Every finding on record at St Johnland Nursing Center

Based on observation, interviews and record review during an abbreviated survey intake number 2707253 the facility failed to ensure adequate supervision and timely risk assessment for an elopement for one (1) of three (3) sampled residents (Resident #1). Specifically, Resident #1 verbalized the desire to leave the facility to a provider who reported it to facility staff, the facility failed to follow the elopement prevention policy and assessed for elopement risk or implement supervision. Resident #1 eloped from the facility and was found outside on the facility grounds 30 minutes later. Findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses including stroke, hemiparesis, and urinary tract infection. A Minimum Data Set Brief Interview for Mental Status (BIMS) completed on 12/09/2025 documented a score of 11, indicating moderate cognitive impairment.Facility policy titled Elopement Prevention (dated 2020) required that upon a significant change in condition, each resident be assessed for elopement risk using the Elopement Risk Tool, and that appropriate interventions be implemented as indicated.A Wandering/Elopement Evaluation dated 12/08/2025 documented that Resident #1 was not at risk for elopement at that time.Neuropsychology Note by Psychologist #1 on 01/03/2026 at 02:34PM documented Resident #1 was observed walking unassisted into dayroom with staff members encouraging them to sit. They looked to exit the door unused other than for emergencies. Resident #1 sat, trying to convince staff to allow them to leave. The note further documented Resident #1 baseline personality structure likely included some degree of suspiciousness, but this trait was likely exacerbated by the stroke; it appeared more intense than the reduction in suspiciousness that had been previously noted when compared to initial consultation. The Note documents Resident #1 were also oriented on initial consult; today they stated it was 12/17/2026. Resident #1 expressed feeling less anxious at end of our meeting. Nursing is aware of mental status change and the need for continued observation with additional steps taken as defined by Medical Doctor who is being apprised of resident's condition by Registered Nurse. Will continue to follow throughout rehab stay.There is no documented evidence that an elopement risk reassessment was completed after 1/3/2026 when staff became aware of Resident #1 desire to leave. There is no documented evidence of enhanced supervision or elopement interventions on 1-3-2026.Nursing Progress Note dated 1/3/2026 at 9:04 pm by Licensed Practical Nurse #1 documented Resident alert and verbally responsive with periods of confusion. Medical Doctor was notified at 7:35 PM by the on-call supervisor that the resident was found outside the building at approximately 6 PM, sitting on the curb with no apparent distress. Resident #1 was safely brought back to the unit. Medical Doctor evaluated the situation and advised transfer to the emergency room for further evaluation.Video surveillance was reviewed by state agency and the Administrator on 01/15/2026 at 12:05 PM showed that on 01/03/2026 at approximately 5:17 PM, Resident #1 exited the facility through an exterior door unaccompanied and undetected. At approximately 5:52 PM, staff are observed entering the building with Resident #1.The temperature around the facility on 01/03/2025 as recorded by www.weather.gov documented the high of 30degrees Celsius and low of 20 degrees Celsius.Facility Accident and Investigation dated 01/03/2026 documented Resident #1 left the facility and was found outside approximately 30 minutes later, uninjured. The Certified Nursing Assistant assigned to Resident #1 on the Head Injury Rehabilitation Unit (HIRU) reported that they last observed Resident #1 at approximately 5:00 PM. The report concluded there was no neglect or failure to supervise. Facility five (5) day report submitted to the New York State Department of Health dated 01/06/2026 documented Resident #1 was ambulating independently throughout the elopement, consistent with their baseline functional mobility with residual left sided hemiparesis. During an interview with Psychologist #1 on 01/15/2026 at 2:25 PM, the psychologist stated that Resident #1's desire to leave was new and different from prior behavior, and that the resident had never previously voiced exit-seeking behavior. They stated the unit nurse was aware of exit seeking behavior and was working to inform the Medical Doctor.Registered Nurse Supervisor was not available for an interview on 1/15/2026.During an interview with the Director of Nursing on 01/15/2026 at 9:15 AM, the Director confirmed that Resident #1 was found outside the facility and has since been discharged to an assisted living facility. During a telephonic interview with Director of Nursing on 02/25/2025 at 10:01 AM they stated Resident #1 left the facility through a door adjacent to the kitchen area. They stated the Registered Nurse Supervisor was responsible to assess Resident #1 for elopement risk when they began voicing a desire to leave but they were responding to a fall at the time. Resident #1 eloped before they could be seen by the Registered Nurse Supervisor. 415.12(h)(1)

Based on observation, record review, and interviews during the abbreviated survey 2645588 , the facility did not ensure the residents right to be free from abuse and neglect for one (Resident #1) of three residents reviewed. Specifically, during a transfer Certified Nursing Assistant #1 needed to lower Resident #1 to the floor when their (Resident #1) legs became weak. This resulted in an injury to Resident #1's left knee requiring first aid. Certified Nursing Assistant #1 completed the transfer by themselves although the comprehensive care plan and Kiosk Nursing instructions documented Resident #1 was to have two staff member assistances with transfers.The finding is :The facility Abuse Prevention Identification Investigation and Reporting policy dated October 2016 reviewed April 2025 documented neglect defined as means failings provide timely, consistent, safe, adequate, and appropriate services, treatment, and/or care to a resident of a residential care facility, while the resident is under the supervision of the facility, including but not limited to: nutrition, medication, therapy, sanitary clothing, surroundings, and activities of daily living. Neglect may include but is not limited: Failure to carry out physician orders, medication omission, treatment omission or failure to follow the care plan or provide emergency services.Resident #1 was readmitted to the facility on [DATE] with diagnoses that include urinary tract infection (Infection in any part of the urinary system), atrial fibrillation (irregular heartbeat originating in the heart's upper chamber) hypertension (high blood pressure) chronic obstructive pulmonary disease (progressive lung disease that causes obstructed air flow).The Minimum Data Set (an assessment tool) dated 10/14/2025 documented Resident #1 had a Brief Interview for Mental status score of 13 indicating intact cognition. The Minimum Data Set (an assessment tool) dated 10/19/2025 documented Resident #1's transfer status as requiring transfer from chair to bed and toilet transfers required the assistance of two or more helpers to complete the activity.A Comprehensive Care Plan for Resident #1 dated 3/15/2025 and updated 10/14/2025 documented assist resident with Activities of Daily Living tasks as needed daily and to see the plan of care instructions on kiosk nursing instructions.The kiosk nursing Instructions audit dated 10/15/2025 at 2:56 pm documented Resident#1 had a support change from one-person physical assist to two plus persons physical assistance for transfers.An Accident and Incident report dated 10/15/2025 documented that on 10/15/2025 at 6:45 pm, Certified Nursing Assistant #1 was transferring Resident #1 using one person assist contrary to the plan of care which specified a two- person assist for all transfers involving Resident #1 from the wheelchair to the bed and Resident #1 was lowered to the floor when their legs became weak resulting in a scab being removed from the left knee requiring first aid. Resident #1 remained alert and oriented, and no other significant injury was observed.A Treatment Administration Record dated 10/15/2025 at 7:33pm documented to left knee opening, cleanse with normal saline, apply Neosporin, cover with dry protective dressing daily and as needed until healed.During an interview with Certified Nursing Assistant #1 on 2/5/2026 at 11:38 am, they stated they were transferring Resident #1 from the wheelchair to the bed by themselves because that was their (resident #1's) status prior to their readmission on [DATE]. They stated they did not check the kiosk nursing Instructions for Resident#1's transfer status prior to transferring them. Certified Nursing Assistant #1 stated they usually do not check if they are familiar with the residents. Certified Nursing Assistant #1 also stated that when Resident #1's knees weakened during the transfer, they had to lower resident number one to the floor.During an interview with Registered Nurse #2 on 2/5/2026 at 2:00 pm, they stated Resident #1 was on the floor lying on their left side. Resident #1 denied pain, discomfort or hitting their head. Resident #1 was observed with an open area on their left knee measuring 3 centimeters by 3 centimeters by 0 centimeters. Registered Nurse #2 stated that nurse practitioner #1 ordered a treatment to the left knee opening to cleanse with normal saline, apply Neosporin, cover with dry protective dressing daily and as needed until healed.During an interview with the Director of Nursing on 2/5/2026 at 3:40 pm, they stated they expected Certified Nursing Assistant #1 to check the kiosk for Resident #1's current transfer status at the beginning of the shift prior to transferring and caring for Resident #1.415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (NY00372994 and NY00364939) the facility did not ensure that resident's received adequate supervision to remain free from sexual abuse for three (3) of three (3) residents (Resident #2, #3, and #4) reviewed for abuse. Specifically, on 12/16/2024 at approximately 8:00 AM, License Practical Nurse #2 responded to a call for help from the dining room and observed that Resident #1 was touching the genital area of Resident #2. License Practical Nurse #2 intervened and removed Resident #2. Resident #1 was left unsupervised and immediately began rubbing the genital area of Resident #3. Additionally, on 02/22/2025, Registered Nurse #4 heard Resident #4 yelling get out, and when they entered Resident #4's room they observed Resident #4 in bed, the bed linens were pulled down, Resident #4's pants were pulled down below the waist, and Resident #1's hands were at the genital area of Resident #4. This resulted in actual harm for Resident #2, #3, and #4 which was Immediate Jeopardy with the likelihood to cause harm to the health and safety of other residents. This was evidenced by the following: The review of the facility policy Abuse, Prevention, Identification, Investigation and Reporting dated 06/2023 documented it is the policy of the facility to assure all residents are free from abuse and the facility has taken steps within its control to prohibit and prevent abuse per state, facility and federal regulations. The policy further documented sexual abuse is defined as nonconsensual sexual contact of any type with a resident. Examples of sexual abuse include but are not limited to unwanted intimate touching of any kind especially of the breasts or perineal area. Resident #1 was admitted with diagnoses that included Alzheimer's disease (a progressive disorder that causes memory loss and confusion) and deep vein thrombosis (blood clots). The review of the Quarterly Minimum Data Set (an assessment tool) dated 10/10/2024 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognitive deficit. The review of the Comprehensive Care Plan titled Abuse dated 11/17/2024 documented Resident #1 displays the following behaviors: verbally inappropriate behavior, sexually inappropriate behavior. A care plan update dated 12/16/2024 further documented Resident #1 inappropriately touched peers on 12/16/2024. The interventions included every 30-minute monitoring and redirect behaviors. Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease. The review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe impairment for decision making. The review of the Comprehensive Care Plan (CCP) dated 04/24/2024 titled at risk of abuse-victim documented interventions including, monitor for signs of abuse and Psychiatry follow-up as needed. Resident #3 was admitted to the facility with diagnoses that included peripheral vascular disease (blood vessels become blocked, reducing blood flow to the extremities), and Alzheimer's disease. The review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairments. The review of the Facility Investigation dated 12/16/2024 documented Resident #1 was seated at a table in the dining room waiting for breakfast, and Resident #3 and Resident #2 were seated next to Resident #1 at the same table. Licensed Practical Nurse #2 heard Resident #2 calling for help. Licensed Practical Nurse #2 then observed Resident #1 rubbing Resident #2's clothing at the perineal area. License Practical Nurse #2 immediately removed Resident #2 away from Resident #1. Resident #1 then proceeded to place their hand inside of Resident #3's pants. Licensed Practical Nurse #3 observed Resident #1 rubbing their own genital area while their other hand was touching Resident #3's genital area. The facility investigation concluded there is probable evidence of abuse, neglect or mistreatment. During an interview conducted on 02/08/2025 at 10:40 AM with Licensed Practical Nurse #2, they stated they were on duty 12/16/2024 and heard Resident #2 screaming. When they responded to the dining room, they saw Resident #1 rubbing Resident #2's clothing at the genital area. License Practical Nurse #2 stated they immediately removed Resident #2 from Resident #1 to separate them. They stated Resident #1 was seated in a chair at the dining/dayroom table and they turned and observed Resident #1 had one hand in their own pants and had their other hand in the pants of Resident #3, and both hands were observed moving up and down. They stated they should have moved Resident #1 away from all other residents. During a telephone interview conducted on 02/07/2025 at 8:30 AM with Licensed Practical Nurse #3, they stated on 12/16/2025 at about 7:45 AM they heard staff and a resident speaking in a loud voice saying stop. Licensed Practical Nurse #3 stated they observed Resident #1 sitting in their wheelchair with their hand inside the pants of Resident #3. They further stated they unlocked Resident #1's wheelchair and started to move it and then observed Resident #1's other hand inside their own pants touching themselves and both hands were moving in an up and down motion. They stated the dining room is clearly visible when staff are at the nurse's station. When residents are present in the dining room and a nurse leaves the nurses station, the staff periodically check the dining room. They stated they are not aware of any requirement that staff members should be present in the dining room when residents are in that room. During an interview conducted on 02/09/2025 at 3:30 PM with the Director of Nursing, they stated on 12/16/2024 Resident #1, as the aggressor, should have been removed from the day room by Licensed Practical Nurse #2, but they removed the victim. Resident #1 then touched another Resident. They further stated Resident #1 was immediately placed under supervision, one to one (1:1) and transferred to the hospital for aggressive behavior. The Director of Nursing stated Resident #1 was seen in the emergency department and returned without further recommendations. The Director of Nursing further stated Resident #1 was scheduled for psych follow-up outpatient but was not able to locate the consult forms. Resident #4 had a diagnosis of Alzheimer's disease with a Brief Interview mental Status Score of 5, indicating severe cognitive impairment. Review of the Facility investigation dated 02/22/2025 documented Resident #1 was observed in Resident #4's room. An employee statement obtained by Registered Nurse #2 documented Registered Nurse #4 stated they saw Resident #1 in the room of Resident #4 touching and rubbing the genital area of Resident #4. The facility investigation concluded there is probable evidence of abuse, neglect or mistreatment. During an interview conducted on 03/04/2025 with Certified Nursing Assistant #4 they stated on 2/22/2025, during the 3:00 PM to 11:00 PM shift, they observed Resident #1 hanging around Resident #4. They stated before they went on break, they told Registered Nurse #1 to watch Resident #1. When they returned from break Registered Nurse #1 informed them that Resident #1 was observed rubbing the genital area of Resident #4 and attempted to touch Registered #4 inappropriately. During an interview conducted with Registered Nurse #4 on 03/04/2025 at 12:20 PM, they stated on 02/22/2025 at approximately 10:00 PM they responded to the room because Resident #4 was yelling get out, and they observed Resident #1 at the bedside. The sheet and pants of Resident #4 were pulled down and Resident #1's hands were observed extended over Resident #4. During an interview conducted with Registered Nurse #2 on 03/04/2025 at 11:34 AM they stated prior to 02/22/2025 Resident #1 was on 30-minute checks. They further stated Resident #1 was moved to the current unit secondary to sexually inappropriate behaviors on the previous unit in December. Registered Nurse #2 stated most of the residents on this unit are cognitively impaired and not able to consent to sexual contact. They further stated they conducted an interview with Registered Nurse #4 on 02/23/2025 who stated they saw Resident #1 touching and rubbing Resident #4's genital area. During an interview conducted with Family Member #1 of Resident #2 on 03/04/2025 at 10:30 AM, they stated they were notified of an incident by the facility in December of inappropriate touching that was done by another resident. Family Member #1 stated Resident #2 is very private and would have been upset by someone touching them without consent. During an interview conducted on 03/04/2025 at 11:00 AM with Family Member #2 of Resident #4, they stated they were notified by the facility that someone was in the room of Resident #4 on 02/22/2025 and touched them inappropriately. Family Member #2 stated they were told Resident #4 was screaming get out because they would not want to be touched in that manner and was likely very upset. During an interview conducted with the Medical Director on 03/04/2025 at 11:00 AM, they stated residents should not be touched by other residents in a sexually inappropriate manner. The facility is responsible to ensure that residents are safe. 415.4(b)(1)(i)

Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00358060, NY 00355385, NY 00357476, and NY 00358655) initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified for four (Inn, Head Injury Rehabilitation Unit, Muhlenberg, and [NAME] Hall) of seven nursing units reviewed during the Sufficient Nursing Staffing Task. Specifically, during an observation on 12/8/2024 (Sunday) 13 of 15 residents in the Head Injury Unit were still in bed at 11:38 AM due to insufficient staffing. Resident #38, who resided in the Inn unit, did not receive showers as scheduled on 11/28/2024 and 12/2/2024 due to understaffing. On 11/29/2024, the [NAME] Unit had only one Certified Nursing Assistant (#13) assigned for a unit census of 46. Certified Nursing Assistant #13 stated they only took care of 15 residents who were on their original assignments and did not know if any care was provided to the other 31 residents until the morning when additional staff came to get the residents out of bed. Additionally, staff on the Muhlenberg unit stated they were understaffed and were unable to complete their assignment including providing showers to the residents. The findings are: The facility's Staffing policy and procedure dated 11/2024 documented unit staffing needs are determined by taking into consideration case mix index information, unit acuity, number of residents requiring nursing rehabilitation, tube feedings, intravenous therapy, blood glucose monitoring, suctioning, tracheostomy care, special treatments, special wound care, special equipment, etc. and residents requiring at least two nursing aides for bed care, transfers, and bathing. Replacement of staff is undertaken if there is a call-in. Nurses and Certified Nurse Assistants are replaced with on-call staff or staff who stay overtime, if necessary. When the need arises, residents may be transferred to another unit or staff may be borrowed [from other units]. The Facility assessment dated [DATE] documented the facility must ensure there are enough staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in 5483.35(a)(3). The facility assessment documented the following staffing plan for direct care staff: -Day Shift (7:30 AM-3:30 PM): One Registered Nurse, one to two Licensed Practical Nurses per unit, and two to four Certified Nurse Assistants per unit, except for Muhlenberg which required one to two Certified Nurse Assistants. -Evening Shift (3:30 PM-11:30 PM): One Registered Nurse Supervisor, one to two Licensed Practical Nurses per unit, and two to four Certified Nurse Assistants per unit, except for Muhlenberg which required one to two Certified Nurse Assistants. -Night Shift (11:30 PM-7:30 AM): One Registered Nurse Supervisor, one to two Licensed Practical Nurses per unit, and two to three Certified Nurse Assistants per unit, except for Muhlenberg which required one to two Certified Nurse Assistants. -The daily staffing sheet for 12/8/2024 during the day shift (7:30 AM- 3:30 PM) documented the following: -The Head Injury Rehabilitation Unit had a census of 15 residents with two Registered Nurses and one Certified Nursing Assistant. -The Inn Unit had a census of 40 residents with two Licensed Nurses, a third Licensed Nurse working from 6:30 AM to 10:00 AM, and two Certified Nurse Assistants. -The [NAME] Unit had a census of 50 residents with two Licensed Nurses and three Certified Nurse Assistants. -The [NAME] Hall Unit had a census of 46 residents with two Licensed Nurses and three Certified Nurse Assistants. -The Muhlenberg Unit had a census of 17 residents with one Licensed Nurse and one Certified Nurse Assistant. -The Sub-Acute ([NAME] Hall) Unit had a census of 22 residents with two Licensed Nurses and two Certified Nurse Assistants. -The Sunset Hall Unit had a census of 40 residents with two Licensed Nurses and three Certified Nurse Assistants. An undated facility list entitled HIRU Ext X 2 Residents, documented 13 residents in the Head Injury Rehabilitation Unit required two-person assistance with care. During an observation on 12/8/2024 at 11:38 AM on the Head Injury Rehabilitation Unit, there was only one Certified Nurse Assistant for 15 residents. There was a total of two residents that were out of bed, the remaining 13 residents were still in bed. During an interview on 12/8/2024 at 11:39 AM, Certified Nurse Assistant #11, who worked at the Head Injury Rehabilitation Unit, stated they were assigned to 15 residents by themselves today (12/8/2024). Certified Nurse Assistant #11 stated all the residents require two-person assistance. Certified Nurse Assistant #11 stated they always work alone and one nurse sometimes helps them to get the residents out of bed. Certified Nurse Assistant #11 stated they were only able to shower one of three residents who were scheduled for a shower today because they were the only Certified Nursing Assistant assigned to the unit and the nurse is too busy to help with providing resident care. Certified Nurse Assistant #11 stated they have to perform bed mobility without assistance when the residents require two-person assistance. Certified Nurse Assistant #11 stated they were responsible for serving breakfast and lunch for all of the residents on the unit and did not have time to provide resident showers or get the residents out of bed. During an interview on 12/8/2024 at 11:49 AM, Registered Nurse #5, who worked at the Head Injury Rehabilitation Unit, stated it is not safe to work with one Certified Nurse Assistant because all the residents on the unit require two-person assistance. Registered Nurse #5 stated all the residents require turning, repositioning, and toileting every two to four hours and it is not done because of short staffing. Registered Nurse #5 stated they try to assist Certified Nurse Assistant #11 as much as possible; however, they are primarily responsible for medication administration and treatments. During an interview on 12/8/2024 at 9:32 AM, Registered Nurse #4, who worked at the Muhlenberg Hall, stated there was only one Certified Nurse Assistant assigned to the unit for 17 residents. Registered Nurse #4 stated the unit has many residents who require two-person assistance, and one Certified Nurse Assistant cannot perform care by themselves. Registered Nurse #4 stated they must help the Certified Nurse Assistant and it takes time away from their responsibilities. During an interview on 12/8/2024 at 9:32 AM, Certified Nurse Assistant #8, who was the assigned Certified Nursing Assistant on the Muhlenberg Hall Unit, stated they were assigned to care for all 17 residents on the unit. Certified Nurse Assistant #8 stated they cannot provide resident showers and are always late with getting the residents out of bed. -Resident #38 was admitted with the diagnoses of Rheumatoid Arthritis, Spinal Stenosis and Malnutrition. The Minimum Data Set assessment dated [DATE] documented Resident #38 had a Brief Interview for Mental Status assessment score of 15, indicating the resident had intact cognition. Resident #38 did not have a documented history of rejection of care. Resident #38 was dependent on staff to shower/bathe themselves. A record review of the Inn Unit shower book revealed that in November 2024, Resident #38's shower days were Mondays and Thursdays. A review of the Certified Nurse Assistant Accountability Record revealed there was no documented evidence that Resident #38 received a shower on 11/28/2024 and 12/2/2024. A review of Resident # 38's Comprehensive Care Plans last revised on 12/10/2024 revealed no documented behaviors or refusals of showers and the resident was dependent on staff for showers. A record review of staffing sheets, assignments, and census logs revealed the following: - On 11/28/2024, the census on the Inn Unit was 38 residents. The daily staffing sheet for 11/28/2024 documented that two Certified Nurse Assistants were assigned to the evening shift (3:30 PM-11:30 PM). The Inn unit Certified Nurse Assistant evening shift assignment sheet dated 11/28/2024 documented that 19 residents were assigned to each Certified Nurse Assistant. - On 12/2/2024, the census on the Inn Unit was 38 residents. The daily staffing sheet for 12/2/2024 documented that two Certified Nurse Assistants were assigned to the evening shift (3:30 PM-11:30 PM) with a third Certified Nurse Assistant scheduled to start their shift at 7:30 PM. The Inn unit Certified Nurse Assistant evening shift assignment sheet dated 12/2/2024 documented only two Certified Nurse Assistants with 19 residents each. An undated facility list entitled Inn unit assist x2 documented 23 residents in the Inn Unit who required two-person assistance with transfers. An undated facility list entitled Inn unit: Residents Requiring Assistance with Incontinence Care documented 31 residents. A record review of Resident Nursing Instructions on 12/9/2024 for 40 residents in the Inn Unit revealed nine residents were dependent or required substantial/maximal assistance/partial assistance with eating. During the dining observation task on 12/3/2024 at 12:39 PM, Resident #38 was observed seated at the dining table with other residents. Resident #38 stated to the other residents that they (Resident #38) did not get their shower yesterday (12/2/2024) and did not get showered last week Thursday (11/28/2024) because of short staffing. During an observation and interview on 12/6/2024 at 3:39 PM, Resident #38 was observed in their room watching television and stated the facility does not have enough nursing staff. Resident #38 stated the evening shift Certified Nurse Assistants sometimes come in late or are too busy, so they skip their (Resident #38's) shower. Resident #38 stated on 12/3/2024, they reported the missed showers on 12/2/2024 and 11/28/2024 to the dayshift nurse. Resident #38 was given a shower on 12/3/2024 after they reported the missed showers. During an interview on 12/6/2024 at 2:40 PM, Licensed Practical Nurse #1 stated Resident #38's usual shower days were Mondays and Thursdays. Resident #38 complained to them (Licensed Practical Nurse #1) that Resident #38 did not have a shower on Monday (12/2/2024). Licensed Practical Nurse #1 stated they questioned the staff who worked on the 12/2/2024 evening shift and were informed that the unit was short-staffed, a Certified Nurse Assistant came in at 7:30 PM, and it was too late to provide Resident #38's shower. During an interview on 12/6/2024 at 3:45 PM, Certified Nurse Assistant #4 stated on Thanksgiving, 11/28/2024, they could not give Resident #38 a shower due to short staffing. Certified Nurse Assistant #4 stated the Inn unit is always short-staffed with Certified Nurse Assistants. Certified Nurse Assistant #4 stated there are usually only two Certified Nurse Assistants on the 3:30 PM to 11:30 PM shift and when there are only two Certified Nurse Assistants on the unit, they have to rush through providing resident care and skip resident showers. During an interview on 12/9/2024 at 1:30 PM, Certified Nurse Assistant #5 stated the facility has been understaffed since COVID-19 and has not made any changes. Certified Nurse Assistant #5 stated that understaffing is not fair to the residents because, with fewer staff members available, the residents do not receive the care they deserve. Certified Nurse Assistant #5 stated on 12/2/2024, there was only one other Certified Nurse Assistant assigned to the Inn Unit with them. Certified Nurse Assistant #5 stated when there are only two Certified Nurse Assistants on the unit, they have about 19-20 residents each on their assignment. Certified Nurse Assistant #5 stated that with an assignment that high, they could not give showers. Certified Nurse Assistant #5 stated that on the evening shift, they have to transfer up to eight residents with a Hoyer lift back into bed. Certified Nurse Assistant #5 stated that the nurse tries to assist with feeding and transfers but cannot always be interrupted with their medication administration or treatments. Certified Nurse Assistant #5 stated that some residents have to wait until the end of the shift to get transferred back to bed when the overnight shift staff come in. Certified Nurse Assistant #5 stated residents often complain about not receiving showers, having to wait for assistance back to bed, and waiting for incontinence care. During an interview on 12/9/2024 at 2:11 PM, Certified Nurse Assistant #6 stated the facility has staffing problems. Certified Nurse Assistant #6 stated the facility recently stopped using staffing agencies to fill in the call-outs. Certified Nurse Assistant #6 stated on 12/2/2024, during the evening shift they were assigned to Resident #38. There were just two aides on the unit and a third Certified Nurse Assistant was scheduled to come in at 7:30 PM, but they never came. Certified Nurse Assistant #6 stated they often just have two aides for a full unit of 40 residents and there is not enough time to provide showers to the residents. Certified Nurse Assistant #6 stated it is impossible to provide showers when they have 19-20 residents on their assignment. Certified Nurse Assistant #6 stated they have about 16 residents who require a Hoyer transfer back to bed with two-person assistance. Certified Nurse Assistant #6 stated they sometimes have to wait for the overnight shift to report to work to get assistance with transferring a resident to bed. Certified Nurse Assistant #6 reported the residents do complain about delays in care due to short staffing. -The facility's Daily Staffing Schedule dated 11/29/2024 documented that [NAME] Hall had a census of 46 residents with one Certified Nurse Assistant scheduled on the 11:30 PM to 7:30 AM shift. The [NAME] Hall unit Certified Nurse Assistant Night shift assignment sheet dated 11/29/2024 documented that one Certified Nurse Assistant ( #13) was assigned to 15 residents. There were no additional Certified Nurse Assistants assigned to the remaining 31 residents on the unit. During an interview on 12/6/2024 at 12:58 PM, Certified Nurse Assistant# 3 stated the facility is understaffed all the time and on the weekends, there are two Certified Nurse Assistants to care for up to 50 residents. Certified Nurse Assistant #3 stated last Saturday 11/30/2024, they reported to work on the day shift and there was only one Certified Nurse Assistant who worked the overnight (11:30 PM-7:30 AM) shift for 11/29/2024. Certified Nurse Assistant #3 stated when the facility does not provide nursing staff, they cannot give all the care the residents need including showers. During an interview on 12/9/2024 at 12:59 PM, Certified Nurse Assistant #13 stated they work a lot of double shifts to fill in callouts. Certified Nurse Assistant #13 stated they worked alone during the 11:30 PM-7:30 AM shift in the [NAME] Hall Unit on 11/29/2024. Certified Nurse Assistant #13 stated the nursing supervisor was made aware that the [NAME] Hall Unit had only one Certified Nurse Assistant and the nursing supervisor stated they would send help. Certified Nurse Assistant #13 stated they were unsure if the nursing supervisor sent help to the unit and they only cared for the residents on their assignment. Certified Nurse Assistant #13 stated they can only do so much when they work alone on the unit. Certified Nurse Assistant #13 stated they only took responsibility for their assigned residents and did not know if the other residents on the unit were cared for by other staff. During an interview on 12/9/2024 at 2:38 PM, Licensed Practical Nurse #8 stated on 11/29/2024, there was only one Certified Nurse Assistant on the 11:30 PM to 7:30 AM shift. The nursing supervisor only sent over nursing staff to help get residents out of bed in the morning. During an interview on 12/10/2024 at 11:48 AM, Staffing Coordinator #1 stated the Nursing Supervisor and the Assistant Director of Nursing Services #1 and #2 informed them of the number of nurses and Certified Nurse Assistants required for each unit. The Assistant Director of Nursing Services #2 told Staffing Coordinator #1 that it was okay to assign one Certified Nurse Assistant on the Head Injury Rehabilitation Unit. Staffing Coordinator #1 stated they were aware of the facility assessment and the need for 2-4 Certified Nurse Assistants on the Head Injury Rehabilitation Unit. Staffing Coordinator #1 stated the facility does not use a staffing agency. Staffing Coordinator #1 stated there are some days during the day and evening shifts when there are less than two Certified Nurse Assistants assigned to a unit. Staffing Coordinator #1 stated on Sunday, 12/8/2024 there was only one Certified Nurse Assistant assigned to the Head Injury Unit because of a staff callouts. Staffing Coordinator #1 stated the Head Injury Rehabilitation Unit should have a minimum of two Certified Nurse Assistants for each shift because of the facility assessment. During an interview on 12/10/2024 at 12:00 PM, the Assistant Director of Nursing Services #2 stated the facility is short-staffed. Assistant Director of Nursing Services #2 stated the two nurses on the Head Injury Rehabilitation Unit are expected to assist with resident care and transfers. Assistant Director of Nursing Services #2 stated they are aware that the facility assessment requires two Certified Nursing Assistants for the Head Injury Rehabilitation Unit. Assistant Director of Nursing Services #2 stated when staff members report they do not have enough help to give showers, Assistant Director of Nursing Services #2 instructs staff to give the residents a bed bath. During an interview on 12/10/2024 at 12:31 PM, the Director of Nursing Services stated on 11/29/2024 on the [NAME] unit, there should have been three Certified Nurse Assistants staffed for 47 residents on the 11:30 PM to 7:30 AM Shift. The Director of Nursing Services stated they were not aware of the residents' missing showers on the Inn Unit on 11/28/2024 and 12/2/2024 due to short staffing. The Director of Nursing Services stated they expect all residents to get showers as scheduled. The Director of Nursing Services stated the nursing staff should be documenting all care provided. The Director of Nursing Services stated the facility does not use agency staff. The Director of Nursing Services stated they were aware of the short-staffing concerns. There is a problem with staff retention. The Director of Nursing Services stated they are now working on obtaining agency staff to fill Certified Nurse Assistant positions. The Director of Nursing Services stated Registered Nurse Supervisors and the Staffing Coordinator decide the number of Certified Nurse Assistants needed because the Registered Nurse Supervisors and the Staffing Coordinator know if the unit is capable of functioning with one Certified Nurse Assistant and two nurses. During an interview on 12/10/2024 at 1:01 PM, the Administrator stated Residents had complaints of short staffing on the weekends. The Administrator stated staffing has always been a challenge for the facility. The Administrator stated they are not making excuses and they try to fill in positions on the units with the recruitment of new staff and not all new hires stay with the facility. 10 NYCRR-415.13(a)(1)(i-iii)

