Every finding on record at Seneca Health Care Center

Based on interviews and record review conducted during a Complaint investigation (2588244), the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (1) of four (4) residents (Resident #1) reviewed for accidents. Specifically, Resident #1 was care planned not to be left alone in the bathroom while toileting. On 07/12/2025, Resident #1 was left unattended, fell off the toilet and sustained a left hip fracture requiring surgical intervention. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy.The finding is:The policy titled Fall Prevention revised 08/2025, documented that all reasonable steps are taken to keep the resident safe from falls and related injury. Residents would be evaluated for their potential risk for falls to assure that measures were implemented to keep residents safe from falls and related injury. Recommendations from the interdisciplinary team members would be incorporated into the resident's individual care plan and the resident monitored for its effectiveness to prevent falls. The policy titled Interdisciplinary Care Planning revised 09/2025, documented the comprehensive resident-centered care plan was developed by the interdisciplinary team upon admission and reviewed/updated on a regular basis throughout the resident's length of stay. The comprehensive care plan and Kardex must always be current and accurately reflect the resident's status. The care plan/Kardex must always be reviewed by staff prior to initiating resident care. Care plans were accessible in electronic format to any person involved in care of the resident. Resident #1 had diagnoses including vascular dementia (type of dementia caused by reduced blood flow to the brain) with behavioral disturbances, Parkinson's disease (progressive neurodegenerative disorder that affects movement, balance, and coordination), and post-traumatic stress disorder (PTSD). The Minimum Data Set (a resident assessment tool) dated 06/17/2025, documented Resident #1 was severely cognitively impaired, was usually understood, and usually understands others. The Care Plan Report with a revision dated 09/19/2023 (current) documented Resident #1 was at risk for falls related to elimination, medication, and mobility. The plan documented interventions to remind the resident to call for assistance; required a low bed with a winged mattress and a gym mat on floor; non-skid shoes/slippers; safety education, and to monitor for medication side effects. Staff to stay with resident (inside the bathroom) for toileting. The Kardex dated 07/11/2025, documented Resident #1 required a moderate assist of one (1) staff member for transfers and a minimal assist of one (1) staff member for ambulation. Documented under elimination included instructions for 'Staff to stay with resident (inside bathroom) for toileting'. The facility investigation dated 07/12/2025 at 7:25 PM signed by the Director of Nursing, documented Resident #1 experienced a fall on the floor in their bathroom. Certified Nurse Aide #1 assisted Resident #1 onto the toilet in the bathroom in their room. Resident #1 was incontinent. Certified Nurse Aide #1 left the room to retrieve clean linen to provide care, taking approximately Less than two (2) minutes. Upon their return, Resident #1 was found on the floor in the bathroom doorway. A handwritten statement dated 07/12/2025 completed by Certified Nurse Aide #1documented they took Resident #1 to the bathroom and noticed they were incontinent of urine. They needed more supplies, so they stepped out of the room for thirty seconds to get supplies from the linen cart. Returned to the room and found Resident #1 lying outside the bathroom door. A nursing progress note by Registered Nurse #1 dated 07/12/2025 at 8:37 PM, documented status post (after) Resident #1 was found on the floor, they complained of left hip pain with passive (assisted movement) range of motion. Their left leg was slightly shorter and abducted (outwardly rotated). The family and Nurse Practitioner #1 were updated. A new order was received to obtain x-rays of the resident's left hip, pelvis, and femur. Nurse Practitioner #1 spoke with Resident #1's family and informed them that Resident #1 may need surgery if the x-rays were positive (for fractures). The note documented the family did not want surgery and may opt for comfort measures. A nursing progress note by Licensed Practical Nurse Supervisor #1 dated 07/12/2025 at 8:43 PM, documented Resident #1 was found lying flat on the floor on their back at the bathroom doorway. Licensed Practical Nurse Supervisor #1 documented that Certified Nurse Aide #1 stated they had put the resident on the toilet then stepped out to grab supplies to complete incontinent care. Resident #1 self-ambulated and fell. Resident #1 complained of left hip pain and that there were no visible injuries.The Radiology Results Reports dated 07/13/2025 with an examination date of 07/12/2025 documented an acute (new onset) fracture of the left proximal femur with displacement, and complex comminuted fracture of the intertrochanteric left femur (a broken hip where the femur meets the pelvis, at the top of the thigh bone).Review of untitled facility document dated 07/14/2025, Nurse Practitioner #2 documented they assessed Resident #1 on 07/13/2025 after they sustained a fall, reviewed the x-rays which demonstrated a fracture of the left femoral neck with displacement/ overriding fracture fragments. Resident #1 was assessed, and their left limb was shortened by approximately 1.5 - 2 inches with external rotation. Resident #1 winced with mild attempts to evaluate limb during exam. After discussion with Resident #1's Health Care Proxy, Resident #1 was transported to the emergency room for surgical evaluation and given Morphine (opioid used to relieve severe pain) for pain management during transport. The hospital Discharge summary dated [DATE] documented Resident #1 was evaluated after a fall resulting in a left hip fracture and complained of stable pain in their left hip. Resident #1 was taken to the operating room for a left intramedullary trochanteric rodding (surgically inserting a metal rod (or nail) into the hollow center of the femur bone to stabilize it) on 07/15/2025. During a telephone interview on 10/29/2025 at 10:19 AM, Certified Nurse Aide #1 stated they were familiar with Resident #1. Certified Nurse Aide #1 stated they took Resident #1 into their bathroom after dinner and transferred them on to the toilet. Resident #1 had been incontinent, so they went to get linens to provide care. Upon their return, Resident #1 was lying on the floor in their bathroom. Certified Nurse Aide #1 stated they had not reviewed Resident #1's care plan or Kardex prior to providing care, and knew they should have.During a telephone interview on 10/20/2025 at 12:23 PM, Nurse Practitioner #2 stated they did not take the initial call on 07/12/2025 regarding Resident #1's fall, but did review the x-ray results and evaluated Resident #1 the following day. Nurse Practitioner #2 stated they spoke with Nurse Practitioner #1 to get more information and reviewed the x-ray results with Resident #1's Health Care Proxy. Upon their assessment, it was determined the resident would likely need surgical repair, so they ordered Resident #1 to be sent out to the emergency room. Nurse Practitioner #2 stated if Resident #1 had a care plan intervention to not be left alone in the bathroom, they would have expected staff to remain with them. During a telephone interview on 10/20/2025 at 12:42 PM, Licensed Practical Nurse Supervisor #1 stated they were not aware that Resident #1 was care planned to not be left alone in the bathroom, and that was a break in care plan. If Certified Nurse Aide #1 would have stayed with Resident #1, they could have prevented the fall. Certified Nurse Aide #1 should have pulled the emergency call cord in the bathroom and waited for someone to answer it and get them linen.During an interview on 10/29/2025 at 1:13 PM, the Medical Director stated they would have expected Certified Nurse Aide #1 to have reviewed Resident #1's care plan prior to providing care. They stated a fracture was a serious injury. The Medical Director stated, There was a possibility Certified Nurse Aide #1 could have prevented Resident #1's fall if they had not left the room, but Resident #1 could have fallen either way. During an interview on 10/29/2025 at 2:03 PM, the Director of Quality and Education stated they expected all certified nurse aides to review care plans prior to providing resident care. With the incident on 07/12/2025, Certified Nurse Aide #1 did not follow the care plan for Resident #1, and the resident sustained a fracture. During re-interview on 11/05/2025 at 9:56 AM, they stated after the fall they had determined this was an isolated incident based on trending of falls within the facility. Certified Nurse Aide #1 was re-educated on reading and following the plan of care. During a telephone interview on 10/29/2025 at 2:10 PM, Nurse Practitioner #1 stated they were informed on 07/12/2025 after the fall that Resident #1's left lower extremity was shorter than the right and had pain with passive range of motion. They ordered x-rays of the left hip, femur, and pelvis and spoke with Resident #1's Health Care Proxy regarding possible surgical intervention. Nurse Practitioner #1 stated Resident #1 being left alone on the toilet was a break in their care plan that resulted in a fracture, which was a serious injury, and the serious injury caused harm to Resident #1. During an interview on 10/29/2025 at 2:45 PM, the Director of Nursing stated a break in a plan of care would be when staff does not follow the care plan. Their expectation was for all staff to read and follow residents' individualized care plans. Ultimately, Resident #1 had an intervention not to be left alone in the bathroom. Certified Nurse Aide #1 left them alone in the bathroom, the resident fell which resulted in a fracture. During an interview on 10/29/2025 at 2:56 PM, the Administrator stated they expected the certified nurse aides to review resident care plans prior to providing care. Not following a resident's plan of care may be a break in their plan. The Administrator stated a broken bone would be a serious injury. The Administrator stated, it was an accident, not intentional.10 NYCRR 415.12(h)(2)

Based on interview and record review conducted during the Standard survey completed on 11/8/24, the facility did not ensure the resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States for one (Resident #119) of one resident reviewed for voting. Specifically, Resident #119 was not afforded the right to vote in the November 2024 Presidential Election. The finding is: The policy and procedure titled Residents' Rights: Voting dated 10/2024 documented the facility affirm and support the right of residents to vote. The Activities Department, with the assistance of nursing, will evaluate the resident's voting ability and preferences upon admission and as needed. The resident's voting preferences will be documented on the care plan. Current regulations under Residents' Rights related to exercising the right as a citizen of the United States to vote, including the use of mail for mail-in or absentee ballots include exercise of rights: the resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. The facility will ensure residents can exercise their right to vote, whether in-person by mail, absentee ballot, or other authorized process. The facility will coordinate and engage with voting programs, as appropriate. This may include mobile polling in residential facilities performed by a bipartisan team of workers and/or assistance in registering to vote, requesting an absentee ballot, or completing a ballot from an agent of the resident's choosing, including a family representative, LTC (long term care) Ombudsmen or nursing home staff (or other personnel permitted to perform these functions, per state law). For residents who are otherwise unable to cast their ballots in-person, the facility will ensure residents have the right to receive and send their ballots via the U.S. Postal Service, or other authorized mechanism allowed by the State or locality. Resident #119 had diagnoses including depression, diabetes, and anxiety. The Minimum Data Set (a resident assessment tool) dated 8/27/24 documented Resident #119 was cognitively intact, was understood, and understands. The Minimum Data Set documented it was very important for Resident #119 to do their favorite activities. The comprehensive care plan revised on 11/20/23 documented Resident #119 was independent with decision-making skills. Interventions included provide information to make safe/independent decisions, respect choices and voting: registered to vote. The Activities Review with effective date 3/19/24 and 8/6/24 documented Resident #119 had an intervention that documented registered to vote. The Resident Council Meeting Minutes dated 9/26/24 documented new business: residents wanting to vote for U.S President in upcoming election. The meeting minutes were signed by the Resident Council President and Director of Activities. Resident #119 was recorded as attending the Resident Council Meeting. Review of an absentee ballot request documented the absentee ballot request was received by the County Board of Elections for Resident #119 on 10/7/24 and it would be mailed to the facility address. The documented contained ways to contact the County Board of Elections including two phone numbers, an address, and an email. Review of the nursing progress notes 9/1/24 through 11/7/24 lacked documented evidence that Resident #119 was provided with the opportunity to vote in the November 2024 Presidential Election. During an interview on 11/5/24 at 8:22 AM, Resident #119 stated they were told approximately three weeks prior that they would be able to vote. They stated voting was very important, so much that it was crucial. They stated the Activities Director was supposed to communicate to a voting department and voting people would come in but nobody ever came. During an interview on 11/7/24 at 12:07 PM, Resident #119 stated they gave up and never received an election ballot. During an interview on 11/7/24 at 12:21 PM, the Activities Director stated they oversaw assisting the residents to vote. They stated they started at the end of September to early October, they approached every resident in the facility to find out who wanted to vote in the election. They stated they were told by the County Board of Elections that if they had 32 or more residents interested in voting then they would send people to the facility to assist in voting. The Activities Director stated they had 32-35 residents who had wanted to vote so they called the number of a staff member at the County Board of Elections and left a voicemail. The Activities Director stated through the month of October, they called that same staff member at the County Board of Elections, left a message, and never received a call back. They stated they then called the main phone number at the County Board of Elections and spoke to the Principal Election Clerk on 10/31/24. They stated they were able to get some of the absentee ballots for the residents but not all of them and they could not remember if Resident #119's ballot was completed or not, but they should have been able to vote because it was their right. They stated they did not document anywhere in the electronic medical record if Resident #119 voted or not. During a telephone interview on 11/8/24 at 10:10 AM, the Principal Election Clerk stated they were considered a point person at the County Board of Elections for Skilled Nursing Facilities. They stated a representative at the facility would fill out absentee applications to vote and if there were 25 or more residents who wanted to vote then they would send a bipartisan team to assist the residents. They stated the facilities do not need to wait until election time to register the residents to vote, especially if they were staying long term, they could register at any point in the year. They stated the facility had completed the registrations as temporary, and they would expire in December. They stated if they completed the registration marking that they resident had a permanent illness/disability, then they would receive a ballot ever year without having to re-register the long-term care residents. They stated they had 17 voters at the facility receiving absentee ballots and Resident #119 had an online application for a ballot request, but a ballot was not received back by the County Board of Elections. The Principal Election Clerk stated the facility had until 10/26/24 to register and request an absentee ballot for the residents who wanted to vote in the Presidential Election and until Election Day to either have the ballots post marked or dropped off at a pulling site. During an interview on 11/7/24 at 3:23 PM, the Activities Director stated the Resident Roster dated 10/21/24 was the only documentation they had that indicated what ballots were mailed in. If the Resident's name was highlighted that meant that Resident's ballot was mailed in. They stated they did mail in a good chunk of ballots and kept the Administration at the facility updated on the process, but they did not ask for any help with requesting absentee ballots, completing the ballots, or mailing them in. A Resident Roster dated 10/21/24 provided by the Activities Director, documented have ballot's need to mail in. Mailed in. 12 Resident names were highlighted on the document. Resident #119 was not highlighted. During an interview on 11/8/24 at 12:00 PM, the Administrator stated they felt the staff at the County Election Board were the ones that dropped the ball. They stated the Activities Director oversaw the entire process, went resident to resident asking if they wanted to vote, and had a list of maybe 30 people who were interested. They had to re-register the residents which may have been the beginning of the problem and then they waited for the team from the Election Board to come in and they never came in. They stated they felt that the Activities Director followed up with the Election Board accordingly and did their diligence. 10NYCRR 415.3(d)(1)(i)

