Every finding on record at St Peters Nursing and Rehabilitation Center

Based on record reviews and interviews conducted during a survey, the facility failed to ensure residents were free from neglect and abuse for three (3) (Resident #s 2, 15, and 18) of 22 residents reviewed. Specifically, a.) Resident #'s 2 and 18 care plans were not followed resulting in injury; and b.) Resident #15 was prevented from leaving their room by a staff member.Findings include:The Policy and Procedure titled Abuse Prevention and Investigation Policy, dated 3/25/2025, documented abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical pain, harm, or mental anguish, deprivation of goods or service and neglect was defined as the failure to provide timely, consistent, safe, adequate and appropriate services, treatment and care including nutrition, medication, and therapies.The policy and procedure titled Interdisciplinary Care Conference and Care Planning, dated 06/27/2023, documented the purpose of a comprehensive care plan is to promote effective and person-centered care, continuity of care, communication among nursing facility staff, increase resident safety, and safeguard against adverse events.Resident #2Resident #2 was admitted to the facility with the diagnoses of unspecified diastolic congestive heart failure (when the heart's main pumping chamber - the left ventricle - stiffens and cannot properly relax to fill with blood), morbid severe obesity due to excess calories (chronic disease defined by a body mass index of 40 or higher resulting from complex biological and environmental factors), and chronic kidney disease (when the kidneys are damaged and cannot filer blood as they should). The Minimum Data Set (an assessment tool) dated 02/13/2026 documented the resident could be understood, could understand others, and was cognitively intact.The Comprehensive Care Plan titled Actual/Potential Impaired Ability/Inability to perform Activities of Daily Living (bathing, grooming, dressing, mouth care) due to weakness, initiated 09/23/2022 documented the resident required substantia/maximum assistance for upper body bathing and was fully dependent on staff to bath their lower body.The Kardex dated 09/09/2025 stated Resident #2 required substantial/maximal assistance by two (2) staff members with the use of enabler bars for bed mobility.The Summary of Event dated 09/09/2025 at 11:00 AM documented Resident #2 received a skin tear to their right upper arm while care was being provided. The summary documented that Certified Nurse Aide #1 provided care to Resident #2 without additional assistance.The Progress note dated 09/09/2025 at 11:30 AM documented Registered Nurse #1 was called to Resident #2's room to assess a skin tear to the right upper arm measuring 4.3 centimeters by 3 centimeters. The skin was approximated; steri-strips were applied and covered with a dry protective dressing. Certified Nurse Aide #1 stated to Registered Nurse #1 that the skin tear was obtained during care (rolling Resident #2).The Progress note dated 09/09/2025 at 4:03 PM documented Resident #2's bed mobility was 2 staff assist and the Certified Nurse Aide #1 did not roll Resident #2 with additional assistance and the resident obtained a skin tear during care.The Employee Statement completed by Certified Nurse Aide #1 on 09/09/2025 documented the skin tear occurred when they were changing Resident #2.The Resident Version of Occurrence transcribed by Registered Nurse #1 on 09/09/2025 documented Resident #2 stated the skin tear happened when Certified Nurse Aide #1 turned them.The Nursing Home Investigative Report Submission #18730 submitted by Director of Nursing #2 dated 09/11/2025 documented there was reasonable cause to believe that abuse, neglect, or mistreatment occurred, and the incident was a care plan violation.Resident #15Resident #15 was admitted to the facility with diagnoses of type 2 (two) diabetes mellitus (chronic metabolic disorder where the body either resists insulin or doesn't produce enough of it), major depressive disorder (a severe mood disorder causing persistent feelings of sadness, hopelessness, and a loss of interest in activities), and hypertension (a condition in which the force of blood pushing against the artery walls is consistently too high, also known as high blood pressure). The Minimum Data Set, dated [DATE], documented the resident could be understood and could understand others and was cognitively intact.On 02/02/2026 Resident #15 reported to Licensed Practical Nurse #6 that Certified Nurse Aide #4 had grabbed their arm and pushed them in their wheelchair back to their side of the semi-private room when they attempted to leave the room, stating I'm not letting you leave. Licensed Practical Nurse #6 informed the supervisor at that time and an investigation was started.The facility investigation of this facility reported incident documented numerous statements including a statement from Resident #15.The investigation report documented the incident happened on 02/02/2026 at 8:30 PM.The statement from Resident #15 dated 02/02/2026 documented the resident asked Certified Nurse Aide #4 to move linen on the floor out of their way, claiming Certified Nurse Aide #4 grabbed them by the arm and pushed them back when they attempted to leave the room. The statement from Licensed Practical Nurse #6 documented that they did not witness the incident but did receive the accusation from Resident #15 against Certified Nurse Aide #4.The Summary of Event dated 02/02/2026 documented Certified Nurse Aide #4 was sent home.Certified Nurse Aide #4's employee file documented they were terminated from employment on 02/03/2026 for substandard job performance, abuse, neglect, or mistreatment of a patient or resident, and violation of resident rights.During an interview on 5/27/2026 at 10:30 AM, Director of Nursing #1 stated Certified Nurse Aide #4 was removed from the building as soon as Resident #15 accused them of abuse and placed on suspension pending investigation. They stated the allegation was verified and Certified Nurse Aide #4 was terminated because of this incident.During an interview on 5/28/2206 at 3:10 PM, Licensed Practical Nurse #6 stated when Resident #15 reported the accusation to them, they went to Certified Nurse Aide #4 to ask what happened and called the supervisor who began the investigation. They stated Certified Nurse Aide #4 was removed from the floor and patient care within fifteen minutes of the report.Resident #18Resident #18 was admitted to the facility with diagnoses of dementia (an umbrella term for a decline in mental ability - such as memory loss, impaired judgment, and confused thinking - severe enough to interfere with daily life), anemia (a condition characterized by a lack of enough healthy red blood cells to carry sufficient oxygen to body tissues), and gastro-esophageal reflux disease (chronic digestive condition where stomach acid or bile flows back in to the esophagus, irritating and inflaming the lining of the esophagus causing discomfort). The Minimum Data Set, dated [DATE], documented the resident could be understood and could understand others. The resident was cognitively intact. The Comprehensive Care Plan titled, Alteration in mobility related to limited range of motion, limited strength, weakness, initiated 08/01/2022, included the seating intervention for a standard wheelchair with cushion and standard leg rests.The Summary of Event dated 10/15/2025 documented Resident #18 was transported from the therapy room to the unit without leg rests on their wheelchair, resulting in the resident's foot dragging and turning while being pushed in the wheelchair. The summary documented leg rests were not applied to the wheelchair by the assigned Certified Nurse Aide #4 before resident transport to the therapy room. The resident reported on 10/16/2025 that their ankle hurt. The Kardex dated 10/23/2025 documented under wheelchair bound / mobility that the seating was a standard wheelchair with cushion and standard leg rests.The acknowledgment form for Select Physical Therapy, Occupational Therapy, and Speech License Pathologist Rehabilitation documented that for resident transport in wheelchair: residents must have leg rests applied prior to being transported to the therapy department, and was signed by Rehabilitation Technician #1 on 10/24/2025.The Communication/Medical Provider note, dated 10/16/2025, stated an X-ray of the right ankle and foot had been ordered.The Communication/Medical Provider note, dated 10/16/2025, documented the medical provider was informed of X-Ray results of right ankle indicating a right lateral ankle sprain.The Medical Provider Note dated 10/17/2025 documented the resident was seen for pain in the right ankle after the X-Ray indicated a right ankle strain. During an interview on 5/27/2026 at 10:30 AM, Director of Nursing #1 stated both the involved certified nurse aide (Certified Nurse Aide #4) and Rehabilitation Technician #1 had received education on proper transport of residents. They stated this was the first write-up for Certified Nurse Aide #4. 10 New York Codes, Rules, and Regulations 415.4

Based on record review and interviews conducted during a survey, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, Resident #1 did not receive ordered treatments of Santyl ointment (a prescription topical ointment used to clean and remove dead tissue form severe burns and chronic skin ulcers), and dry dressing to left foot on the dates on 12/04/2026 - 12/09/2026.Findings include:Resident #1 was admitted to the facility with diagnoses of paroxysmal atrial fibrillation (an intermittent condition where the upper chambers of the heart beat chaotically and out of sync,) history of other venous thrombosis and embolism (a blood clot that blocks the flow of blood through a vein), and diaphragmatic hernia without obstruction or gangrene (a condition where the abdominal organs push through a defect in the diaphragm and become severely trapped). The Minimum Data Set (an assessment tool) dated 02/27/2026 documented the resident could be understood and understood others, and had moderately impaired cognition.Review of policy titled Skin & Wound Care documented licensed practical nurse would change dressings per order and will document wound appearance and changes.Review of Treatment Administration Record dated December 2025 documented completion of treatment to left medial foot on the dates of 12/03/2025, 12/04/2025, 12/06/2025, 12/07/2025, 12/08/2025 and 12/09/2025.Review of nursing progress note dated 12/10/2025 at 12:46 PM written by Registered Nurse #2 documented upon completing weekly wound rounds with wound nurse, resident was found to have a dressing applied to left foot with the date 12/03/2026. Registered Nurse #2 documented upon investigation, treatment was ordered to be completed on the evening shift daily, it was found that nurses documented that treatment was complete/performed when it was not.Review of statement dated 12/10/2025 at 2:23 PM written by Registered Nurse #5 documented Resident was seen today (12/10/2025) on weekly wound rounds. Dressing that was found intact was dated 12/03/2025. Order for wound care is Santyl ointment with dry gauze daily. No signs of active infection. Now able to stage as a stage 3 (three). Wound noted to be larger in size this week. There was a very light tan film over wound bed. Review of investigation dated 10/10/2025 at 12:27 PM completed by Director of Nursing #1 included statements from Licensed Practical Nurse #1 stating they put a dressing on the bottom of the foot. They thought that was medial aspect. They could not recall which foot and also stated there wasn't a wound present.Review of investigation dated 12/10/2025 at 12:20 PM completed by Director of Nursing #1 included a statement from Licensed Practical Nurse #2 stating they did multiple treatments and omitted the treatment in error.Review of investigation dated 12/10/2025 at 12:20 PM completed by Director of Nursing #1 included statement from Licensed Practical Nurse #3 stating they had signed prior to completing the treatment and had so much to do they didn't get back to it.Review of resident version of occurrence form dated 12/10/2025 at 12:20 PM, Resident #1 stated they were unaware that treatment was not being completed as they lose track of time.Review of medication or treatment error re-education form documented re-education of Licensed Practical Nurse #'s 1, 2, and 3 on 12/10/2025 on Administration of medication and completing treatments as ordered.During an interview on 05/22/2026 at 11:10 AM, Licensed Practical Nurse #4 stated a treatment should never be signed for prior to completing the treatment. They stated they would look at the order first, change the dressing as ordered, and then document in the electronic health record.During an interview on 05/22/2026 at 11:15 AM, Licensed Practical Nurse #5 stated that any treatment they did was documented in the electronic health record after the completion of the treatment. 10 New York Codes, Rules and Regulations 415.12(c)(2)