Based on observation, record review, and interviews during the recertification initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task observation on 12/4/2024. Specifically, the facility did not monitor the temperature of cold food items (sandwiches, potato salad, pudding) at the time of meal service. The finding is: A facility policy and procedure titled Food Preparation, documented time/temperature control for safe food (formerly known as potentially hazardous food) means a food that requires time/temperature controls for safety to limit pathogenic organism growth or toxin formation. The Dining Services Director/Cook(s) is responsible for food preparation techniques, which minimize the amount of time food items are exposed to temperatures greater than 41 degrees Fahrenheit and/or less than 135 degrees Fahrenheit or per state regulation. The Cook(s) ensures that all foods are held at appropriate temperatures, greater than 135 degrees Fahrenheit (or as state regulation requires) for hot food holding and less than 41 degrees Fahrenheit for cold food holding. A facility policy and procedure titled Food Storage: Cold documented that frozen and refrigerated food items will be appropriately stored in accordance with the guidelines of the Food and Drug Administration food code. The Dining Services Director/Cook(s) ensures that all perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below except during necessary periods of preparation and service. During an observation of the kitchen on 12/4/2024 at 11:07 AM, a hi-riser food truck was observed with a variety of sandwiches and individual cups of potato salad. The tray line lunch service began at 11:15 AM. There was no documented evidence that cold food temperatures were taken. During an interview on 12/4/2024 at 11:16 AM, the Executive Chef stated cold food temperatures are not obtained because the food is held in the refrigerator, therefore they use the refrigerator temperature for the cold food items. The Executive Chef tested the temperature of several food items not stored in the refrigerator and were being served during the lunch meal service. The temperature findings were: a tuna sandwich was measured at 50 degrees Fahrenheit, a ham sandwich was measured at 48 degrees Fahrenheit, potato salad was measured at 48 degrees Fahrenheit, and pudding was measured at 50 degrees Fahrenheit. The Executive Chef stated that the cold food temperature should be between 30 to 40 degrees Fahrenheit. The Executive Chef stated that with these increased food temperatures, there is an increased risk of foodborne illness for the residents. During an interview on 12/04/2024 at 11:22 AM, Registered Dietitian #1 stated that serving temperatures for cold food items should be kept under 30 degrees Fahrenheit. During an interview on 12/05/2024 at 11:34 AM, the General Manager of the vendor company that provides dietetic services to the facility stated that cold food should never be above 41 degrees Fahrenheit. They further stated that the cold food that was not stored in the refrigerator should have been held on a bed of ice. The General Manager of the vendor company that provides dietetic services to the facility stated if the cold food was stored above the required temperature range, there could be potential for harm/foodborne illness. 10 NYCRR 415.14(h)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure each resident was treated with respect and dignity and provided care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This was identified on one ([NAME] Unit-secure dementia unit) of seven nursing units observed during the dining task. Specifically, during the lunch meal observation on 12/4/2024 on the [NAME] unit, there were 11 dining tables in the room. At least 3 to 4 residents were seated at each table. The lunch meal was being served by the nursing staff from the first meal transport rack. At all of the tables, some residents had received their lunch trays and were eating, while other residents at the same table had not received their lunch trays because the second lunch transport rack and smaller cart had not arrived on the unit from the kitchen. The finding is: The facility's policy titled Resident Rights, dated 6/2024, documented in accordance with the facility's mission and philosophy of care and state and federal regulations and privacy practice, all residents have a right to exercise their rights as residents of the facility in order to continue their lives with dignity, respect, and meaning. During an observation on 12/4/2024 at 11:55 AM on the [NAME] unit, all of the residents on the unit were situated by nursing staff in the unit dining area and were seated at tables awaiting the delivery of the lunch transport racks from the kitchen. During an interview on 12/4/2024 at 12:12 PM, Licensed Practical Nurse #2 stated one of the lunch transport racks was due at 11:59 AM and the others (one lunch transport rack and a smaller cart) were due at 12:04 PM as per the lunch delivery schedule. Licensed Practical Nurse #2 stated the transport racks have not arrived yet and they are usually late. During an interview on 12/4/2024 at 12:22 PM, Licensed Practical Nurse #3 stated the meal trays had not yet arrived from the kitchen. The kitchen staff is aware the meals are consistently delivered late from the kitchen because the nurses sign a form that documents the time the lunch racks are delivered to the unit and the form is delivered back to the kitchen manager. All the residents are ready for their lunch meal and the nursing staff is ready to serve the meal; we are just waiting for the kitchen to deliver the lunch. During an interview and observation on 12/4/2024 at 12:27 PM, the first lunch transport rack arrived on the unit. Licensed Practical Nurse #3 stated a second transport rack and a smaller transport cart are still to come from the kitchen because all the lunch trays do not fit on one transport rack. During an observation on 12/4/2024 at 12:29 PM, a smaller lunch transport cart arrived on the unit. Nursing staff were observed distributing the meal trays from the first rack and from the smaller cart to the residents. During an observation on 12/4/2024 at 12:40 PM, there were 11 tables with 3-4 residents seated at each table. Lunch trays were served to some residents on each table and those residents were eating their meals; however, there were other residents at those same tables who had not been served their trays of food yet. During an observation on 12/4/2024 at 12:41 PM, the last lunch transport rack arrived on the unit. During an interview on 12/5/24 at 9:41 AM, Certified Nursing Assistant #2 stated the meal delivery racks are often late and this has been an ongoing issue. The delivery of the meal trays to the residents depends on when the meal transport racks arrive on the unit. The meal transport racks come at different times. Certified Nursing Assistant #2 stated, Maybe dietary can tell us which transport rack is coming first so we can seat residents accordingly and serve those residents all at the same time. During an interview on 12/5/2024 at 11:35 AM, the General Manager for the corporate entity responsible for kitchen and dining operations stated the present meal delivery system is causing delayed meal transportation to the units, and changes need to be made. The General Manager stated they were fully aware that there were meal delivery issues. There needs to be a conversation between nursing, kitchen, and dietary to coordinate when the meal delivery rack is coming so the residents can be seated together and served at the same time. When residents are eating at a table and other residents at the same table are not, that is a dignity issue. During an interview on 12/9/2024 at 10:50 AM, the Director of Nursing Services stated each resident on a table should be served their meal at the same time. Even though the residents on the [NAME] unit are confused, the act of eating is something you do not forget and all the residents should eat together rather than watching others eat. 10 NYCRR 415.3(d)(1)(i)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure it developed and implemented a comprehensive person-centered care plan for each resident to meet each resident's medical and nursing needs. This was identified for one (Resident #152) of one resident reviewed for Accommodation of Needs. Specifically, Resident #152 had a physician's order for a wheelchair with bilateral leg rests. Resident #152 was observed on multiple occasions sitting in the wheelchair without the leg rests. The finding is: The facility's policy titled Wheelchair Safety, effective March 2017, documented you must never transport a resident without foot pedals regardless of locomotion status. Make sure feet are on foot pedals when the resident is in the wheelchair. The facility's policy titled Wheelchair Transport, dated March 2017, documented that foot pedals must be on the chair if staff are pushing a resident. The feet must be on the foot pedals. Resident #152 was admitted with a diagnosis of Alzheimer's Disease. The 10/21/2024 Annual Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented that the resident used a wheelchair. A physician's order dated 10/2/2024 documented a standard wheelchair with foam cushion and bilateral elevating leg rests. A Comprehensive Care Plan titled Activities of Daily Living-Functional Abilities: Self Care and Mobility Care Plan, effective 10/28/2024, documented the resident has self-care and mobility limitations related to Advanced Dementia. An intervention included providing a standard wheelchair with foam cushion and bilateral elevating leg rests. During an observation on 12/3/2024 at 11:45 AM, Resident #152 was observed in the open recreation area on the [NAME] unit (secure dementia unit), sitting in their wheelchair. The wheelchair did not have bilateral leg rests in place, the resident was wearing socks and the resident's feet were resting on the floor. Certified Nursing Assistant #1 was overheard noting Resident #152's wheelchair did not have leg rests. Certified Nursing Assistant #1 left the area and returned moments later with two leg rests and said they were the wrong size for the resident's wheelchair. Eventually, Resident #152 walked to the lunch area with the assistance of another Certified Nursing Assistant. During an interview on 12/3/2024 at 11:50 AM, Certified Nursing Assistant #1 stated they were not regularly scheduled to the resident's unit. When they noticed the resident did not have the leg rests on their wheelchair, they went to check the spare supply area where leg rests are kept but there were no leg rests that fit Resident #152's chair. Certified Nursing Assistant #1 stated they had also checked Resident #152's room for leg rests but there were none in the room. During an observation on 12/3/2024 at 2:30 PM, Resident #152 was observed in the recreation area sitting in their wheelchair with no leg rests on the wheelchair. The resident's feet were on the floor with socks on. During an observation on 12/4/2024 at 12:02 PM, Resident #152 was observed in the lunch area waiting for lunch. The resident was sitting in a wheelchair with no leg rests. During an interview on 12/5/2024 at 9:15 AM, the Rehabilitation Department Director stated most of the residents are provided the leg rests so the residents' legs do not hang down. The leg rests are also needed while transporting residents from one place to another. The Rehabilitation Department Director stated Resident #152 did not self-propel their wheelchair with their feet therefore, the leg rests should always be used on the wheelchair as per the physician's order. During an observation on 12/5/2024 at 9:35 AM, Resident #152 was observed at breakfast in the [NAME] unit dining area. The resident was sitting in a wheelchair with no leg rests. The resident had socks on and their feet were on the floor. During an interview on 12/5/2024 at 9:46 AM, Licensed Practical Nurse #2 stated a work order was put in yesterday with the maintenance department to get the leg rests for Resident #152's wheelchair. Licensed Practical Nurse #2 stated they just noticed that the resident's wheelchair did not have the leg rests. During an observation on 12/5/2024 at 9:51 AM, while Resident #152 was still in the dining area, a maintenance staff member was observed fitting leg rests to the resident's wheelchair. During a re-interview on 12/5/2024 at 12:30 PM, Certified Nursing Assistant #1 stated staff are not supposed to move residents in a wheelchair without leg rests because of safety issues. Certified Nursing Assistant #1 stated on 12/3/2024 when they were moving residents from the recreation area to the dining area, they noticed that Resident #152 did not have leg rests. Licensed Practical Nurse #3 told them to check the spare supply room and the resident's room, but there were no leg rests for the resident's wheelchair on the unit. During an interview on 12/5/2024 at 1:08 PM, the Director of Nursing Services stated if there is a physician's order for the use of leg rest, the leg rests should have been put on the wheelchair. The Certified Nursing Assistant should not have been directed to find the spare wheelchair parts. That is not the Certified Nursing Assistant's job. As soon as the staff noticed that the leg rests were not there, they should have called the Maintenance and Rehabilitation department. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interview during the recertification initiated on 12/3/2024 and completed on 12/10/2024, the facility failed to ensure, to the extent practicable, the participation of the resident and the resident's representative(s) for the development of the resident's care plan. This was identified for one (Resident #66) of three residents reviewed for Care Planning. Specifically, the facility did not conduct interdisciplinary care plan meetings and did not provide notice of invitation to the resident or the resident's representative to participate in the quarterly assessments. The finding is: A facility policy and procedure titled Care Planning, effective 7/2016, revised 10/2024, documented creating a comprehensive, individualized care plan for each resident based on the assessments performed using the Minimum Data Set and ensuring compliance with Federal and State regulations. Quarterly and annual updates to the care plan, or as required due to significant changes in a resident's condition. The care plan meeting must include an interdisciplinary team. Residents and/or their legal representatives must be actively involved in the care planning process. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status of seven, indicating severe cognitive impairment. A five-day Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status of 10, indicating moderate cognitive impairment. The medical record lacked documented evidence that Resident #66 or the resident's representative was invited to the care plan meetings. A Social Work progress note dated 10/23/2024 documented resident was reviewed for quarterly assessment. There appears to be no significant change in status at this time. The resident was alert and verbally responsive with some forgetfulness and was able to make needs known to staff. The Resident's Family was involved and supportive. Social Work will continue to provide one-to-one visits for support. A Psychiatry consultation dated 10/17/2024 documented the resident can make their own health decisions. During an interview on 12/04/24 at 9:43 AM Resident #66 stated they did not recall attending a care plan meeting but would want to participate in the process and discuss their care. During an interview on 12/05/24 at 2:36 PM, the Director of Social Work stated the facility invites the resident and their family members to the annual and significant change reviews. The Director of Social Work stated they were not certain if a resident with a Brief Interview for Mental Status of ten should be invited to participate in the care plan meetings. They further stated there was no documented evidence that Resident #66 or their family members were invited to the quarterly care plan meetings. The Director of Social Work further stated for the quarterly assessment, the interdisciplinary team only completes the Minimum Data Set assessment with updates to the care plans; however, the team does not meet. During an interview on 12/5/2024 at 2:54 PM, Social Worker #1 stated for the quarterly review, they complete the Minimum Data Set Assessment and review the care plans. They further stated that for the quarterly assessments, there are no meetings held with the interdisciplinary teams, and the resident or their representatives are not invited. During an interview on 12/5/2024 at 2:59 PM, the Minimum Data Set Coordinator stated that the facility was not having quarterly care plan meetings. The meetings are only held for admissions, annuals, and significant change assessments, and as requested or Ad Hoc meetings. For the quarterly reviews, all disciplines only complete the Minimum Data Set assessments and update the care plans. During an interview on 12/5/2024 at 3:04 PM, the Chief Nursing Officer stated that the social work department is responsible for scheduling the interdisciplinary meetings. The meetings are held for quarterly, significant change, complaints, and annual reviews. They further stated that the residents are invited barring a cognition impairment. The Chief Nursing Officer stated they were not aware that the interdisciplinary care plan team was not holding meetings at all for the quarterly assessments. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observation, record review, and interviews during the recertification and abbreviated survey (NY 00361065) initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure the resident environment remained as free of accident hazards as possible and the residents received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #73) of six residents reviewed for Accidents. Specifically, Resident #73 required two-person assistance with bed mobility and for a mechanical lift transfer to and from the bed. On 11/18/2024, Certified Nursing Assistant #14 turned and positioned Resident #14 by themselves and used a mechanical lift transfer to transfer Resident #73 from bed to their wheelchair without assistance. The finding is: The Facility Policy for Hoyer Lift Transfer last revised on 4/2023 documented Lift transfers must be completed by two employees using the following procedure to ensure the safe transfer of residents and protect employees from injury. The procedure documented nursing staff will explain the procedure to the resident, follow the mechanical lift (manufacturer's) instructions for the use of the mechanical lift, and use two employees for safety. Resident #73 was admitted with diagnoses including Alzheimer's Disease, Cerebral Infarction, and Type 2 Diabetes Mellitus. The Annual Minimum Data Set (MDS) dated [DATE] documented the Resident had severely impaired cognition. The resident had functional limitations in the range of motion on both the lower and upper extremities. The resident was dependent on two or more helpers for bed mobility and required the helper to make all the effort. The Resident Nursing Instructions (care instructions provided to the Certified Nursing Assistants) effective 6/3/2024 documented Resident #73 was dependent on two or more staff members' physical assistance for bed mobility. The Resident Nursing Instructions effective 11/22/2024 documented that Resident #73 was dependent on two or more staff members' physical assistance for mechanical lift transfers. The transfer instructions dated 11/18/2024 documented to ensure the resident was centered in the mechanical lift pad prior to lifting (the resident tends to lean to the right side) and to assist the resident in crossing arms over the chest for transfers. The physician's orders dated 11/28/2024 documented using a mechanical lift with a U-shaped sling with the assistance of two persons for transfers. The Fall/Injury care plan dated 5/3/2019 and reviewed on 11/18/2024 documented Resident #73 was at increased risk for falls or injury related to a history of falls and injury, Cerebrovascular Accident with right Hemiplegia (weakness), need for assistance with activities of daily living, Dementia, Contractures, and Seizure Disorder. Interventions included but were not limited to keeping the bed in the lowest position and checking the resident frequently to ascertain needs. The care plan note dated 11/18/2024 documented the resident had a bruise on their head that measured 2 centimeters on a round raised area with a 0.25-centimeter linear small opening to their forehead. The Accident and Incident Report dated 11/18/2024 documented that after showering Resident #73, the assigned Certified Nursing Assistant #14 placed Resident #73 back to bed with a mechanical left with two-person assistance. Certified Nursing Assistant #14's statement documented they were assisted by the nurse for this transfer, and they observed the resident grabbing at the mechanical lift bar and immediately after the event, the Certified Nursing Assistant noticed a lump on the resident's forehead. Resident #73 was unable to explain the event due to impaired cognition. Resident #73 departed the facility for a scheduled dialysis appointment and was sent to the hospital Emergency Department for a Computed Tomography scan of the head from the Dialysis Center because the resident receives heparin during dialysis. The Computed Tomography scan results were negative, but the resident was admitted on [DATE] at 5:00 PM with the diagnosis of Left Face Hematoma. The Accident and Incident Report concluded that Certified Nursing Assistant #14 did not ask for assistance. The nurses did not assist Certified Nursing Assistant #14 with the mechanical lift transfer and Certified Nursing Assistant #14 performed Resident #73's transfer independently. During an observation on 11/03/2024 at 11:00 AM, Resident #73 was observed in their room seated in their wheelchair with a faded discoloration on the left upper face. Resident #73 was not able to engage in an interview. During an interview on 12/05/2024 at 12:30 PM, Certified Nursing Assistant #14 stated Resident #73 required two-person assistance for bed mobility and mechanical lift transfers. Certified Nursing Assistant #14 stated they utilized the draw sheet to position Resident #73 in the bed during the morning care and incontinence care. Certified Nursing Assistant #14 stated after they placed Resident #73 on the mechanical lift sling, they hooked the sling to the mechanical lift and left the room to get assistance. Certified Nursing Assistant #14 stated then they transferred Resident #73 alone because they thought a nurse was in the hallway. Certified Nursing Assistant #14 stated no one physically helped them to transfer Resident #73 out of the bed. Certified Nursing Assistant #14 stated the unit was not short of staff on 11/18/2024. Certified Nursing Assistant #14 stated they did not observe Resident #73 hit their forehead. Certified Nursing Assistant #14 stated Resident #73 may have put their face on the mechanical lift bar which caused the forehead lump. During an interview on 12/05/2024 at 12:55 PM, Licensed Practical Nurse #4 stated on 11/18/2024 at approximately 12:00 PM, Certified Nursing Assistant #14 brought Resident #73 to the nurse's station and reported that Resident #73 was ready for dialysis pick up. Licensed Practical Nurse #4 stated they brought Resident #73 to the lunchroom to eat before the dialysis appointment and observed Resident #73's face with a lump and a small cut. Licensed Practical Nurse #4 stated they administered medication to the resident in the morning and the resident did not have that lump in the morning. Certified Nursing Assistant #14 told them that Resident #73's head was resting on the mechanical lift bar which may have caused the lump. Licensed Practical Nurse #4 stated Certified Nursing Assistant #14 did not ask for assistance with the mechanical lift transfer. Licensed Practical Nurse #4 stated Registered Nurse #3 and Registered Nurse #7 assessed Resident #73 and notified the Physician. Resident #73 was subsequently transported to the Dialysis Center and the Dialysis Center sent Resident #73 to the hospital to rule out a head injury. During an interview on 12/05/2024 at 1:10 PM, Registered Nurse #3 stated on 11/18/2024, they were called to the nurse's station by Licensed Practical Nurse #4 to assess Resident #73's face. Registered Nurse #3 stated they observed the raised area on Resident #73's forehead with a small opening. Registered Nurse #3 stated they reported the injury to Registered Nurse #7 immediately. Registered Nurse #3 stated Certified Nursing Assistant #14 did not ask for help with Resident #73's transfer. Registered Nurse #3 stated Resident #73 required two persons' assistance for bed mobility and transfer. During an interview on 12/05/2024 at 1:29 PM, Registered Nurse Risk Manager #7 stated Registered Nurse Risk Manager #7 stated they interviewed all staff scheduled on the unit and found out Certified Nursing Assistant #14 did not ask for assistance with the lift transfer and later admitted to transferring Resident #73 without assistance. During an interview on 12/09/2024 at 2:31 PM, Certified Nursing Assistant #1 stated that Certified Nursing Assistant #14 did not ask for assistance to transfer Resident #73 on 11/18/2024. Certified Nursing Assistant #1 stated Resident #73 required two-person assistance with transfers and bed mobility. Certified Nursing Assistant #1 stated they did not observe the resident with any skin changes prior to the accident. During an interview on 12/09/2024 at 2:34 PM, Certified Nursing Assistant #7 stated Certified Nursing Assistant #14 did not ask for assistance with transferring Resident #73 on 11/18/2024. Certified Nursing Assistant #7 stated Resident #73 required two-person assistance with the mechanical lift transfers. Certified Nursing Assistant #7 stated they did not see any skin changes on the resident before the accident. During an interview on 12/09/2024 at 3:11 PM, Licensed Practical Nurse #9 stated they were not assigned to Resident #73 for the medication administration on 11/18/2024 and Certified Nursing Assistant #14 did not ask for assistance with transferring Resident #73 out of bed. Licensed Practical Nurse #9 stated Resident #73 required two-person assistance with the mechanical lift for transfers. During an interview on 12/09/2024 at 3:19 PM, Certified Nursing Assistant #15 stated Certified Nursing Assistant #14 did not ask for assistance with transferring Resident #73 out of bed. Certified Nursing Assistant #15 stated the mechanical lift transfer requires two-person assistance. Certified Nursing Assistant #15 stated if anyone does a mechanical transfer alone, it could result in an accident. Certified Nursing Assistant #15 stated they did not see any skin changes on the resident before the accident. During an interview on 12/10/2024 at 12:29 PM, the Director of Nursing Services stated that Certified Nursing Assistant #14 did not follow the plan of care to utilize the mechanical lift to transfer the resident. The Director of Nursing stated the mechanical lift transfers required two-person assistance and it was not acceptable for Certified Nursing Assistant #14 to transfer the resident without a second staff member. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interviews during the recertification and abbreviated survey (NY 00361065) initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident needs, This was identified for one (Resident #73) of six residents reviewed for Accidents. Specifically, Resident #73 required two-person assistance with bed mobility and mechanical lift transfers. On 11/18/2024, Certified Nursing Assistant #14 turned and positioned Resident #14 by themselves and used a mechanical lift transfer to transfer Resident #73 from bed to their wheelchair without assistance. The finding is: The Facility Policy for Hoyer Lift Transfer last revised on 4/2023 documented Lift transfers must be completed by two employees using the following procedure to ensure the safe transfer of residents and protect employees from injury. The procedure documented nursing staff will explain the procedure to the resident, follow the mechanical lift (manufacturer's) instructions for the use of the mechanical lift, and use two employees for safety. The facility employee counseling form dated 1/30/2023 documented that Certified Nursing Assistant #14 received a verbal education on 1/30/2024. Certified Nursing Assistant #14 was assigned to a resident who required extensive assistance of two persons for a transfer and Certified Nursing Assistant #14 transferred the resident without a second staff member. The resident became weak, was lowered to the floor, and had no injury. The form documented This is determined to be a failure to follow the resident's plan of care. Any further issues of this nature will require progressive discipline up to and including termination. Corrective Action: The Certified Nurse Assistant was instructed to always check the plan of care before providing care to the resident. If the resident's transfer status is two-person assistance, another Certified Nurse Assistant is to assist. A review of Certified Nurse Assistant #14's facility in-service education records revealed Certified Nurse Assistant #14 did not receive re-education regarding resident transfers in 2024. Resident #73 was admitted with diagnoses including Alzheimer's Disease, Cerebral Infarction, and Type 2 Diabetes Mellitus. The Annual Minimum Data Set (MDS) dated [DATE] documented the Resident had severely impaired cognition. The resident had functional limitations in the range of motion on both the lower and upper extremities. The resident was dependent on two or more helpers for bed mobility and required the helper to make all the effort. The Resident Nursing Instructions (care instructions provided to the Certified Nursing Assistants) effective 6/3/2024 documented Resident #73 was dependent on two or more staff members' physical assistance for bed mobility. The Resident Nursing Instructions effective 11/22/2024 documented that Resident #73 was dependent on two or more staff members' physical assistance for mechanical lift transfers. The transfer instructions dated 11/18/2024 documented to ensure the resident was centered in the mechanical lift pad prior to lifting (the resident tends to lean to the right side) and to assist the resident in crossing arms over the chest for transfers. The physician's orders dated 11/28/2024 documented using a mechanical lift with a U-shaped sling with the assistance of two persons for transfers. The Fall/Injury care plan dated 5/3/2019 and reviewed on 11/18/2024 documented Resident #73 was at increased risk for falls or injury related to a history of falls and injury, Cerebrovascular Accident with right Hemiplegia (weakness), need for assistance with activities of daily living, Dementia, Contractures, and Seizure Disorder. Interventions included but were not limited to keeping the bed in the lowest position and checking the resident frequently to ascertain needs. The care plan note dated 11/18/2024 documented the resident had a bruise on their head that measured 2 centimeters on a round raised area with a 0.25-centimeter linear small opening to their forehead. The Accident and Incident Report dated 11/18/2024 documented that after showering Resident #73, the assigned Certified Nursing Assistant #14 placed Resident #73 back to bed with a mechanical left with two-person assistance. Certified Nursing Assistant #14's statement documented they were assisted by the nurse for this transfer, and they observed the resident grabbing at the mechanical lift bar and immediately after the event, the Certified Nursing Assistant noticed a lump on the resident's forehead. The Accident and Incident Report concluded that Certified Nursing Assistant #14 did not ask for assistance. The nurses did not assist Certified Nursing Assistant #14 with the mechanical lift transfer and Certified Nursing Assistant #14 performed Resident #73's transfer independently. The facility employee Corrective Action dated 11/18/2024 documented that Certified Nursing Assistant #14 did not follow the plan of care and performed two-person assistance via a mechanical lift without assistance from staff resulting in resident injury. Certified Nursing Assistant #14 was previously warned or suspended for a similar occurrence. During an observation on 12/03/2024 at 11:00 AM, Resident #73 was observed in their room seated in their wheelchair with a faded discoloration on the left upper face. Resident #73 was not able to engage in an interview. During an interview on 12/05/2024 at 12:30 PM, Certified Nursing Assistant #14 stated Resident #73 required two-person assistance for bed mobility and mechanical lift transfers. Certified Nursing Assistant #14 stated they utilized the draw sheet to position Resident #73 in the bed during the morning care and incontinence care. Certified Nursing Assistant #14 stated after they placed Resident #73 on the mechanical lift sling, they hooked the sling to the mechanical lift and left the room to get assistance. Certified Nursing Assistant #14 stated then they transferred Resident #73 alone because they thought a nurse was in the hallway. Certified Nursing Assistant #14 stated no one physically helped them to transfer Resident #73 out of the bed. Certified Nursing Assistant #14 stated the unit was not short of staff on 11/18/2024. Certified Nursing Assistant #14 stated they did not observe Resident #73 hit their forehead. Certified Nursing Assistant #14 stated Resident #73 may have put their face on the mechanical lift bar which caused the forehead lump. During an interview on 12/05/2024 at 1:29 PM, Registered Nurse Risk Manager #7 stated Registered Nurse Risk Manager #7 stated they interviewed all staff scheduled on the unit and found out Certified Nursing Assistant #14 did not ask for assistance with the lift transfer and later admitted to transferring Resident #73 without assistance. Registered Nurse Risk Manager #7 stated Certified Nursing Assistant #14 had a previous history of not utilizing two persons and was educated at that time related to the incident. During an interview on 12/10/2024 at 12:29 PM, the Director of Nursing Services stated Certified Nurse Assistant #14 did not follow Resident #73's plan of care to utilize the mechanical lift to transfer with a second person. The Director of Nursing stated the facility would not tolerate such behavior and it was not safe for the resident. The Director of Nursing stated the mechanical lift required two-person assistance and it was not acceptable for Certified Nursing Assistant #14 to transfer the resident without a second staff member. 10 NYCRR 415.26(c)(1)(iv)