Based on observation, record review, and interview conducted during the Standard survey completed on 11/8/24, the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for two (Resident #3 and #119) of three residents reviewed for choices. Specifically, Resident #3 was provided bed baths instead of showers as planned and per their preference; Resident #119 was not provided with showers twice a week per their preference. The findings are: The policy and procedure titled Resident Preferences and Accommodation of Needs revised on 11/4/21, documented the resident has a right to reside and receive services in the facility with reasonable accommodations of individual needs, personal, and cultural, expect when the health or safety of the individual or other residents would be endangered. Residents will be offered the opportunity to participate in formulation of their plan of care, morning and bedtime routines and bath schedules. The policy and procedure titled Bathing and Grooming revised 2/2019 documented tub baths or showers are given by all nursing personnel as scheduled/preferred. The policy and procedure titled Resident Rights and Responsibilities revised on 4/2/24 documented it is the objective of the facility to provide the Patient/Resident with optimal nursing and psychosocial care. Every effort is made by the staff to meet the Patient/Resident's individual needs and requirements. 1. Resident #3 had diagnoses including diabetes mellitus, chronic obstructive pulmonary disease (lung disease) and obesity. The Minimum Data Set, dated dated dated [DATE], documented Resident #3 was understood and understands and was cognitively intact. The Minimum Data Set documented, Resident #3 was dependent for transfers, required substantial/maximal assistance (helper does more than half of the effort) for showering and there were no refusals of care. The Annual Minimum Data Set, dated dated dated [DATE] documented it was somewhat important for Resident #3 to choose between a tub bath, shower, bed bath, or sponge bath. The comprehensive care plan reviewed 10/9/24 documented Resident #3 had a self-care performance deficit for bathing related to activity intolerance and limited mobility. Interventions included supervision for upper body bathing and maximal assistance with one assist for lower body bathing, showers on Thursday on 3:00 PM-11:00 PM shift. The care plan documented Resident #3 was independent with decision making skills and interventions included to offer choices related to care routine. Review of the Visual/Bedside Kardex (a guide used by staff to provide care) dated 11/8/24, documented Resident #3 was to have a shower on Thursdays on the 3:00 PM-11:00 PM shift. The north unit shower book located at the nurse's station contained Quality Improvement Skin Inspection sheets dated 7/31/24, 8/22/24, 9/19/24, and 10/24/24 that documented Resident #3 had received bed baths. There were no showers documented as given from 7/31/24 -10/24/24. There were no sheets dated after 10/24/24. Review of the Progress Notes dated 10/1/24 through 11/8/24 revealed no documented evidence Resident #3 had received or refused their showers. During an interview on 11/4/24 at 10:46 AM, Resident #3 stated it had been about a year since they had been able to use the shower, they stated they received bed baths but preferred a shower. Resident #3 stated they had been told by several staff that the shower beds would not hold over 300 pounds and that they were over the weight limit to use a shower bed. Resident #3 stated they had been told by therapy it was not safe for them to use the shower bed because of their weight. Resident #3 stated it was important for them to take a shower instead of a bed bath to prevent infections. During an interview on 11/6/24 at 12:27 PM, Licensed Practical Nurse #5 stated they were unsure how staff determined whether residents required the use of a shower chair or shower bed, it might be on the care plan. Licensed Practical Nurse #5 stated that bed baths would be given in place of showers only if that was the resident's preference or if they were ill. During an observation and interview on 11/7/24 at 9:22 AM, Certified Nurse Aide #5 stated Resident #3 received a bed bath because the shower beds would not hold over 300 hundred pounds. They stated Resident #3 had been aware of the weight capacity issue and they were unsure the last time Resident #3 was able to take a shower. Certified Nurse Aide #5 stated they were not sure where the weight capacity was listed for shower beds but believed it was on the back of the shower bed. Observed the shower beds and a shower chair located in the shower room with Certified Nurse Aide #5 present. There was no weight capacity listed on them. During an interview on 11/7/24 at 11:02 AM, the Assistant Director of Nursing/Infection Preventionist (covering as Unit Manager for the north unit) stated that Resident #3 was scheduled to have showers and was not aware of any reason Resident #3 could not use the shower bed. They stated that therapy determined whether a resident used a shower bed or shower chair for bathing and was unaware of what the weight capacity was for the shower equipment, they would check with the maintenance director. During a follow up interview on 11/7/24 at 1:42PM, the Assistant Director of Nursing/Infection Preventionist stated they had verified the weight capacity of the shower beds with the maintenance director and reviewed the manufacturer's manual for the shower beds. They stated that all facility shower beds had a weight capacity of 450 pounds and there were no residents in the facility that exceeded this weight capacity. The Assistant Director of Nursing/Infection Preventionist stated Resident #3 should have received their showers and was unsure who would have informed Resident #3 that they were over the weight capacity for the shower beds. They stated it was important to honor Resident #3's preferences because it was their home. During an interview on 11/7/24 at 2:53 PM, the Director of Rehabilitation stated that physical therapy and occupational therapy completed quarterly evaluations on all residents to determine shower assistance and transfers. They stated that they were not aware of any therapy staff stating Resident #3 would not be safe to use a shower bed for bathing. The Director of Rehabilitation reviewed Resident #3's physical and occupational therapy discharge summary notes dated 10/1/24 from the electronic medical record and stated Resident #3 transferred with a mechanical lift and would have been safe to use the shower bed. During an interview on 11/8/24 at 12:00 PM, Licensed practical nurse #5 stated they believed Resident #3 received bed baths instead of showers because of a weight limit issue. They stated they were unsure who had said there was a weight limit on the shower beds, but it was the general impression the staff on the unit had. Licensed Practical Nurse #5 stated they were not aware of the specific weight capacity for shower beds and chairs. During an interview on 11/8/24 at 11:37 AM, the Director of Nursing stated that showers and baths were determined based on resident's preferences and would expect staff to honor resident preferences because it was what they requested. The Director of Nursing stated they were unaware Resident #3 was not receiving their showers and was unsure who had informed Resident #3 that they were over the weight capacity for the shower bed. The Director of Nursing stated based off the actual weight capacity of the shower beds, they would have expected staff to have provided Resident #3 with their shower because it was their preference. 2. Resident #119 had diagnoses including depression, diabetes, and morbid obesity. The Minimum Data Set, dated dated dated [DATE] documented Resident #119 was understood, understands, and was cognitively intact. Resident #119 required partial/moderate assistance with bathing. Review of the comprehensive care plan revised on 8/27/24 documented Resident #119 had a self-care performance deficit related to activity intolerance, impaired balance and limited mobility. An intervention revised on 4/9/24 documented Resident #119 was scheduled to have a shower on Wednesdays during the 7:00 AM-3:00 PM shift. Review of the Nursing Admission Evaluation dated 11/18/23 documented Resident #119 preferred to have two showers per week. The Visual Bedside/Kardex dated 11/7/24 documented Resident #119's shower was scheduled on Wednesdays on the 7:00 AM-3:00 PM shift. Review of the north unit shower book located at the nurse's station, revealed Resident #119 was scheduled for one shower on Wednesdays during the 7-3 shift. Review of the Quality Improvement Skin Inspection sheets, located in the shower book, dated 9/4/24 through 11/6/24, revealed Resident #119 received one shower a week. Review of the nursing progress notes 8/1/24-11/7/24 revealed no documented evidence that Resident #119 was offered or given more than one shower per week. During an interview on 11/5/24 at 8:22 AM, Resident #119 stated they wanted to two showers per week, and they asked a Certified Nurse Aide in the past, but they told them they could not have more than one shower a week because there were too many residents. Resident #119 stated after they were told no, they did not ask anyone else because they thought everyone would give the same answer. During an interview on 11/7/24 at 12:13 PM, Certified Nurse Aide #6 stated they looked at the shower list in the shower binder at the nurse's station to know which residents were scheduled for a shower and it was the unit coordinator who updated the shower schedule. Certified Nurse Aide #6 stated residents were showered once a week, but some were showered twice a week. They stated after a resident was showered, whoever gave the shower would fill out a skin inspection sheet and the nurse would then sign off that the shower was given. Certified Nurse Aide #6 stated if a resident wanted to have two showers the shower list should be updated because it was the residents' choice, and it would make them happy. During an interview on 11/8/24 at 8:11 AM, Licensed Practical Nurse #7 stated usually residents received a shower once a week unless they were on the subacute unit or had a preference. They stated upon admission, residents were asked how often they would like showers. Licensed Practice Nurse #7 stated usually it was the unit coordinator who was responsible to make the shower schedule. They stated when residents voiced their preference for when they wanted a shower, it should be followed because it's their choice and for their dignity. During an interview on 11/8/24 at 8:19 AM, the Assistant Director of Nursing/Infection Preventionist (covering as Unit Manager on the north unit) stated if Resident #119 wanted an additional shower during the week they should have notified a nurse or the Assistant Director of Nursing. They stated if the Certified Nurse Aide was asked by Resident #119 for an additional shower every week, then it was the responsibility of the Certified Nurse Aide to communicate that to a nurse. The Assistant Director of Nursing stated they were unaware that Resident #119 wanted two showers a week and unfortunately, they did not check the original admission evaluation or care plan when Resident #119 moved units. During an interview on 11/8/24 at 8:57 AM, Licensed Practical Nurse #8, who completed the Nursing Admission Evaluation, stated when they completed admission evaluations, they would ask the resident how many showers they wanted per week and then update the shower schedule. They stated it was important for residents to choose how often they wanted a shower because it was their personal preference and choice. They stated the unit coordinators or nurses on the unit would be responsible for communicating shower preference when residents moved units. During an interview on 11/8/24 at 9:47 AM, Social Worker #1 stated unless a family member or resident came to them asking for a change with their care, they were not responsible for updating residents' preferences. They stated when a resident changed rooms from one unit to another, they were responsible to let the responsible party know the resident was moving units. They stated they were unaware Resident #119 wanted two showers a week. Social Worker #1 stated during admission and room changes, it was the responsibility of the nursing staff to ask Resident #119 their preferences. During an interview on 11/8/24 at 11:45 AM, The Director of Nursing stated it was expected for residents' preferences to be followed and updated as they requested. They stated Resident #119 should have been offered showers twice a week because they requested showers twice a week and that was their preference. They stated it should have been communicated they wanted two showers a week when they changed units and the Certified Nurse Aide that they told should have communicated their preferences to the nurse. The Director of Nursing stated it was the responsibility of the Social Workers to ask residents their preferences every quarter. 10 NYCRR 415.5 (b)(3)

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00351900) during the Standard survey completed on 11/8/24, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (Resident #1, #16 and #96) of eight residents reviewed. Specifically, Resident #1 was observed with greasy hair, Resident #16 and Resident #96 were observed to have dried brown debris under their fingernails. The findings are: The policy and procedure titled Bathing and Grooming revised 2/2019, documented residents were bathed as often as necessary to maintain cleanliness. Tub baths or showers are given by all nursing personnel as scheduled/preferred. The policy and procedure titled Nail Care revised on 10/11 documented the purpose was to ensure cleanliness and to prevent infection. Routine nail care was to be done following a bath/shower whenever possible. 1. Resident #1 had diagnoses that included multiple sclerosis (a progressive disease, involving nerve cells in the brain and spinal cord, that can cause numbness, impairment of muscular coordination), acquired absence of kidney, and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 7/1/24 documented Resident #1 was cognitively intact, was understood, and understands. The Minimum Data Set documented it was very important for Resident #1 to choose between a shower and a bed bath, and the resident was dependent on staff for showers. The comprehensive care plan revised on 9/12/24, documented Resident #1 had a self-care deficit for bathing related to multiple sclerosis, activity intolerance and limited mobility. The resident required maximal assist of two staff for upper body and were dependent on two staff for their lower body. The Visual/Bedside Kardex (a guide for staff providing care) dated 11/8/24 documented Resident #1 was to have shower on Mondays on the 7:00 AM-3:00 PM shift and they required maximal assist of two staff for upper body and were dependent on two staff for their lower body. During an interview and observation on 11/5/24 at 8:29 AM, Resident #1 was lying in bed with their hair pulled back. Resident #1's hair was visibly greasy. Resident #1 stated they had not received their shower yesterday (11/4/24) and a bed bath was not offered. During an interview on 11/7/24 at 9:56 AM, Certified Nurse Aide #3 stated they were unable to give Resident #1 a shower on Monday (11/4/24) due to some staffing conflicts. Certified Nurse Aide #3 stated they updated the Unit Manager, who went and spoke with Resident #1 regarding the issue. Certified Nurse Aide #3 stated Resident #1 was understanding and accepted the offer to receive a shower the next day (11/5/24). Certified Nurse Aide #3 stated Resident #1 was given a bed bath on Tuesday (11/5/24). Certified Nurse Aide #3 stated they had not documented or updated the nurse that Resident #1 received a bed bath instead of a shower, and they should have. During an interview on 11/7/24 at 12:36 PM, Licensed Practical Nurse #4 Unit Manager stated they were aware Certified Nurse Aide #3 was unable to give Resident #1 a shower on their scheduled shower day, Monday, and spoke with the resident themself. Licensed Practical Nurse #4 stated Resident #1 received a bed bath the next day, Tuesday. Licensed Practical Nurse #4 stated residents should be offered showers, especially if it was important to them. During an interview on 11/7/24 at 12:42 PM, Resident #1 stated they would really like their hair washed and were unable to have it washed if they didn't receive a shower. Resident #1 stated Certified Nurse Aide #3 came in and gave them a bed bath and did not offer a shower on Tuesday. Resident #1 stated they usually only end up receiving one actual shower a month, so their hair was only washed once a month, and that bothered them. During a follow up interview on 11/7/24 at 12:56 PM, Certified Nurse Aide #3 stated they had noticed that Resident #1's hair was greasy during the bedbath and they did not wash the resident's hair. They stated Resident #1 had not mentioned wanting their hair washed. Certified Nurse Aide #3 stated it was important for residents to have their hair washed for dignity reasons. During an interview on 11/8/24 at 12:41 PM, the Director of Nursing, in the presence of the Administrator, stated they expected staff to ask residents if they wanted a shower. The Director of Nursing stated they would have expected Certified Nurse Aide #3 to offer Resident #1 their shower. They stated shower days were listed in the resident's care plan and Certified Nurse Aides and nurses were responsible for ensuring showers were given according to the care plan. The Director of Nursing stated they would have expected Certified Nurse Aide to update the nurse if a bed bath was given instead of a shower. They stated it was a resident right to receive showers according to their care plan. The Administrator stated they agreed with what the Director of Nursing stated. 