Based on record review and interviews during an abbreviated survey (Case #NY00307971), the facility did not ensure that it promoted and facilitated the resident's right to self-determination through support of the resident's choice for 2 (Resident #s 1 and 2) of 3 residents reviewed. Specially, Resident #1 chose not to have a shower on 1/3/2023, their scheduled shower day. Resident #1 told the Certified Nurse Aide (CNA) #1 they did not want their shower, but CNA #1 continued to give them one and the resident became agitated. Resident #2 chose not to get undressed and ready for bed on 1/5/2023 at 5:00 PM, when CNA #1 told them they needed to. Resident #2 told CNA #1 no several times and CNA #1 then pulled the resident's shirt off over their head, and the resident became upset. This is evidenced by: The Policy and Procedure titled Resident Rights revised on 10/27/2022, documented the resident had the right to self-determination; the resident had the right to choose activities, schedules (including sleeping and waking times) consistent with his or her interests. The P&P included Your Rights as a Nursing Home Resident in New York State (NYS) published by the NYS Department of Health, and documented under self-determination that the resident had the right to be offered choices and allowed to make decisions that were important to them; to make personal decisions such as what to wear, when to sleep or how to spend free time; and to accept or refuse care and treatment. Resident #1: Resident #1 was readmitted to the facility with diagnoses of dementia (unspecified severity) without behavioral disturbance, spondylopathies lumbar region (disease of the vertebrae in the lower spine), and chronic kidney disease. The Minimum Data Set (MDS - an assessment tool) dated 12/5/2022, documented the resident was cognitively intact. Review of the Comprehensive Care Plan (CCP) for actual/potential impaired ability/inability to perform ADLs (bathing, grooming, dressing, mouth care) due to balance problems and weakness, last revised on 1/3/2023, documented the resident was to receive a shower by the CNA on Tuesday during the 7:00 AM - 3:00 PM shift. The CNA Care Card dated 1/3/2023, documented the resident was to receive a shower on Tuesday during the 7:00 AM - 3:00 PM shift. The CNA Assignment North [unit] dated 1/3/2023, 7:00 AM - 3:00 PM shift, documented CNA #1 was assigned to Resident #1 and the resident was to receive a shower. Review of the facility's Investigation Summary Form dated 1/3/2023 at 11:30 AM, documented CNA #1 reported to Registered Nurse Manager (RNM) #1 that while showering Resident #1, they became angry when CNA #1 inadvertently wet the back of the resident's hair while washing their back. Resident #1 started to kick and hit CNA #1, and then grabbed the shower hose and hit the wall after trying to hit CNA #1 with it. CNA #1 rinsed the soap off the resident when they said to stop. -Resident #1 was interviewed by the facility and stated that CNA #1 entered their room and started pushing their wheelchair stating, We're going to the shower. Resident #1 stated they did not want to do it when CNA #1 told them to because they did not feel ready. Resident #1 stated they did not have their teeth in or nothing. Resident #1 stated they were pushing back stating, I'm not ready and CNA #1 brought them to the [shower] room anyway. Resident #1 stated that CNA #1 started spraying them with the water and shooting them all over with it, getting their hair wet. Resident #1 stated that they were very proud of their hair and did not like it when anyone touched it. The On-site Re-Education form for CNA #1 signed by RNM #1 and the Assistant Director of Nursing (ADON) on 1/3/2023, documented the reason for the re-education was CNA #1 rinsed off the resident after they asked CNA #1 to stop during the shower. Education provided documented that when a resident tells you to stop, you must stop. CNA #1 was to reapproach later to rinse with wet wash cloth as the resident allowed. During an interview on 1/9/2023 at 11:24 AM, Resident #1 stated that the lady [CNA #1] came in and grabbed their wheelchair and said they were going to have a shower. Resident #1 told them to please leave them alone. Resident #1 stated CNA #1 told them they were going to take one and then Resident #1 told them to take their hand off their wheelchair. Resident #1 stated CNA #1 then brought Resident #1 to the shower room and got their hair wet and stated they did not want anyone touching their hair. Resident #1 stated they grabbed the shower thing [hose] and told CNA #1 to get away from them. Resident #1 stated that someone heard Resident #1 arguing with CNA #1 in the shower and came into the room. During an interview on 1/9/2023 at 1:45 PM, CNA #1 stated Tuesday, 1/3/2023, was Resident #1's shower day. CNA #1 stated they went into the resident's room after breakfast and told them it was their shower day. CNA #1 stated Resident #1 told them to make sure it was warm in the shower room. CNA #1 stated they brought the Resident #1 to the shower room and transferred them from the wheelchair to the shower chair. CNA #1 stated they started to wet the resident's body with the shower hose and some of the water hit the back of the resident's hair. CNA #1 stated, That pissed [them] off. CNA #1 stated Resident #1 said that they paid a lot to their barber for their hair to be done. CNA #1 stated Resident #1 started moving themselves out of the shower room stating no and said they did not want a shower. CNA #1 stated the resident still had soap on them and they rinsed the resident off. CNA #1 stated the RN came in the room because they heard a noise. CNA #1 stated the noise was from the shower head that the resident had thrown. CNA #1 stated they were supposed to leave an agitated resident and get help, but they did not. CNA #1 stated they were sent home. During an interview on 1/9/2023 at 2:49 PM, RNM #1 stated CNA #1 was re-educated on 1/3/2023, and was told that when a resident refused care, they needed to stop what they were doing and report it to the nurse. RNM #1 said they even had CNA #1 repeat what they were told. The Assistant Director of Nursing (ADON) #1 was present and stated they told CNA #1 even if the resident was soapy, they needed to stop the shower because the resident told them to stop. During an interview on 1/13/2023 at 12:00 PM, the Director of Nursing (DON) #1 stated there were few things that CNA #1 could have done differently with Resident #1. The DON #1 stated CNA #1 could have asked the resident if they would accept a bed bath instead of the shower; could have left the resident and re-approached later; and could have told the nurse so they could see if a different shower day could be scheduled. The DON #1 stated they would not have brought the resident to the shower room when they stated they did not want a shower. During an interview on 1/13/2023 at 12:22 PM, the Administrator (ADMIN) #1 stated they had a resident rights policy in place and stated with resident rights and dignity, no means no. The ADMIN #1 stated that depending on the situation, CNA #1 could have reapproached the resident or could have given the resident other options such as a sponge bath. The ADMIN #1 stated CNA #1 should have let the nurse know that the resident did not want a shower. Resident #2: Resident #2 was admitted to the facility with diagnoses of multiple sclerosis (MS), cognitive communication deficit, and history of falling. The MDS dated [DATE], documented the resident had moderate cognitive impairment. Review of the CCP for actual/potential impaired ability/inability to perform ADLs (bathing, grooming, dressing, mouth care) due to weakness, last updated 12/15/2022, documented Resident #2 dressed their upper body with extensive assistance and their lower body with total assistance in bed. The CNA Care Card dated 1/5/2023, documented Resident #2 dressed their upper body with extensive assistance and their lower body with total assistance in bed. Review of the facility's Investigation Summary Form dated 1/5/2023 at 5:00 PM, documented Resident #2 reported the CNA took Resident #2's shirt off for care, when Resident #2 told them they did not want care at that time. It was documented that CNA #1 continued to perform care against the resident's wishes. Human Resources (HR) was to be called for CNA #1 to be terminated. The Corrective Action Notice for CNA #1 dated 1/9/2023, documented termination for Violation of the Corrective Action Policy - Failure to maintain proper work standards. CNA #1 failed to stop care when the resident stated they did not want the care to continue. CNA #1 removed the resident's shirt when the resident stated, No, don't remove my shirt as I have company coming. During an interview on 1/9/2023 at 11:46 AM, Resident #2 stated that it was around 6:30 PM, when [CNA #1] came into the room and told them that they wanted them to take their clothes off to get ready for bed. Resident #2 stated they told CNA #1 no several times, but they just kept telling them to take their clothes off. Resident #2 stated CNA #1 pulled their shoes off and threw them and then CNA #1 pulled their shirt off above their head. Resident #2 stated they started yelling for a nurse to come in and CNA #1 left the room. During an interview on 1/9/2023 at 1:45 PM, CNA #1 stated on 1/5/2023, they worked the 7:00 AM - 3:00 PM shift and was asked to stay later. CNA #1 stated they were to leave at 7:00 PM and wanted to get the resident ready for dinner and bed. CNA #1 stated they told Resident #2 what they were there for and stated the resident did not want their clothes taken off and the resident said no. CNA #1 stated when the resident told them to stop, they continued to take the resident's shirt off. CNA #1 stated the resident was upset and CNA #1 left the room. During an interview on 1/9/2023 at 2:49 PM, RNM #1 stated they had explained to CNA #1 on 1/3/23, that when a resident refused care, they needed to stop what they were doing and report it to the nurse. RNM #1 stated CNA #1 was terminated on 1/5/2023. During an interview on 1/13/2023 at 12:00 PM, the DON #1 stated they would have expected CNA #1 to respect Resident #2's wishes when they said they did not want to get ready for bed and stated CNA #1 could have asked the resident if there was anything they could do for them at that moment. The DON #1 stated that if Resident #2 told CNA #1 clearly that they had company coming, then they would not want to be in their night gown during the visit. During an interview on 1/13/2022 at 12:22 PM, the ADMIN #1 stated no means no. The ADMIN #1 stated CNA #1 should have gone to the nurse and told them the resident did not want to get undressed and they could not complete their assignment. 10 NYCRR 415.5(b)(1-3)