Based on observation, record review, and interviews conducted during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure that all medications and biologicals were stored properly and labeled in accordance with currently accepted pharmaceutical principles and practices. This was identified for one (Resident #19) of six residents reviewed for Accidents. Specifically, the facility did not ensure that medications were properly labeled and stored. Two tubes of Voltaren analgesic cream, which were not labeled with the resident's name or directions of application, were observed in Resident #19's room on their nightstand. There was no staff in the vicinity. The findings are: Resident #19 had a diagnosis of Diabetes Mellitus and Peripheral Vascular Disease. A quarterly Minimum Data Set assessment dated [DATE] documented Resident #19 had a Brief Interview for Mental Status of 15 indicating the resident had intact cognition. The Minimum Data Set documented Resident #19 received scheduled pain medication and did not have any pain in the five days prior to the assessment completion. During an observation on 12/04/24 at 10:47 AM, two unlabeled tubes of Voltaren cream were observed on Resident #19's nightstand. Resident #19 was present in the room and stated they usually apply the cream to their hands. During an observation on 12/05/24 at 9:58 AM, two unlabeled tubes of Voltaren cream were observed on Resident #19's nightstand. Resident #19 was not present in the room at the time of the observation. Physician's orders documented Bengay (topical analgesic) Ultra strength five percent topical patch to be applied to the left side of the neck, dated 10/24/2024 and renewed on 11/18/2024 for Spondylolisthesis (a spinal condition where a vertebra slips out of place and onto the bone below it) of the Cervical region. There was no documented evidence of a physician's order for the Voltaren cream. A Comprehensive Care Plan titled Pain, effective 10/11/2023, documented the resident was at risk for pain due to decreased mobility, muscle weakness, severe Peripheral Vascular Disease, and Spondylolisthesis of the Cervical region. The interventions included administering medications as ordered, observing the effectiveness of the medication, and encouraging the resident to report pain to the caregiver. The care plan was reviewed on 6/28/2024 and documented that the resident was without noted reports of pain. During an interview on 12/6/2024 at 10:40 AM, Licensed Practical Nurse/Patient Care Coordinator #1 stated residents are not allowed to self-medicate without an assessment and physician's orders, including the analgesic creams. Additionally, the residents' families are advised to not bring medications as the facility will supply them. Licensed Practical Nurse/Patient Care Coordinator #1 stated they were not aware Resident #19 had two tubes of Voltaren cream in their room. During an interview on 12/06/24 at 1:45 PM, the Director of Nursing Services stated medications should not be stored in the resident rooms. The Director of Nursing Services stated that the residents should not be self-administering their medication unless they were assessed for self-administration, and had a physician's order. 10 NYCRR 415.18 (d)