2. Resident #16 had diagnoses which included anxiety, and depression, and adult failure to thrive. Review of the Minimum Data Set (a resident assessment tool), dated 10/7/24, documented Resident #16 was cognitively intact, understood and understands and required partial/moderate assistance for personal hygiene. The Visual/Bedside Kardex Report (a guide for staff to provide care), dated 11/7/24, documented that Resident #16 required minimal assistance for personal hygiene and nail care on bath day (Friday 3:00 PM-11:00 PM shift) and as needed. The comprehensive care plan, revised on 9/27/24, documented the resident had a self-care performance deficit related to limited mobility, and limited range of motion. The plan included to provide verbal cues/encouragement. Resident #16 required maximum assistance for bathing. During observations on 11/4/24 at 9:00 AM and 11/5/24 at 9:01 AM, Resident #16 had long fingernails with brown debris underneath all nails. During an interview on 11/5/24 at 9:05 AM, Resident #16 stated the aides don't cut their fingernails. Their shower day was on Fridays, and they haven't had a shower in a couple of weeks, staff haven't offered to clean or cut their nails. Resident #16 stated they hoped they could get a manicure with activity staff. During further observations on 11/5/24 at 3:34 PM, 11/6/24 at 9:10 AM, and 11/7/24 at 9:11 AM, Resident #16 had long fingernails with dried brown debris underneath. During an interview on 11/7/24 at 11:17 AM, Certified Nurse Aide #3 stated nails were trimmed and cleaned on bath/shower days but were checked daily with care. Nails could be trimmed and cleaned anytime. During an observation and interview on 11/7/24 at 11:20 AM, Licensed Practical Nurse #4 Unit Manager observed Resident #16's fingernails and stated the nails were long, dirty and possibly cleaned during the bed bath on 11/1/24 but not trimmed. There's no way they'd grow that fast in six days. During a telephone interview on 11/7/24 at 12:26 PM, Certified Nurse Aide #4 stated they did not trim Resident #16's fingernails on 11/1/24. Typically, they would document that nail care was provided on the shower sheets but did not have time. During a telephone interview on 11/8/24 at 10:51 AM, Licensed Practical Nurse #3, Nurse Educator stated nail care was important for the resident's comfort, hygiene, and cleanliness. Dirty nailbeds could cause infection. During an interview on 11/8/24 at 11:57 AM, the Assistant Director of Nursing/Infection Preventionist stated nurses and certified nurse aides were responsible to ensure activities of daily living were completed, especially nail care and showers. Nail care was basic hygiene and should be provided daily. During an interview on 11/8/24 at 12:41 PM, the Director of Nursing, in the presence of the Administrator, stated Certified Nurse Aide #4 should have cleaned and trimmed Resident #16's fingernails after the bed bath on 11/1/24. Resident #16 had the right to receive proper care including nail care. Nails should be cleaned daily and cleaned and trimmed on shower days whether they had a shower or a bed bath. 3. Resident #96 had diagnoses which included dementia, depression, and anxiety. The Minimum Data Set, dated dated dated [DATE], documented Resident #96 was sometimes understood, sometimes understands, was severely cognitively impaired and had no refusals of care. Resident #96 required partial/moderate assistance for personal hygiene. The Visual/Bedside Kardex Report dated 11/7/24, documented Resident #96 required moderate assistance for personal hygiene and nail care was to be provided on bath day and/or as needed. The comprehensive care plan, revised on 1/9/22, documented Resident #96 had a self-care performance deficit related to activity intolerance, Alzheimer's Disease (dementia), impaired balance and limited mobility. Interventions included moderate assistance and nail care on bath day and/or as needed. Review of the nursing progress notes dated 10/1/24 through 11/5/24, revealed no documented evidence Resident #96 refused nail care. During an observation on 11/4/24 at 10:36 AM, Resident #96 was eating a Danish with their right hand. Their fingernails on both hands were trimmed but had dried brown debris under them. Resident #96's fingers of their right hand were observed to enter their mouth as they ate their Danish. During an observation on 11/5/24 at 11:45 AM, Resident #96's fingernails on both hands had dried brown debris underneath them. During an observation on 11/6/24 at 8:11 AM, Certified Nurse Aide #7 provided morning care for Resident #96. While assisting Resident #96 with washing their hands, Certified Nurse Aide #7 stated to Resident #96 that they needed to have their fingernails cleaned but would do that later. During an observation on 11/6/24 at 8:49 AM, Certified Nurse Aide #7 provided Resident #96 with their breakfast tray and handed the resident a banana. Resident #96's fingernails were observed with brown debris under them while they were eating the banana. During an interview on 11/6/24 at 1:40 PM, Certified Nurse Aide #7 stated they did not clean Resident #96's fingernails, they should have cleaned them during morning care because Resident #96 had debris under their nails, and they ate some foods with their hands. Certified Nurse Aide #7 stated they did not know what was under Resident #96's fingernails. They stated bacteria could be under the fingernails and they should have been cleaned before eating their breakfast. During an interview on 11/8/24 at 8:11 AM, Licensed Practical Nurse #7 stated it was the certified nurse aides and the nurse's responsibility to make sure residents fingernails were trimmed and cleaned because it was just part of care. They stated fingernails should be cleaned every day and whenever they were dirty. During an interview on 11/8/24 at 8:16 AM, the Assistant Director of Nursing/Infection Preventionist stated Resident #96's fingernails should have been cleaned when Certified Nurse Aide #7 saw they needed to be cleaned during morning care because it was general hygiene. During an interview on 11/8/24 at 11:37 AM, the Director of Nursing stated they expected nail care to be completed on shower days and/or as needed. The Director of Nursing stated Resident #96 should have had their nails cleaned if they needed it, during morning care and prior to receiving breakfast. They expected nails to be kept clean for dignity and cleanliness. 10 NYCRR 415.12 (a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 11/8/24, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for two (Residents #27 & #53) of three residents reviewed. Specifically, there was a lack of a urology follow- up following a cystoscopy (diagnostic test to inspect the interior lining of the bladder and urethra), and a foley leg bag was not used during day time hours as planned (#53); and infection control practices were not maintained (#27 & #53). In addition, staff inaccurately documented the placement of the foley leg bag in the treatment record (#53). The finding is: The policy and procedure titled Process for Scheduling Outside Appointments, revised 6/24, documented the facility will assist the resident in gaining access to specialty providers per their preference and per provider recommendations when needed for the resident's health and well-being. The facility will assist residents and their representatives in locating and utilizing any available resources the resident needs. Resident appointments will be scheduled with assigned provider per provider recommendation and resident request. An order for appointment to be placed in the electronic medical record/designated location. Nursing to communicate to the unit clerk/designee that there is an order for requested appointment. Unit clerk/designee to schedule an appointment based on the order, medical necessity, cognitive status, and mode of transportation. Resident and family will be made aware of the status of the appointment. The policy and procedure titled Catheter Drainage Bag Care: Urinary, revised on 5/13, documented the catheter and tubing must remain patent, with the drainage bag kept below the level of the bladder, to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. Care should be taken to make sure the tubing does not touch or drag on the floor. Drainage leg bags may be used to allow residents who require an indwelling catheter, more dignity and independence while out of bed. 1. Resident #53 had diagnoses which included severe sepsis (a severe blood infection), urinary tract infection, and bladder outlet obstruction (abnormal urine flow). The Minimum Data Set (a resident assessment tool) dated 9/4/24, documented Resident #53 had cognitively intact, was understood, and understands. Resident #53 had an indwelling foley catheter. The undated comprehensive care plan documented Resident #53 had a urinary catheter. Interventions included to monitor for signs and symptoms of a urinary tract infection, and to wear a urinary leg bag during daytime hours. Additionally, the care plan included annual urology consults. The Visual/Bedside Kardex (guide used by staff to provide care) dated 8/13/24 and verified by Licensed Practical Nurse Unit Manager #2 as current documented to provide urinary catheter care every shift. Review of the Hospital Discharge Summary dated 6/4/24, documented severe sepsis secondary to urinary retention, bladder outlet obstruction, and urinary tract infection. The Hospital Discharge Summary further documented to continue the foley catheter and follow up with urology. Review of the Order Summary Report dated 7/31/24 documented an active physician's order to apply a foley leg bag in the morning and remove at bedtime with a start date of 8/2/24 and there was no end date. In addition, there were no physician's orders for a urology consult. a. Review of the cystoscopy operative note dated 8/2/24 documented Resident #53 was discharged back to the facility with a foley catheter and required follow up as an outpatient for further management of urinary retention. The medical provider's Interval Note dated 8/14/24 documented Resident #53 had a cystoscopy on 8/2/24 and required a foley catheter for obstructive uropathy. Medical Provider #1 documented that Resident #53 needed to follow up with the urologist. Progress Notes date 8/14/24 completed by Medical Records Assistant #2 documented they arranged transportation and a urology follow up from the cystoscopy on 8/2/24. The appointment was scheduled for 9/12/24 at 3:15 PM. Review of the Nursing Progress Notes on 9/12/24 revealed no documented evidence that Resident #53 attended the urologist appointment, or the appointment was missed or rescheduled. During a telephone interview on 11/6/24 at 11:40 AM, Reception Supervisor #1 at the urology clinic stated they had phoned the nurse on the unit at the facility on 9/11/24 that Resident #53's appointment was rescheduled from 9/12/24 at 3:15 PM to 9/18/24 at 10:15 AM and couldn't recall which nurse they had spoken with. Resident #53 was a no show on 9/18/24. The facility never followed up on the missed appointment. Review of the [NAME] Unit twenty-four-hour report sheets dated 9/11/24 through 9/18/24 revealed there was no documented evidence that Resident #53's urology appointment was rescheduled to 9/18/24. There was no documented evidence that Resident #53 attended the scheduled urology appointment on 9/18/24. During an interview on 11/7/24 at 9:39 AM, Medical Provider #1 Medical Provider #1 stated Resident #53 missed their appointment due to transportation issues on 9/12/24 and was not a big deal. The treatment would not have changed. During an interview on 11/7/24 at 9:40 AM, Licensed Practical Nurse Unit Manager #2, stated appointment/transportation sheets were filled out by the nurse then given to medical records for outside appointments. The sheets included the date, time, location, the transportation company, and whether an escort was needed. Medical Record Assistant #1 emailed a monthly list and tracked appointments. Revisions were emailed weekly. During a telephone interview on 11/8/24 at 10:05 AM, Medical Records Assistant #2 stated they were unaware the 9/12/24 appointment was rescheduled to 9/18/24. During an interview on 11/08/24 at 12:23 PM, the Director of Nursing, in the presence of the Administrator, stated appointment/transportation sheets were not included in their process. Medical records arranged out of the facility appointments and the facility needed to improve their process. b. During an observation on 11/5/24 at 2:56 PM, Resident #53's foley catheter drainage bag was contained in a privacy bag under their wheelchair. The resident was not utilizing a urinary leg bag as planned. Review of the Treatment Administration Record on 11/5/24 at 3:00 PM Revealed Licensed Practical Nurse #1 initialed the foley leg bag was applied on the 7:00 AM -3:00 PM shift. During an observation and interview on 11/6/24 at 10:05 AM eight inches of the catheter tubing, containing yellow urine, and was lying on the floor under Resident #53's wheelchair. The resident was not utilizing a urinary leg bag as planned. Resident #53 stated they preferred the leg bag and was more comfortable. During an interview on 11/6/24 at 10:28 AM, Certified Nurse Aide #2 stated catheter tubing should be kept off the floor and Resident #53 should have had their leg bag on. During an observation and interview on 11/6/24 at 10:33 AM, Certified Nurse Aide #1 stated the urinary catheter tubing should not touch the floor. They had a hard time stuffing and securing the tubing into the privacy bag. At 10:35 AM Certified Nurse Aide #1 cleaned the catheter tubing with an alcohol swab and then placed the catheter tubing onto the floor and stated while exiting Resident # 53's room, nurses applied foley leg bags. During an interview on 11/6/24 at 10:36 AM, Licensed Practical Nurse #1 stated they had seen the catheter tubing on the floor earlier this morning, signed they had applied the leg bag on the treatment administration record and forgot to apply the leg bag. They stated the leg bag provided dignity and comfort. Licensed Practical Nurse #1 stated the catheter tubing on the floor was an infection risk and Resident #53 was prone to infection. During an observation and interview on 11/6/24 at 10:40 AM, Licensed Practical Nurse Unit Manager #2 stated bacteria on the tubing from the dirty floor could cause infection and was inappropriate. Licensed Practical Nurse #1 should have applied the leg bag before they got Resident #53 out of bed, they should sign off the treatment administration record after the leg bag was on. They stated the leg bag reduced the risk of infection. During an interview on 11/7/24 at 9:39 AM, Medical Provider #1 Medical Provider #1 stated as a preventative infection control measure the foley catheter tubing should not be on the floor. c. Review of the physician's telephone orders dated 11/6/24 revealed Medical Provider #1 ordered Resident #53 a chest x-ray, complete blood count with differential and complete metabolic profile (blood work), a urinalysis, and culture and sensitivity (urine diagnostic test). Vital signs were ordered every four-hours for forty-eight hours. During an interview on 11/7/24 at 8:45 AM Resident #53 stated they felt shaky, chilled, and off, and on 11/6/24 they were given an antibiotic for a urinary tract infection. During an interview on 11/7/24 at 10:08 AM, Licensed Practical Nurse, Unit Manager #2 stated Resident #53 displayed mild confusion and lethargy, so Medical Provider #1 ordered a urinalysis and culture and sensitivity. The Order Summary Report dated 11/7/24 documented an active physician's order for Ceftriaxone Sodium Solution (antibiotic) Reconstituted 1 gram. Inject 2.8 cubic centimeter (cc) intramuscularly one time a day for urinary tract infection until 11/8/24. Review of the 11/2024 Medication Administration Record revealed Resident #53's urine specimen was collected on 11/6/24 and one dose of Ceftriaxone Sodium Solution reconstituted 1 gram was administered as ordered for a possible urinary tract infection. Lab Results Report collected 11/6/24 and received on 11/7/24 documented the urinalysis with microscopic reflex showed a large amount of leukocyte esterase (enzyme indicative of infection). During an interview on 11/8/24 at 11:22 AM, the Assistant Director of Nursing/ Infection Preventionist stated Resident #53 was at risk for urinary tract infections. Certified Nurse Aide #1 should have secured the clean catheter tubing in the privacy bag and to avoid contamination. The Assistant Director of Nursing/ Infection Preventionist expected residents to wear leg bags when out of bed unless they refused. During an interview on 11/8/24 at 11:32 AM, Medical Provider #1 stated Resident #53 complained of being chilled on 11/6/24 and covered them with a few doses of antibiotics due to Resident #53's susceptibility to urosepsis. Resident #53 was symptomatic for a urinary tract infection. During an interview on 11/08/24 at 12:23 PM, The Director of Nursing, in the presence of the Administrator, stated the foley leg bag would have prevented the tubing from lying on the floor and did not think the tubing on the floor contributed to the current urinary tract infection. Licensed Practical Nurse #1 should have applied the leg bag then signed the treatment administration record. 