Based on record review and interviews during an abbreviated survey (Case #NY00298281), the facility did not ensure the resident's right to be free from abuse for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure Resident #1, who was cognitively intact and recovering from a stroke, was free from abuse on the night of 6/28/2022 when Resident #1's roommate (Resident #2), who was also cognitively intact, placed their hand under Resident #1's brief, and tried to place Resident #1's hand on Resident #2's genital area stating they were having trouble ejaculating and wanted Resident #1's help. Resident #1 reported that Resident #2 made two attempts to do that. Additionally, the facility did not ensure Resident #2's behaviors during the daytime hours on 6/28/2022 were assessed after two male therapy staff reported Resident #2 told them they were having trouble ejaculating and groped (to touch or fondle someone for sexual pleasure) them. This is evidenced by: Refer to F609 Refer to F610 The Policy and Procedure (P&P) titled Elder Justice Act Policy effective 11/28/2016, documented in accordance with Resident Abuse Reporting Law and the Elder Justice Act, it was the policy of the facility that all residents would be free from abuse, neglect, mistreatment, and exploitation. The P&P defined sexual abuse as non-consensual sexual contact of any type with a resident. The P&P titled Abuse, Neglect, & Misappropriation Prevention & Investigation Prohibition Policy effective 11/28/2016, documented residents had the right to be free from verbal, sexual, physical, mental (including mental anguish) abuse. Finding #1: The facility did not ensure Resident #1 was free from sexual abuse during the night of 6/28/2022. Resident #1: Resident #1 was admitted to the facility with diagnoses of hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side, aphasia (a brain disorder where a person has trouble speaking or understanding other people speaking), and recurrent major depressive disorder. The Minimum Data Set (MDS; an assessment tool) dated 6/23/2022, documented the resident was cognitively intact. Review of the Comprehensive Care Plan (CCP) last revised on 9/27/2022, documented the resident had the potential for physical/psychological injury/victim of abuse related to aggressive behaviors of another resident. The CCP goals documented the resident would be free of injury caused by another resident and the resident's rights would be maintained at all times. The CCP interventions documented to remove the resident from immediate danger if able, when the other resident exhibited outbursts or aggressive behaviors. The CCP did not include documentation of the incident of sexual abuse reported by the resident on 6/29/2022. Review of the Sub-Acute MD/NP (Medical Doctor/Nurse Practitioner) Follow-Up Note form dated 6/29/2022 at 11:22 AM, written by Physician (MD) #1, documented an inappropriate advancement by their roommate was reported to the staff. The Nursing Progress Note dated 6/29/2022 at 1:42 PM by the Assistant Director of Nursing/former Registered Nurse Manager (RNM) #1, documented the resident reported inappropriate sexual touch by their roommate during the night shift. The resident's roommate was moved to another room with one-to-one care. Review of an undated statement written by Resident #1, documented Resident #2 came over and stated they were having difficulty ejaculating and wanted Resident #1's help. Resident #1 documented Resident #2 kept trying. The resident documented no, then yes to reporting it to the law enforcement agency. Review of the Social Work/Case Worker Progress Note dated 6/29/2022 at 4:21 PM, written by Case Worker (CW) #1, documented they and Social Worker (SW) #1 met with Resident #1 about the resident's concerns regarding an incident that took place overnight with their roommate. Resident #1 wrote down on paper what took place. CW #1 documented Resident #1 stated they felt comfortable and safe now that the roommate was out of the room and away from them. Resident #1 was informed that the facility would be filing a report with local law enforcement and the resident agreed to speak to them. Psychological services and daily emotional support was/would be offered to the resident. Resident #1 denied psychological support at this time. Resident #2: Resident #2 was admitted to the facility with diagnoses of surgical aftercare following surgery of the circulatory system, chronic congestive heart failure (CHF), and need for assistance with personal care. The Minimum Data Set (MDS-an assessment tool) dated 6/30/2022, documented the resident independently made decisions regarding tasks of daily life. The COMS BIMS (brief interview for mental status) Evaluation dated 6/22/2022 at 7:04 PM by the Registered Nurse (RN), documented a BIMS score was 15.0 intact cognitive response. Review of the CCP last revised 6/29/2022, documented the resident exhibited inappropriate behaviors of sexually touching males. The CCP goals documented the resident would not show any physically aggressive actions toward other residents. The CCP interventions documented one-to-one monitoring; no male caregivers; and develop and use a contract with resident to achieve desired behavior. The COMS - Skilled Evaluation dated 6/29/2022 at 9:01 PM, written by the RN, documented Resident #2 was on one-to-one supervision for behaviors with male staff and residents. The Discharge Summary Note dated 6/30/2022 at 1:14 PM, written by RNM #1 documented Resident #2 discharged from the facility against medical advice (AMA). Review of the HERDS: NH (Nursing Home) Incident Form - NH submitted on 6/29/2022 at 3:14 PM by SW #1, documented the incident date and time was 6/29/2022 at 1:00 AM. It documented there was reasonable cause to believe that abuse, neglect, or mistreatment occurred; the facility investigation was complete; and a report was made to law enforcement. It documented the following: -Upon entering the resident's room for the morning, the Licensed Practical Nurse (LPN) #1 asked Resident #1 how their night was, and the resident stated, It sucked. -LPN #1 asked Resident #1 why and the resident made a masturbation hand gesture with their hand and pointed to their roommate, Resident#2. -LPN #1 asked Resident #1 if Resident #2 touched them and Resident #1 stated Pretty much. LPN #1 asked if their genital area was touched, and the resident stated they tried to but could not go underneath (meaning they could not get their hand underneath the underwear brief). -Resident #1 then reported they pushed Resident #2 away and Resident #2 then took Resident #1's right hand and tried to have the resident touch Resident #2's genital area. Resident #1 pulled their hand away and Resident #2 did not pursue the issue any further. -When SW #1 went in to talk to Resident #1, the resident essentially reiterated the entire incident and added, Resident #2 came over and said they were having trouble ejaculating and wanted Resident #1's help. They kept trying two times. I pushed them off, then they stopped. -Resident #2 was removed from the room and placed on one-to-one supervision by an aide around the clock and would be provided for the duration of the resident's stay. -Resident #1 was given a private room and was offered emotional support immediately by the SW (Social Work) team. Resident #1 declined SW's offer to have them meet with the facility psychologist, but it would be offered continually throughout the resident's stay. The resident was informed and planned to assist the facility with emotionally supporting the resident. -SW discussed with Resident #1 about filing a report with the police. Resident #1 declined to press charges but was agreeable to speak with police once the facility decided that filing a report would be appropriate. The Police Department Incident/Accident Referral dated 6/29/2022, documented Incident # 22-089921. During an interview on 11/3/2022 at 11:01 AM, Resident #1 stated that Resident #2 came over to them in the middle of the night and wanted Resident #1 to jerk Resident #2 off. Resident #1 stated that they told the resident No. Get out of here. Resident #1 stated that they told the night shift staff that Resident #2 had been (Resident #1 made a masturbation hand gesture) but staff did not do anything about it. Resident #1 stated that Resident #2 tried to touch them but did not. Resident #1 stated that Resident #2 wanted them to (Resident #1 made a masturbation hand gesture) and kept pulling Resident #1's hand and wanted them to touch Resident #2. Resident #1 stated that they did not know how it made them feel; the resident's faced turned red; and then they put their head down and were silent. The surveyor asked if they felt safe and Resident #1 stated, I guess so. Resident #1 stated that the day next day, they took Resident #2 out of the room. Resident #1 stated the police were called and they did not think that any charges were filed. During an interview on 11/3/2022 at 12:15 PM, SW #1 stated they were informed of the allegation of sexual abuse on 6/29/2022 at 8:30 AM, the same day that it was reported by LPN #1, who was the nurse that worked the morning shift and received the report from Resident #1. SW #1 stated that they interviewed the resident and asked if Resident #2 got their hand under Resident #1's brief, and the resident wrote no. Resident #1 said Resident #2 touched them over their brief. SW #1 then asked if they could call their daughter and the resident initially wrote no, and then later agreed and wrote yes. SW #1 stated that Resident #1 agreed with calling the police and talking to them. SW #1 was present when Resident #1 talked to the police and told them what they had previously told the nurse but did not want to file any charges. The police also talked to Resident #2 and SW #1 was present during the interview. SW #1 stated that the police told Resident #2 that they could not touch people inappropriately and told the resident to keep their hands to themselves. SW #1 stated that they did a quick check of the residents on the unit to see if Resident #2 had been going into resident rooms and no one came forward with any concerns. SW #1 stated that they wanted to call Resident #2's family/representative but Resident #2 would not confirm the phone number but then got a hold of a family member and demanded them to come and get them. During an interview on 11/3/2022 at 3:08 PM, LPN #1 stated they no longer worked at the facility. LPN #1 stated that Resident #1 was upset that Resident #2 tried to touch them but did not. Resident #1 told them they were able to get Resident #2 to go away. During an interview on 11/4/2022 at 10:33 AM, SW #1 stated that the spiritual care staff talked to Resident #1 daily following the incident. SW #1 stated they talked to the resident's daughter and decided it was best to address their emotional state and put Resident #1 in a private room so they did not have to worry about a roommate. The resident's daughter told SW #1 that the resident wanted the door shut and did not want to be bothered. SW #1 stated that Resident #1 was anxious following the incident and needed continued emotional support. SW #1 stated they made the resident a do not disturb sign for the door and told staff to not enter the room unless the call light was on, so that the resident could have their own time. During an interview on 11/4/2022 at 11:20 AM, RNM #1, stated they recalled a report that Resident #1 woke up to Resident #2 standing over them and it made Resident #1 feel uncomfortable because they were trying to sleep. RNM #1 stated they did not recall any sexually appropriate behavior with Resident #2 and Resident #1. RNM #1 stated they moved Resident #2 to a private room afterwards. During an interview on 11/4/2022 at 12:56 PM, the Director of Nursing (DON) #1 stated they were notified on 6/29/2022 of an incident with Resident #2 and Resident #1. The DON #1 stated they did not see the incident as an allegation of abuse because Resident #2 tried to do something but did not go through with it. The DON #1 stated that if it was abuse, they would have been more highly involved with the investigation. The DON #1 stated that SW #1 usually handled resident-to-resident altercations and talked to residents and family. The DON #1 stated that resident-to-resident altercations were different than any other type of investigation and there would not be an Accident/Incident Report completed for the incident. The DON #1 stated that when they did an investigation, they would write an investigation summary that stated what the complaint was; what was done for the resident and employees; and would have written all the steps that were taken to avoid something like that from happening in the future, the best they could. The DON #1 reviewed the HERDS: NH (Nursing Home) Incident Form - NH submitted on 6/29/2022 at 3:14 PM by SW #1, and stated, So, if it bothered the victim and they did not feel safe and it sounds like they did not, it would be an allegation of abuse? During an interview on 11/4/2022 at 2:56 PM, the Administrator (ADMIN) #1 stated that they were aware of the report that Resident #1 made on 6/29/2022 and stated that it got filtered to them at 9:00 AM on 6/29/2022. ADMIN #1 stated Resident #1 reported to the day nurse that Resident #2 had inappropriately touched Resident #1. Resident #2 was on Resident #1's side of the room and had their hand on Resident #1's blanket. ADMIN #1 stated they could not remember the details. ADMIN #1 stated that they considered it an allegation of abuse and started an investigation. During an interview on 11/7/2022 at 3:02 PM, MD #1 stated that the only time they knew anything about Resident #2's inappropriate sexual behavior with staff, was when Resident #2 had assaulted their roommate. MD #1 stated that they assessed Resident #1 but did not get a chance assess Resident #2, because they left the facility AMA. During an interview on 11/8/2022 at 4:12 PM, the Medical Director (MD) #2 stated they were aware of the incident and knew that the police came to the facility. Finding #2: The facility did not ensure an assessment of Resident #2's behaviors on 6/28/2022 during the daytime hours, when two male therapy staff reported that the resident told them they were having trouble ejaculating and that the resident had groped them. Review of an email dated 6/28/2022 at 1:06 PM by the Director of Rehabilitation Services (DRS) #1 and addressed to the Social Worker (SW) #1; Case Worker (CW) #1; Registered Nurse Manager (RNM) #1; and Case Manager (CM) #1, documented they wanted to pass on the following information as they were not sure if it was happening to anyone else. The DRS #1 documented Resident #2 had been sexually inappropriate with two of their male staff. Resident #2 tended to want to touch them and groped them inappropriately today. The DRS #1 asked their staff to let Nursing know, which they did by passing on the findings to the medication nurse. The Behavior Note dated 6/28/2022 at 10:34 PM by LPN #2, for Resident #2 was incorrectly documented in Resident #1's medical record. LPN #2 documented the male CNA reported that the resident was in an extreme episode of masturbation and groping this evening. The resident asked the male CNA to help them cream their penis. During an interview on 11/3/2022 at 2:00 PM, the DON #1 stated the written on 6/28/2022 at 10:34 PM by LPN #2 belonged to Resident #2. Review of Resident #2's medical record, documented no changes to the CCP and no assessments dated 6/28/2022, for the resident's sexually inappropriate behaviors on 6/28/2022. Also, there was no documentation the Administrator and the MD were notified. Review of the Employee Statement dated 6/29/2022 by the Physical Therapy Assistant (PTA) #1, for date of occurrence 6/28/2022, documented Resident #2 was being seen for therapy in their room and was found with their pants down. PTA #1 asked the resident to pull up their pants. Resident #2 pulled up their pants and performed the exercises. Afterwards, Resident #2 sat to rest and leaned forward to check the therapist's ID card clipped to their chest. Resident #2 then quickly groped PTA #1's private part and leaned back. Resident #2 then continued the therapy session. When PTA #1 was about to leave, Resident #2 held PTA #1's hand very tight and stated, I have a very hard time ejaculating, but maybe it will get better soon. Resident #2 let go of PTA #1's hand and they left the room and PTA #1 immediately reported Resident #1's behavior to the DRS #1. Review of a statement by the Certified Occupational Therapy Assistant (COTA) #1 dated 6/29/2022, documented that upon entering Resident #2's room, Resident #2 was being bathed by an aide, while the resident was seated in their wheelchair. COTA #1 asked if they could take over and have the resident complete their bathing task for therapy. As soon as the aide left the room, Resident #2 told COTA #1 they were having trouble ejaculating. COTA #1 told the resident they would not be able to help them with that and was able to redirect the conversation. Prior to donning a brief, the resident began to touch their own genitals and COTA #1 told the resident they should not be doing that in the company of anyone else and redirected the resident to don their pants. Resident #2 stood up after pulling up their pants and then the resident attempted to grab their groin. COTA #1 told the resident it was inappropriate, redirected the resident and finished the therapy session. The Therapy Director was made aware. During an interview on 11/3/2022 at 1:03 PM, Certified Nurse Aide Trainee (CNAT) #1 stated they no longer worked at the facility. CNAT #1 stated that when they started their shift on 6/28/2022 at 1:00 PM, everyone already knew that Resident #2 had been sexually inappropriate with a coworker and CNAT #1 was told by RNM #1 and LPN #1 that the resident had grabbed another male CNA's penis. CNAT #1 stated that during their shift, they answered Resident #2's call light and when they entered the room, the resident was noted to be masturbating. CNAT #1 stated Resident #2 then asked them to put lotion on their penis and implied that they wanted the lotion to masturbate. CNAT #1 stated they told the resident they could not and then reported it to LPN #1. CNAT #1 stated that there were other staff that witnessed the resident masturbating that same day. CNAT #1 stated that they reported to the LPN #1 because they were a mandated reporter and knew that if you see something, say something and also because CNAT #1 felt unsafe in the situation and at the same time wanted Resident #2 to get the care they needed. CNAT #1 stated that they felt that LPN #1 should have reported it to RNM #1. CNAT #1 stated that the only reason they went into the resident's room to take care of them was because all of the other CNA's were avoiding the resident and would not go in the room. During an interview on 11/3/2022 at 2:06 PM, CNA #2 stated that they worked the night shift on 6/28/2022. CNA #2 stated that all they could remember was that Resident #2 was masturbating that night. CNA #2 stated that Resident #1 did not report anything to them during the night. During an interview on 11/3/2022 at 2:20 PM, PTA #1 stated, He groped me. PTA #1 asked the surveyor if they could reenact the incident. PTA #1 stated they had transferred the resident to the wheelchair and was sitting across from the resident. Resident #2 asked them what their name was, and PTA #1 lifted up their ID badge to show the resident. Resident #2 told PTA #1 they could not see it asked PTA #1 to come closer to them. PTA #1 moved closer to resident and then the resident touched PTA #1's face under their chin with one hand and grabbed their private area with the other hand. PTA #1 stated they were shocked and did not say anything to the resident. PTA #1 stated they left the room and told LPN #1 that the resident had groped them. PTA #1 stated they then told the DRS #1. PTA #1 stated that they saw the resident in the morning on 6/28/22, and that was when the resident groped them. PTA #1 stated they felt sorry for Resident #1 because they were a bit helpless because of their physical condition. PTA #1 stated Resident #1 had left-sided weakness. PTA #1 stated they believed Resident #2 groped another therapist that same day because the other therapist heard about them being groped and stated that it had happened to them too. During an interview on 11/3/2022 at 3:08 PM, LPN #1 stated that on 6/28/2022, Resident #2 was noted to be constantly masturbating and they reported it to RNM #1. LPN #1 stated that everyone knew about the inappropriateness of Resident #2's actions on 6/28/2022 and stated staff were warned not to go into their room without a partner. LPN #1 stated that they went into Resident #2's room with CNAT #1, when they had to give medications. LPN #1 stated that PTA #1 told LPN #1 that the resident had groped them. LPN #1 stated they told RNM #1, and PTA #1 told their supervisor. LPN #1 stated that nothing was done about it. During an interview on 11/4/2022 at 10:33 AM, SW #1 stated they were not aware of an incident on 6/28/2022, with Resident #2 and PTA #1. During an interview on 11/4/2022 at 11:20 AM, RNM #1 stated they were not aware that Resident #2 had groped PTA #1. RNM #1 stated if staff reported they were groped, RNM #1 would have reported to the DON, the MD, and the SW. RNM #1 stated Resident #2 would have been assessed by the physician, have a care plan in place right away, and interviewed the resident. RNM #1 then stated they knew Resident #2 had sexual behaviors that were reported, and a police report was made for Resident #2. RNM #1 stated a care plan for exhibiting inappropriate behaviors of sexually touching males was initiated on 6/29/2022. RNM #1 stated a verbal contract was developed and stated the resident discussed with the SW that they would not inappropriately touch staff or other residents. During an interview on 11/4/2022 at 12:16 PM, the DRS #1 stated that PTA #1 and COTA #1 told them Resident #2 touched them inappropriately and they both wrote a statement. The DRS #1 stated they recalled sending an email about it to SW #1, RNM #1, and probably the Director of Nursing (DON). The DRS #1 stated they may have talked to SW #1 or Nursing about the reports from staff. During an interview on 11/4/2022 at 12:56 PM, the DON #1 stated they did not know PTA #1 was groped prior to the incident on 6/29/2022, with Resident #2 and Resident #1. The DON stated they did not know COTA #1 was groped by Resident #2 until just now, during the interview. The DON #1 stated they only knew about PTA #1 and CNAT #1 because of what they read in a statement from another staff member. The DON #1 stated they did not have statements by PTA #1 and COTA #1. The DON #1 stated that if they were the nurse on the floor and they learned about it on 6/28/2022, they would have reported it to the physician; would have looked at putting Resident #2 in their own room; and would have put it in a care plan. On 11/4/2022 at 1:56 PM, SW #1 provided the surveyor with statements dated 6/29/2022 by PTA #1 and COTA #1. On 11/4/2022 at 2:09 PM, SW #1 provided the surveyor with the email dated 6/28/2022 by the DRS #1. SW #1 stated that they did not do anything when they received the email because they considered it an employee issue and thought RNM #1 would address it. SW #1 stated that at the end of the day they (all of the email recipients) should have put their heads together and developed a plan to address the situation. During an interview on 11/4/2022 at 2:54 PM, RNM #1 review the email dated 6/28/2022 by the DRS #1. RNM #1 stated they really did not remember the email. During an interview on 11/4/2022 at 2:56 PM, the ADMIN #1 reviewed the email dated 6/28/2022 by the DRS #1. The ADMIN #1 stated they were not aware of the email. They were made aware of the incident that happened with PTA #1 but was not aware of the incident with COTA #1 until later. The ADMIN #1 stated they should have been made aware on 6/28/2022 and would have asked SW #1 and RNM #1 to talk to Resident #2, and to talk to staff. The ADMIN #1 stated they would not have made the [NAME] that Resident #2 was at risk for groping another resident but would have had the resident evaluated and assessed both physically and mentally. The ADMIN #1 stated they would have notified the MD after the initial RN assessment and would have would have reviewed care planning. During an interview on 11/7/2022 at 9:40 AM, COTA #1 stated they were working with Resident #2 and were helping them get washed up and then of a sudden, the resident groped COTA #1. COTA #1 told the resident it was inappropriate, to stop, and told them they did not want them to do it again. COTA #1 stated that the resident did not get upset and acted like it never happened and was not a big deal. COTA #1 stated they continued to work with the resident and then went back to therapy room and PTA #1 said something had already happened to them. COTA #1 stated they were almost certain that it happened to both of them on the same day because PTA #1 was pretty upset about it. COTA #1 stated they told the DRS #1, and they did not tell anyone from nursing. During an interview on 11/7/2022 at 1:42 PM, CNA #3 stated that CNAT #1 was a young man and was frightened to go into Resident #2's room on 6/28/2022, because the resident told CNAT #1 that they wanted them to help them to massage their penis for them. CNA #3 stated they told CNAT #1 to report it. CNA #3 stated that Resident #2 had also been showing themselves to other aides. CNA #3 stated that every time staff would go into the room to help the resident, the resident was butt naked with their hand on their penis and a smile on their face. CNA #3 stated that Resident #2 was mobile and could walk. During an interview on 11/7/2022 at 3:02 PM, MD #1 stated if they were informed on 6/28/2022, they would have probably sent Resident #2 out to the hospital for an assessment and possible diagnostic testing for their hypersexual behavior to rule out an organic cause, and for a psychological evaluation. During an interview on 11/8/2022 at 4:12 PM, the Medical Director (MD) #2 stated that they were aware that Resident #2 was inappropriate with one of their caregivers that was approximate to their discharge date . MD #2 stated that Nursing and Therapy would have been aware of the resident's behaviors on 6/28/2022, because the aides and the therapists would have reported it. MD #2 stated that there should have been a discussion with Resident #2 on 6/28/2022, by Social Work, Nursing, and Therapy regarding sexual expression in a long-term care. During an interview on 11/15/2022 at 12:56 PM, CW #1 stated they were the caseworker for Residents #1 and #2. CW #1 stated they spoke with SW #1 after they received the email from the DRS #1 that stated Resident #2 had tried to grope a male therapist. CW #1 stated that SW #1 was the licensed SW, and they were responsible for addressing complaints. CW #1 stated they told SW #1 that the situation needed to be addressed. CW #1 stated they believed that SW #1's response to the email was that it was sent to give them the heads up and not for them to do anything about it. CW #1 stated they called Resident #2's primary care physician (PCP) about the allegations and gave them specific detail. Review of the SW/CW Progress Note dated 6/28/2022 at 1:39 PM, documented CW #1 spoke to the PCP to inform them of the resident's admission to the facility; asked if they had an emergency contact and was told they did not. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case # NY00298281), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse to the State Agency for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure that an allegation of sexual abuse reported by Resident #1 on 6/29/2022, was reported within 2 hours after the allegation was made. The allegation was made at 7:30 AM and was reported to the Administrator at approximately 9:00 AM but was not reported to the New York State Department of Health (NYSDOH) until 3:14 PM on 6/29/2022, approximately 8 hours after the allegation was made. This is evidenced by: Refer to F600 Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side, aphasia (a brain disorder where a person has trouble speaking or understanding other people speaking), and recurrent major depressive disorder. The Minimum Data Set (MDS; an assessment tool) dated 6/23/2022, documented the resident was cognitively intact. Review of the facility's annual abuse training documented the following policies: The Policy and Procedure titled Elder Justice Act Policy effective 11/28/2016, documented in accordance with Resident Abuse Reporting Law and the Elder Justice Act, it was the policy of the facility that all residents would be free from abuse, neglect, mistreatment, and exploitation. A report to the New York State Department of Health (NYSDOH) must be made immediately, but no later than 2 hours after forming the suspicion that an allegation met the following criteria: there was suspicion that abuse occurred. The P&P defined sexual abuse as non-consensual sexual contact of any type with a resident. The P&P titled Abuse, Neglect, & Misappropriation Prevention & Investigation Prohibition Policy effective 11/28/2016, documented residents had the right to be free from verbal, sexual, physical, mental (including mental anguish) abuse. All employees had an obligation and an expectation to report such abuses when they had reasonable suspicion and/or cause to believe that such an incident occurred. The facility was to follow guidelines as outlined in the federal/state regulations, Dear Administrator Letters, CMS State Operations Manual Appendix PP, and facility P&Ps. Staff would report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services, or their designee as soon as was reasonably possible. The purpose of the P&P was to provide a framework for training employees in prevention, identification, and reporting; protecting residents at risk; and investigating allegations of abuse. The P&P documented that a report to the NYSDOH must be made immediately, but no later than 2 hours after forming the suspicion that an allegation met the following criteria: there was suspicion that abuse had occurred. There was no documented evidence of a facility investigation summary at the time of the survey. The Investigation Summary Form dated 6/29/2022 at 1:00 AM, was sent to the surveyor via email on 11/9/2022 at 11:16 AM. It documented an event regarding Resident #2, reported by Resident #1 to LPN #1, was discovered on 6/29/2022 at 7:30 AM. The investigation was initiated by SW #1 on 6/29/2022 at 7:30 AM. Review of the HERDS: NH (Nursing Home) Incident Form - NH submitted to the NYSDOH on 6/29/2022 at 3:14 PM by the Social Worker (SW) #1, documented Licensed Practical Nurse (LPN) #1 received an allegation of sexual abuse by Resident #1, upon entering the resident's room for the morning. LPN #1 immediately acted and reported to SW #1. The NYSDOH Intake Information form (Case # NY00298281) dated 6/30/2022, documented receipt of a facility reported incident that was submitted to the NYSDOH on 6/29/2022 at 3:14 PM. The date/time of occurrence was documented as 6/29/2022 at 1:00 AM. During an interview on 11/4/2022 at 10:33 AM, SW #1 stated they were informed of the allegation of sexual abuse made by Resident #1 on 6/29/2022, when they reported for work at around 8:00 AM or 8:30 AM on 6/29/2022. SW #1 stated they then notified the Director of Nursing (DON) #1 and the Assistant Director of Nursing/former Registered Nurse Manager (RNM) #1. SW #1 stated they told them that a nurse came to them and reported some pretty serious allegations. SW #1 stated they then talked to the Administrator (ADMIN) #1. SW #1 stated they submitted a report to the NYSDOH on 6/29/2022. SW #1 stated it was their understanding that the report had to be submitted within 24 hours and was not aware of the 2-hour window. During an interview on 11/4/2022 at 11:20 AM, RNM #1 stated that the DON #1 usually reported incidents to the NYSDOH. RNM #1 stated that they know now that allegations of abuse have to be reported within 2 hours of the allegation. During an interview on 11/4/2022 at 12:56 PM, the DON #1 stated that prior to the new regulations, if you received a report of abuse, it was not a 2-hour window, it was 24 hours; and it was only reported to the NYSDOH if you thought you had abuse and enough information for abuse. During an interview on 11/4/2022 at 2:56 PM, the ADMIN #1 stated that the allegation of sexual abuse by Resident #1 got filtered to them during morning meeting on 6/29/2022 around 9:00 AM. The ADMIN #1 stated, From the time you suspect abuse occurred, you have a 2-hour window to report to the NYSDOH. 10 NYCRR 415.4(b)(2)

