/22-9/2/2014 documented nine different LPNs correctly administered [MEDICATION NAME]to the resident according to the sliding scale portion of the order. The resident's documented blood sugars ranged from a low of 50 to a high of 280 during this time period and the units of [MEDICATION NAME] administered ranged from 0 to 6 units. There is no documented evidence that licensed nursing staff contacted the physician to clarify the order to give an excessive dose of 100 units of [MEDICATION NAME]3 times a day. The EMAR documented on 9/2/2014 at 6:13 AM LPN #1 injected the resident with "routine insulin per MD order." Nursing progress notes dated 9/2/2014 documented the resident received insulin at 6:30 AM, FSBS was 72 afterward, peanut butter and jelly sandwich, orange juice and other nourishments were provided, physician and family contacted and the resident was sent to the hospital at approximately 7 AM. Written statements from LPNs #1, 2 and 12 were obtained by the facility. LPNs #1 and 2 documented that LPN #1 drew up 100 units of [MEDICATION NAME] insulin, handed it to LPN #2 who administered it. LPN #12, who was working as a CNA (certified nurse aide), began getting morning blood sugars and stated Resident #1's blood sugar needed to be obtained at which point LPN #2 recognized the medication error and informed LPN #1 of the error. The hospital admission history and physical dated 9/2/2014 documented the resident was admitted with iatrogenic (caused by medical care) [DIAGNOSES REDACTED] (low blood sugar)when she was injected with 100 units of [MEDICATION NAME] Insulin at 6:20 AM. The resident's blood sugar upon admission was 40 and she remained hypoglycemic after 3 doses of D 50. At the time of the dictation the resident was switched over to a 10 % [MEDICATION NAME] intravenous with the plan set for her to remain at the hospital for observation and hourly blood sugar monitoring until her blood sugar remained above 120 for two consecutive checks, then the IV would be discontinued and she would need to maintain a blood sugar of at least 120 for two additional checks and then return to her nursing home. The discharge summary documented the resident's first blood sugar above 120 occurred at 3:48 PM on 9/2/2014. She was discharged back to the nursing home on 9/3/2014 at approximately 9:44 AM. During interview with LPN #12 (10/3/2014 at 9:45 AM) she stated she administered insulin to Resident #1 during the prior night (early morning of 9/1/2014) and used the sliding scale parameters despite the documented portion "inject 100 units." She stated she recognized the "inject 100 units" part of the order as a transcription error, considered it to be a dose she "would never give", did not have time to address it and informed the LPN on the next shift. On 10/3/2014 at 2 PM the Minimum Data Set Specialist/Computer Trainer/LPN was interviewed. She stated when entering insulin orders into the EMAR staff must double click on insulin orders to see the entire order including the sliding scale. LPN #2 was interviewed on 10/10/2014 at 9:45 AM. She stated; -on the morning of 9/2/2014 at approximately 6:30 AM LPN #1 handed her a syringe and told her it was insulin and directed her to give it to Resident #1 which she did; -she noticed the insulin syringe was totally full which meant it was 100 units and did not check the resident's orders or blood sugar, and administered the insulin; -she assumed because it was such a large dose that she had given a long acting insulin for which this dose did not seem unusual to her; and -after she gave the resident the insulin she offered to help LPN #12 who was checking resident blood sugars; -LPN #12 told her to check the blood sugar of Resident #1 at which point she realized a medication error had occurred; and -immediately checked Resident #1's insulin order and saw that it was [MEDICATION NAME], a short acting insulin, so she informed LPN #1, gave the resident orange juice and peanut butter and jelly sandwich after her blood sugar reading was 72, LPN #1 notified the physician who ordered that the resident be sent out to the hospital. LPN #13 was interviewed on 10/10/2014 at 12:40 PM and stated she was supposed to confirm the accuracy of the EMAR entries made by LPN #8 as a part of the facility's two LPN verification process. She stated that when she reviewed the resident's EMAR for accuracy on 8/22/2014 she did not notice the order included "inject 100 units." She stated after the events of 9/2/2014 she re-reviewed the order of 8/22/2014 and noticed the transcription error. She stated she would never administer a dose of 100 units of insulin. During interview with LPN #8 on 10/10/2014 at 1 PM she stated she should have clicked "give as directed" in the EMAR and not "inject." She stated she had never transcribed an insulin order by herself prior to this date. She stated