2. Resident #27 had diagnoses that included hydronephrosis with renal and ureteral calculous obstruction (enlargement of the kidney due to blockage), chronic kidney disease stage 3, and history of urinary tract infections. The Minimum Data Set, dated dated dated [DATE], documented Resident #27 had moderate cognitive impairment, was understood and understands. Resident #27 had an indwelling foley catheter. The undated Visual/Bedside Kardex documented Resident #27 required a moderate assist of 2 staff members with a sit to stand lift for toileting and to offer incontinent care every 2-3 hours. The Visual/Bedside Kardex documented Resident #27 required foley catheter care every shift. The current comprehensive care plan documented staff were to encourage fluid intake and to monitor Resident #27 for symptoms of a urinary tract infection. During an observation on 11/05/24 at 8:44 AM, Resident #27 was sitting in their wheelchair next to the bed. An empty black privacy bag was hanging off the bottom of the wheelchair. The foley catheter drainage bag was lying directly on the floor along with 6-8 inches of tubing, underneath the resident's wheelchair. The room had a strong odor of urine. At 9:50 AM, the foley catheter drainage bag was hanging from the left arm rest of their wheelchair and was positioned above the level of their bladder. During an interview on 11/7/24 at 12:27 PM, Licensed Practical Nurse Unit Manager #4 stated they were not aware Resident #27's foley catheter drainage bag had been on the floor, but they saw Resident #27's foley catheter drainage bag hanging on the side of their wheelchair arm rest on 11/5/24. Licensed Practical Nurse #4 stated foley catheter drainage bags should always be below the level of the bladder and be in a privacy bag, never on the floor or hanging from a wheelchair arm rest. Licensed Practical Nurse #4 stated the Nurses and Certified Nurse Aides were responsible for ensuring foley catheter drainage bags were placed appropriately to prevent back flow and infections. Additionally, Licensed Practical Nurse #4 stated Resident #27 had a history of urinary tract infections. During an interview on 11/7/24 at 12:29 PM, Certified Nurse Aide #6 (assigned to resident on 11/5/24) stated they were unaware Resident #27's foley catheter drainage bag was on the floor or hanging from their arm rest on 11/5/24. Certified Nurse Aide #6 stated appropriate placement of foley catheter drainage bags was important for infection and sanitary reasons. During an interview on 11/08/24 at 11:22 AM, the Assistant Director of Nursing/ Infection Preventionist stated there was a risk for infections, specifically urinary tract infections, if foley catheter drainage bags were left lying on the floor or positioned above the level of the bladder. The Assistant Director of Nursing/Infection Preventionist stated their expectations would be for foley catheter drainage bags to be in a privacy bag with tubing off the floor, below the level of the bladder. The Assistant Director of Nursing/Infection Preventionist stated all nursing staff were responsible for ensuring appropriate placement of foley catheter drainage bags. During an interview on 11/8/24 at 12:23 PM, the Director of Nursing, in the presence of the Administrator, stated foley catheter drainage bags should be in a privacy bag and not on the floor, as it could lead to a possible infection. The Director of Nursing stated foley catheter drainage bags should never be above the level of the bladder. The urine would flow back into the bladder and could lead to a bladder infection. The Director of Nursing stated all staff were responsible to ensure foley catheter drainage bags and tubing are placed appropriately. 10NYCRR 415.12 (d) (2)

Based on observation, interviews, and record review completed during a Standard survey completed on 1/12/23, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #48) of 4 residents reviewed. Specifically, Resident #48 required 1:1 observation for safety as per their Kardex (guide used by staff to provide care). Resident #48 had an unwitnessed fall in their room on 10/17/22 and sustained a right femur (long thigh bone) fracture that required hospitalization and surgical intervention. This resulted in actual harm to Resident #48 that was not Immediate Jeopardy. The finding is: The facility policy and procedure (P&P) titled Fall Prevention with a revised date of 04/2015, documented recommendations from the interdisciplinary team members will be incorporated into the resident's individual care plan. The facility P&P titled Interdisciplinary Care Planning with a revised date of 1/18/2021, documented the Kardex must always be current and accurately reflect the resident's status. The facility P&P titled Suicide Precautions with a revised date of 9/16/2020, documented residents expressing suicidal ideations or death wishes, will be closely monitored and immediate intervention and follow-up will take place to assure resident safety. If hospital transfer is not indicated, the resident will be placed on a twenty-four-hour suicide watch, which can be extended as long as deemed necessary. In instances where 1:1 visual observation is initiated, both clinical and non-clinical staff may be used. The Kardex will be updated to reflect goals and interventions initiated. 1. Resident #48 had diagnoses including vascular dementia, psychotic disorder with delusions, and major depressive disorder. The Minimum Data Set (MDS, a resident assessment tool) dated 10/4/22 documented Resident #48 had severe cognitive impairment, moderate depression, and had one fall, without injury, since admission. The Progress Notes dated 10/13/22, 2:45 PM, documented Resident #48 expressed suicidal ideations, was placed on 1:1 observation, and the facility was awaiting a STAT (immediately) psychiatric evaluation. The Psychiatric Consultation dated 10/13/22, documented the following recommendations for Resident #48: discontinue Seroquel (antipsychotic medication); start Ativan (antianxiety medication) 0.25mg (milligrams) twice a day; and place resident on 15-minute checks. The Progress Notes dated 10/13/22, 4:58 PM documented MD #1 was updated regarding the psychiatric consultation recommendations. New orders were received from MD #1 to discontinue Seroquel, start Ativan 0.5mg twice a day and every 6 hours as needed, and to follow-up with psychiatry in one week. Nursing will maintain 1:1 supervision. The Progress Notes dated 10/14/22 through 10/16/22 documented that Resident #48 was on 1:1 supervision to ensure safety. Resident #48's Kardex dated 10/14/22, 10/16/22, and 10/17/22 documented for staff to provide 1:1 observation for safety. The facility Accident and Incident (A&I) Report dated 10/16/22, 10:00 AM, documented Resident #48 was intentionally placing themselves on the floor, sliding out of bed onto gym mat, sliding out of wheelchair, and attempting to crawl and scoot on buttocks on floor, and refusing to allow staff to intervene. The updated Kardex documented to provide 1:1 supervision to ensure safety. The facility A&I dated 10/17/22, 10:37 AM documented Resident #48 was last seen by a Certified Nurse Aide (CNA #2) at 10:35 AM and was found on the floor by a Physical Therapist (PT #1) at 10:37 AM. The resident had a hematoma (collection of blood under the skin) to the right side of their head with bleeding. The A&I documented new orders for STAT x-ray of right knee, hip, and pelvis for complaints of increased pain and decreased ROM (range of motion). The Kardex in effect at the time of the fall documented to provide 1:1 supervision to ensure safety. The updated Kardex after the fall documented to provide 1:1 supervision to ensure safety. A handwritten statement completed by PT #1 dated 10/17/22 documented they walked by Resident #48's room and found the resident laying on the floor near the doorway with noticeable blood on the floor, they notified nursing staff, and waited with the resident until a nurse arrived. A handwritten statement completed by CNA #2 dated 10/17/22 documented they were summoned to Resident #48's room by a physical therapy staff member and the resident was on the floor. CNA #2 documented they had checked on Resident #48 about 5 minutes before the resident was found on the floor. A handwritten statement completed by CNA #1 (responsible for care at the time of the fall) dated 10/17/22 documented they provided morning care on Resident #48 at 9:15 AM and that the resident was on 15-minute checks and safe in bed. There was no documented evidence in Resident #48's medical record that Resident #48 was on 15- minute checks at the time of the fall. The Radiology Results Report dated 10/18/22 documented Resident #48 sustained an acute fracture of the right proximal (nearer center of body or point of attachment) femur. The Progress Notes dated 10/18/22 documented Resident #48 was sent to the emergency room for evaluation of a right femur fracture. The hospital Discharge Summary dated 10/25/22 documented Resident #48 had an acute impacted displaced intertrochanter right hip fracture and was admitted to the hospital to have a trochanteric nailing (surgical procedure). During an interview on 1/12/23 at 10:54 AM, the Registered Nurse (RN) Unit Manager (UM) #1 stated Resident #48 was placed on 1:1 supervision for safety secondary to behaviors. The RN UM #1 stated the psychiatry consult recommended every 15-minute checks on 10/13/22, but the resident was placed on 1:1 supervision for safety secondary to nursing judgment. RN UM #1 stated 1:1 supervision meant that one staff member was to be always with the resident. During an interview on 1/12/23 at 11:22 AM, MD #1 stated Resident #48 was placed on 1:1 supervision for suicidal ideation and the resident was acutely agitated. MD #1 stated they could not comment on care planned interventions, but they considered a fracture a major injury. During an interview on 1/12/23 at 11:45 AM, CNA #1 stated they could not recall if they were responsible for Resident #48 on 10/17/22 and could not recall if the resident required 1:1 supervision. During an interview on 1/12/23 at 11:52 AM Licensed Practical Nurse (LPN) #1, the nurse assigned to Resident #48 on 10/17/22, stated they were aware Resident #48 required 1:1 supervision. LPN #1 stated the facility was short staffed on 10/17/22, and there weren't enough CNAs on the unit to provide a 1:1 for Resident #48. During an interview on 1/12/23 at 12:08 PM, the Director of Nursing (DON) stated the facility's plan was to provide 1:1 supervision secondary to the resident exhibiting behaviors. The DON stated Resident #48 was care planned for 1:1 supervision at the time of the fall and expected staff to provide 1:1 supervision. Additionally, care plans and the Kardex updated in the electronic medical record (EMR) as soon as changes are made in a residents' plan of care. During an interview on 1/12/23 at 12:17 PM, CNA #2 stated someone from the therapy department alerted them that Resident #48 was found on the floor. CNA #2 stated the physical therapist was the only other staff member in the resident's room and was unsure whether the resident was on 1:1 supervision. During an interview on 1/12/23 at 12:34 PM, the Administrator stated they expected staff to follow the interventions on the Kardex, and Resident #48 should have had 1:1 supervision at the time of the fall on 10/17/22. NYCRR 415.12(h)(2)

Based on interview and record review during the Standard survey started on 1/5/23 and completed on 1/12/23, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees A, B, C, D) of five employees reviewed who were hired in the last four months and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their employment. The findings are: The facility's policy and procedure titled, Criminal Background Checks (Fingerprinting), revised 2/2022, documented that the facility does not employ or otherwise engage individuals who have a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, misappropriation of property, or mistreatment. Additionally, the facility will check the nurse aide registry and sex offender registry for all new hires, agency staff, volunteers, and students. Review of the facility's New Hire Document Checklist, a tool for HR Directors to track needed documents for each new hire, revealed a CNA verification check and the New York State Nurse Aide Registry website were listed in the column titled, Must Be Completed Prior to Hire. 1a. Review of the personnel file for Employee A (Certified Nurse Aide - CNA) revealed Employee A was hired on 9/21/22 and the New York State Nurse Aide Registry Verification Report was dated 12/20/22. Employee A's last date worked was 11/25/22. During an interview on 1/11/23 at 9:25 AM, the Scheduler stated Employee A worked on the North Unit. The Scheduler added that Employee A worked as a Resident Aide on the 11:00 AM to 7:00 PM shift, then after certification, worked as a CNA on the 7:00 AM to 3:00 PM shift. 1b. Review of the personnel file for Employee B (Housekeeping Aide) revealed Employee B was hired on 9/21/22 and the New York State Nurse Aide Registry Verification Report was dated 12/20/22. Employee B was a current facility employee. During an interview on 1/11/23 at 9:05 AM, the Assistant Environmental Services Manager stated Employee B worked three days per week on the 7:00 AM to 3:00 PM shift throughout all four resident units. 1c. Review of the personnel file for Employee C (CNA) revealed Employee C was hired on 10/5/22 and the New York State Nurse Aide Registry Verification Report was dated 12/20/22. Employee C was a current facility employee. During an interview on 1/10/23 at 9:15 AM, the Scheduler stated Employee C mainly worked on the South Unit on the 11:00 PM to 7:00 AM shift, and sometimes picked up a 3:00 PM to 11:00 PM shift. Employee C could be assigned to any resident unit when picking up a shift. 1d. Review of the personnel file for Employee D (Activities Leader) revealed Employee D was hired on 9/28/22 and the New York State Nurse Aide Registry Verification Report was dated 12/20/22. Employee D's last date worked was 10/24/22. During an interview on 1/11/23 at 9:15 AM, the Activities Director stated Activities Leaders worked all over the building, they conducted large group activities in the Activities Room or in the Dining Room, and they conducted small group activities and one on one visits with residents on all four resident units. The Activities Director stated Activity Leaders worked anywhere between 7:00 AM and 7:00 PM and their hours were rotated. During an interview on 1/10/23 at 2:00 PM, the Human Resources (HR) Director/Recruiter stated the New York State Nurse Aide Registry should be checked for all new hires before they start working at the facility and a verification sheet should be printed for the personnel file. The HR Director/Recruiter added that an audit was performed in December 2022 and it was discovered that some of the Nurse Aide Registry checks had not been done. During an interview on 1/10/23 at 2:40 PM, the Regional HR Director stated they performed the audit in December 2022. They further stated during the audit, they noted missing Nurse Aide Registry check verification sheets. At the time of the audit, the Nurse Aide Registry was checked and a verification sheet was printed for all new employees. The Regional HR Director stated after the audit, they reviewed the policy and procedure and the New Hire Document Checklist, but changes were not needed. They further stated they re-educated the HR Director/Recruiter on the procedure and reinforced the importance of the New Hire Document Checklist. The Regional HR Director stated they advised the facility Administrator of the situation in an email. During an interview on 1/10/23 at 2:55 PM, the Administrator stated they were made aware that the Nurse Aide Registry checks were not being done timely, as a result of the audit performed by the Regional HR Director in December. The Administrator stated the HR Director/Recruiter's work was overseen by both the Administrator and the Regional HR Director and the results of the audit were discussed with the corporate team and will be discussed at the next Quality Assurance team meeting. Additionally, the Administrator stated the Nurse Aide Registry should always be checked prior to start of employment for all new employees. During an interview on 1/11/23 at 11:30 AM, the HR Director/Recruiter stated it was their responsibility to check the Nurse Aide Registry for each new employee and print the verification sheet for the personnel file. The HR Director/Recruiter stated they started this position in April 2022 and at that time, the Regional HR Director provided close training and guidance. After the training period, the Nurse Aide Registry checks were being done, but not always timely. They further stated they had the New Hire Document Checklist prior to the audit, but after the audit, they received additional education on the importance of timely Nurse Aide Registry checks and proper use of the New Hire Document Checklist was reinforced. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview, and record review conducted during the Standard survey started on 1/5/23 and completed on 1/12/23 the facility did not ensure that the resident is free from physical restraints for the purposes of discipline or convenience, and that are not required to treat the resident's medical symptoms when the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Specifically, for one (Resident #122) of one resident reviewed there was no documentation identifying the medical symptom being treated and no signed physician's order for a trial of the seatbelt from 4/26/22 through 7/19/22. In addition, through observation the staff did not release the seat belt restraint every 2 hours and did not offer toileting on 1/10/23 and during meals on 1/6/23, 1/9/23, and 1/10/23 the seat belt was not released per the plan of care. The Minimum Data Set (MDS-a resident assessment tool) was coded inaccurately for the restraint. The finding is: The facility policy and procedure (P&P) titled Restraints Procedure For Application & Removal dated 11/16 documented the facility creates and maintains an environment that fosters minimal use of restraints. The purpose of selective restraint use is to enhance resident quality of life by insuring safety while promoting an optimal level of function and treatment of a specific medical symptom that requires use of restraints. Physical restraints will not be used for staff convenience or for the purpose of discipline or as a substitute for direct care, activities and other services. Restraints are applied after physician's order is obtained. When restraints are utilized, they will be the least restrictive for the least amount of time. Restraints are to be released and resident repositioned Q (every) 2 hours. The State Operations Manual issued 10/21/22 defined a physical restraint as any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body and cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to their body. Examples of the facility practices that mean the definition of physical restraint include but not limited to using devices in conjunction with a chair, such as belts, that the resident cannot remove and prevents the resident from rising. 