Based on record review and interviews during an abbreviated survey (Case # NY00298281), the facility did not ensure in response to an allegation of abuse, that it had evidence that all alleged violations were thoroughly investigated for 1 (Resident #1) of 3 residents reviewed. Specifically, Resident #1 reported an allegation of sexual abuse on 6/29/2022. The facility did not have evidence that the alleged violation was thoroughly investigated. This is evidenced by: Refer to F600 Resident #1: Resident #1 was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side, aphasia (a brain disorder where a person has trouble speaking or understanding other people speaking), and recurrent major depressive disorder. The Minimum Data Set (MDS; an assessment tool) dated 6/23/2022, documented the resident was cognitively intact. The Policy and Procedure (P&P) titled Abuse, Neglect, & Misappropriation Prevention & Investigation Prohibition Policy effective 11/28/2016, documented the following for investigation/identification: the resident(s) would be assessed and any necessary care and treatment provided; the Nursing Supervisor/Nurse Manager would initiate the investigation on the shift in which the incident was observed, the report was first received, or when the abuse was suspected, and would notify the Director of Nursing (DON). The DON or designee would coordinate the investigation and review of facts concerning the incident. The review would include all pertinent items on the Investigation Checklist for the Allegation of Resident Abuse/Neglect/Mistreatment document. Residents involved should preferably be interviewed by a Social Worker. Residents should be assessed and counseled for any actual or potential psychosocial harm. A thorough investigation included the following: a statement from the resident, if they were able to provide a statement about the incident, an explanation of the evidence reviewed; what documents (i.e. care plans, policies and procedures) were reviewed and why the documents were selected for review, the conclusion reached as a result of the investigation with a discussion of its basis, and any changes made to care plans or processes. Review of the HERDS: NH (Nursing Home) Incident Form - NH submitted to the New York State Department of Health (NYSDOH) on 6/29/2022 at 3:14 PM by SW #1, documented there was reasonable cause to believe that abuse, neglect, or mistreatment occurred; the facility investigation was complete; and a report was made to law enforcement. There was no documented evidence of an Accident/Incident Form dated 6/29/2022, for the allegation of sexual abuse. There was no documented evidence of a facility investigation summary at the time of the survey. An email dated 11/14/2022 at 9:58 AM by the Administrator (ADMIN) #1 and addressed to the surveyor, documented the Director of Nursing (DON) #1 summarized all of the information that was provided in the (investigation) summary, and it was compiled on the date it was sent to the surveyor. The facility Investigation Summary dated 6/29/2022, was attached to the email. Review of the Investigation Summary Form dated 6/29/2022 at 1:00 AM, sent to the surveyor via email on 11/9/2022 at 11:16 AM, documented the following: -The date of the incident report was not documented. -An immediate assessment of the alleged victim, Resident #1 was not documented. -An interview with the alleged perpetrator, Resident #2 was not documented. The summary documented that on 6/30/2022, Resident #2 left AMA (against medical advice). -There was no documented evidence that a record review for pertinent information related to the alleged violation, as appropriate, such as progress notes, incident reports and medication administration records was conducted. -The summary documented 6 residents were interviewed and that Social Work interviewed patients on the low side of unit 1 North to confirm that Resident #2 or any other unauthorized persons had not entered their room. It documented that all residents confirmed that only facility staff had been entering the rooms. Review of the Daily Census dated 6/29/2022, documented 19 residents, excluding Resident #s 1 and 2, resided on the unit. There was no additional documentation that the other 13 residents were interviewed. -The Record Review Conclusion documented to include review of assessments, care plans, progress notes, assignments, diagnosis, disciplinary actions and follow up, etc.). There was no documented evidence that a record review was conducted. There was no documented evidence of an Investigation Checklist for the Allegation of Resident Abuse/Neglect/Mistreatment, per the facility's policy titled Abuse, Neglect, & Misappropriation Prevention & Investigation Prohibition Policy effective 11/28/2016, at the time of the survey. The checklist was requested and provided by the facility on 11/22/2022. In an email dated 11/22/2022 at 3:55 PM by the Administrator (ADMIN) #1 and addressed to the surveyor, documented the checklist was checked off today per the surveyor's request for the checklist and included information available from the file and EMR (electronic medical record). Review of the undated Checklist for the Allegation of Resident Abuse/Neglect/Mistreatment documented: -The statement of the victim was obtained, obtained, reviewed, and placed in the investigation file. There was no documentation that the aggressor's statement was obtained. -The checklist documented that the face sheet with diagnosis; most recent history and physical; physician's current orders; nurses notes 48 hours before and after the occurrence; care plan(s) related to the occurrence; care plan Kardex (resident care card); new care plan(s) generated by the occurrence; most recent MDS; and staff assignments were placed in the investigation file. There was no documented evidence of the documents in the investigation file that was provided by the facility at the time of the survey. During an interview on 11/3/2022 at 12:15 PM, SW #1 stated they interviewed Resident #1 and had them write a statement. SW #1 stated they interviewed residents by doing a quick check to see if Resident #2 was going into resident rooms. SW #1 stated that no one came forward. SW #1 stated they did not interview Resident #2 and stated they were present when police interviewed the resident. SW #1 stated that the Case Worker (CW) #1 was involved in the investigation and no longer worked at the facility. SW #1 stated that they took the lead and showed CW #1 how to handle situations like this. During an interview on 11/4/2022 at 10:33 AM, SW #1 stated they were involved in the investigation because they would investigate resident-to-resident altercations. SW #1 stated they interviewed residents and the DON #1 interviewed staff. SW #1 said they never saw an Accident/Incident Form for the incident and stated they did not review any records for Resident #s 1 and 2. SW #1 stated that Nursing asked them to submit the report to the NYSDOH. SW #1 stated they did not reach out to Resident #2 or their family/representative. SW #1 stated that their main goal was to ensure Resident #1 felt safe again. During an interview on 11/4/2022 at 12:56 PM, the Director of Nursing (DON) #1 stated they were notified on 6/29/2022 of an incident with Resident #2 and Resident #1. The DON #1 stated they did not see the incident as an allegation of abuse because Resident #2 tried to do something but did not go through with it. The DON #1 stated that if it was abuse, they would have been more highly involved with the investigation. The DON #1 stated that SW #1 usually handled resident-to-resident altercations and talked to residents and family. The DON #1 stated that resident-to-resident altercations were different than any other type of investigation and there would not be an Accident/Incident Report completed for the incident. The DON #1 stated that when they did an investigation, they would write an investigation summary that stated what the complaint was; what was done for the resident and employees; and would have written all the steps that were taken to avoid something like that from happening in the future, the best they could. The DON #1 reviewed the HERDS: NH (Nursing Home) Incident Form - NH submitted on 6/29/2022 at 3:14 PM by SW #1, and stated, So, if it bothered the victim and they did not feel safe and it sounds like they did not, it would be an allegation of abuse? The DON #1 stated they did not review the medical record for Resident #s 1 and 2 during the investigation. During an interview on 11/4/2022 at 2:56 PM, the ADMIN #1 stated that the incident reported by Resident #1 was considered an allegation of abuse and an investigation was started. The ADMIN #1 stated the investigation was a team effort. SW #1 was responsible for resident-to-resident altercations and interviewed both residents and other residents and Nursing assisted with contacting staff. The ADMIN #1 stated that no other residents had concerns. The ADMIN #1 stated that SW #1 talked to Resident #2, and they denied their actions. The ADMIN #1 stated that local law enforcement was notified and talked to Resident #2, and the resident denied their actions. The ADMIN #1 stated that Resident #2 called their designated representative, and they came and took the resident out of the facility, AMA. The ADMIN #1 stated the facility's investigation was completed on 6/30/2022. During an interview on 11/15/2022 at 12:56 PM, CW #1 stated they were involved in the investigation and SW #1 was lead person in charge of the investigation. CW #1 stated they took direction from SW #1, who was advised by the ADMIN #1, who told them to investigate the incident and to talk to Resident #1 and other residents on the unit. CW #1 stated that SW #1 was supposed to see all the residents on the unit to make sure no one else was subjected to sexual abuse. CW #1 stated that SW #1 interviewed residents on one side of the unit and then forgot to do the other side. CW #1 stated they were a case worker and discharge planner, not a social worker. CW #1 stated they did not go with SW #1 when they interviewed the other residents. CW #1 stated that the Nursing department would usually let Social Work handle everything. 10 NYCRR 415.4(b)(3)