she would never inject 100 units of insulin. LPN #1 was interviewed on 10/17/2014 at 9:40 AM and stated she; -clicked on the drop down box on the EMAR once so she did not see the complete order for the resident's [MEDICATION NAME] order, she only saw "give [MEDICATION NAME] Insulin 100 Units Subcutaneous" and missed the sliding scale portion of the order; -initially thought 100 units was a large dose but she was interrupted when a resident on the unit fell and she never went back to re-check the order again and drew up the 100 units; -handed the syringe which contained 100 units of [MEDICATION NAME] to LPN #2 and directed LPN #2 to administer it to the resident at about 6:20 AM; and -returned to the medication cart and LPN #2 told her of the medication error, they each looked at the order and realized they missed the sliding scale. During interview of the DON (Director of Nursing) on 10/3/2014 at 9:30 AM she acknowledged a transcription error occurred, remained in the EMAR and staff injected an excessive dose of insulin. She stated multiple issues combined had created a "perfect storm." The facility Administrator was interviewed on 11/4/2014 at 9 AM. He stated he had all clinical policies reviewed by the facility's medical group when he joined the facility two years ago. He acknowledged the issues with LPN #1's past performance and that there was a delay in implementing steps to address her needs. He stated he was unaware of these issues at the time. NYCRR 415.12 (m)(2)

Based on observation, interview, and record review during the standard survey, it was determined for 1 of 1 married couples in the survey sample, (Residents #9 and 28), the facility did not ensure the residents' rights to share a room with their spouse. Specifically for Resident's #9 and 28 there was no plan developed that allowed the residents to share a room; there was no documented rationale addressing the residents living separately on different units; and there was no plan developed for the residents to consistently spend time together. This resulted in actual harm that is not immediate jeopardy, for Resident #9 when he exhibited sadness, depression and hopelessness, and for Resident #28 when she consistently exhibited sadness, crying, tearfulness and anxiety, related to their separate living arrangement, Findings include: 1) Resident #28 was admitted to the facility's locked, special care, dementia unit on June 20, 2011 with [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] identified the resident with moderate cognitive impairment. The MDS documented the resident wandered and exhibited behavior symptoms. The social services note dated June 29, 2011 documented the resident received support from her daughter who was very attentive. Social services noted the daughter was leaving to return to her home, which was out of the State. The note documented social services would support the resident and her family as needed. On September 30, 2011 social services documented the resident became weepy as she wanted to see her family. There were no social service notes between the June 29, 2011 note and the September 30, 2011 note. It was unclear what assistance social services was providing to the resident to assist with adjustment to her loss of home and family. The physician orders [REDACTED]. On November 8, 2011 the resident's spouse, (Resident #9) was admitted to the facility from the hospital, for short term placement. There was no social service documentation in Resident #28's medical record related to the admission of her spouse. The comprehensive care plan (CCP) documented on November 9, 2011 the resident's spouse was a resident on a different unit. The plan included arranging convenient times between the units for the residents to visit; and offering to make the arrangements for visits with her spouse if she wished to do so. The CCP recorded the responsible disciplines were nursing (including the certified nurse aides), activities and social services. Between November 9, 2011 and December 7, 2011 behavior observations, documented by nursing staff in the "Mood and Behavior - Incident Based" charting, described the resident as: making negative statements; observed with sad, pained facial expressions; cries or is tearful; and wandered without a purpose. All or some of these behaviors were charted on November 17, 19, 21, 23, 28, 29, 30, 2011 and December 5, 2011. The social services note dated December 7, 2011 documented the resident was a "quiet lady" who was alert but confused. The note recorded the resident was stable in her "overall condition" and, that the resident's spouse was currently a resident on another unit. Social services noted the resident enjoyed being able to visit with her spouse him, and they would continue to assist and support the resident and her family as needed. There was no documented evidence