1. Resident #122 had diagnoses which included Parkinson's disease, dementia with Lewy Bodies (abnormal deposits of protein in the brain), and anxiety. The MDS dated [DATE] documented Resident #122 was severely cognitively impaired, usually understood and usually understands. The MDS documented one fall since admission or prior assessment. Section P Restraints documented used in chair as other used less than daily during the look back period. The Comprehensive Care Plan (CCP) dated 10/4/22 documented transfer self- performance deficit related to dementia, impaired balance and Parkinson's Disease. The planned intervention included out of bed to wheelchair with self-release seat belt. Falls and Physical Restraints related to dementia with Lewy bodies, self-transfers, and repeated falls. The restraint device (seat belt) was to be released Q2 hours and as needed, for all meals, toileting and ambulation. Interdisciplinary Team (IDT) to evaluate and monitor effects of the restraint and complete the restraint review. The Visual/Bedside Kardex Report (a guide used by staff to provide care) dated 1/10/23 and identified as current by Registered Nurse (RN) #2 Unit Manager (UM), documented to release the self-release safety belt every 2 hours and as needed for meals, toileting, ambulation, range of motion (ROM), and positioning. Resident #122 was to be located in an area of increased observation when awake and prevented self-ambulation. During an observation on 1/5/23 at 10:38 AM Resident #122 was in their wheelchair across from the nurse's station. The wheelchair had a black seat belt attached to the seat of the wheelchair with a fastened buckle around Resident #122's waist. Resident #122 was unable to unfasten the seat belt buckle on command. During an observation on 1/6/23 at 12:27 PM and 1/9/23 at 12:24 PM staff was observed assisting Resident #122 with the lunch meal. Resident #122 had the seat belt buckled and fastened. During a continual observation on 1/10/23 between 9:39 AM and 12:33 PM the following was revealed: - 9:39AM Resident #122 was in the wheelchair across from the nurse's station with the black seat belt buckle fastened and locked. Resident #122 was observed fidgeting with the straps of the belt buckle. -11:19AM staff redirected Resident #122 to remain seated as Resident #122 attempted to rise from the wheelchair. Seat belt buckle fastened and secured. No staff released the belt or offered toileting. -11:39AM Resident #122 remained in wheelchair across from the nurse's station. The seat belt was fastened and secured. No staff offered toileting or released the seat belt after 2 hours. -11:53AM, Licensed Practical Nurse (LPN) # 4 placed an over the bed table in front of Resident #122 and offered potato chips and a drink. The seat belt was secured. -12:14PM LPN # 2 delivered and assisted Resident #122 with their meal without unfastening the seat belt. The facility Accident & Incident Reports dated 4/26/22 documented Resident #122 had 2 falls from the wheelchair. On 4/26/22 at 10:10AM Resident #122 attempted to self-transfer out of the wheelchair, lost balance and fell back into the wheelchair. The wheelchair tipped sideways. The immediate care plan change included an ambulation program. On 4/26/22 at 2:30PM, Resident #122 self- transferred, lost balance and fell at the nurse's station. The immediate care plan changes to prevent reoccurrence was to trial a self-release belt. The Twenty-Four-Hour Nursing Services Supervisor Report dated 4/26/22 documented 2 falls. The self-release belt was to be monitored for tolerance while out of bed and the belt was to be kept off for meals. The Physical Therapy Post Fall Review with an effective date of 4/26/22 documented a witnessed fall. Resident #122 self-transferred out of wheelchair, lost balance and fell . The Director of Rehab documented Resident #122 released the seat belt safely and physical therapy trialed the self-release belt with the wheelchair. The Progress Notes titled Quality of Life Note documented on 6/30/22 Resident #122 was no longer able to release the seat belt. Physical Therapy would assess the seat belt and determine whether resident #122 was able to release the seat belt. Review of the entire medical record revealed no documented evidence of a signed physicians order for the trial of the self-release belt from 4/26/22 until 7/20/22 and no documentation of the medical symptoms being treated. Review of the Treatment Administration Record from 4/26/22 through 7/19/22 revealed no documented evidence of a physician's order for the seat belt restraint device. Further review of the Treatment Administration Record from 7/20/2022 through 1/12/2022 revealed Resident #122 had a seat belt restraint device when out of bed and released every 2 hours and as needed for meals, toileting, range of motion (ROM) & exercise. During an interview on 1/10/23 at 12:28 PM, LPN #2 stated the seat belt was a restraint device and prevented falls. The seat belt should be released every 2 hours, for meals and for toileting every 2-3 hours. During an interview on 1/11/23 at 11:23 AM certified nurse aide (CNA) # 4 stated Resident #122 should have been toileted prior to meals and was not. CNA #4 was aware the belt had to be released every 2 hours and stated the day was very busy and couldn't get to the resident in time. The seat belt reminded the resident not to stand up and self-transfer and prevented them from leaning forward in the wheelchair and reduced the risk of falls. During an interview on 1/11/23 at 2:44 PM, LPN # 3 stated the seat belt was a restraint device which prevented Resident #122 from falling. LPN #3 stated Resident #122 is always kept within view of the staff when out of bed. We do not have the staff to provide the constant 1:1 that's needed. LPN #3 stated the seat belt was used for dementia with Lewy bodies. LPN #3 stated By no means was the seat belt utilized for staff convenience. The belt was for resident safety. Nurses were responsible to ensure that the belt was released every 2 hours. During an interview on 1/11/23, at 2:50 PM, RN # 2, UM stated nurses ensured CNAs released the seat belt every 2 hours, for toileting, meals and ambulation and documented on the TAR. CNA #4 should have released the seat belt after 2 hours and toileted Resident #122 before lunch per the care plan. Residents shouldn't feel restricted while eating. During an interview on 1/12/23 at 8:21 AM, RN #3, MDS Coordinator stated the MDS was copied and pasted from the previous MDS. Section P was coded incorrectly and should have been coded as a Trunk restraint. During an interview on 1/12/23 at 8:56 AM, the Medical Provider stated staff monitored Resident #122 closely for falls. Resident #122 leaned forward, and self-transferred. The seat belt was used for dementia with Lewy Bodies, prevented falls, and was safe. The Medical Provider agreed to the seat belt due to Resident #122's difficult behaviors associated with the disease. We couldn't let them keep falling, it was the least restrictive care plan intervention. The seat belt allowed staff to Tend to other resident's and Kept the resident safe. During an interview on 1/12/23 at 9:35 AM, the Director of Rehab stated typically safety belts were not issued after 2 falls. Resident #122 self-transferred under close observation and required constant re direction from the nursing staff. The seat belt was trialed after the second fall on 4/26/22. The Director of Rehab was Unaware the trialed seat belt required a signed physician's order. Prior interventions included an ambulation program. Resident #122 released the seat belt upon evaluation 4/26/22 until the Quality of Life meeting on 6/30/22. Resident #122 could no longer unclip the belt on command and a restraint assessment was completed. Per the policy the seat belt required to be released every 2 hours for toileting, ambulation, and meals. During an interview on 1/12/23 at 12:51 PM, the Director of Nursing (DON) stated CNA #4 should have toileted Resident #122 and released the seat belt after 2 hours, and before lunch as per the care plan and policy. A physician's order for the trialed seat belt should have been signed by the Medical Provider at the start of the trial. The DON expected the MDS to be coded correctly according to the RAI (Resident Assessment Instrument) and was not. During an interview on 1/12/23 at 12:55 PM, the Administrator was unaware what the regulations were for restraints. The seat belt was used for Parkinson's' and dementia with Lewy Bodies. CNA #4 should have released the seat belt after 2 hours, before lunch and offered toileting every 2-3 hours. The seat belt was the least restrictive, appropriate device for the resident. 415.4(a)(2)(iii)

Based on observation, interview, and record reviews conducted during a Standard survey started on 1/5/2023 and completed on 1/12/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for two (Residents #48, #65) of four residents reviewed for ADLs. Specifically, there was lack of hand hygiene and glove changes in between fecal incontinence care and perineum (genital area) care. In addition, the CNAs (certified nursing assistants) touched objects (residents' clothing, lift sling, gym mat and pillowcases) while wearing the same gloves used to provide incontinence care. The findings are: Review of the facility policy and procedure (P&P) titled Perineal Care dated 6/22 documented perineal care provided comfort. The procedure included: Wash hands, apply gloves; Wash perineal area from front to back to prevent contamination. Remove gloves, wash hands, and apply new gloves. 1. Resident #48 was admitted to the facility with diagnoses including fracture of right femur, arthritis, type 2 diabetes mellitus. with other specified complications. The Minimum Data Set (MDS, a resident assessment tool) dated 11/12/22 documented Resident # 48 was severely cognitively impaired, was frequently incontinent of bowel and bladder and required total assistance of two staff members. The comprehensive care dated 9/28/2022 documented Resident # 48 was incontinent of bowel and bladder, required total assist of 2 staff members and incontinence care every 2 to 3 hours. During an observation of incontinence care on 1/09/23 at 11:39 AM, the Resident #48 was incontinent of urine and stool. CNA #2 did not change gloves and wash hands after completing fecal incontinent care and before perineum care. CNA #2 then proceeded to dress the resident using the same gloves, touched the resident's head, forehead and other environmental surfaces/areas (bed, lift sling and Geri-chair. Additionally, there was no barrier placed between the resident and bed. During an interview 1/09/23 at 1:08 PM, CNA #2 stated they were allergic to latex, used special gloves that were left in their car, and was unable to change their gloves during care. CNA #2 stated they should have changed their gloves. CNA #2 stated they should have changed their gloves between care areas, and before changing residents' clothes and transferring them into their Geri-chair. During an interview on 1/11/23 at 9:28 AM, Registered Nurse (RN) Unit Coordinator (UC) #1, stated they would expect the aides to wash their hands, change gloves/use clean gloves, between care areas, as well as use a draw sheets or chucks in incontinence care, to prevent infection. At 2:35 PM, in a follow up interview RN UC #1 stated they would expect peri-incontinent care to be performed from front to back for infection prevention/control purposes. During an interview on 1/11/23 at 2:29 PM, the Director of Nursing (DON), stated it would be a breach of infection control protocols if the resident was completely soiled and a risk for infection transmission if the CNA did peri care from back to front and moving from unclean to other area without washing hands and/or changing gloves. 2. Resident #65 was admitted with diagnoses which included diabetes mellitus, dementia, and anemia. The MDS dated [DATE] documented Resident #65 was cognitively intact and required extensive assistance of one staff member for personal hygiene. The Comprehensive Care Plan (CCP) dated 1/5/23 documented Resident #65 was incontinent of bowel and bladder. The planned interventions included to provide incontinent care every 2-3 hours and as needed. During an observation of morning care on 1/9/23 at 10:51 AM, CNA #6 provided fecal incontinent care and did not change their gloves or wash hands before providing perineal care (genitalia). CNA #6 repositioned the gym mat during care and did not perform hand hygiene and continued care with the same gloves. After morning care was completed CNA #6 replaced two soiled pillowcases with the same gloves without performing hand hygiene. During an interview on 1/9/23 at 11:03 AM, CNA #6 stated hand hygiene was performed after care was completed and did not change their gloves after fecal incontinent care, before perineal care. My gloves were not visibly soiled. CNA #6 stated they should have performed hand hygiene in between fecal incontinent care and perineal care, after touching the gym mat, and before changing the pillowcases for infection control purposes. During an interview on 1/11/23 at 2:46 PM, RN #2 Unit Manager stated the mat was considered contaminated. CNA #6 should have changed their gloves before continuing care. Washing front to back and washing hands was the best practice to prevent the spread of bacteria. During an interview on 1/12/23 at 10:47 AM, LPN #2 (Director of Quality and Education) stated hand hygiene was expected before care, and after fecal incontinent care. CNA #6 should have replaced their gloves after touching the gym mat and before touching the clean pillowcases to avoid contamination. During an interview on 1/12/23 at 11:11 AM, the DON stated hand hygiene was expected before care, and after incontinent care for standard infection control measures and would have expected CNA #6 replaced their gloves after touching the gym mat and touching the pillows. NYCRR 415.12(a)(3)

Based on interview and record review conducted during a complaint investigation (Complaint #NY 489) during the Standard survey completed on 3/12/20, the facility did not ensure that all alleged violations of abuse including injuries of unknown origin are reported immediately in accordance with State Law through established procedures. One (Resident #101) of two residents reviewed for abuse reporting had an issue. Specifically, the facility did not report an allegation of abuse to the New York State Department of Health (NYS DOH) within the 2-hour required time frame. The finding is: A facility policy entitled Abuse Reporting and Facility Incident Reporting dated 7/2017 documented that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and reasonable suspicion of a crime against a resident are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator and to the official in accordance with state law through established procedures. 1. Resident #101 has [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set (MDS - a resident assessment tool) dated 2/20/20 revealed the resident had severe cognitive impairment. Review of a Nursing Progress Note dated 9/30/19 revealed the resident was alert and oriented x3 (oriented to person, place and time) with confusion at times. Review of an untitled, undated investigation report documented that a Concern was identified on 9/23/19. The Report documented that a Resident Aide (RA #1) was talking to a Certified Nurse Aide (CNA #1) at the Nurses' Station and stated that CNA #2 was inappropriate with Resident #101. While in Resident #101's room, CNA #2 told RA #1 that the resident was crazy and had been locked up in a mental institution about six times. CNA #2 asked the resident if he/she was crazy and stated, tell her you are crazy. Tell her how many times you have been locked up. RA #1 stated she was the only one in the room with CNA #2 and while the CNA provided care to the resident, the resident's head hit the wall twice and the resident stated Ow, my head. CNA #2 mocked the resident and repeated what the resident said. CNA #2 provoked the resident to talk dirty and stated he/she is a perv (pervert) and makes dirty comments. The investigation report documented that RA #1 did not report the 9/19/19 incident until 9/23/19 at 8:00 PM. Review of a handwritten statement provided by RA #1 dated 9/23/19 revealed that while CNA #2 was changing Resident #101, she bounced his/her head off the wall. Both times the resident shouted Ow, my head and CNA #2 mocked the resident by saying Ow, my head. CNA #2 kept stating that the resident was a perv and that he/she makes dirty comments. RA #1 documented that the resident didn't initiate anything, CNA #2 provoked him/her to talk dirty. The resident agreed that he/she was better after being changed and CNA #2 leaned over the resident stating Why, cut my boobs are in your face? The resident laughed and CNA #2 said you are such a perv. CNA #2 repeated the same behavior on Friday 2/20/19. Review of an undated, written statement revealed CNA #2 documented the resident was joking around and she told the resident he/she was being crazy. When we do something he/she doesn't like, he says fxxx, then you know something happened. He did not say that. Even small stuff I report. Review of an untitled document dated 9/23/19 revealed that Resident #101 was interviewed by the Registered Nurse (RN #2) Nursing Supervisor and Resident #101 denied being fearful of anyone. When asked if anyone had ever hit his/her head on anything, the resident stated yes. When asked if the person made him/her feel bad about him/herself, the resident stated yes. When asked if the staff person was taking care of him this evening (9/23/19), the resident stated yes and identified CNA #2. The RN (#2) Nursing Supervisor inspected the resident's skin, head and scalp, no injury was noted, and the resident had no complaints of pain. Review of an email dated 9/23/19 at 10:10 PM, sent to both the Director of Nursing (DON) and the Administrator from the RN (#2) Nursing Supervisor revealed a statement was obtained from CNA #2 and she was sent home. The email documented that Resident #101 was not fearful. The resident stated yes when asked if anyone here made him/her feel bad and if the person that took care of him/her was working tonight. (CNA #2 was assigned to the resident on 9/23/19). Review of an on line submission email from the NYS DOH Bureau of Complaints and Analysis dated 9/24/19 at 11:37 AM revealed the facility submitted the incident to NYS on 9/24/19 at 8:22 AM and that the incident occurred 9/19/19 at 8:00 PM. During an interview on 3/6/20 at 12:30 PM, the DON stated she received a call from the RN (#2) Nursing Supervisor on 9/23/19 at about 8:45 PM. She directed the Supervisor to talk to the resident and send CNA #2 home. The DON stated that RA #1 was kind of a gossip and wanted to find out more to see if her story was reliable. The DON stated that she now knows she should have reported (the incident) within the two-hour time frame, as any allegation of abuse should be. During an interview on 3/12/20 at 2:30 PM, the Administrator stated she was aware that abuse allegations should be reported within a two-hour timeframe. 