Based on observations, record reviews and interviews during the recertification survey the facility did not ensure each resident was treated with respect and dignity for one (Resident #32) of two residents reviewed. Specifically, for Resident #32, the facility did not ensure a catheter drainage bag was covered when the resident was out of bed and in common areas of the facility. This is evidenced by: Resident #32 Resident #32 was admitted to the facility with the diagnoses of dementia, obstructive and reflux uropathy and benign prostatic hyperplasia with lower urinary symptoms. The Minimum Data Set (MDS - an assessment tool) dated 9/10/22 documented the resident was severely cognitively impaired. A Policy and Procedure (P&P) titled Long Term Catheterization of Urinary Bladder revised 6/14/17 documented a urinary catheter drainage bag should be kept covered. During an observation on 11/9/22 at 12:47 PM, Resident #32 was in the dining room. Resident's urinary catheter drainage bag was visible and not covered. During an observation on 11/10/22 at 11:13 AM, Resident #32 was in a common area by the nurse's station. Resident #32's urinary catheter drainage bag was visible and not covered. A Physician's Order dated 11/11/22 documented Foley size 16 French 10 milliliter change per schedule every evening shift every 30 days for benign prostatic hypertrophy and as needed. During an interview on 11/16/22 at 10:13 AM, Licensed Practical Nurse (LPN) #1 stated the catheter bag should be covered with a privacy bag when out of bed. Privacy bags were kept on the unit in an unlocked closet that was accessible to all staff. During an interview on 11/16/22 at 10:13 AM, Registered Nurse (RN) #1 stated the catheter bag should be covered. During an interview on 11/16/22 at 10:46 AM, Certified Nursing Assistant (CNA) #1 stated the catheter bag should be covered whenever the bag is visible in public areas like a dining room or television area. During an interview on 11/16/22 at 2:47 PM, the Director of Nursing (DON) stated whenever a resident with a urinary catheter is out of bed, the bag should be covered at all times. 10NYCRR 415.3(c)(1)(i)