Based on record review and interviews during the Recertification Survey initiated on 12/3/2024 and completed 12/10/2024, the facility did not ensure each resident was provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This was identified for one (Resident #79) of three residents reviewed for Food. Specifically, Resident #79 verbalized disliking the food served to them and specified they were not assessed for their food preferences. Finding include: The facility's vendor policy Food Preferences documented that it is the center policy that individual dining, food, and beverage preferences are identified for all residents/patients. Action Steps include that the Dining Services Director or designee will interview the resident or resident representative to complete a Food Preference Interview within the admission process. The purpose of identifying individual preferences for dining location, and meal times, including times outside of the routine schedule, food, and beverage preferences. The Food Preference Interview will be entered into the medical record. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. Resident # 79 has diagnoses including Cushing's syndrome, unspecified Type 2 Diabetes Mellitus, and Chronic Kidney Disease. The 11/17/2024 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The resident had no behaviors and had no significant weight loss. During an interview on 12/03/2024 at 02:05 PM, Resident #79 stated they were not assessed for food preferences. The breakfast is served with pork and beef they don't eat. The resident further stated they were never provided a menu to choose their meals. A review of the resident's Dietary assessments dated 11/13/2024 revealed no documentation of an assessment for food preferences. The comprehensive care plan (CCP) for Nutrition revised on 11/11/2024 documented that the resident was on a Therapeutic Diet and was at risk for malnutrition. Interventions include adhering to diet consistency restrictions during recreational programs, and identifying and catering to resident food preferences- no pork/beef. The comprehensive care plan was updated on 12/2/2024 to include the resident's updated food preferences; no pork no beef. The meal ticket was updated and the care plan is ongoing. The food preferences interview form completed on 11/12/24 did not document the resident's food preferences. During an interview on 12/09/2024 at 12:02 PM, Dietician #1 stated the resident did not want to endorse their food preferences on admission, and that is why the food preferences were not documented or assessed upon admission. The Dietician stated on December 2, 2024, the resident reported they dislike pork and beef and this was updated on the comprehensive care plan and their meal tracker. The Licensed Practical Nurse # 6 was interviewed on 12/10/2024 at 10:21 AM and stated the resident would refuse their meal and tell me the next day that the meal was not satisfactory. The resident does not receive a menu and am not aware why the resident does not receive a menu. The General Manager from the contract company that provides dietary services to the facility, was interviewed on 12/10/2024 at 10:00 AM and stated Food preferences should be documented in the resident medical record. The dietician should have assessed the resident's food preferences. The meal tracker is updated when food preferences are obtained. A menu is given to any alert and oriented resident. The resident can choose their selections from the menu. The General Manager from the contract company that provides dietary services to the facility stated they did not know why Resident #79 did not receive a menu. The Director of Nursing Services was interviewed on 12/10/24 at 11:45 AM and stated if a resident chooses not to endorse food preferences, the dietician should have documented this in the medical record. The comprehensive care plan should reflect this. 10 NYCRR 415.14

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #46) of five residents observed during medication administration. Specifically, during the medication administration observation for Resident #46 on 12/4/2024, Registered Nurse #1 handled the oral medication tablets with their bare hands and administered those medications to the resident. The finding is: The facility's policy titled Medication Pass via Medication Cart, dated 12/2016, documented to follow infection control policies while administering medication. Hold the back of the blister card over the souffle cup and pop the pill into the cup without touching the pill. The facility policy titled Infection Control-Strategy of Investigation, Control, Prevention, last reviewed 4/2023 documented, that the facility will investigate, control, and prevent infections through a structural program of observation, reporting, and education. The purpose is to prevent the spread of infections; to prevent the occurrence and/or spread of contagious or communicable disease; to identify and control nosocomial infections through education and effective treatment; and to increase awareness of staff as to modes of transmission, courses, and treatment of infectious disease. Resident # 46 was admitted with diagnoses including Diabetes Mellitus, Cerebrovascular Accident, and Depression. The 9/25/2024 Annual Minimum Data Set assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact. During the medication pass observation on 12/4/2024 at 8:50 AM for Resident #46, Registered Nurse #1 prepared the following physician-ordered medications for administration: Amlodipine (blood pressure medication) 5 milligrams tablet, Vitamin D3 (supplement) 1,000-unit tablet, Eliquis (blood thinner) 5 milligrams tablet, Famotidine (antacid) 20 milligrams tablet, Fluoxetine (antidepressant) 20 milligrams capsule, Furosemide (diuretics) 40 milligrams tablet, Keppra (anti-seizure) 500 milligrams tablet, Memantine (Dementia medicine) 10 milligrams tablet, Potassium Chloride (supplement) 20 milliequivalent (tablet), and Vitamin C (supplement) 500 milligram tablet. The nurse removed each tablet/capsule from their respective blister pack/bottle, without touching the tablets/capsules, and placed them in a souffle cup. Registered Nurse #1 entered Resident #46's room and explained each medication to the resident by pouring the medications from the souffle cup onto the resident's overbed table. The table was not sanitized and did not have a barrier on it. Registered Nurse #1 touched each medication with their bare hand while they explained each medication to the resident. After explaining all the medications to the resident, the nurse picked up all the medications with bare fingers, placed them back in the souffle cup, and then administered the medications to the resident. During an interview on 12/4/2024 at 8:55 AM, Registered Nurse #1 stated the resident said it was OK to place the medications on the overbed table; however, they probably should have placed a barrier on the table and should have used gloves when touching the medications. During an interview on 12/5/2024 at 8:19 AM, the Registered Nurse Inservice Coordinator stated handling medications with bare hands is not acceptable. Nurses can explain what the medication is without handling the medication; nurses should never touch the medication with their bare hands. During an interview on 12/5/2024 at 8:36 AM, the Director of Nursing Services stated handling the medications with bare hands absolutely should not have happened. During an interview on 12/9/2024 at 10:30 AM, the Registered Nurse Infection Preventionist stated the nurse should not touch the medications with bare hands. There are ways to show and teach the resident which medications are being given without touching the medications. 10 NYCRR 415.19(a)(1-3)

Based on observations, record review, and interviews during the Recertification Survey and abbreviated Survey (NY 00358655) initiated on 12/03/2024 and completed on 12/10/2024, the facility did not ensure call bells were within reach for each resident at their bedside. This was identified for one (Resident #39) of five residents reviewed for Activities of Daily Living. Specifically, Resident #39, who was assessed to require assistance with transfer and locomotion, was observed on several occasions with a tap call bell out of reach. The finding is: Resident #39 was admitted with diagnoses including Traumatic Brain Injury, Anoxic (lack of oxygen) Brain Injury, and Myocardial Infarction (heart failure due to lack of blood supply to the heart). The Quarterly Minimum Data Set, dated dated dated [DATE] documented no Brief Interview for Mental Status score because Resident #39 was rarely or never understood. The Minimum Data Set documented Resident #39 had impairment to the upper and lower extremities. Minimum Data Set documented Resident #39 used a wheelchair for mobility, and was dependent (helper does all the effort, resident does none of the effort) on staff for wheelchair mobility. A Comprehensive Care Plan titled Communication effective 9/17/2020 and last reviewed on 9/20/2024 documented interventions that included the use of a tap call bell placed on a foam block on either the right or left knee when out of bed for effective use of call bell. During an observation on 12/03/2024 at 11:14 AM, Resident #39 was observed sitting in a wheelchair in their room. A tap call bell was hanging on the wall on a hook to the left of the bed and was out of the resident's reach. During an additional observation on 12/06/2024 at 11:16 AM, Resident #39 was observed sitting in a wheelchair in their room. The tap call bell was placed on the bed and was out of the resident's reach. During observation and interview on 12/06/2024 at 11:19 AM, Registered Nurse Personal Care Coordinator (Nurse Manager) #3 went to Resident #39's room and confirmed the tap call bell was out of the resident's reach. Registered Nurse Personal Care Coordinator (Nurse Manager) #3 stated the tap call bell should be on the resident's right or left knee. Resident #39 is non-verbal and requires the tap bell to be placed on the right or left knee. The resident is dependent upon staff to move them in their wheelchair. Nursing staff should place the call bell within reach when the resident is in bed and on the resident's knee when they are out of bed. During an interview on 12/6/2024, at 12:58 PM, Certified Nursing Assistant #3 stated they placed the tap call bell on the resident's lap after they transferred the resident to the wheelchair on 12/06/2024. Certified Nursing Assistant #3 stated they always position the call bell on the lap when the resident is in the wheelchair and on the resident's chest near their hand when in bed. Certified Nursing Assistant #3 stated they did not know how the call bell ended up on the bed on 12/6/2024. During an interview on 12/9/ 2024 at 11:48 AM, the Chief Nursing Officer (Director of Nursing Services) stated that the call bell should always be kept within reach of the resident. The Certified Nursing Assistants must ensure the call bell is accessible to the residents. Additionally, the medication nurse is in the room administering medications, they should also make sure the call bell is within reach. 10 NYCRR 415.29

Based on observation, record review, and interviews during the Recertification Survey and Abbreviated survey (Complaint #NY00278415) initiated on 5/11/2023 and completed on 5/18/2023, the facility did not ensure that each resident received assistive devices to prevent accidents. This was identified for one (Resident #124) of nine residents reviewed for accidents. Specifically, Resident #124, who was cognitively intact was pushed by Physical Therapist (PT) #1 from the patio to the resident's room on 6/21/2021. PT #1 pushed the wheelchair without the leg rests in place contrary to the facility's leg rest policy. Subsequently, Resident #124's left leg got caught under the wheelchair. Resident #124 was transferred to the hospital and was diagnosed with a left femur (thigh bone) fracture. This resulted in actual harm to Resident #124 that is not Immediate Jeopardy. The finding is: The Facility's Leg Rest policy dated October 2017 documented all residents are issued wheelchairs with leg rests as appropriate. The elevating leg rest are always either on the wheelchair for dependent propellers (resident who do not have the ability to move their wheelchair) or placed in the leg rest bag provided on the back of the wheelchair for self-propellers (ability to wheel themselves) or intermittent propellers (ability to sometimes wheel themselves and may need assistance). The Facility's Wheelchair policy dated 3/2017 documented the staff member will adjust leg elevators (leg rests) and foot pedals to accommodate resident's abilities to handle the wheelchair. If a staff member was pushing a resident, ascertain that the resident's feet are on the foot pedals. Foot pedals must be on the wheelchair if staff are pushing a resident. Resident #124 was admitted with diagnoses including Parkinson's Disease and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #124 had intact cognition. The resident required extensive assistance of two persons for transfer. The resident utilized a wheelchair for mobility and had no functional limitation in range of motion. Resident #124 required limited assistance of one person for locomotion on the unit and ambulated with limited assistance of one person in their room. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL) dated 10/4/2019 and last reviewed 6/16/2021 documented to provide assistance for (wheelchair) locomotion and to assist resident with supportive devices. The nursing progress note, written by a Registered Nurse (RN), dated 6/21/2021 at 3:40 PM documented PT #1 was working with Resident #124 and their (Resident #124) foot got caught under the wheelchair. Resident #124 complained of pain to PT #1. The Medical Doctor (MD) #1 was made aware and ordered an x-ray of the left knee and left leg. A Physician's order dated 06/21/2021 document to obtain a Portable x-ray of the left knee and left lower leg to rule out fracture. The Nursing Progress Note, written by an RN, dated 6/21/2021 at 9:30 PM documented the x-rays were completed and the resident's MD was made aware of a verbal report from the x-ray company that Resident #124 had a left displaced distal femur fracture. The area around and above the left knee was swollen and tender. Resident #124 stated that pain was bad 10/10. MD #1 ordered a onetime dose of Oxycodone 5 milligrams (mg) and to send the resident to the emergency room (ER). The MD #1's progress note dated 6/21/2021 at 10:47 PM documented the resident complained of left knee pain with swelling. The resident's left leg was caught under the wheelchair while the resident was pushed. The x-rays revealed a left distal femur fracture. The resident was sent to the ER for evaluation. The nursing progress note, written by an RN, dated 6/21/2021 at 9:51 PM documented Resident #124 was transferred to the Hospital emergency room (ER). The Hospital ER discharge summary dated 6/21/2021 at 11:47 PM documented Resident #124 reported to the ER doctor that Resident #124 normally wheel themselves, but while PT #1 pushed their wheelchair Resident #124's foot got caught under the wheelchair. The nursing progress note, written by an RN, dated 6/22/2021 at 6:51 AM documented Resident #124 returned from the ER at 3:30 AM via stretcher. Residents #124 had a left leg soft cast in place. The occurrence and investigation report dated 6/21/2021 documented PT #1 did not follow facility policy and procedure to use leg rests to propel the resident's wheelchair. The incident was reported to the NYSDOH on 6/24/2021. Resident #124's written statement dated 6/21/2021 documented Resident #124 pushed their wheelchair themselves and went to the patio without any leg rests on the wheelchair. PT #1 came to the patio and told the resident that they wanted to walk the resident. Resident #124 propelled their chair themselves into the facility. PT #1 asked the resident to lift up their arm and stated that (PT #1) would push the resident the rest of the way. PT #1 started to push the resident and the resident's foot went under the wheelchair. The resident was observed sitting in a wheelchair on the patio on 5/11/2023 at 12:30 PM reading a book. Resident #124's wheelchair was observed with a leg rest bag attached to the back of the wheelchair with the leg rests inside the bag. Resident#124 had their feet resting on the ground. Resident #124 was interviewed on 5/11/2023 at 12:30 PM and stated they wheel themselves to the patio. Resident #124 stated on 6/21/2021 PT #1 came and informed them it was time for their Physical Therapy session, and they had to go to Resident #124's room. Resident #124 stated they informed PT#1 they could not be wheeled without leg rests because they could not keep their legs up that long. Resident #124 stated PT #1 reassured Resident #124 that their legs were strong enough. Resident #124 stated they were able to hold their legs up until they got into the facility, but their left leg got tired. The left leg then dragged under the wheelchair and got caught between the floor and the wheelchair. Resident #124 stated they screamed then they passed out for a moment from the pain. Resident #124 stated PT #1 stopped, placed the leg rests onto the wheelchair, and then wheeled Resident #124 to their room. Resident #124 stated since the accident their Activities of Daily Living had declined. The resident stated before the accident they were able to walk for short distances with help but after accident they could not walk. Physical Therapist (PT) #1 was interviewed on 5/18/2023 at 9:43 AM stated on 6/21/2021 they wanted to bring the resident to the resident's room from the patio for a PT session. PT #1 stated that the leg rests were behind the wheelchair and Resident #124 was self-propelling their wheelchair. PT #1 assisted the resident and started to push the resident's wheelchair and instructed the resident to keep their feet off the ground. PT #1 stated they were either too busy or were confident that the resident was able to hold their legs up, therefore, they did not put the leg rests on the wheelchair prior to propelling the resident's wheelchair. The resident's left leg got caught between the carpet and the wheelchair. The resident screamed in pain. PT #1 stated they then placed the leg rests on the wheelchair and wheeled the resident to their room, applied the ice pack to the resident's leg, and notified the nurse of the incident. PT #1 stated the resident was crying in pain. PT #1 stated they were aware of the facility policy and knew they should have placed the leg rests on the wheelchair prior to wheeling the resident. PT #1 stated they were suspended for a day because of the incident. The Accident and Incident Prevention education training record dated 4/29/2021 revealed that PT #1 was educated regarding use of leg rests during all transports to prevent accidents. The Director of the Rehabilitation was interviewed on 5/18/2023 at 10:40 AM stated as per the facility's wheelchair policy every resident who has a wheelchair must have leg rests. When a staff member wheels a resident, they must place the leg rests on the wheelchair before pushing the resident in the wheelchair. The Director of Rehabilitation stated all staff members are educated on the facility policy during the first day of their orientation and that PT #1 should have placed the leg rests before wheeling Resident #124 to their room. The Acting Director of Nursing Services (DNS) was interviewed on 5/18/2023 at 1:30 PM and stated that they started working at the facility in October 2022. The DNS reviewed the accident and incident report with the surveyor and stated PT #1 should have followed the leg rest policy. MD #1 was interviewed on 5/18/2023 at 12:37 PM and stated Resident #124 was alert and oriented at the time of the accident. The resident was transferred to the hospital for evaluation and sustained a left femur fracture. 10 NYCRR 415.12(h)(2)