415.4(b)(4)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY 195) completed during the Standard survey completed on 2/1/19, the facility did not ensure that all alleged violations of abuse, exploitation or mistreatment, were thoroughly investigated for one (Resident #349) of six residents reviewed for abuse. Specifically, the facility did not complete a thorough investigation for a resident with suspected subtle nondisplaced fractures (broken but remains in place) of the right seventh and eighth ribs on the midaxillary line (anatomical line, mid-lateral rib cage area). The finding is: The facility policy and procedure (P&P) entitled Facility Incident Investigation with a revision date of 10/11 documented the facility will conduct an immediate and through investigation, upon discovery of an incident to include but not limited to abuse, neglect and injuries of unknown injury. The Director of Nursing (DON) would utilize the Abuse Investigation Summary Form to include but not limited to witness statements, resident statements, facility investigation and a plan to prevent reoccurrence. 1. Resident #349 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 8/9/18 documented the resident was moderately cognitively impaired, understands and was understood. The MDS documented the resident required extensive assist with all activities of daily living (ADL's) and required the assist of two people for transfers and walking in her room. Additionally, the resident required extensive assist of two people for bed mobility. Review of the comprehensive Care Plan with a cancel date of 10/18/18 revealed the resident had a self-care deficit related to impaired balance and left hip surgery. The intervention sit to stand lift with 2 assist; sling trim color: yellow was resolved 8/22/18. Review of the Progress Notes dated 8/18/18 at 6:32 PM revealed the transferred with 2 c/a (contact assist) sit to stand and was non- ambulatory. Review of the Progress Notes dated 8/18/18 at 6:41 PM revealed the resident was out on pass (OOP) with family and returned to the facility via family auto without incident. There was no documented evidence the resident had any pain. Review of the Progress Notes dated 8/19/18 at 3:34 AM revealed the resident had no complaints of (c/o) pain. Review of the Progress Notes dated 8/21/18 at 3:43 AM revealed the resident was alert & (and) oriented, able to make needs known. Cooperative with hands on care. Color fair, skin warm and dry, respirations are full & easy, no SOB (shortness of breath), no (resp) respiratory distress noted and had no c/o pain or discomfort. Additionally, a progress note dated 8/21/18 at 9:19 AM documented the resident was seen by the Nurse Practitioner (NP) and there were no new orders received. Review of the Progress Notes dated 8/22/18 at 8:38 AM revealed a new order was received for an x-ray of the right ribs related to pain. Review of the NP Interim Note dated 8/22/18 revealed the resident stated she had pain at her right side that started last night and the plan included to obtain rib films (x-ray). Review of the Progress Notes dated 8/22/18 at 11:37 AM revealed x-ray results received, showing subtle suspected non-displaced fractures of the 7th and 8th ribs. The NP was notified and a new order for [MEDICATION NAME] with Aspercream 4% (used to treat pain) topically to the right ribs was ordered twice daily. The Progress Note further revealed that physical therapy was notified to adjust the plan of care and the family was updated. Additionally, the progress note documented the RP (responsible party) did state the resident was transferred while OOP (out on pass) on 8/18/18 with two people picking her up by her arms. Review of the x-ray report dated 8/22/18 revealed under Impression: suspect subtle nondisplaced fractures of the right seventh and eighth ribs in the midaxillary line. Small pleural effusion (collection of fluid in the pleural cavity) with compressive atelectasis (lung cannot fully inflate) versus infiltrate (fluid collection in the lung). Correlate clinically to exclude pneumonia. Review of the NP Interval Note dated 8/23/18 revealed the resident in not complaining of further right rib pain. Review of the Progress Notes dated 8/23/18 at 12:21 PM and 3:50 PM revealed the resident had c/o of right rib pain and Aspercream with [MEDICATION NAME] was applied. Review of the Progress Notes dated 8/24/18 at 10:46 PM revealed the resident had c/o right rib pain and Aspercream with [MEDICATION NAME] was applied. An interview on 2/1/19 at 1:36 PM with the Director of Nursing (DON) and the Administrator revealed there was a different DON at the time of the incident. It was determined the resident complaints of pain happened when she went out on pass. The Administrator stated that an investigation was completed and documented in the notes; however, did not have documented evidence that an investigation was completed to include an Abuse Investigation Summary Form, witness statements, resident statements, facility investigation and a plan to prevent reoccurrence. During an interview on 2/1/19 at 1:42 PM, the Medical Director stated the results of the x-ray were inconclusive because it is subtle and nondisplaced, and it is so hard to say if it's a fracture or not. During an interview on 2/1/19 at 2:29 PM, the DON stated that she contacted the former DON at the time of the occurrence and she wrote a statement today (2/1/19) regarding her conversation with the resident. A telephone interview on 2/1/19 at 2:46 PM with the former DON revealed she just wrote the statement today (2/1/19) of her conversation with the resident on 8/23/18. She also stated she knew the resident had fractures at the time and went to follow up with the resident. Additionally, the former DON stated the Unit Manager at the time documented the phone conversation with the family but she could not recall if any of the staff were interviewed or if statements were obtained. 415.4 (b)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/1/19 the facility did not ensure that residents who require [MEDICAL TREATMENT], received services consistent with professional standards of practice. Specifically, one (Resident #298) of one resident reviewed for [MEDICAL TREATMENT] had an issue involving the lack of ongoing communication and collaboration by the facility staff and the staff of the [MEDICAL TREATMENT] center regarding dressing changes to the AVF (arteriovenous fistula) access site (a tube or device surgically implanted to create an artificial connection between an artery and a vein) resulting in the pressure dressing not being removed. The finding is: Review of the policy and procedure (P&P) entitled A/V Fistula/Graft Care dated 11/2003 documented after [MEDICAL TREATMENT] treatments, leave the dressing in place for at least four hours unless otherwise instructed by the [MEDICAL TREATMENT] staff. It is important to take the dressing off as soon as possible after four hours to assist in the healing of the puncture site. 1. Resident #298 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) documented the resident was understood, understands and was cognitively intact. Also, the MDS documented the resident was receiving [MEDICAL TREATMENT] services. Review of the Comprehensive Care Plan with initiation date of 1/16/19 revealed the resident needs [MEDICAL TREATMENT] related to [MEDICAL CONDITION] and was to attend [MEDICAL TREATMENT] Monday, Wednesday and Friday. Interventions included to monitor shunt site post [MEDICAL TREATMENT] for hemorrhage and site care flushes and dressing changes completed at [MEDICAL TREATMENT] center. During an observation/interview on 1/24/19 at 9:07 AM, the resident lifted his left arm sleeve and showed the surveyor his access site for [MEDICAL TREATMENT]. The AVF access site was observed to have a dressing/ bandage on it. The resident stated, [MEDICAL TREATMENT] put the dressing on yesterday. It was supposed to come off last night. [MEDICAL TREATMENT] told me if they don't take it off, then I should. Review of the nursing Progress Note dated 1/23/19 and 1/28/19 revealed the resident went out to [MEDICAL TREATMENT] but there was no documentation regarding the removal of the bandage at the left arm AVF site after the residents return. Review of the [MEDICAL TREATMENT] Treatment Flow Sheet dated (MONTH) 2019 revealed to monitor the left arm shunt site for signs and symptoms of infection, bleeding and hemorrhage. However, there was no documented evidence that the AVF access site dressing was removed. During an observation/interview on 1/29/19 at 7:32 AM, the resident lifted his left arm sleeve and showed the surveyor his access site for [MEDICAL TREATMENT]. The AVF access site was observed to have a dressing/ bandage on it. The resident stated the dressing was from [MEDICAL TREATMENT] yesterday (1/28/19), and they (nurses) only take it off when I ask them to; like when it starts to bleed. The resident further stated that [MEDICAL TREATMENT] tells him the dressing should be taken off after four hours. During an interview on 1/29/19 9:02 AM, Registered Nurse (RN) Unit Manager #1 after reviewing the facility P&P entitled A/V Fistula/Graft Care stated, the nurse was supposed to remove the dressing after four hours and they did not have and MD (medical doctor) order to remove the dressing. RN #1 also stated she needed to get an MD order to remove the dressing. During a telephone interview on 1/29/19 9:38 AM, the Clinical Coordinator at the [MEDICAL TREATMENT] center stated there was no set time frame, and the facility should personalize the dressing removal for each resident. The resident should be monitored closely for bleeding because each resident is different. The dressing should not be left on till the next time he comes to [MEDICAL TREATMENT], and there should be MD recommendations to remove the dressing. During an interview on 1/29/19 at 12:34 PM, the Director of Nursing (DON) stated the nurses were to take off the dressing after four hours. 415.12

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY 195) completed during the Standard survey completed on 2/1/19, the facility did not ensure that all alleged violations of abuse, exploitation or mistreatment, were thoroughly investigated for one (Resident #349) of six residents reviewed for abuse. Specifically, the facility did not complete a thorough investigation for a resident with suspected subtle nondisplaced fractures (broken but remains in place) of the right seventh and eighth ribs on the midaxillary line (anatomical line, mid-lateral rib cage area). The finding is: The facility policy and procedure (P&P) entitled Facility Incident Investigation with a revision date of 10/11 documented the facility will conduct an immediate and through investigation, upon discovery of an incident to include but not limited to abuse, neglect and injuries of unknown injury. The Director of Nursing (DON) would utilize the Abuse Investigation Summary Form to include but not limited to witness statements, resident statements, facility investigation and a plan to prevent reoccurrence. 1. Resident #349 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 8/9/18 documented the resident was moderately cognitively impaired, understands and was understood. The MDS documented the resident required extensive assist with all activities of daily living (ADL's) and required the assist of two people for transfers and walking in her room. Additionally, the resident required extensive assist of two people for bed mobility. Review of the comprehensive Care Plan with a cancel date of 10/18/18 revealed the resident had a self-care deficit related to impaired balance and left hip surgery. The intervention sit to stand lift with 2 assist; sling trim color: yellow was resolved 8/22/18. Review of the Progress Notes dated 8/18/18 at 6:32 PM revealed the transferred with 2 c/a (contact assist) sit to stand and was non- ambulatory. Review of the Progress Notes dated 8/18/18 at 6:41 PM revealed the resident was out on pass (OOP) with family and returned to the facility via family auto without incident. There was no documented evidence the resident had any pain. Review of the Progress Notes dated 8/19/18 at 3:34 AM revealed the resident had no complaints of (c/o) pain. Review of the Progress Notes dated 8/21/18 at 3:43 AM revealed the resident was alert & (and) oriented, able to make needs known. Cooperative with hands on care. Color fair, skin warm and dry, respirations are full & easy, no SOB (shortness of breath), no (resp) respiratory distress noted and had no c/o pain or discomfort. Additionally, a progress note dated 8/21/18 at 9:19 AM documented the resident was seen by the Nurse Practitioner (NP) and there were no new orders received. Review of the Progress Notes dated 8/22/18 at 8:38 AM revealed a new order was received for an x-ray of the right ribs related to pain. Review of the NP Interim Note dated 8/22/18 revealed the resident stated she had pain at her right side that started last night and the plan included to obtain rib films (x-ray). Review of the Progress Notes dated 8/22/18 at 11:37 AM revealed x-ray results received, showing subtle suspected non-displaced fractures of the 7th and 8th ribs. The NP was notified and a new order for [MEDICATION NAME] with Aspercream 4% (used to treat pain) topically to the right ribs was ordered twice daily. The Progress Note further revealed that physical therapy was notified to adjust the plan of care and the family was updated. Additionally, the progress note documented the RP (responsible party) did state the resident was transferred while OOP (out on pass) on 8/18/18 with two people picking her up by her arms. Review of the x-ray report dated 8/22/18 revealed under Impression: suspect subtle nondisplaced fractures of the right seventh and eighth ribs in the midaxillary line. Small pleural effusion (collection of fluid in the pleural cavity) with compressive atelectasis (lung cannot fully inflate) versus infiltrate (fluid collection in the lung). Correlate clinically to exclude pneumonia. Review of the NP Interval Note dated 8/23/18 revealed the resident in not complaining of further right rib pain. Review of the Progress Notes dated 8/23/18 at 12:21 PM and 3:50 PM revealed the resident had c/o of right rib pain and Aspercream with [MEDICATION NAME] was applied. Review of the Progress Notes dated 8/24/18 at 10:46 PM revealed the resident had c/o right rib pain and Aspercream with [MEDICATION NAME] was applied. An interview on 2/1/19 at 1:36 PM with the Director of Nursing (DON) and the Administrator revealed there was a different DON at the time of the incident. It was determined the resident complaints of pain happened when she went out on pass. The Administrator stated that an investigation was completed and documented in the notes; however, did not have documented evidence that an investigation was completed to include an Abuse Investigation Summary Form, witness statements, resident statements, facility investigation and a plan to prevent reoccurrence. During an interview on 2/1/19 at 1:42 PM, the Medical Director stated the results of the x-ray were inconclusive because it is subtle and nondisplaced, and it is so hard to say if it's a fracture or not. During an interview on 2/1/19 at 2:29 PM, the DON stated that she contacted the former DON at the time of the occurrence and she wrote a statement today (2/1/19) regarding her conversation with the resident. A telephone interview on 2/1/19 at 2:46 PM with the former DON revealed she just wrote the statement today (2/1/19) of her conversation with the resident on 8/23/18. She also stated she knew the resident had fractures at the time and went to follow up with the resident. Additionally, the former DON stated the Unit Manager at the time documented the phone conversation with the family but she could not recall if any of the staff were interviewed or if statements were obtained. 415.4 (b)(3)