Based on record review and interview during a recertification survey, the facility did not ensure that written notification was sent to the resident, the resident's representative, and a representative of the Office of the State Long-Term Care Ombudsman of the resident's transfer or discharge and the reasons for the move for 3 (Resident #'s 13, 29, and #100) of 3 residents reviewed for hospitalization . Specifically, for Residents #'s 13 and #100, the facility did not ensure there was documentation that the facility provided written notification to the resident, the resident's representative, or the Ombudsman when the residents were admitted to a hospital from the facility and for Resident #29, the facility did not provide written notice of admission to a hospital to the Ombudsman. This is evidenced by: Resident #13 Resident #13 was admitted to the facility with the diagnoses of hemiplegia after cerebral vascular accident, diabetes mellitus, and peripheral vascular disease. The Minimum Data Set (MDS - an assessment tool) dated 9/12/2022, documented the resident could understand, was understood with severely impaired cognition for daily decision making. A Progress Note dated 10/03/2022 at 10:14 AM, documented the following: LOA via stretcher for vascular intervention possibly surgery. Family with resident. A Progress Note dated 10/04/2022 at 7:47 AM, documented the following: Per 11 to 7 nurse, resident vascular procedure was not done yesterday and was admitted last night for procedure today. A Progress Note dated 10/05/2022 at 4:11 PM, documented the following: Returned to unit from hospital via stretcher, supervisor aware. During an interview on 11/16/2022 at 2:48 PM, the Social Worker (SW) #1 stated they were not aware they were responsible to notify the family and ombudsman about transfer discharge in writing. Changes in staff had occurred and the SW had just become aware this was their job duty. Transfer discharge, notification to ombudsmen, and bed hold for Resident #13 could not be found and had not been completed as required. During an interview on 11/17/2022 at 10:48 AM, the Administrator stated there was no evidence that written family notification or notification to the ombudsmen had been completed for Resident #13. The Social Workers for the facility are responsible to do this and evidence that this was completed could not be found. Resident #29 Resident #29 was admitted to the facility with the diagnoses of paroxysmal atrial fibrillation, unspecified injury of left hip and other asthma. The Minimum Data Set (MDS - an assessment tool) dated 9/12/2022, documented the resident could understand, was understood and was cognitively intact. A Progress Note dated 9/7/22 at 6:58 PM documented resident's vital signs showed continued tachycardia (rapid heartbeat) and drop in blood pressure. An order was obtained from medical provider to send the resident to the emergency department for evaluation. Resident's emergency contact was notified over the phone. A Progress Note dated 9/26/22 at 1:34 PM documented the resident returned to the facility after a hospitalization for atrial fibrillation. During an interview on 11/16/22 at 2:30 PM, Social Worker (SW) #2 stated they did not believe the Ombudsman was contacted after Resident #29's discharge to the hospital. During an interview on 11/16/22 at 3:01 PM, SW #1 stated a former employee had been handling the ombudsman notification of discharge, but that employee was no longer at the facility. SW #2 stated they are now aware it is the responsibility of the Social Work Department to notify the Ombudsman when a resident is discharged from the facility. During an interview on 11/17/22 at 11:09 AM, the Administrator stated the Ombudsman should have been informed about any resident's transfer and admission to the hospital. Resident #100 Resident #100 was admitted to the facility with the diagnoses of malnutrition, anemia, and dysphagia. The Minimum Data Set (MDS - an assessment tool) dated 10/05/2022, documented the resident could understand, was understood with severely impaired cognition for daily decision making. A Progress Note dated 9/24/2022 at 9:55 AM, documented the following: MD in this AM and lab draw done with difficulties, MD contacted Health Care Proxy and sent out to the emergency room for evaluation. A Progress Note dated 10/03/2022 at 12:56 PM, documented the following: Resident readmitted to the facility from the hospital. Resident 100 was readmitted with a g-tube. During an interview on 11/16/22 1:39 PM, Social Worker #1 stated that she hadn't done the notification to family and the Ombudsmen had not been done. SW #2 had not been instructed this was something that needed to be done by them. Another employee who was no longer at the facility had been responsible for this and SW #2 was not aware this needed to be completed until recently. During an interview on 11/16/2022 at 3:11 PM, the Administrator stated the written notification to families for transfer/discharge to the hospital and the ombudsman notification for Resident #100 had not been completed per regulation. The SW #1 had not been aware this was required and should have been completed by them. 10NYCRR415.3 (h)(1)(iii)(a-c)

Based on record review and interview during a recertification survey, the facility did not ensure written notice which specifies the duration of the bed-hold policy, was provided to the resident and the resident representative at the time of transfer for hospitalization . This was evident for 3 (Residents #'s 13, 29, and #100) of 3 residents reviewed for hospitalization . Specifically, for Residents #'s 13, 29, and #100, the facility did not ensure the resident and the resident's representative were notified in writing of the bed hold policy when the residents were admitted to the hospital. This is evidenced by the following: The Policy and Procedure (P&P) titled Bed Retention Policy effective 11/28/16, stated when a hospital transfer occurs, the resident and/or designated representative will be notified verbally or in writing by nursing or social services by the next business day. Resident #13 Resident #13 was admitted to the facility with the diagnoses of hemiplegia after cerebral vascular accident, diabetes mellitus, and peripheral vascular disease. The Minimum Data Set (MDS - an assessment tool) dated 9/12/2022, documented the resident could understand, was understood with severely impaired cognition for daily decision making. A Progress Note dated 10/03/2022 at 10:14 AM, documented the following: LOA via stretcher for vascular intervention possibly surgery. Family with resident. A Progress Note dated 10/04/2022 at 7:47 AM, documented the following: Per 11 to 7 nurse, resident vascular procedure was not done yesterday and was admitted last night for procedure today. A Progress Note dated 10/05/2022 at 4:11 PM, documented the following: Returned to unit from hospital via stretcher, supervisor aware. During an interview on 11/16/2022 at 2:48 PM, the Social Worker (SW) #1 stated there was no evidence a written bed hold for Resident #13 could had been completed as required. A previous staff person had been responsible for doing this and was no longer at the facility. During an interview on 11/17/2022 at 10:48 AM, the Administrator stated there was no evidence that written notification for bedhold had been completed for Resident #13 during the most recent hospitalization . The Social Workers for the facility are responsible to do this and evidence that this was completed could not be found. Resident #29 Resident #29 was admitted to the facility with the diagnoses of paroxysmal atrial fibrillation, unspecified injury of left hip and other asthma. The Minimum Data Set (MDS - an assessment tool) dated 9/12/2022, documented the resident could understand, was understood and was cognitively intact. A Progress Note dated 9/7/22 at 6:58 PM, documented the resident's vital signs showed continued tachycardia (rapid heartbeat) and drop in blood pressure. An order was obtained from the medical provider to send the resident to the emergency department for evaluation. Resident's emergency contact was notified over the phone. A Progress Note dated 9/26/22 at 1:34 PM, documented the resident returned to the facility after a hospitalization for atrial fibrillation. During an interview on 11/16/22 at 2:30 PM, Social Worker (SW) #2 stated the bed retention policy is reviewed with the family or resident upon admission and it should be done again upon any facility-initiated discharge. During an interview on 11/17/22 at 11:09 AM, the Administrator stated the resident and family should have been made aware in writing of the bed hold policy upon transfer and admission to the hospital. Resident #100 Resident #100 was admitted to the facility with the diagnoses of malnutrition, anemia, and dysphagia. The Minimum Data Set (MDS - an assessment tool) dated 10/05/2022, documented the resident could understand, was understood and their cognition for daily decision making was severely impaired cognition. A Progress Note dated 9/24/2022 at 9:55 AM, documented the following: MD in this AM and lab draw done with difficulties, MD contacted Health Care Proxy and (the resident) was sent out to the emergency room for evaluation. A Progress Note dated 10/03/2022 at 12:56 PM, documented the following: Resident readmitted to the facility from the hospital. Resident 100 was readmitted with a g-tube. During an interview on 11/16/2022 at 2:48 PM, the Social Worker (SW) #1 stated there was no evidence a written bed hold for Resident #100 had been completed as required. A previous staff person had been responsible for doing this and was no longer at the facility. During an interview on 11/17/2022 at 10:48 AM, the Administrator stated there was no evidence that written notification for bedhold had been completed for Resident #13 during the most recent hospitalization . The Social Workers for the facility are responsible to do this and evidence that this was completed could not be found. 10NYCRR415.3(h)(4)(i)(a)

Based on record review and interviews during an abbreviated survey (Case # NY 733) completed on 2/25/2022, the facility did not ensure residents remained free from physical abuse for 1 (Resident #3) of 3 residents reviewed. Specifically, during care, Resident #3 struck CNA #1 who responded by slapping Resident #3 in the face. This is evidenced by: The Policy and Procedure (P&P) titled Abuse Prevention and Protection Protocol last revised 11/10/2019, documented the facility was to provide orientation on hire and annually to all staff on issues related to abuse prohibition practices such as: appropriate interventions to deal with aggressive reactions of residents. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (an assessment tool) dated 12/19/2021, documented the resident had severe cognitive impairment. The Comprehensive Care Plan for inappropriate behaviors initiated on 11/22/2013 and revised 11/14/2021, documented Resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff interventions included, providing 2 caregivers, re-direction, offering choices, and re-approaching after the resident settled down. A facility Abuse Investigation initiated by the Director of Nursing (DON) on 11/19/2021 documented they were notified on 11/19/2021 at 3:00 PM that an agency CNA had witnessed an incident of resident abuse on 11/12/2021 on the 3-11 shift. The conclusion of the investigation documented, this occurrence meets the definition of physical abuse to a resident. There was a staff witness and the accused confessed to the incident. All 3 employees were terminated for abuse and failure to report the abuse. The agency CNA that reported the incident was re-educated on abuse reporting. An undated written statement by CNA #2, documented that on 11/12/2021 they were assisting CNA # 1 to care for Resident #3, when the resident swung their arm, hitting CNA #1 in the face. CNA #1 responded by slapping the resident in the face. A written statement dated 11/19/2021 by CNA #1 documented that, on 11/12/2021, CNA #1 was getting Resident #3 in bed with help from an agency CNA when the resident became combative hitting the CNA in the face. CNA #1 slapped the resident in return. During a telephone interview on 2/24/2022 at 9:50 AM CNA #2 stated they witnessed CNA #1 slap Resident #3 in the face after the resident struck CNA #1 while they were providing care. During an interview on 2/24/2022 at 12:20 PM the Administrator stated a CNA slapped a resident, it was witnessed by another CNA and 2 other staff were aware of what happened. The DON ' s investigation resulted in staff being terminated, one for the abuse and the others for not reporting. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #NY 733) completed on 2/25/2022, the facility did not ensure all alleged violations involving abuse were immediately reported to the administrator of the facility, not later than 2 hours after the allegation was made if the events that cause the allegation involved abuse for 1 (Resident #3) of 3 residents reviewed for abuse. Specifically, an allegation of abuse witnessed by a Certified Nurse Aide (CNA) during the evening shift on 11/12/2021, was not reported to the Administrator until 11/19/2021. This is evidenced by: The Policy and Procedure (P&P) titled Abuse Prevention and Protection Protocol last revised 11/10/2019, documented all employees have an obligation to report abuse when they have reasonable cause to believe that such an incident has occurred. The incident must be reported immediately to the Nursing Supervisor, Nurse Manager, Director of Nursing (DON), and the Administrator. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (an assessment tool) dated 12/19/2021, documented the resident had severe cognitive impairment. The Comprehensive Care Plan for inappropriate behaviors initiated on 11/22/2013 and revised 11/14/2021, documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included, providing 2 caregivers, re-direction, offering choices, and re-approaching after the resident settled down. A facility Abuse Investigation initiated by the Director of Nursing (DON) on 11/19/2021 documented they were notified on 11/19/2021 at 3:00 PM that an agency CNA had witnessed an incident of resident abuse on 11/12/2021 on the 3-11 shift. The conclusion of the investigation documented, this occurrence meets the definition of physical abuse to a resident. There was a staff witness and the accused confessed to the incident. All 3 employees were terminated for abuse and failure to report the abuse. The agency CNA that reported the incident was re-educated on abuse reporting. An undated written statement by CNA #2, documented that on 11/12/2021 they were assisting CNA # 1 to care for Resident #3, when the resident swung their arm, hitting CNA #1 in the face. CNA #1 responded by slapping the resident in the face. A written statement dated 11/19/2021 by CNA #1 documented that, on 11/12/2021, CNA #1 was getting Resident #3 in bed with help from an agency CNA when the resident became combative hitting the CNA in the face. CNA #1 slapped the resident in return. In a written statement dated 11/19/2021 LPN #3 documented that on 11/13/2021 or 11/14/2021 they were approached in the hallway and told that over the weekend a CNA slapped a resident. LPN #3 told the CNA they should not be talking about that. LPN #3 also documented I should have immediately notified my superior, but due to an overwhelming shift that night, I continued to pass meds. Documentation of a telephone interview on 11/19/2021 with CNA #3, in the presence of facility DON, Administrator, and Social Worker, CNA #3 stated that on 11/12/2021 they were told by CNA #1 that Resident #3 hit them so hard it knocked their glasses off and they reacted by slapping the resident in the face. CNA #3 stated they, probably should have reported it. During an interview on 2/24/2022 at 9:50 AM CNA #2 stated they witnessed CNA #1 slap resident #3 in the face after the resident struck CNA #1 while they were providing care. CNA #2 stated they received abuse training and knew the incident should have been reported immediately but felt sorry for CNA #1 because they felt bad about hitting the resident and would probably get fired, so they did not report the abuse to anyone for a few days. During an interview on 2/24/2022 at 12:20 PM the Administrator stated CNA #1 had slapped Resident #3, which was witnessed by another CNA, and 2 other staff were aware of what happened. None of the staff reported the abuse for a few days. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food preparation and serving areas and equipment are to be kept clean, kitchen equipment is to be kept in good repair, and a test kit is to be provided to measure the parts per million (ppm) concentration of the solution used to sanitize equipment. Specifically, equipment in the main kitchen and unit kitchenettes were not clean, equipment was not in good repair, and an accurate test kit was not provided. This is evidenced as follows. The main kitchen and the kitchenettes were inspected on 07/29/2019 at 10:15 AM. In the main kitchen and unit kitchenettes, the shelving, drawers, mixer, slicer, ABC fire extinguisher, microwave ovens were soiled with food particles; the floor in the floor right of the sink in the Unit 4 kitchenette was soiled with a black build-up. In the main kitchen, the interior plastic panel of the Nor-Lake reach-in refrigerator was cracked exposing the insulation liner, and the handwashing sink faucet was leaking. On the unit kitchenettes, the shelving below the handwashing sinks was warped, had peeling or missing laminate, and was not cleanable. The label of the chemical concentrate used to manually sanitize food equipment was reviewed on 07/29/2019. The label states that the efficacy range of the sanitizer chemical is to be between 150 ppm and 400 ppm. When requested on 07/29/2019 at 10:15 AM, the facility could not provide a test kit with the required graduations to measure the concentration of the chemical solution used to sanitize food equipment. The Director of Nutrition Services stated in an interview on 07/29/2019 at 10:15 AM, that he will purchase the correct chemical test kit, he will clean all soiled items found and double check staff assigned to cleaning equipment, and though he has not yet, he will put in an electronic work order for the refrigerator, drawers, handwashing sink, and shelves under the kitchenette sinks. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.112(c), 14-1.170, 14-1.171