any discussion occurred related to the husband and wife being together, if they so chose. The "Mood and Behavior - Incident Based" charting, documented the resident exhibited sad, pained facial expressions; cried or was tearful, and/or wandered without a purpose on December 23, and 28, 2011 and on January 3 and 8, 2012. An activities note documented on January 19, 2012 the resident's husband had lunch with her twice that week and the resident was "always happy to see him and offers a big smile to him." The note recorded the resident was "always asking" where her family was and staff would then see if the resident's husband was able to come and eat with her. There was no evidence a specific plan was in place for the spouses to be with one another on a regular basis. The "Mood and Behavior - Incident Based" charting documented the resident had sad, pained facial expressions and/or was crying or tearful, on January 30, 31, 2012 and on February 4, 5, and 7, 2012. On February 12, 2012 nursing documented the resident was weepy and the staff called her spouse's unit to see if they could have dinner together. The resident was taken to visit with him before dinner. The note recorded when the resident returned to her unit, she stated she was happy to see him and she appeared much calmer. The note documented the plan was to encourage regular visits. On February 14, 2012 the surveyor observed the resident in her room at 11:30 AM. The resident appeared sad. On February 14, 2012 at 11:30 AM the certified nurse aide (CNA) was in the hallway and informed the surveyor that the resident's husband lived on another unit. The CNA said the resident was very sad without him, and was always so happy whenever she saw him. She stated the resident's spouse had been in the service, and she often thought he was away oversees, when she did not see him, and that made her very sad. On February 15, 2012 at 11:30 AM, the resident was observed in her room sitting with her spouse and smiling. They were facing each other and holding hands. The resident smiled, looked at him and said "it's like Christmas" being together. They told the surveyor they had been married over [AGE] years and were still "very much in love." At 12 PM on February 15, 2012 the resident was was observed seated at the table, holding hands with her spouse, waiting for lunch to be served. On February 15, 2012 activities documented the resident's spouse had lunch with her on the unit and the resident was "so happy and enjoyed her time" with him. At 5:30 PM on February 15, 2012 the surveyor observed the resident sitting at a table in the dining room, with other residents, waiting for dinner to be served. The resident had a sad affect and stated "I miss him." A few minutes later, a CNA served the resident and asked her how she was, she responded "lonesome." The CNA said "lonesome, you have all these people sitting with you." The resident did not respond. On February 16, 2012 the surveyor observed the resident wandering around the unit at 1:30 PM. She had a puzzled look on her face, and said she was looking for her husband, that she did not know if he was dead or alive. The resident was observed by the surveyor from 1:30 PM until 3:05 PM and her spouse was not with her. When the surveyor interviewed 3 CNAs who were familiar with the resident on February 16, 2012 at 1:30 PM they said the resident never goes down to her spouse's unit. They said someone would call to see if he could come to her unit. The unit social worker was interviewed on February 17, 2012 at 9:30 AM. She stated the resident was a very quiet lady, who was sometimes resistant to care. The social worker said the resident was always in a pleasant mood and seemed pretty content. She stated the resident often asked for her husband and liked to be with him. The social worker stated it was nice to "see her face light up" when she was with him. She said she was not aware of the resident being tearful, and expected the staff to let her know so she could visit with the resident to discuss her feelings. The social worker stated the resident's spouse was at the facility for short term rehabilitation and "they" would not put someone receiving "rehab" on a "locked dementia unit." She stated she was not familiar with the resident's spouse as she was not his social worker, and said he would only be able reside on the locked unit if he had behaviors or was a flight risk. She stated if Resident #28 was late stage dementia "they" might transfer her off the unit. In summary, Resident #28 experienced harm when she consistently exhibited sadness, crying, tearfulness; and anxiety when she was unable to be with her spouse as the facility: - did not develop and implement a plan in a timely manner to allow the resident to be with her spouse; - did not develop a plan for the resident to be with her spouse on a