Based on observation, interview, and record review during the Standard survey completed on 9/27/17, the facility did not store, prepare, distribute, and serve food under sanitary conditions. One of one Activities Room observed for sanitary conditions had a dishwashing practice that lacked either heat or chemical sanitization for dishes that were washed in the automatic dishwashing machine and dishes that were washed by hand. The findings are: 1. Observation on 9/20/17 at approximately 10:55 AM revealed the Activities Room had a residential-style automatic dishwasher. Further observation revealed the dishwasher was not equipped with a temperature gauge. Interview with the Activities Director on 9/21/17 at approximately 9:15 AM revealed the Activities Room hosts breakfasts on a weekly basis and luncheons two times per month for the residents and the dishes from these events are washed either in the Activity Room's dishwasher or one-bay sink. Further interview with the Activities Director revealed she has no way to check the water temperature or chemical sanitizer level of the dishwasher. During an interview on 9/25/17 at approximately 8:20 AM, the Activities Director presented the dishwashing detergent that is used for washing dishes in the dishwasher, which was a grocery store brand that said, contains sodium [MEDICATION NAME] and chlorine bleach on the label. Observation on 9/26/17 at approximately 11:10 AM revealed the Activities Director ran the dishwasher. Interview with the Activities Director at this same time revealed she set up the dishwasher as she normally would by choosing the normal wash and hi temp wash settings. Further observation revealed at 12:50 PM the cycle was completed and a chlorine test strip that was obtained from the Main Kitchen, was applied to the dishes in the machine, immediately following the cycle. The test strip reveled there was no chlorine in the dishwasher's final rinse water. Interview with the Activities Director at the time of the observation revealed she does not have her own set of chlorine test strips and she has never used a chlorine test strip to check the chlorine level of either the dishwasher water or the water from hand-washing dishes in the one-bay sink. Review of the manufacturer's user instructions for the automatic dishwasher revealed the hi temp wash setting increases the target water temperature during the wash portion of the cycle, but does not provide specific temperatures. Additional review of the manufacturer's user instructions revealed this machine has a steam sanitize setting which will raise the water temperature in the final rinse to approximately 154 degrees Fahrenheit, which will sanitize dishes in accordance with NSF/ANSI Standard 184 for Residential Dishwashers, and it further states that certified residential dishwashers are not intended for licensed food establishments. Interview with the Activities Director on 9/26/17 at approximately 11:10 AM revealed she never uses the dishwasher ' s steam sanitize setting. Review of the facility policy titled Temperature/Sanitizing Log, revised 12/2008, revealed dish machine wash and rinse cycle temperatures will be checked and logged daily, and a low temperature dishwasher must have a wash temperature of 120 degrees Fahrenheit and 50 parts per million hypochlorite (chlorine) on dish surface in the final rinse. 2) Observation on 9/20/17 at approximately 10:55 AM revealed the Activities Room had a one-bay sink. Interview with the Activities Director on 9/21/17 at approximately 9:15 AM revealed the Activities Room hosts breakfasts on a weekly basis and luncheons two times per month for the residents and the dishes from these events are washed either in the Activity Room's dishwasher or one-bay sink. During an interview on 9/25/17 at approximately 8:20 AM, the Activities Director presented the dish soap and sponge that are used to wash dishes by hand in the one-bay sink. Observation at this time revealed the sponge was attached to the end of a hollow plastic handle into which the dish detergent was poured. Further observation revealed the dish soap was a grocery store brand Review of the facility policy titled Three-Section Sink Usage, revised 9/2010, revealed when washing dishes by hand, the first compartment is to be filled with hot water and detergent, the second compartment is to be filled with clear, hot water for rinsing, and the third compartment is to be filled with clear hot water and one of the following chemical sanitizing agents: at least 50 parts per million of chlorine, at least 125 parts per million of iodine, or at least 200 parts per million of quat (quaternary ammonium chlorides). 415.14(h) 14-1.112 14.1.113 14-1.115

Based on observation, interview, and record review, conducted during a Standard survey completed on 9/27/17, it was determined that the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Three of four units (North, East, West) observed for housekeeping and maintenance services revealed the residents' environment was not maintained in a sanitary, and comfortable manner. Specifically, issues involved resident care equipment that was unclean and/or in disrepair; this included: toilets, commodes, fall floor mats, floors, wheelchairs, bed linens, and urine odors in hallways, resident rooms, and bathrooms. The findings are: 1. a.) Intermittent observation 9/20/17 between approximately between 9:00 AM and 3:00 PM revealed on the East Unit the vinyl wood look floors in the main hallway adjacent to the nursing unit were dirty with debris and the area smelled like stale urine. b.) Intermittent observations on 9/21/17 between 9:00 AM to 3:00 PM revealed the following: North Unit - Resident Room #205 - the toilet bowl was dirty with a brown stained ring along water line and brown streaks in the back of the bowl; the bathroom had a stale musty smell of urine coming from floor; the commode liner was dirty with multiple specks of brown debris. The toilet is shared by four people. - Resident Room #206 - the resident's sleeping area of the room smelled of stale urine. East Unit - Hallway - the vinyl wood look floors in the main hallway adjacent to the nursing unit were dirty with debris and the area smelled like stale urine. - Resident Room #101 - the wheelchair had dried food crumbs on the cushion and in between cushion and seat. Interview with Family Member A on 9/21/17 at 9:15 AM revealed the entire building could use a thorough cleaning and the halls were always cluttered with wheelchairs. They also stated that the facility could do a better job of cleaning their relative's room. Interview with Family Member B on 9/21/17 at 9:30 AM revealed that the building smells like urine at the main entrance. They also stated their relative's room usually has food wrappers and other debris on the floor. During an interview on 9/21/17 at approximately 9:55 AM, Resident A stated the toilet, which is for use for four residents, is often left dirty and is unpleasant to use. The resident stated she can self-ambulate to the toilet; however, the other three residents require staff assistance for toileting and the room should not be left in that unclean condition. The resident also stated that it's an undignified way to live, always having to use a dirty toilet. During an interview on 09/21/17 at approximately 2:30 PM, Family Member C stated that the East Unit is often dirty and smelly. Interview with the Director of Maintenance on 9/21/17 at approximately 3:20 PM revealed that the resident's bathroom floors are stripped and waxed once a year. He also stated that the floors are over [AGE] years old and should be replaced. c.) Observation on 09/22/17 at approximately 7:20 AM revealed that four rooms on the East Unit had seven floor mats which were tan in color which were in ill repair; specifically, ripped and torn, stained and dirty. This involved Resident Rooms 117, 114, 104 and 107. d.) Observation on 9/22/17 at approximately 12:11 PM revealed the Resident B was seated in a wheelchair next to her bed which had a bottom sheet soiled with brown streaks in the middle of the sheet, which appeared to be fecal streaks. During the observation, the resident stated that staff frequently leave the bed soiled long after she has gotten out of bed for the day and it bothers her, I shouldn't have to live like this when I'm [AGE] years old. During an interview on 9/27/17 at approximately 8:00 AM the Licensed Practical Nurse (LPN #3) Unit Coordinator stated that the CNA's (certified nurse aide) are supposed to clean the resident's room and change the bed immediately after getting the residents out of bed and certainly should not have left the resident to watch TV next to a bed with fecal stained sheets. e.) Intermittent observations on 9/25/17 between 6:00 AM and 1:00 PM revealed the following: North Unit - Resident Room #205 - the toilet bowl remained dirty with the brown stained ring along water line and brown streaks in the back of the bowl; the smell of stale urine remained in the bathroom; and the commode liner remained dirty with multiple specks of brown debris. In addition, there was a piece of used, wadded up toilet paper next to the toilet on the floor. - Resident Room #206 - the smell of stale urine remained in the resident sleeping area. East Unit - Resident Room #101 - the wheelchair remained soiled with dried food crumbs on the cushion and in between cushion and seat. Additionally, observed was an unlabeled urinal and opened packages of barrier ointment on top of the toilet tank in a shared bathroom. - Resident Room #102 - there were two beige fall floor mats that had multiple tears in the vinyl cover exposing the foam and the mats were soiled with multiple areas of black and brown debris on them. West Unit - Resident Room #134 - there was an unlabeled fracture pan placed in the handrail next to the toilet; the toilet commode seat arms were torn and the foam was exposed and the tape was coming off the vinyl of the seat arms. The bathroom was shared by two people. f.) Intermittent observations on 9/26/17 between 7:00 AM and 9:00 AM revealed the following: - Resident Room #205 - the toilet bowl remained dirty with a brown ring along the water line and the brown streaks in the back of the bowl; the stale smell of urine remained in the bathroom; the commode liner was still dirty with multiple specks of brown debris. - Resident Room #206 - the smell of stale urine remained in the resident's sleeping area. East Unit - Resident Room #101 - the wheelchair remained soiled with dried food crumbs on the cushion and in between cushion and seat. Additionally, the unlabeled urinal and opened packages of barrier ointment on top of the toilet tank remained in the shared bathroom. - Resident Room #102 - the two beige fall floor mats remained soiled and in disrepair. West Unit - Resident Room #134 - the unlabeled fracture pan remained in the handrail next to the toilet; and the toilet commode seat arm rests remained in disrepair. Interview with Housekeeper #2 on 9/25/17 at 9:45 AM revealed that she did not change the water in her mop bucket because of the chemicals in it. She also stated she only changes the water if the room was really filthy. Interview with Housekeeper #4 on 9/25/17 at 10:10 AM revealed that they use a pad system. They have the pads in a bucket of cleaning solution and they are supposed to change the pads on the mop head before mopping another resident's room. Interview and observation with LPN #2 Unit Coordinator on 9/26/17 at approximately 8:00 AM revealed that the shared bathroom floor between Resident Room #205 and #206 was dirty and there was a faint odor of urine. She also stated that she expects her staff to wipe the toilet with a Cavi (a cloth wipe with disinfecting chemicals) wipe if the toilet or commode is dirty with feces. Interview with CNA #1 on 9/26/17 at approximately 8:10 AM she stated that there is a schedule for wheelchairs to be cleaned on specific days by maintenance. She stated that the evening shift brings wheelchairs to maintenance to be cleaned but she didn't know why the residents wasn't taken to maintenance. Interview with Housekeeper #4 on 9/26/17 at approximately 8:15 AM he stated that if there was an issue with any of the resident's equipment or it needed to be repaired he would tell the Unit Manager. He then stated the manager would notify maintenance of any repairs. Interview with LPN Unit Coordinator #3 on 9/26/2017 at approximately 8:30 AM revealed that she expects her staff to label resident equipment and store the equipment in the resident's night stand. She also expects her staff to report any issues with resident equipment. She stated that she will have the mats that are in disrepair thrown out and replaced with new ones. Interview with LPN Unit Coordinator #4 on 9/26/2017 at approximately 8:45 AM revealed that she expects her staff to label and store the resident's care equipment in the resident's night stand in a wash basin. She also expects her staff to her staff to report any issues with resident to her so she can notify maintenance. She will let maintenance know so they can get a new commode chair for this resident's bathroom. Interview with the Director of Maintenance on 9/26/17 at approximately 9:00 AM revealed that he sends out an email every night to all the units for wheelchairs to be brought to maintenance to be cleaned. If there was an issue with a commode chair in disrepair, he would expect staff to report it to their manager so they can report it to maintenance. He stated that the equipment in disrepair would be replaced immediately. g.) Additional observation on 09/27/17 at approximately 7:00 AM revealed the three-in one commode over the toilet between Resident Rooms 205 and 206 had a copious amount of brown fecal material on the rear and the room was malodorous. During an interview on 9/27/17 at approximately 7:00 AM, the North Unit Night Charge LPN #8, stated that the CNA had just toileted the resident in the adjacent room, who requires bathroom assistance and the CNA should have cleaned the commode when the resident was finished using the room. During an interview on 9/27/17 at approximately 9:00 AM the resident's Social Worker #1 stated that several months ago the resident complained about some issues with her room because the toilet was always left in a mess. The social worker stated this came from a family meeting and she discussed the issue with environmental staff and the North Unit Coordinator. A request for documentation of the meeting yielded the social worker had no documentation of those concerns or the subsequent follow-up. Review of the facility policy titled Maintenance dated 6/1/2000 revealed that the facility including furnishings and equipment shall be maintained in good repair. Review of the facility policy titled Bedpans/Urinals dated 8/2005 revealed that bedpans and urinals should be cleaned and returned to the bottom shelf of the bedside stand. 415.5(h)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 9/27/17, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADL's) receives the necessary services to maintain good grooming and personal hygiene. Three (Resident #149, 27, 136) of seven residents observed for ADL's has issues. Specifically, Residents #149 and #27 had unwanted facial hair, Resident #27 had dark, crusted material under the fingernails and resident #136 had incomplete incontinent care. The findings are: 1. Resident #149 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/4/17 revealed that the resident has moderate cognitive impairment, is usually understood and usually understands. The resident requires extensive staff assistance for personal hygiene. Observation on 9/20/17 at approximately 10:30 AM revealed a staff member (Certified Nurse Aide (CNA)) was shaving this resident who had a three-five-day beard growth. Review of the Visual/Bedside Kardex Report (guide used by staff to provide care) dated 9/26/17 revealed the resident washes his own face and hands and staff are to complete the remainder of the resident's personal hygiene needs. During an interview on 09/20/17 at approximately 2:30 PM, the resident stated that he would like to get shaved every morning; however, staff normally only shave him every three to five days. During an interview on 09/26/17 at approximately 10:00 AM, the Licensed Practical Nurse Unit Coordinator (LPN #3) stated that residents' facial hair should be removed when visible or according to the resident's preference. 2. Resident #27, was admitted to the facility on [DATE], has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident is cognitively intact, is understood and usually understands. The resident requires extensive staff assistance for personal hygiene and toilet use. Review of the Visual/Bedside Kardex Report dated 9/26/17 revealed the resident's personal hygiene needs were listed as nail care on bath day and/or as needed, staff washes face prior to meals and for bathing directs the staff to wash the resident's upper body and lower body; there are no directions about facial hair. Observation on 9/20/17 at approximately 12:10 PM revealed that the resident had very long chin an upper lip hairs which were visible and had dirt and debris underneath her fingernails that was visible through chipped nail polish. During the observation on 9/20/17 at 12:10 PM, the resident stated the facial hair bothered her and that she was waiting for a shower and hoped the staff would finish her grooming. Review of the skin check sheet dated 9/20/17 revealed a skin check was done after the resident's shower and there were no issues. Observation on 09/22/17 at approximately 7:24 AM revealed Certified Nurse Aide (CNA #1) transferred the resident fully clothed from the bed to the wheelchair and stated the night shift staff performed the resident's morning care. The resident was observed with very long facial hair on the chin and upper lip. During an additional observation on 9/22/17 at approximately 7:30 AM, the resident told the CNA she slept in clothes last night because staff put her to bed in them and she wanted to be changed. The CNA transferred the resident back to bed and completed incontinence care and changed her clothes. The CNA did not shave the resident or complete any other personal care. During an interview on 09/26/17 at approximately 10:00 AM, LPN #3 Unit Coordinator stated that residents' nails should be cleaned and trimmed on shower day and facial hair should be removed when visible or according to the resident's preference. During an interview on 09/26/17 at approximately 2:00 PM, CNA #1 stated if I saw facial hair on resident would shave it. 3. Resident #136, was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident, has no cognitive impairment and usually understands and is usually understood. The resident requires extensive staff assistance for toilet use and personal hygiene, is occasionally incontinent of bowel and bladder, and is at risk for pressure ulcer/skin breakdown. Review of the Visual/Bedside Kardex Report dated 9/26/17 revealed the resident requires incontinent care as needed. Observation on 9/22/17 at approximately 9:45 AM revealed CNA #9 transferred the resident from the bed to the toilet to provide incontinence care. When the CNA removed the resident's brief it was urine soaked and yellow from the front to the back and sides across the surfaces. The surveyor noted that the urine soaked brief was in contact with the resident's abdomen, buttocks, hips and upper inner thighs while ambulating to the bathroom. When the CNA provided incontinence care, she did not wash the resident's abdomen, buttocks, hips, and upper inner thighs. During an interview on 9/26/17 at approximately 2:00 PM, Licensed Practical Nurse (LPN) Clinical Coordinator #1 stated that the CNA's are taught to wash all body parts that come in contact with the urinary incontinence. Review of the facility's policy and procedure entitled Incontinent Care last revised on 9/14 revealed instructions to wash the perineum, anus, and buttocks; there is no instruction to wash all areas exposed to urinary contact. 