Based on observation, interview and record review during the recertification survey the facility did not ensure it developed and implemented a Comprehensive Person-Centered Care Plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for three (Resident #'s (55, 77, and #85, ) of 24 residents reviewed. Specifically, for Resident #55, the facility did not ensure a CCP was developed for the care and treatment of [REDACTED].#77, the facility did not ensure a comprehensive care plan was developed and implemented to meet the resident's need for the use of splints and positioning devices, and for Resident #85, the CCP for visual impairment was person centered and included the services required to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by: Resident #55: The facility did not ensure a CCP was developed for the care and treatment of [REDACTED]. Resident #55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated [DATE], documented the resident was without cognitive impairment. The resident's medical record did not include a CCP for the care and treatment of [REDACTED]. A Social Service assessment dated [DATE], documented the resident had a [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:34 AM, the resident was observed crying in her room and stated her dog died . She stated she has a [DIAGNOSES REDACTED] and was told she won't be able to safely return home. During an interview on [DATE] at 9:30 AM, Resident #55 stated she is sad and not sleeping well. Resident #55 stated she is not coping well with recent events in her life. The resident stated she has spoken with the nurse about her feelings of sadness. During an interview on [DATE] at 1:35 PM, Registered Nurse (RN) #5stated she was aware the resident had a [DIAGNOSES REDACTED]. RN #5 stated the resident was sad about the recent passing of her dog. RN #5 stated the resident did not have a care plan in place for the treatment of [REDACTED]. During an interview on [DATE] at 2:37 PM, the Resident and Family Services Manager stated the resident should have had a resident specific care plan in place for the care and treatment of [REDACTED]. During an interview on [DATE] at 1:02 PM, the Director of Nursing stated the resident should have a care plan in place for the [DIAGNOSES REDACTED]. The DON stated it was the responsibility of the Resident and Family Care Services Department to enter the care plan for psychosocial needs including depression. Resident #77: The facility did not ensure a comprehensive care plan was developed and implemented to meet the resident's need for the use of splints and positioning devices Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated [DATE], documented the resident had a mild cognitive impairment During an observation on [DATE] at 3:20 PM, the resident was noted with the right forearm and hand and right lower leg and foot secured to the secured to the wheelchair's arm splint device and foot rest with elastic bandages. The resident's medical record did not include a CCP to address the use of splints, positioning devices, or the use of elastic bandages. During an interview on [DATE] at 11:46 AM, Registered Nurse (RN) #1 reported the elastic wraps were used daily as a positioning device to keep the limbs from falling from the arm and leg rests, impeding the resident's ability to self-propel the wheelchair. During an interview on [DATE] at 1:07 PM, the Director of Nursing stated there should be a care plan in place that addresses the use of the splint and elastic wraps. Resident #85: The facility did not ensure the CCP for visual impairment was person centered and included the services required to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #85 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated [DATE], documented the resident was without cognitive impairment. The Comprehensive Care Plan (CCP) for Alteration in Vision as evidenced by complaints of vision problems dated [DATE]. It documented to orient to environment, and keep items in field of vision. The Admission and Social Work (SW) information sheet dated [DATE], documented that the resident needed glasses. A SW assessment dated [DATE], documented the resident wore glasses but they were not in the facility. During an interview with the resident on [DATE] at 9:40 AM, the resident stated he/she needed his/her glasses. The resident asked the surveyor where his/her TV remote was; he/she could not see it. The remote was on top on his/her bedding in front of him/her. Surveyor instructed the resident which way to move his/her hand to touch it, and he/she found it by feel. During an interview on [DATE] at 09:50 AM, the Unit Secretary stated the resident was scheduled for cataract surgery twice that had to be postponed both times. She is in the process of rescheduling it again. The Comprehensive Care Plan (CCP) for Alteration in Vision did not include the resident's cataract, need for glasses or pending surgery. During an interview on [DATE] at 09:43 AM, the Registered Nurse Manager (RNUM) stated the CCP should have had the resident's need for glasses, the [DIAGNOSES REDACTED]. She did not know why it was not. 10NYCRR 415.11(d)(3) z

Based on observation, record review and interviews during the recertification survey, the facility did not ensure that residents received treatment and care in accordance with standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 (Resident #'s 77, 101, and 407) of 24 residents reviewed. Specifically, for Resident #77, the facility did not recognize or assess the risks associated with the use of splinting and immobilizing devices and for Resident #407, the facility did not ensure the residents [DIAGNOSES REDACTED].#101, the facility did not ensure that the resident, who had severe swallowing difficulties, was out of bed for meals per Speech Therapy recommendations. This is evidenced by: Resident #77: Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/11/2020, documented the resident had a mild cognitive impairment. On 10/01/20 at 3:20 PM and 10/7/2020 at 11:15 AM, the resident was observed using the left foot to self-propell a wheelchair with the right forearm and hand secured by an elastic bandage to a splinting device and the armrest of the wheelchair, and the right lower leg and foot secured by elastic bandage to the wheelchair leg/footrest. During a review of the resident's medical record (Comprehensive Care Plans, Multidisciplinary Progress Notes, and Physician's Orders) for the past 6 months there was no documentation of the use of elastic bandages being used to secure the resident to the wheelchair. During an interview on 10/07/20 at 11:46 AM, Registered Nurse (RN) #1 reported elastic wraps are used daily to hold the resident's leg to the wheelchair because it would regularly fall off the footrest and stop him/her from self-propelling the wheelchair, potentially causing a fall and the wrap on the resident's arm helps to maintain a comfortable position in the wheelchair. RN #1 stated there should be a physician's order and care plan for the use of the wraps, she was unable to find either in the medical record. When asked if the wraps were released throughout the day and if the resident's skin under the wraps was monitored for breakdown, RN #1 stated the nurses would be responsible for that and it should be documented on the Medication or Treatment Administration Record. Upon review RN #1 reported it was not there because there was no physician's order. During an interview on 10/07/20 at 1:07 PM, the Director of Nursing stated there should be a care plan in place that addresses the use of the splint and elastic wraps that includes monitoring of the resident's skin as well as regular release of the wraps to prevent skin breakdown. Resident #407: Resident #407 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/27/2020, documented the resident was without a cognitive impairment. On 10/1/20 at 10:58 AM, the resident was observed lying in bed, left leg red/purple in color, skin was dry with large flaking areas of skin noted, and swollen. On 10/5/20 at 10:06 AM, the resident was observed lying in bed, left leg remains red, swollen with dry flaking skin. Red/ pink drainage noted from the left lateral calf. The Policy and Procedure titled Skin and Wound Care last revised on 11/20/19, documented to assess/ inspect the resident's skin on admission and to monitor closely for changes; to establish a comprehensive interdisciplinary care plan; to promptly and accurately document regarding any new skin issues. The policy stated weekly skin inspections would be completed by a licensed staff member and results would be documented in the medical record. A Clinical Admission Evaluation note dated 9/21/20, documented the resident was admitted to the facility after [DIAGNOSES REDACTED]. The resident complained of pain to the left lower extremity, the skin was reddened and discolored and scaly with [MEDICAL CONDITION] (a condition in which fluid builds up in tissues and causes swelling). During a review of the resident's medical record from 9/22/20-10/5/20, the Comprehensive Care Plan, Multidisciplinary Progress Notes, Treatment Administration Records and Physician's Notes sis not include documentation for the monitoring/ assessment, or treatment of [REDACTED]. During an interview on 10/5/20 at 10:07 AM, the resident reported that staff have not provided treatment to his/her legs since admission. During an interview on 10/7/20 at 10:54 AM, the Registered Nurse Unit Manager (RNUM) #4 stated the resident has very dry skin to her left leg and a [DIAGNOSES REDACTED]. Registered Nurse Unit Manager (RNUM) #4 stated Resident #407's legs should have been assessed at a minimum of weekly and documentation of the findings should be in the medical record. RNUM #4 stated the resident should have had a care plan in place to ensure treatment and monitoring of the skin and [MEDICAL CONDITION] of the left leg occurred. RNUM #4 stated she was not aware the resident's legs were dry, scaly or bleeding until this morning. During an interview on 10/07/20 at 12:32 PM, the Director of Nursing (DON) stated she would expect resident's [DIAGNOSES REDACTED]. The DON would expect documentation and assessment to reflected in the resident's medical record. The facility did not ensure that the resident, who had severe swallowing difficulties, was out of bed for meals per Speech Therapy recommendations. Resident #101: Resident #101 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/11/2020, documented the resident had a severe cognitive impairment. The following observations were made: -10/1/20 at 9:42 AM, the resident was in bed with clothing protector on and half consumed meal tray on overbed table against the wall. -10/2/20 at 10:04 AM, the resident was in bed and stated the surveyor that he/she wanted to get up. -10/05/20 at 9:45 AM, and 12:06 PM, the resident was in bed; his/her bed breakfast tray was on the overbed table against the wall at the end of the bed with food consumed. -10/6/20 at 11:30 AM, the resident was in bed being fed by staff. The resident was noted with wet cough. A Speech Therapy Evaluation and Plan of treatment dated 10/2/20, documented the resident was seen due to reports of coughing during intake. It documented that the resident's dysphagia rehabilitation was expected to be poor and that the resident was at defiinite risk for aspiration, choking, and wet or gurgly voice quality after swallowing liquids. A CCP for Nutritional risk dated 10/3/20, documented the resident was on strict aspiration precautions; he/she was to be upright and out of bed (OOB) for all PO (by mouth) and was to be upright for at least 30 minutes following PO intake. A Progress Note dated 10/5/20, documented that a code blue was called this morning for unresponsiveness after choking. The resident was awake and denied discomfort. During an interview on 10/2/20 at 3:24 PM, Licensed Practical Nurse (LPN) #4 stated the resident was not gotten out of bed today due to the staffing. During an interview on 10/7/20 at 10:55 AM, Certified Nursing Assistant (CNA) stated on 10/5/20, she was feeding the resident in bed when he/she started choking. The nurse layed him/her back and it got worse. The nurse got nervous and called a code blue. The Medical Doctor (MD) was there and came up. During an interview on 10/07/20 at 12:03 PM the Speech Therapist (ST) stated a CNA would be safe feeding the resident if they are familiar with him but if not should be fed by a nurse . He should be out of bed for all meals and she was not aware of the choking episode. During an interview on 10/7/20 at 1:08 PM, the Director of Nursing stated the recommendation was clearly there for a reason and the resident should have been out of bed for meals. 10NYCRR415.12