regular basis while they were not living together; and - did not document a rationale that addressed the married couple living separately, and not in a shared room or on the same unit. 2) Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On November 8, 2011 the social worker documented the resident was admitted to the facility from the hospital for short term rehab. The discharge plan was for eventual return home. The resident was familiar with the facility, as his wife was a resident there, prior to his admission. The comprehensive care plan (CCP) documented on November 8, 2011, the resident was awaiting transfer to a semi-private room as he had not requested a private room "upon admission." The plan included offering him a tour of the new unit and room when a bed became available and allowing him to vent his feelings regarding an impending transfer. Social work notes documented the following: - On November 17, 2011 the social worker found the resident recently had feelings of being down, depressed or hopeless; - On December 12, 2011 the social worker documented the resident visited his wife as often as possible; and - On December 27, 2011 the resident was recently having feelings of being down, depressed, or hopeless over his wife's failing health. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired and had fluctuating disorganized thinking, little interest in doing things, was feeling down, depressed and had trouble concentrating on things. The MDS documented the resident exhibited verbal behavioral symptoms directed toward others and at times rejected care. The resident required extensive assist in transferring, toileting, dressing, and ambulating in his room. He was independent in a wheelchair and fed himself after set-up. The CCP dated January 31, 2012 documented the resident's wife was also a resident of the facility and he would be able to visit her on a regular basis. Activities, nursing and social services were to arrange convenient times between units for a visit. There was no documented evidence when this was to occur and no evidence the resident was going to be able to share a room with his wife, or be transferred near, his wife. The CCP documented the resident was to be assisted in making a smooth transition to his new room. On January 31, 2012 the social worker documented the resident had feelings of being down, depressed or hopeless. On February 14, 2012 the social worker documented the resident's discharge plan was permanent placement at the facility. The note recorded the resident had hoped to go home, suffered from periods of depression and benefited from staff support and reassurance during these times. The social worker recorded the resident visited his wife often. There was no documented evidence of a plan for the resident to share a room with his spouse, or for the residents to reside on the same unit. During an interview with the social worker on February 16, 2012 at 3 PM, the social worker said the resident did not want to leave his wife "yesterday." She stated he was on a waiting list for a semi-private room and "we will see" about transferring him to the unit with his wife. He came in for short term rehab, but now needed to stay as he needed more care than could be provided at home. During an interview with the registered nurse (RN) manager on February 16, 2012 at 4:30 PM, she said the family felt the resident would be able to return home after receiving rehabilitation. The RN stated the resident was not safe to be by himself, so he would live at the facility permanently. She said she was not sure if the family wanted the resident on the same unit as his wife. The RN stated she was concerned about how he would react if he moved to his wife's unit. She stated he told staff the other day his wife found someone new and was going to divorce him. On February 17, 2012, at 10:30 AM, the Director of Resident Services (social services) stated in an interview, he was not aware of a definite plan for the resident to be with his spouse. He stated, he was not aware of the resident having a [DIAGNOSES REDACTED]. He said there should be a social work note in the resident's record regarding the husband and wife's relationship, and the plan for their living arrangements (whether or not they could reside together). In summary, Resident #9 experienced harm when he exhibited depression and hopelessness related to his spouse's failing health and he was unable to be with her consistently, as the facility: - did not develop and implement a plan in a timely manner to allow the resident to be with his spouse; - did not develop a plan for the resident to be with his spouse on a regular basis while they were not living together; and - did not document a rationale that addressed the married couple living separately, and not in a shared room or on the same unit. 10 NYCRR 415.(f)(3)