Based on interviews, and record review during the Recertification Survey and Abbreviated survey (Complaint # NY00315350) initiated on 5/11/2023 and completed on 5/18/2023, the facility did not ensure that each resident remained free from abuse. This was identified for one (Resident #142) of two residents reviewed for abuse. Specifically, a Certified Nursing Assistant (CNA) #3 was observed hitting Resident #142's shoulder, waiving a phone directly in front of the resident's face, and speaking in a loud manner while accompanying the resident to a medical appointment outside of the facility. The finding is: The facility's Policy and Procedure titled Abuse, Identification, Investigation and Reporting dated 10/2016 and last revised on 4/2023, defined physical abuse as inappropriate physical contact with a resident which harms or is likely to harm the resident. Resident #142 was admitted with diagnoses including Unspecified Malignant Neoplasm of Skin of the Face, Transient Cerebral Ischemic Attack, and Type 2 Diabetes Mellitus. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 8 which indicated the resident had moderately impaired cognition. The MDS documented the resident did not exhibit behavioral symptoms. A nursing progress note dated 4/24/2023 documented that Registered Nurse (RN) #2 was called to the resident's room to assess a scratch on the resident's right wrist. Resident #142 was noted with a small 1 centimeter (cm) scratch on the right wrist and a 3 cm X 2 cm bruise on the right hand. Resident #142 stated the scratch and the bruise happened when they went out to a radiation appointment. The resident had no complaints of discomfort. A complaint / grievance form dated 4/24/2023 documented that Resident #142 went out to a medical appointment for radiation for skin cancer on 4/24/2023. Upon return, Resident #142 reported to RN #2 that CNA #3 grabbed the resident's hand when they (CNA #3) were accompanying the resident to a medical appointment and that the resident did not want CNA #3 to take them on medical appointments anymore. A statement taken from Resident #142 by the Risk Manager on 4/25/2023 at 10:00 AM documented that the resident stated, Yes, she grabbed my wrist and caused this (points to superficial 1 cm linear red mark on R anterior wrist) and this bruise on my hand (points to R dorsal hand 3 cm x 2 cm dark purple area without swelling) was already there, but maybe a little bigger. Or may be the same size, but it's darker and it's tender to the touch. It was tender before, but more now. It doesn't hurt if I don't touch it. A statement was taken from CNA #3 by the Acting Director of Nursing Services (DNS) on 4/24/2023 at 7:43 PM. CNA#3 denied grabbing Resident # 142's wrist or hand at any time. CNA #3 stated they turned their back for one second and Resident #142 was rolling themselves out of the medical suite. CNA #3 stated they grabbed the resident's wheelchair and then pushed the resident's wheelchair out the door. CNA #3 stated that they were taking the resident to a different suite to use the bathroom. They stated that they assisted the resident to the bathroom and that it was uneventful. CNA #3 also stated at one point Resident #142 was hungry and was given a bag of pretzels by one of the office staff members. CNA #3 stated they had to take the pretzels away from the resident because they were unsure of the resident's diet and was concerned about choking. CNA #3 stated that Resident #142 got upset and was yelling before rolling out of the office to the other suite. A statement was taken from the Receptionist at the radiation clinic by the Acting DNS on 4/26/2023. The Receptionist stated that Resident #142 and CNA #3 were there for a 1:30 PM radiation treatment appointment. After the treatment Resident #142 and CNA #3 were in the waiting room waiting for the transport. Resident #142 was offered snacks. CNA #3 was acting aggressively, tapping the resident's shoulders aggressively and was in the patients face. CNA #3 was also waving their phone and placing the phone right in front of the resident's face. The Receptionist stated that they told CNA #3 to keep their hands to themselves, quiet down, and go in the hallway to wait for transportation. The Comprehensive Care Plan (CCP) titled Abuse dated 4/28/2023 documented resident is at risk for abuse related to decreased mental status and history. During an interview with CNA #3 on 5/17/23 at 3:24 PM, CNA #3 denied grabbing the resident or touching the resident in an aggressive manner. During an interview with the Acting DNS on 5/18/2023 at 1:45 PM, they stated that they completed an investigation on 4/28/2023 and came to the determination that abuse likely occurred. This conclusion was made based on the testimony from the Receptionist at the radiation clinic office and resulted in the termination of CNA #3. During an interview with the Receptionist on 05/18/2023 at 3:20 PM they stated that they were present on 4/24/2023 and witnessed the interaction between CNA #3 and Resident #142. The Receptionist heard a very loud exchange between Resident # 142 and CNA #3 while they were awaiting transportation in the waiting area which prompted the Receptionist to come out to the waiting area. The resident and CNA #3 were observed to be arguing over a bag of pretzels and CNA #3 was observed tapping the resident's right shoulder in a very hard manner. CNA#3 was speaking loudly to the resident and waving their cell phone around the resident's face. The Receptionist asked CNA #3 to get away from the resident and ultimately asked CNA #3 to leave the waiting area with the resident because CNA #3 was causing a loud disturbance to the other patients. 10NYCRR 415.4(b)(1)(i)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00303861) initiated on [DATE] and completed on [DATE] the facility did not ensure that services provided or arranged by the facility meet professional standard of quality. This was identified for one (Resident #356) of two residents reviewed for accident. Specifically, Resident #356 was readmitted on [DATE] on the 3:30 PM-to 11:30 PM shift with diagnoses of Head Injury and Chest Contusion. The resident was placed on the 24-Hour Report for monitoring. There was no documented evidence in the medical record that the resident was assessed on the 11:30 PM-7:30 AM shift. The finding is: The facility's Admission/Readmission Vital Signs policy and procedure last reviewed ,d+[DATE] documented for all admission and readmission to have regular monitoring of vital signs. Upon admission the admitting nurse will obtain physician orders for vital signs monitoring; this includes the monitoring of Blood Pressure, Pulse, Respiration, Temperature, and Oxygen Saturation. All new admission and readmission residents will be placed on the 24-Hour Shift Report and documented on each shift for 7 days at a minimum. Resident #356 was readmitted with diagnoses that included Head Injury, Chest Contusion, and Face Laceration. The 5-Day Minimum Data Set (MDS) assessment dated [DATE], prior to the most recent readmission, documented the resident required extensive assistance of two staff members for bed mobility and required extensive assistance of one staff member for transfers, walking in room. A Nurse's note dated [DATE] at 5:35 PM documented the resident was noted to be lying on the floor in their room on their left side with their left arm underneath them and was bleeding profusely from the left side of their head. The resident denied pain. The resident fell forward out of the wheelchair when attempting to pick up a pen that fell to the floor. The Physician was informed and ordered to send resident to the hospital. A Hospital Patient Discharge Summary dated [DATE] documented the diagnoses of Contusion to Chest, Head Injury, Falls, and Laceration of Face. A Nurse's note dated [DATE] at 5:59 PM documented the resident was readmitted from the hospital at 4:15 PM status post fall. The resident was alert and oriented to person and place with some confusion. The resident's blood pressure was ,d+[DATE] millimeter of Mercury (mmHg). A Physician's order dated [DATE] at 6:59 PM documented to apply Oxygen at 2 to 3 liters per minute via nasal cannula or mask as needed (PRN) for oxygen saturation (SPO2) of less than 92% between the hours of 6:00 PM and 9:00 AM for shortness of breath (SOB). There was no documented evidence of a nurse's note that included an assessment and or monitoring of the resident's vital signs on the 11:30 PM - 7:30 AM shift. A Nurse's expiration note dated [DATE] at 8:29 AM documented the resident was observed unresponsive to painful stimuli, pupils fixed and dilated/non-reactive, absence of spontaneous respirations, no audible breath sounds, no palpable blood pressure, or pulse. A late entry note dated at [DATE] (12 days after the resident expired), written by Licensed Practical Nurse (LPN) # 2, documented the resident was alert and verbal and was able to make needs known. The note further documented the resident had no complaint of pain or discomfort and slept well throughout the shift. A Review of the resident's electronic monitoring record revealed there was no vital signs documented on the 11:30 PM - 7:30 AM shift. The last documented Blood Pressure was on [DATE] at 10:36 AM. LPN # 2, who worked on the 11:30 PM - 7:30 AM shift on [DATE], was interviewed on [DATE] at 1:13 PM. LPN #2 stated that the resident was readmitted from the hospital on [DATE]. Routinely all residents who are readmitted from the hospital are placed on the 24-Hour Report, vital signs are monitored, and nurses' notes are documented in the resident's medical record. LPN #2 stated that they did not document in the medical record and did not recall why they did not write a note. LPN #2 stated that they should have written a note for the resident and monitoring of the resident's vitals should have been completed. LPN #2 stated that they documented a late entry note on [DATE] because either the Patient Care Coordinator or the Registered Nurse (RN) Supervisor reviewed the progress notes and ask them to document a note. LPN #2 stated that they could not recall if anything remarkable occurred with the resident on [DATE]-[DATE] night. The Assistant Director of Nursing Services (ADNS), who was the RN Supervisor on duty when the resident was readmitted from the hospital, was interviewed on [DATE] at 3:34 PM. The ADNS stated the admission nurse is responsible for writing an admission note then a follow up note should be written by the medication nurse. The ADNS stated that the resident should then placed on the 24-Hour Report for vital sign monitoring. The ADNS further stated that when a resident is monitored on the 24-Hour Report, every shift should document a progress note and vital signs are completed on the resident. The Resident's Physician was interviewed on [DATE] at 1:38 PM and stated they expected the staff to monitor the resident who are readmitted from the hospital according to the facility's protocol. The Physician further stated they expected the resident's vital signs be monitored every shift and an assessment be completed and documented in the resident's medical record. The Director of Nursing Services (DNS) was interviewed on [DATE] at 3:38 PM and stated when a resident is readmitted to the facility, they are placed on the 24- Hour Report for vital sign monitoring. The DNS stated that the expectation was for LPN #2 to complete vital signs of the resident and document the progress of the resident in the progress notes. 10 NYCRR 415.11(c)(3)(i)

Based on interviews and record review during a Recertification Survey and an Abbreviated Survey (Complaint# NY00289075) initiated on 5/11/2023 and completed on 5/18/2023 the facility did not ensure that each resident who is unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain safe transfers. This was identified for one (Resident #18) of five residents reviewed for ADLs. Specifically, Resident #18 was assessed as at risk for falls and required two-person assistance for transfers to and from the bed as per the resident's plan of care. On 12/31/2021 Certified Nursing Assistant (CNA) #4 transferred Resident #18 by themselves from a chair to the bed causing Resident #18 to fall during the transfer. The finding is: The Policy/Procedure on ADLs updated 12/2022 documented to provide assistance as needed for ADLS to prevent incidents and maintain safety. Resident #18 was readmitted to the facility with diagnoses that include Congestive Heart Failure and Gout. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident had intact cognition. The resident required extensive assistance of two staff members for transfers. The Comprehensive Care Plan (CCP) dated 6/29/2020 documented the resident was at risk for falls due to attempts to self-transfer at times. The interventions included to encourage the resident to ask for assistance as needed. The Physician's order dated 12/20/2021 documented to transfer the resident with extensive assistance of two staff members. The Resident Care Profile (CNA accountability record that provides instructions to the CNAs regarding resident care needs) updated on 12/20/2021 documented the resident required extensive assistance of two persons with transfers. A nursing progress note, written by Registered Nurse (RN) #4, dated 12/31/2021 at 11:16 PM documented the writer was called by Certified Nurse Assistant (CNA) #4 because Resident #18 fell during a transfer from a wheelchair into bed. The resident slid off the bed. The resident stated, Physical Therapy showed me the new way to transfer to bed, you raise the bed and get on it. I missed getting on the bed. I landed on the floor. Maybe I was too far from the bed but I am not sure. An Accident/Incident report dated 12/31/2021 documented Resident # 18 sustained a fall while being transferred from a chair into the bed. There were no apparent injuries. The resident complained of some discomfort to the left shoulder, right hip, and knees. X-Rays were completed and were negative for fracture. The resident's plan of care indicated the resident needed two-person assistance for transfers. The assigned CNA #4 transferred the resident with one-person assistance. The resident told CNA #4 they (Resident #18) had learned a different way to transfer themselves in therapy and wanted to try what they learned. As per CNA #4, the resident was alert and they (CNA #4) wanted the resident to try the transfer they (Resident #18) had learned in therapy. The resident slipped and fell to the floor at the bedside while attempting the transfer. CNA #4 was disciplined by the Director of Nursing Services (DNS) and was suspended for one day. A statement submitted by the CNA on 1/4/2022 documented the resident wanted to get into to bed the way Therapy showed them. The CNA stood behind the resident during the transfer from a wheelchair into the bed and the resident fell . CNA #4 was unavailable for an interview. RN # 5 was interviewed on 5/18/2023 at 3:55 PM and stated they initiated the Accident and Incident report and the investigation for the incident on 12/31/2021 related to Resident #18. The CNA made a mistake by transferring the resident by themselves. The resident sustained no injuries. The Acting Director of Nursing Services (DNS) was interviewed on 5/18/2023 at 3:56 PM and stated CNA #4 transferred the resident by themselves and should have transferred the resident using two-person assistance as per the directions in the CNA accountability record and according to the Physician's orders. 10NYCRR 415.12(a)(3)

Based on record review and interviews during the Recertification Survey initiated on 5/11/2023 and completed on 5/18/2023, the facility did not ensure that it maintains medical records for each resident that are complete and accurately documented. This was identified for one (Resident #74) of one resident reviewed for Dialysis. Specifically, the Physician's monthly notes dated 4/17/2023 and 5/11/2023 did not address the resident's right upper extremity Deep Vein Thrombosis (DVT) status. The finding is: The facility's Physician Services policy and procedure dated 12/2022 documented that the Physician must review the resident's total program of care, including medications and treatments, at each visit. Resident #74 was admitted with diagnoses that include End Stage Renal Disease (ESRD) on Hemodialysis, Acute Embolism and Thrombosis of Deep Vein of Right Upper Extremity, and Hypertension. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severely impaired cognition. The Renal Disease ESRD, On Hemodialysis Comprehensive Care Plan (CCP) dated 5/3/2019 documented that the resident had a Left (L) Arteriovenous (AV) fistula (a surgical connection made between an artery and a vein) that was not functioning. Registered Nurse (RN) #1 updated the CCP on 3/7/2023 and documented that the resident was readmitted on [DATE] with a low hemoglobin level and a positive DVT in the Right Upper Extremity. Continue with plan of care interventions, remain appropriate. The Physician's order dated 3/15/2023 documented to: -Administer Eliquis 5 milligram (mg) tablet by oral route two times per day due to acute embolism and DVT of the right upper extremity. -No blood pressures (BP) or blood draws to the left upper extremity (LUE). -No BP in right arm/DVT. The Physician Readmission note dated 3/17/2023 documented that Resident #74 has a past medical history of right upper extremity DVT, and the resident is on Eliquis. The Physician Monthly Progress note dated 4/17/2023 did not address the resident's right upper extremity DVT status. The Physician documented to continue the current treatment. The Physician Monthly Progress note dated 5/11/23 did not address the resident's right upper extremity DVT status. The Physician documented to continue the current treatment. The attending physician (MD) was interviewed on 5/18/2023 at 12:17 PM and stated that Resident #74 has a history of a blood clot in the right upper arm. The MD stated that the clot was treated. The MD stated that they (MD) were made aware by a nurse on 5/17/2023 about the orders to not take a BP on both arms and they (MD) discontinued the order to not take a BP in the right upper arm based on clinical judgement. The MD stated that the resident was stable and has no swelling in the right upper arm for more than 3 months. The MD stated they last saw the resident on 5/11/2023. The MD stated that the reason the order was not discontinued at that time was because they were not aware that the order to not take the blood pressure from the right arm was still active. The MD stated that resident #74's DVT status was not addressed in their monthly progress notes and should have been addressed. The Medical Director was interviewed on 5/18/2023 at 1:04 PM. The Medical Director stated that they (Medical Director) expected physicians to address residents' current issues in the monthly progress notes. The Medical Director stated that they expected physicians to review the residents' most current status and medical needs and condition. 10 NYCRR 415.22(a)(1-4)