415.12(a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 9/27/17, the facility did not ensure that each resident receives adequate supervision and assistance to prevent accidents. Specifically, one (Resident #60) of three residents observed for accidents had an issue with the lack of implementation of the planned intervention of an EZ sip lid (disposable drink through lid) for safety with hot beverages after the resident spilled a hot beverage on self, sustaining a grade one burn (burn that results in pain and reddening of the outer layer of skin). The finding is: Review of facility policy and Procedure entitled Accident/Incident, Continuous (sic) Quality Improvement Summary, Investigation and Prevention dated 4/15 included the Supervisor verifies that a Care Plan change has been made to prevent reoccurrence at the time of collection from the unit. 1. Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/12/17 revealed the resident is severely cognitively impaired, is sometimes understood and sometimes understands. In addition, the MDS documented that the resident has no swallowing deficit and requires supervision for eating. Review of the Care Plan, with a review date of 9/25/17 revealed the resident had a self-performance deficit for eating r/t (related to) cognitive and physical impairments. Interventions included intermittent verbal cues/physical assist from staff. Review of Kardex (guide used by the Certified Nurse Aide (CNA) to provide care) with a print date of 9/26/17 included the resident eats breakfast, dinner, and supper on unit and required intermittent verbal cues/physical assist. Review of an Incident Report (A&I) dated 8/11/17 at 16:00 (military time) (4:00 PM) revealed the resident was given hot chocolate while in activities. The resident spilled the hot chocolate on her lap and sustain a burn on her left and right thighs. Resident was brought back to unit and a cold compress was applied to the areas immediately. The burn on the resident's left thigh measured 2 cm (centimeters) x 2 cm and the right thigh burn measured 8 cm x 9 cm. The immediate care plan changes to prevent re-occurrence was to apply sippy lid on hot beverages. Observation of Resident #60 on 9/22/17 during the breakfast meal revealed the resident did not receive a EZ sip lid on her breakfast tray for hot beverages. Review of facility Diet Extension Sheets dated 9/12/17 through 9/25/17 included the following beginning temperature ranges prior to the start of tray line: - Coffee, Tea, Hot Choc. (chocolate): 145 degrees F (Fahrenheit) - 160 degrees F - Soup of the Day: 168 degrees F - 220 degrees F Interview with the Director of Activities on 9/26/17 at approximately 8:25 AM revealed, I was leaving for the day when the Activity Aide went to the kitchen to get coffee and hot water from the kitchen. We just use the packets to make hot chocolate. After Resident #60 was burned we started temping the coffee and hot water in the kitchen and before we serve it to any residents. During the interview, the Activities Director stated Resident #60 does not utilize an EZ sip lid on hot beverages while in activities but that activity staff now prepare Resident #60's hot chocolate half hot water, half milk so it's not too hot. In addition, the interview revealed the Activity Director and staff review the nutrition sheets, that are updated weekly. The Activity Director stated the nutrition sheets communicate resident diets and any special equipment, including EZ sip lids, or allergies [REDACTED]. Review of the facility Nutritional Care Plan Summary dated 9/23/17 revealed no EZ sip lid for Resident #60. Interview with the Registered Dietician (RD) on 9/26/17 at approximately 9:33 AM revealed, the residents' meal ticket was changed this morning when it was brought to my attention by the DON (Director of Nursing) that the resident should have an EZ sip lid for her hot beverages. Up to this point the resident has not been receiving a EZ sip lid for hot beverages because we had no indication she needed one. I was just told this morning the resident had spilled hot beverage on herself last month and she was supposed to have the lid. This was never communicated to dietary. Interview with the Medical Director on 9/26/17 at approximately 9:56 AM revealed, a reasonable time frame for the implementation of the intervention would be the next time a hot beverage is being served to the resident. It is reasonable to expect it (EZ sip lid) should have happened sooner. Interview with the DON on 9/26/17 at approximately 10:21 AM revealed, the care plan change from the A&I needed to make its way on to the care plan and it didn't. It was missed and we just discovered it was missed this morning. 415.12(h)(1)

Based on interview and record review conducted during a Standard Survey completed on 9/27/17 the facility did not maintain clinical records on each resident in accordance with accepted professional standard and practices that are complete, accurately documented. One (Resident #12) of twenty-three residents reviewed for documentation had issues. Specifically, the physician's orders [REDACTED]. The finding is: 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 9/6/17 revealed the resident is moderately cognitively impaired, is understood and usually understands. Review of the comprehensive care plan, (CCP) with a review date of 9/14/17 revealed the resident was at risk for dehydration related to fluid restrictions and [MEDICAL TREATMENT]. Interventions included to monitor the resident's intake and output, and to provide 1500 ml (milliliters) of fluids daily as ordered. Review of the Order Summary Report dated 7/26/17 revealed an order dated 5/2/2017 for N&H (nutrition and hydration) Fluid Restriction every shift fluid restriction. SEE TEAM BOOK for fluid restriction documentation sheet. Review of a Dietary Quarterly Review note dated 8/28/17 revealed the resident is on a no added salt diet, potassium restricted with a 1500 fluid restriction- dietary provides 900 ml and nursing provides 600 ml/24 hrs. Additionally, the note documented will monitor intakes. Review of the Medication Administration Record [REDACTED]. Review of a form entitled Fluid Restriction undated (a number nine is documented under month, and was identified as current) revealed the amount of fluid Dietary provides in a 24- hour period was left blank. The amount of fluid Nursing provides in a 24-hour period was left blank. Additionally, the breakdown of fluids allowed for each shift was also blank. Further review of the form revealed a lack of documentation of fluid acceptance from 9/1/17- 9/24/17 for at least 26 of 72 shifts. An interview with a Licensed Practical Nurse (LPN# 5) on 9/26/17 at 10:36 AM revealed LPN #5 could locate the fluid restriction order in the electronic MAR, MD order, and the fluid restriction form but did not know how much fluid the resident should receive in a 24-hour period or per shift from nursing. During an interview on 9/26/17 at 10:48 AM, the LPN Unit Coordinator (LPN #4) stated the fluid restriction form is generated each month during change over (the Medication Administration Record [REDACTED]. The nurses would look at the sheet to see how much they can give the resident during each shift. After reviewing the fluid restriction form; LPN #4 stated, That's a problem because it is not filled in on the sheet; so, they (nurses) won't know (how much fluid the resident should have during the shift). During an additional interview on 9/26/17 at 2:25 PM, LPN #4 stated if there are blanks on the form then that means the nurse forgot to fill it in, this is our fault and the nurse was spoken to yesterday. During an interview on 9/27/17 at 9:01 AM, the Medical Director stated the order should state, fluid restrictions 1500 cc (cubic centimeter/equivalent to a milliliter) in a twenty-four-hour period. Review of a facility policy and procedure entitled Fluids- Standard/ Push/ Restrictions dated 11/07 revealed a physician's orders [REDACTED]. 415.22 (a) (1,2)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/16/16, the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, are thoroughly investigated. One (Resident #187) of three residents reviewed for non-pressure related skin conditions had an issue involving the lack of an investigation of an injury of unknown source. The finding is: 1. Resident #187 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - a resident assessment tool) dated 5/15/16 revealed that the resident is cognitively intact, understands, and is understood. Review of the comprehensive care plan (CCP) dated 5/26/16 revealed that the resident was care planned for skin related injury with a goal for the resident to be free from ecchymosis (purplish patch under the skin) and skin tears through the next review. Review of the Certified Nurse Aide (CNA) care plan dated 8/11/16 revealed the section for skin integrity documented skin and feet check with daily care, document weekly on shower day. The Bathing section documented that the resident's shower days are on Mondays and Thursdays during the 3:00 PM to 11:00 PM shift. The CNA care plan also documented that the resident receives PROM (passive range of motion - exercises performed on the resident by nursing staff) to the left shoulder and bilateral wrists five times per week. Observation on 8/11/16 (Thursday) at approximately 8:40 AM revealed the resident had a quarter-size, light purple bruise on the inner aspect of her left arm. The resident pulled up her left sleeve revealing another purple colored bruise approximately 2.5 inches long and ¼ inch wide. When the resident was asked what happened to her arm, she stated It happened the other day. I don't know where they came from. I probably hit my arm and I didn't even know. Review of the resident's Shower Sheets dated 7/4/16 to 8/11/16 revealed the sheets included documentation of skin and nail inspections and there was no documentation that the resident had bruising or other skin issues. Review of Nursing Progress Notes dated 7/24/16 to 8/11/16 revealed there was no documentation regarding the condition of the resident's skin. Interview with resident on 8/12/16 at approximately 7:43 AM revealed that the bruises remained on the left arm and the resident remembered how the bruises occurred. The resident stated that the ROM (range of motion aide) Aide grabbed her arm too tight and when she complained, the Aide let go of her arm. Interview with a Certified Nurse Aide (CNA #1) on 8/12/16 at approximately 8:18 AM revealed that the CNA helps the resident dress herself and the resident is usually independent with dressing. The CNA also stated that she did not notice any bruises or skin issues on the resident. Interview with a Licensed Professional Nurse (LPN #4) on 8/12/16 at approximately 8:21 AM revealed that she was not aware that Resident #187 had any skin issues. The LPN stated that she expects her staff to report any skin issues to the nurse or to her. The LPN also stated that they would do an investigation after measuring the bruises. During an interview on 8/12/16 at approximately 8:30 AM, the Director of Nursing (DON) stated that she expects staff to report skin issues immediately to the nurse and the nurse to the supervisor. The DON also stated that she would start an investigation. During an observation of ROM on 8/12/16 at approximately 9:04, the resident stated to the ROM Aide this is what you did to me on Wednesday (gesturing to her left arm) and when I complained to you, you looked at me cross-eyed. Interview with the ROM Aide on 8/12/16 at approximately 9:12 AM revealed that the ROM Aide did not recall ever touching the resident's arms. The ROM Aide stated that she never put pressure on that arm and that she did not recall what happened. Review of a facility policy and procedure entitled Bathing and Grooming dated 1/1/2000 revealed that skin condition is monitored minimally once weekly with bath and showers and that changes in skin condition noted with showers /bath/ ADL's (activities of daily living) are reported immediately to the nurse. 415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/16/16, the facility did not periodically review and revise the comprehensive care plan (CCP). One (Resident #33) of 24 residents reviewed for care plans did not have a revision to address a resident to resident altercation involving Resident #33. The finding is: 1. Resident #33 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/24/16 revealed the resident has severe cognitive impairment, usually understands, and is usually understood. Review of the comprehensive care plan (CCP) dated 6/24/16 revealed the resident has depression and dementia with behaviors. Review of a Nursing Progress Note dated 6/26/16 at 10:29 PM revealed an entry dated 6:55 PM which documented that staff observed Resident #33 grab a female resident's breast while sitting next to the resident across from the Nurses' Desk. The Progress Note documented that the residents were immediately separated and the resident was put on report to monitor behavior and to keep the residents separated. Review of a Continuous Quality Improvement report dated 6/26/16 at 6:55 PM revealed that Resident #33 was noted to grab a female resident's breast while sitting next to her in the hallway. The residents were immediately separated by the staff. The Continuous Quality Improvement report documented a plan to obtain a psychiatric (psych) consult for Resident #33. Review of an In-House Consultation Report (psych consult) dated 6/29/16 revealed the resident was seen in evaluation at the facility's request due to sexual inappropriateness. The Report documented that the resident receives a [MEDICAL CONDITION] drug which in the last 2 weeks had a dose reduction. During this time, the staff noted that the resident was more aggressive with mood swings and was noted to touch another resident's breast. The Assessment documented that the resident was sexually inappropriate and irritable during the dose reduction of the antipsychotic. Additional review of the CCP dated 6/24/16 revealed the CCP did not address the 6/26/16 incident when Resident #33 touched the breast of a female resident and did not include the interventions planned by staff to prevent reoccurrence. Review of the untitled Certified Nurse's Aide (CNA) care plan printed on 7/15/16 revealed that staff are to respond to the resident's behaviors with diversions including a snack, a walk, an activity, and reproach as needed. The CNA care plan did not include the intervention identified on 6/26/16 to keep the residents separated Interview with the Licensed Practical Nurse (LPN #4) Unit Coordinator on 8/16/16 at approximately 7:33 AM revealed the LPN was aware of the 6/26/16 resident to resident altercation involving Resident #33. The LPN stated that since the incident, staff have increased the resident's involvement in activities and bird watching and have tried to keep the two residents separated from each other. The LPN stated she did not update the care plan as she does not do the care plan portions for behaviors, mood, etc. Interview with the Social Worker (SW) on 8/16/16 at approximately 7:51 AM revealed the SW was aware of the 6/26/16 resident to resident altercation involving Resident #33. The SW stated that the staff increased the resident's involvement in bird watching and other activities, kept the two residents separated, and requested a psych evaluation. The SW did not update the Resident #33's care plan regarding the resident to resident altercation or the interventions implemented to prevent its reoccurrence. During an interview on 8/16/16 at approximately 8:45 AM, the Director of Nursing (DON) reviewed both the CCP and CNA care plan and stated that the altercation was not on the care plan. Review of a facility policy and procedure entitled Accident/ Incident Continuous Quality Improvement Summary Investigation and Prevention dated 4/15 revealed it is the responsibility of the licensed nursing professional to implement care plan changes to prevent repeat incidents. With the occurrence of an incident, the plan of care will be reviewed by the nursing coordinator and the interdisciplinary team. The review will include an evaluation of the current interventions. 415.11(c)(2)(iii)