Based on observation, record review and interviews during the Recertification Survey initiated on 5/11/2023 and completed on 5/18/2023, the facility did not ensure that an Infection Prevention and Control Program (IPCP) designed to help prevent the development and transmission of infection was maintained. This was identified for one (Resident #147) of five residents reviewed for Pressure Ulcers. Specifically, during a wound care observation for Resident #147's Stage III Pressure Ulcer, the Licensed Practical Nurse (LPN) #3 did not perform hand hygiene after cleansing the wound and prior to donning (putting on) clean gloves. The finding is: The facility's Policy and Procedure for Hand Hygiene dated 12/2022 documented to apply new gloves and perform hand hygiene. Resident # 147 has diagnosis that include Stage III Pressure Ulcer to the sacral region. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and had both short and long term memory impairment. The resident had one Stage III pressure ulcer that was not present on admission. The physician's order dated 4/26/2023 documented to cleanse the Sacral Ulcer with Skintegrity wound cleanser, apply Calcium Alginate Ag+ (silver) topically followed by Optifoam (cover dressing) dressing daily and as needed. The Comprehensive Care Plan (CCP) for Pressure Ulcer/Injury dated 12/5/2022 documented the resident had a Stage III Sacral Pressure Ulcer due to risk factors including impaired mobility. Interventions included to assess wound healing every week by the wound care consultant, and to provide ulcer treatment as per the Physician's orders. A wound care observation was conducted on 5/18/2023 at 11:10 AM with LPN #3. LPN #3 was observed to wash their hands then don (put on) clean gloves. LPN #3 then removed the soiled dressing from the Sacral Stage III Pressure Ulcer. The dressing was observed with moderate amount of blood-tinged drainage. LPN #3 discarded the dressing, washed their (LPN #3) hands, and donned clean gloves. LPN#3 then cleansed the wound three times using a new gauze each time. After cleansing the wound LPN #3 removed the dirty gloves and donned clean gloves without washing their hands. LPN #3 then applied the Calcium Alginate and a dry protective dressing (DPD) to the resident's sacral wound with the same gloves. LPN # 3 was interviewed on 5/18/2023 at 11:35 AM and stated that they receive annual In-service education, including hand hygiene. The LPN further stated that after cleansing the wound they should have removed the gloves, washed their hands, and then donned clean gloves. Registered Nurse (RN) # 3, the Infection Preventionist, was interviewed on 5/18/2023 at 11:45 AM and stated that LPN #3 should have performed hand hygiene after cleansing the wound and prior to donning new gloves when applying the treatment. The Director of Nursing Services (DNS) was interviewed on 5/18/2023 at 5:00 PM and stated that LPN #3 should have washed their hands after cleansing the wound and prior to donning a clean pair of gloves to prevent infection. 10NYCRR 415.19(b)(4)

Facility: St. Johnland NH NY 549 F-TAG: 684-J Date: [DATE] and [DATE] Surveyor: Khaleda [NAME] Based on observations, staff interviews and record review during an abbreviated survey (Complainant # NY 549), completed on [DATE] the facility failed to ensure that a resident received treatment and care in accordance with professional standards of quality for 1 of 4 residents (Resident #1) reviewed for quality of care. Specifically, on [DATE] the resident was found at 3:17 PM having a Grand Mal [CONDITION(S)]. Two Licensed Practical Nurses (LPN) responded to the resident's room. The LPNs reported that they paged the RN supervisor twice so an RN assessment can be performed before initiating a call to EMS. The RN supervisor responded to the unit approximately 18 minutes (at 3:35 PM) post onset of the [CONDITION(S)]. EMS records documented a call was received from the facility at 3:37 PM. EMS arrived at 3:55 PM. Attending physician was not called until EMS was onsite. The resident continued to seize during transfer to hospital and subsequently died at hospital the following day. This resulted in Immediate Jeopardy and Substandard Quality of Care to resident health and safety that was an actual harm for Resident #1. The findings are: The facility's Policy and Procedure titled Care of Residents During [CONDITION(S)] dated ,d+[DATE] documented that, (A nurse will remain with a resident having [CONDITION(S)]. To maintain a patent airway, prevent resident from injuring self and observe type of [CONDITION(S)]. Any staff will stay with the resident having a [CONDITION(S)]. Will notify nurse immediately. Certified Nursing Assistant/Nurse will bring suction machine to the Resident who is having a having [CONDITION(S)]. Maintain a patent airway. Observed type of [CONDITION(S)] like parts of the body affected, level of consciousness, loss of continence and duration of seizures. Notify physician of [CONDITION(S)] and administer medications as ordered. Will document seizures include same information as type of seizures and nursing interventions needed). The facility's Policy and Procedure titled: Medicine/Coverage dated ,d+[DATE] documented that the physician is notified when: The resident's physical, communicative, psychosocial, or functional condition or status changes unexpectedly or substantially. The facility did not provide documented evidence, as they were in the process of investigating the incident related to Resident #1. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 10 that indicates Resident#1 had moderately impaired cognitive status. The Comprehensive Care Plan (CCP) for [CONDITION(S)] Disorder initiated on [DATE] and updated on [DATE] documented interventions that included to administer medication ([MEDICATION(S)]) as ordered by Medical Doctor/Nurse Practitioner, observe for signs and symptoms of [CONDITION(S)] activity, protect resident from injury during [CONDITION(S)] activity. The Dental Consult dated [DATE] documented that the resident has Partial Upper Dentures. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Progress Note (NPN) dated [DATE] at 5:19 PM by the RNS documented that Resident #1 was observed having [CONDITION(S)] activities that lasted for 45 minutes. Oxygen was provided via mask, safety maintained and suction times two. The patient taken to the Hospital for evaluation. The Doctor was notified. A review of the video surveillance with the facility Administrator and Director of Support Services (DOSS) on [DATE] at 12:30 PM revealed that it was time stamped [DATE] from 11:00 AM through 4:14 PM. The video recorded the following: - At 3:17 PM Recreational Personnel (RP) went into Resident #1's room. - At 3:18 PM the RP exited the room. - At 3:19 PM two Licensed Practical Nurses (LPN) #1 and 2 entered Resident #1's room with an oxygen tank. - At 3:26 PM an unidentified staff brought the blood pressure machine into Resident #1's room - At 3:28 PM LPN#1 exited the room - At 3:35 PM LPN#1 and Registered Nurse Supervisor (RNS) entered Resident #1's room - At 3:48 PM RNS exited the Resident's room - At 3:52 PM EMS and RNS entered Resident #1's room. - At 4:14 PM EMS staff observed carrying Resident#1 out on a stretcher An email communication between the facility and their telephone provider dated [DATE] documented that 911 calls are not displayed on the Call Detail Report. The Facility's Emergency Department Communication form dated [DATE] at 3:30 PM documented that the resident was being transferred to the hospital to rule out [CONDITION(S)]. Resident#1 vital signs included pulse 100 (,d+[DATE]), pulse oxygen levels 98 percent (%) (,d+[DATE] %) ,d+[DATE] millimeters of mercury (mmHg) (,d+[DATE]-,d+[DATE]), temperature 97.2 Fahrenheit. (98.6 F), respiration 24 breaths per minute (bpm)(,d+[DATE] bpm). The resident was alert. The EMS report dated [DATE] documented that a call was received from the facility at 3:37 PM. EMS arrived at the facility at 3:46 PM and entered Resident #1's room at 3:55 PM. Resident #1's vital signs at 3:55 PM was oxygen saturation 64 %, blood pressure ,d+[DATE]mm/Hg, respiratory rate was 41. The RNS stated Hurry up Resident #1 is over here and has been having [CONDITION(S)] for the past 40 minutes and I was busy, so I never called 911. The RNS confirmed to the EMS personnel that no medication was administered. The EMS further documented that the EMS crew found Resident #1 having an active tonic/clonic [CONDITION(S)]/status epilepticus [CONDITION(S)]. Resident #1 was presenting cool, pale, diaphoretic and had a nonrebreather mask on their face. Resident #1 was in obvious visual respiratory distress. Resident #1 dentures were noted to be not in their proper place and half in the airway. The EMS removed the dentures and suctioned the blood from Resident#1's airway. Resident #1 was administered Versed (an anti-epileptic medication) to break the seizures. Resident #1 continued to have seizures up upon arrival to the hospital. The Hospital Record dated [DATE] at 4:37 PM documented Resident #1 arrived at the Emergency Department (ED) with seizures. Resident #1 with a history of being found to be seizing approximately 30 to 35 minutes by the nursing home staff. The patient was actively seizing on arrival to ED with twitching of all extremities greatest in the left upper extremity with gaze deviation to the left. The patient received 2 doses of Versed 5 mg Intra -Muscular (IM) in the field and was given [MEDICATION(S)] (Anti-anxiety medication) 2 mg Intra-Venous (IV) twice in ED with resolution of seizures. The CAT (CT) scan did not show any evidence of acute hemorrhage and the case was discussed with the tele-stroke specialist. The patient presented with right sided focal seizures in the movement with current left arm twitching and left gaze preferences. The patient received [MEDICATION(S)] (antiseizure medication) and additional 4 mg of IV [MEDICATION(S)] was recommended as the patient had another [CONDITION(S)]. On [DATE] the patient was unresponsive and without respirations and heart rate. The NPN dated [DATE] documented that a call was received from hospital and the Resident #1's family that Resident #1 has expired at the hospital on [DATE] due to uncontrolled seizures. During an interview with The Unit Clerk (UC) on [DATE] at 2:35 PM and stated that, on [DATE] that approximately 3:00 PM, LPN #1 instructed her to assist in the transferring of Resident #1 to the hospital. UC stated that she did not call 911 until 10 minutes (3:10PM-3:15PM) later, because she was filling out paperwork. The evening shift LPN#3 was on the unit at the time. UC did not recall time EMS arrived at the unit. There is no call log or documentation of the 911 call. The UC stated that she did not call the physician and was not aware if any other staff called the physician. During interviews on [DATE] at 3:15PM and again at 5:36 PM, RNS #1 stated that on [DATE] toward the end of the day-shift she heard a page overhead for RNS STAT (Immediately) to Resident #1's unit. RNS instructed a Certified Nursing Assistant (CNA), name not recalled, to call Resident #1's unit and inquire the reason for the STAT. She was informed that a resident was having [CONDITION(S)] activity. RNS#1 stated that she was the only RNS in the building and was attending to another emergency situation on another unit. RNS#1 stated that she proceeded to Resident#1's room which took time to get there because the hallways are long. Resident #1 was observed having a Grand-Mal [CONDITION(S)]. The resident was seated in a wheelchair and unresponsive. RNS#1 stated that Resident #1 was seizing for approximately 10 minutes prior to her arrival to the unit. She stated that Resident#1's vital signs were stable but there is no documentation. RNS was informed by LPN#1 that the Medical Director (MD) was notified but there was no response and that 911 was called. She stated that the MD called the facility when Emergency Medical Services (EMS) were on the unit. The MD was informed that Resident#1 was seizing for a long time. In a subsequent interview with the RNS on [DATE] at 3:11 PM, she stated the staff was waiting for EMS to arrive. When the EMS arrived, they administered [MEDICATION(S)], oxygen and suctioned the resident. The RNS stated that Resident#1 [CONDITION(S)] activity was an emergent situation and any staff could have called 911. The RNS did not know when or who called 911. The RNS stated that Resident #1 seized for 45 minutes that included transfer to the hospital. During an interview with LPN #1 on [DATE] at 6:39 PM, LPN#1 stated that Resident #1 had a Grand mal [CONDITION(S)] was unresponsive and had an elevated blood pressure. The RNS was paged overhead STAT twice to come to the unit. LPN #1 stated that the staff were waiting for the RNS to assess Resident #1 and get instructions from the RNS to call 911. LPN#1 stated that she could not recall when she called the MD however, she stated there was no answer. The MD called back when EMS was on the unit. LPN #1 stated that she was aware that Resident #1 used dentures. LPN #1 stated she did not check the Resident #1's mouth while the resident was having the seizures and was not aware that the dentures were obstructing the resident's airway. LPN #1 stated that prior to EMS arrival, the staff did not suction Resident #1. EMS suctioned and stabilized Resident #1. During an interview with the MD on [DATE] at 9:40 AM and at 12:19 PM. The MD stated that the RNS notified her that Resident #1 was seizing and that the EMS was on the unit however, she could not recall what time the call was placed. The MD stated that prior to her communication with the RNS there were no calls from the facility's staff. The MD stated that if she was made aware of aware of the resident's condition earlier, she would have ordered to administer [MEDICATION(S)] to control or diminish the [CONDITION(S)] activity. Resident #1's [CONDITION(S)] activity was an extreme situation, it was important for the staff to stabilize the resident. During an interview on [DATE] at 1:04 PM, LPN#2 stated that she stayed with the resident after she became aware of the resident's [CONDITION(S)] activity. LPN #2 stated that the resident was unresponsive and was seizing continuously with a lot of tremors and had secretions coming out from their mouth. Resident #1's oxygen saturation was between ,d+[DATE] %. LPN#2 stated that she did not know that Resident #1 had dentures. LPN#2 did not know who notified the MD or 911 of the resident's change in condition. During an interview with the Nurse Practitioner (NP) #2 on [DATE] at 2:59 PM, the NP stated that on [DATE] she was on-call. The NP #2 stated that at approximately 5:00 PM , the RNS notified her that Resident #1 was transferred to the hospital for [CONDITION(S)] activity. NP #2 did not receive any calls related to Resident #1 from the facility prior to 5:00 PM. The NP #2 stated that either the MD or the NP#2 should have been notified of Resident#1's acute change in condition. During an interview with CNA#3 on [DATE] at 3:42 PM, she stated that when the RNS arrived at Resident#1's room, she instructed the staff to call 911. Subsequently one of the LPNs left the room to call 911. During an interview with the Director of Nursing (DON) on [DATE] at 4:25 PM and stated that the facility became aware of the events regarding Resident #1 when the New York State Department of Health (NYDOH) staff was onsite investigating the case. The video surveillance was not reviewed by the facility. The DON stated that the RNS did not document the incident thoroughly in Resident #1's record. The DON explained that the 45 minutes [CONDITION(S)] activity would be of concern however, the time (45 minutes) included the time 911 was at the facility. The DON stated that an LPN or RN can call 911 for [CONDITION(S)] activity that lasted more than 5 minutes. The DON stated that the staff was stumped because Resident#1's [CONDITION(S)] activity was continuous. The DON stated that the staff should have called the MD and if the staff were unable to reach the MD, then they should have called 911. The DON stated that the facility did not have any documentation of when the MD was notified. The DON stated that waiting 20 minutes to call 911 for someone having a [CONDITION(S)] activity was not a delay. The Hospital informed the facility that Resident #1 expired the following day During an interview with the Administrator on [DATE] at 5:41 PM, the Administrator stated that they were made aware on [DATE] that Resident #1 was transferred to the hospital for seizures. The facility is in the process of investigating the events of [DATE] regarding Resident #1 and does not feel comfortable saying if there was a delay in calling 911. During an interview with the DOSS on [DATE] at 1:11 PM the DOSS stated that the facility's external and internal phone vendors informed them that their call logs do not register 911 calls. A review of the RNS personnel file revealed that on [DATE] the RNS was suspended. Areas where performance needs improvement: timely response to emergent event and accurate nurses' notes. 10 NYCRR 415.12

Based on observations, interviews, and record reviews during an abbreviated and extended survey (Complaint number NY 869) conducted on 7/28/20-7/29/20, the facility failed to have an effective system in place to monitor and supervise residents at risk for elopement and unsafe wandering behaviors for one (Resident #1) of six residents reviewed for Elopement. Specifically, Resident #1 with impaired cognition, a history of elopement, and exhibited exit seeking behaviors was assessed at risk for elopement and required enhanced (1:1 in line of sight) supervision. The staff did not supervise the resident as directed, and the resident was able to pass two alarmed doors to successfully elope from the facility. The resident was found 1 hour and 40 minutes later approximately 2.8 miles away walking down the road. This resulted in potential for serious harm for 34 residents at risk unsafe wandering and elopement that is an Immediate Jeopardy. The findings were: The facility's policy titled Enhanced Supervision dated 1/2019 documented enhanced supervision is an approach for meeting the individualized care needs of residents with behavioral symptoms that potentially put them at risk of injuring themselves or others. The following guidelines will be used for this determination: - One to one supervision - one staff member will be in direct contact with the resident at all times. -Line of sight observation - the resident will be in the sightline of a designated staff member and/or designated person at all times. The staff member responsible may be watching other residents at the same time and does not have to be in direct proximity to the resident being observed but should be close enough to intervene if it becomes necessary The nurse informs all direct caregivers that enhanced supervision is in effect for a resident, starts the enhanced flow sheet, and adds the information to the resident care profile. The direct caregiver observes the resident at the intervals prescribed on the enhanced documentation flow sheet, completes the enhanced supervision flow sheet, and notifies the nurse of any unexpected changes in the resident's behavior. The facility's policy titled Roam Alert System and Protocol dated 2/2020 documented elopement is defined when a resident leaves the premises or a safe area without authorization (i.e an order for [REDACTED]. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 3/12/20 documented the resident's cognitive skills for daily decision making as moderately impaired. The physician's orders [REDACTED]. The Wandering/Elopement Evaluation Guide (Elopement Assessment) dated 3/6/20 documented the resident was resistant to the placement and had a history of [REDACTED]. The Nurse's Progress Notes (NPN) dated 3/10/20 at 4:06 PM documented the resident was attempting to exit the unit, the resident stood up from wheelchair pushing the nurse and staff out of the way, forcing the exit doors to open. The resident was not easily re-directed. The resident was sent to the hospital for evaluation and a Computerized Tomography (CT) Scan of the head. The NPN dated 3/11/20 at 10:40 PM by Licensed Practical Nurse (LPN) #2 documented the resident returned from the emergency room at 6 PM. Enhanced supervision is in progress, the resident has no behaviors. 1:1 direct line of sight. The 24-hour report dated 3/11/20 documented that the resident came back from the hospital, and was placed on enhanced supervision, 1:1 direct line of sight. The PO dated 3/11/2020 documented, roam alert for safety awareness, check every shift for placement of the device. The CCP titled Behavioral Symptoms dated 3/11/20 documented the resident was exit seeking and knows the area, will attempt to exit when staff is not around. The resident is also resistant to care and redirection. The Enhanced Supervision Flow Sheet dated 3/11/20 through 3/12/20 documented Resident #1 was on 1:1 direct line of sight supervision. The flowsheet documented, at 6:00 AM the resident was dressed and placed in the hallway. At 6:15 AM the CNA (#1) documented he gave (the resident) to nurse. The 7:00 AM and 7:30 AM entry documented that the resident was missing. The facility Investigation Summary undated and unsigned, documented, on 3/10/20 the Resident was exhibiting exit seeking behaviors and was difficult to redirect. The resident was sent to the hospital for evaluation and head CT returned on 3/11/20 and was direct line supervision was initiated. On 3/12/20 the resident was last seen at 6:40 AM by RN #1. At 6:50 AM the roam alert alarm on the resident's unit sounded followed by another exit (perimeter) door alarm at 6:51 AM. The ADON and RNS #1 responded to the alarms. Code green was called. The resident was located 2.8 miles away at 8:30 AM. Small abrasions to the right-hand knuckles and right knee observed during a skin check. The RN Unit Manager (RNUM) was interviewed on 7/28/20 at 3:21 PM, she stated Resident #1 exhibited exit seeking behaviors. The RNUM had advised the evening shift LPN #2 to place the resident on enhanced 1:1 supervision if the resident returned from the emergency room . The resident came back from the hospital within 24 hours was placed on enhanced supervision, 1:1 direct line supervision. RNUM stated that 1:1 direct line of sight required staff to monitor the resident all the time. The 3:30 PM -11:30 PM shift LPN #2 was interviewed on 7/29/20 at 4:13 PM and she stated Resident #1 came back from the hospital on her shift on 3/11/20. She was informed by the RN (name not recalled) to place Resident #1 on enhanced supervision and staff to monitor the resident at all times. LPN #2 stated she reported to RN #1 that the resident was on enhanced 1:1 direct line of sight supervision and documented the same in the nursing progress notes, 24-hour report, and the enhanced flow sheet. The 11:30 PM to 7:30 AM shift RN #1 was interviewed on 7/29/20 at 11:08 AM and she stated on 3/11/20 she received a report from LPN #2 to keep a close eye on Resident #1. RN #1 stated she was not aware of the resident's exit seeking behavior. RN #1 stated she did not see or read the enhanced supervision flowsheet and could not recall if she read the 24-hour report. RN #1 stated that she was watching the resident from 6 AM until about 6:35 AM. At 6:35 AM RN #1 went to perform a bladder scan for another resident. She called CNA #1, CNA #1 did not come out of the room, RN #1 left Resident #1 sitting in the hallway. RN #1 stated after the bladder scan when she came out she did not see Resident #1, she heard the perimeter exit door alarm sounding. RN #1 stated she did not hear the roam alert door alarm. She responded to the alarming perimeter door, she did not see Resident #1. The police were informed and found the resident 2 miles away from the facility. The 11:30 PM -7:30 AM shift CNA #1 was interviewed on 7/29/20 at 2:05 PM, he stated he was assigned to Resident #1 on 3/11-3/12/20. He checked Resident #1 every 15-30 minutes. CNA #1 stated he was not aware of the resident's exit seeking behaviors. At approximately 6:00 AM CNA #1 placed the resident in the wheelchair and told RN #1 to monitor the resident. At approximately 6:30 AM, RN #1 told him that she was going to give medications but did not instruct him to monitor Resident #1. CNA #1 stated that he was providing care to another resident and did not hear any alarm sounds. He was told by RN #1 that she was unable to find Resident #1. The 11:30 PM to 7:30 AM shift CNA #2 was interviewed on 7/29/20 at 7:59 AM and stated she worked on 3/11-3/12/20. She was not assigned to Resident #1. After 6:00 AM (not able to recall exact time) CNA #2 stated she was providing care to another resident, and while in resident's room she did not hear a door alarm. When she came out of the room to discard the trash near the nurses' station she heard the unit door roam alert alarming and RN #1 told her that Resident #1 exited the unit. CNA #2 stated she did not receive in-service on Elopement after the incident The Assistant Director of Nursing (ADON) was interviewed on 7/29/20 at 1:33 PM and she stated she was part of the investigation. Resident #1 was supposed to be on the direct line of sight of supervision before the incident because he had exit seeking behaviors. The ADON stated that Resident #1 was not supervised as directed and eloped. The ADON stated that the unit door roam alert alarm could only be heard on the unit and in the nursing office monitor. If the staff was in resident rooms or at the other side of the hallways they may not hear the roam alert door alarm. ADON stated that the investigation concluded that the facility had everything in place, the alarms worked. The 11:30 PM to 7:30 AM Registered Nurse Supervisor (RNS) #1 was interviewed on 7/29/20 at 8:28 AM and stated that Resident #1 had exit seeking behaviors. The resident was placed on 1:1 direct line sight supervision indicating that someone should monitor the resident all the time. On 3/12/20 at approximately 6:45-6:50 AM the unit alarm activated indicating Resident #1 breached the roam alert alarm door. RNS #1 responded to the unit and met RN #1 in the hallway. RN #1 said she could not find Resident #1. RNS #1 told RN #1 that the unit alarm was sounding. Upon entry to the unit, she heard the perimeter exit door sound. RNS #1 responded to the exit door alarm, went outside but did not see Resident #1. A code green and 911 was called. The RNS stated that Resident #1 was not supervised (in the line of sight). The unit RN #1 was inside the room conducting a bladder scan and both CNAs were providing care to the other residents. The Finance Director (FD) was interviewed on 7/28/20 at 4:02 PM and he stated on 3/12/20 the resident was missing. The FD assisted in the search and found Resident #1 at approximately 8:30 AM walking briskly 4-5 miles away on the side of the main road. The resident was sweating and breathing heavily. The resident had no hat or jacket on. The Director of Nursing (DON) was interviewed on 7/29/20 at 2:45 PM and stated staff was expected to watch the resident all the time. Resident #1 was not monitored. The DON did not think that involved staff was educated or given disciplinary action. The Administrator was interviewed on 7/29/20 at 6:05 PM and stated she did not conduct the investigation and was not familiar with the investigation enough. No staff was at fault. There was no issue related to Resident #1's supervision. The Administrator was not aware of the resident's supervision status. The Administrator stated that there was no issue with the investigation and nobody needed to be educated or counseled. 415.12(h)(2)

Based on resident observation, staff interview and record review during an abbreviated survey (Complaint # NY 971), the facility did not ensure the right to be free from physical abuse for one (Resident #1) of three residents reviewed for resident to resident abuse. Specifically, Resident #2 had a history of [REDACTED].#1's room, chasing after her in the hallway with a shoe in hand. Resident #1 had blood over her face with ecchymosis (a discoloration of the skin resulting from bleeding underneath) to her right eye. Resident #2 aggressively grabbed Resident #1's wheelchair causing her to fall to the floor. The altercation continued for over thirteen minutes, unwitnessed by staff. Subsequently Resident #1 was transferred to the hospital and was diagnosed with [REDACTED]. The findings were: The facility Policy and Procedure titled Enhanced Supervision dated (MONTH) (YEAR) documented, Fifteen-minute Observations is instituted on admission, transfer, and return from the hospital or as needed for those that are a high risk for safety. The facility Policy and Procedure titled Abuse, Neglect, Mistreatment: Departmental Investigation and reporting dated (MONTH) (YEAR) defined Resident to Resident Abuse as inappropriate physical contact resulting in bodily injury, or likely to harm a resident. Video Surveillance from Camera 6 and Camera 7 of the hallway on the unit where Resident #1 and Resident #2 resided, dated 1/3/2019, were reviewed in the presence of the Director of Nursing (DON). -8:19 PM Resident #2 was observed entering Resident #1's room. -9:33 PM Resident #1 enters the same room with two shoes on. -9:35 PM Resident #1 exited her room self-propelling in her wheelchair with one shoe on. Resident #1 seen with blood all over her face followed by Resident #2 who was holding a shoe in his left hand. -9:35 PM- 9:47 PM Resident #1 and Resident #2 were seen entering and exiting Resident #1's room with their arms swinging at each other. -9:47 PM Resident #2 was observed pushing Resident #1 in her wheelchair while Resident #1 was holding onto the rails in the hallway. Resident #1 then fell from the wheelchair to the floor. No staff were observed on video entering or exiting Resident #1's room for approximately one hour and 16 minutes, while Resident #2 was located in the vicinity from 8:19 PM until 9:47 PM. 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 10/25/2018 documented intact cognition for the resident. Resident #1 was observed with a yellow/green bruise noted around the right orbital area on 01/09/2019 at 12:20 PM. The Comprehensive Care Plan (CCP) titled Behavior dated 03/16/2015 documented Resident #1 was verbally abusive and becomes agitated towards peers. Interventions included to assess behavior patterns for causative factors. The Nursing Progress Note (NPN) dated 01/03/2019 at 11:36 PM documented by the Registered Nurse Supervisor (RNS) noted that the resident (#1) was observed on the floor outside a room. She had a bloody nose, bruising to the right eye with early signs of bruising to the left inner eye area. The resident indicated an altercation with another resident. She said a resident hit her with a shoe and dragged her. The facility Investigation Report dated 01/03/2019 documented Resident #1 went into her room in her wheelchair and saw Resident #2 was laying in her roommate's bed. An altercation occurred between the two residents. Resident #1 was seen (on video surveillance) coming out of the room with one shoe on and a bloody nose and mouth. Resident #2 admitted he hit Resident #1. He stated she (Resident #1) came towards him like an animal. He thought she (#1) was in the wrong room, he kept trying to push her in her wheelchair away from the room. Resident #1 held the handrail when Resident #2 pulled the wheelchair from behind her. Resident #1 fell out of the chair to the floor. The facility concluded that a resident to resident altercation between the two residents resulted in a physical injury to Resident #1. The Medical Progress Note (MPN) dated 01/04/2019 at 12:46 PM documented Resident#1 had periorbital soft tissue swelling (swelling around the eye), large ecchymosis to the right eye with scleral hemorrhage (blood under the sclera) and ecchymosis to the right hand. The computerized Tomography (CT) of facial bones indicated mild periorbital swelling. The Hospital discharge date d 01/04/2019 at 1:29 PM documented a Facial Contusion. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 12/06/2018 documented severely impaired cognition for the resident and physical behavior symptoms directed toward others. The CCP titled Behavior dated 12/19/2018 documented the resident wandered at times, physical and verbal aggression towards staff and other residents, delusional at times. The CCP was updated on 07/12/2018 and documented the resident entered another resident's room, possible hitting of another resident. Interventions included to provide enhanced supervision and observe the resident's whereabouts. The physician's orders [REDACTED]. The Resident Nursing Instructions (undated) documented 15-minute checks for observation and frequent redirection. The RNS was interviewed on 01/09/2019 at 4:34 PM and stated she assessed Resident #1 after the incident. Resident #1 had a bloody nose; her right eye was bruised, and she had blood on her shirt. Resident #1 stated someone hit her. Resident #2 told the RNS that he was sleeping, and someone woke him up and he hit that person. Resident #1 was sent to the ER. The RNS stated that Resident #2 was on 15-minute observations. The Certified Nursing Assistants (CNAs) and the Licensed Practical Nurses (LPNs) were responsible to complete the 15-minute observations. LPN #1 was interviewed on 01/10/2019 at 10:15 AM and stated she was assigned to Resident #1 and Resident #2. She last saw Resident #1 approximately 8:30 - 8:45 PM in the recreation area. She was at the nursing station when she saw a resident on the floor (via the video surveillance screen). Resident #1 was found two rooms from her own room sitting on the floor with blood on her face. The resident (#1) told LPN #1 he hit me, and he dragged me. All staff denied hearing anything. Both residents were on 15-minute checks. The 15-minute checks were not done. Staff did not go and check the residents' whereabouts every 15 minutes, it's not possible. LPN #1 acknowledged signing the 15 minutes log without checking on Resident #2. She was not sure why Resident #2 was on 15-minute observation; however, she was aware that Resident #2 had a history of [REDACTED]. CNA #1 was interviewed on 01/10/2018 at 3:00 PM and stated she was assigned to Resident #2. He was on 15-minute observations. She recalled seeing him before 9:00 PM. She did not conduct the 15 -minute observation for Resident #2 because the unit was big, and the staff needed more help because of residents' behaviors. The DON was interviewed on 01/17/2019 at 10:45 AM and stated the investigation revealed Resident #2's 15 -minute observation/checks were not completed. Resident #2 was in Resident #1's room for approximately an hour before Resident # 1 entered. It was possible the altercation could have been avoided if the 15 -minute observations were completed. She observed the video surveillance, Resident #1 was seen entering her own room without injury to her face and exited the room with blood all over her face. The 8:30 AM - 4:30 PM Risk manager was interviewed via telephone on 01/17/2019 at 1:36 PM, she stated Resident #2 had not been observed for an hour. Resident #2 had history of resident to resident altercation. The assigned CNA was busy with another resident. The Risk Manager concluded that Resident #2 had physically abused Resident #1 and that there was a breech in the plan of care. 415.15