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was not clean and the area around was littered with refuse. This is evidenced as follows. The trash compactor area was inspected on 10/01/2020 at 11:30 AM. The access room was heavily soiled with a splattered filth on the walls, and the access portal door was heavily soiled with a black filth build-up. The Manager of Housekeeping stated in an interview on 10/01/2020 at 11:30 AM, that she will get going on the cleaning the area. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews during a recertification survey, the facility did not provide the resident or the residents representative with a written summary of the baseline care plan for 6 of (Resident #'s 28, 29, 34, 86, 93, and 124) of 28 residents reviewed. Specifically, for Resident #'s 28, 29, 34, 86, 93, and #124, the facility did not ensure written summaries of the baseline care plan were provided to the resident and/or the resident's representative. This is evidenced by: Review of the facility policy titled Interdisciplinary Care Conference and Care Planning dated 11/28/2016, documented that a baseline care plan and current physician's orders will be given within 48 hours of admission to the resident and/or the designated representative for review and input. Resident and/or designated representative will acknowledge receipt upon admission. Resident #124: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident makes self-understood and is able to understand others. Review of the resident's medical record did not include that a written summary of the baseline care plan given in writing to the resident and/or their representative. During interview on 02/15/19 at 1:00 PM, the Vice President of Clinical Operations stated they did not have proof that the 48-hour care plan was provided to the resident or the residents representative. Resident #34: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident could understand and was understood by others. The Brief Interview of Mental Status (BIMS) score was assessed to be 15/15 and demonstrated no cognitive deficits for decision making. Review of the resident's medical records did not include documentation that a written summary of the baseline care plan was given in writing to the resident and/or their representative at the time of admission. During interview on 2/13/19 at 9:57 AM, Social Worker SW #9 stated she had not completed a 48-hour baseline care plan for the resident. She thought nursing did most of the care plans for the residents. She does add a care plan for residents related to psychosocials but doesn't do it in the first 48 hours of admission. During interview on 02/15/19 at 9:35 AM, Registered Nurse Unit Manager #5 (RNUM) stated they did not have proof that the 48-hour care plan was provided to the resident or the residents representative in writing. RNUM #5 stated after the Director of Nursing's (DON's) review of the residents records, a 48-hour care plan was not located. Resident #93: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. During record review a baseline care plan located in the resident's chart was incomplete, undated, and unsigned by the resident. During interview on 2/13/19 at 2:26 PM, RNUM #5 stated the resident was admitted to the unit from another floor. She was not sure why the baseline care plan had not been completed and given to the resident or the residents representative. 10NYCRR 415.11

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it provided, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for those residents who reside on the subacute unit. Specifically, the residents on the subacute unit did not have activity care plans completed. This was evidenced by: During an interview on 02/11/19 at 10:19 AM, Resident #130 stated she was not aware of activities, and stated she would love to attend the games, crafts or music. No staff member had approached her to invite or assist her in transporting to an activity. During an interview on 02/14/19 at 01:53 PM, the Activity Director stated once a month a calendar is placed in the resident rooms, one for each resident. When she started working at the facility 4 years ago the residents the subacute unit did not have Activity care plans, and I do not do care plans for the residents on the subacute unit. During an interview on 02/14/19 at 03:28 PM, Social Worker #13 stated the focus for the subacute residents is going home after Rehab, not so much for Activities. She was not aware that there were no care plans or documentation of Activities. 10NYCRR415.5(f)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure it had a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not provide adequate information for family and visitors on safe food preparation and handling practices. The policy did not address training of staff to ensure foods from outside are handled in a safe and sanitary manner. This is evidenced as follows: Review of the facility's policy on Food Brought to Residents from the Outside on 02/12/19 at 10:46 AM, did not include that information was provided on the safe range of temperatures required for the preparation and storage of foods, except for instructions to how to reheat foods in the facility's microwave. The procedures did not address training appropriate staff in safe and sanitary handling or storage of food. There was no process to ensure family and visitors were provided with information on safe preparation and handling procedures. The facility's instructions for family and visitors entitled 'Food' in the Resident Handbook did not include instructions on the safe handling and preparation at home of foods to be brought into the facility. During an interview on 02/14/19 at 05:07 PM, the Registered Dietitian stated Social Services handled any instructions given to families and visitors on the safe handling of foods brought in for residents. The Registered Dietitian did not provide any training. During an interview with the Director of Social Services on 02/14/19 at 05:21 PM, she stated that the facility did not provide education to families and visitors about safe food handling, preparation, or storage of foods brought in to residents from the outside. She did not know about this section of the regulation. She stated that she, the Food Service Manager, and the Registered Dietitian would work together to provide an instruction booklet for families and visitors. 10 NYCRR 415.14(h)

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, (YEAR) Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in areas with gas fuel fired equipment. This is evidenced as follows. Observations on 01/11/19 at 9:50 AM, revealed fuel burning appliances in the main kitchen, the boiler room, and the loading dock. Carbon monoxide detection was not provided in these areas. The Director of Plant Operations stated in an interview on 01/11/2019 at 10:45 AM, that he was unaware that of a requirement to provide carbon monoxide protection in these areas. 483.70 (b); (YEAR) International Fire Code, Section 915

Based on observation, record review and interview during the recertification survey, the facility did not maintain an infection prevention and control program (IPCP) to prevent the development and transmission of disease and infection. Specifically, for Resident #25, the facility did not ensure that handwashing and glove changes were performed during wound care; the facility did not ensure that a Licensed Practical Nurse (LPN) performed proper hand sanitizing during medication administration; and the facility did not insure the IPCP policies were reviewed annually. This is evidenced by: Finding #1 Resident #25 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. During an observation on 2/14/19 at 2:55 PM, Licensed Practical Nurse (LPN) #6, provided wound care to the resident's coccyx and buttock. LPN #6 irrigated the coccyx wound with normal saline, collecting contaminated solution onto a 2 x 2 gauze held in her gloved hand. LPN #6 did not change gloves or wash hands before proceeding to pick up a clean 2 x 2 and to place Safegel onto the wound base. LPN #6 then removed a dressing from the buttock wound, changed her gloves and washed her hands. LPN #6 irrigated the buttock wound with normal saline, collecting contaminated solution onto a 2 x 2 gauze held in gloved hand. LPN #6 saturated a clean 2 x 2 in Dakins solution and packed it loosely in the wound with the same gloved hand used to collect solution from the irrigating the wound. During an interview on 2/14/19 at 3:03 PM, LPN #6 stated she was unaware that she needed to change her gloves after irrigating wounds. During an interview on 2/15/19 at 10:42 AM, the Director of Nursing (DON) stated that the expectation is that all nurses providing wound care, change their gloves and wash their hands prior to applying clean gloves. The DON stated that all LPN's are educated on the infection control policies and the importance of changing gloves during wound care when they become soiled. Finding #2 During a medication pass on 02/15/19 at 9:21 AM, LPN #10 was observed administering medication to a resident. LPN #10 had long artificial nails. LPN #10 sanitized her hands using an alcohol based sanitizer neglecting the under side of her nails. LPN #10 opened a stock bottle of Magnesium Sulfate (a supplement), removed the seal on the bottle using her nail, and touched the inside of the bottle with the underside of her nail. LPN #10 administered medication to the resident with applesauce in a medication cup and a spoon. LPN #10 had difficulty giving the resident her pills and touched the residents mouth with the underside of her nails on her right hand. LPN #10 went back to her medication cart, used the alcohol based hand sanitizer, again neglecting the underside of her nails, and began to continue her medication pass. During interview on 02/15/19 at 9:50 AM, LPN #10 stated it is against the policy of her agency to wear artificial nails while working at the facilities. She stated she should have washed her hands and the underside of the nails between resident care and doesn't usually have artificial nails. During interview on 2/15/19 at 10:00 am, the Director of Nursing (DON) stated it is against the policy of the facilities to wear artificial nails while working and providing resident care. She stated she was not aware that LPN #10 had such long nails and would immediately reeducate her on the facility policy and proper handwashing. When using handsanitizer the underside of the nails need to be cleaned to prevent spreading infection from one resident to another. Finding #3 The facility did not ensure that the following IPCP policies and procedures were reviewed annually: 1. Infection Control Program - Last revised 10/2017. 2. Antimicrobial Stewardship Program, Continuing Care Division Skilled Nursing Facilities - Effective date 7/2017. The policy did not include documented review/revised dates. 3. Hand Hygiene - Effective date 3/21/2016. The policy did not include documented review/revised dates. 4. Seasonal Influenza Vaccine Policy (For Health Care Personnel) - Last reviewed/revised 9/2017. During an interview on 02/15/19 at 02:06 PM, the Vice President (VP) of Clinical Operations stated the corporation is working on updating policies and procedures. 10NYCRR415.19(a)(1-3)

Based on observation, record review and interview it was determined during an abbreviated survey (NY 036) the facility did not provide services that maintained a new admission at the highest physical functioning level for 1 ( Resident # 1) of 2 residents reviewed. Specifically the facility did not initiate a system to monitor blood sugars on a Resident who was admitted with a history of Insulin Dependent Diabetes. Subsequently the Resident was transferred to the emergency roiagnom on day four of admission and admitted with DKA (Diabetic Keto-acidosis; a potentially life threatening disorder of diabetes, which is a result of not enough insulin); and acute kidney injury related to dehydration and diabetes) with a blood sugar of 571. This represents an isolated incident that is harm but is not immediate jeopardy. This is evidenced by the following: Policy and Procedure (P&P) entitled Diabetic Management and dated 1/23/09 documented the purpose as to consistently and in an organized fashion manage residents with diabetes and to document such care. Insulin dependent diabetic residents with routine orders documented perform fingerstick's as ordered, observe residents for signs and symptoms of hypo/[MEDICAL CONDITION]. Signs and symptoms (s/s) of [MEDICAL CONDITION] are listed as increased thirst, polyuria (excessive urination), malaise, drowsiness, headache, weakness, shortness of breath and not dry skin. Standards of Medical Care in Diabetes-2012, copy written by the American Diabetes Association, originally approved 1988, most recent review/revision October 2011. "Some patients cannot be clearly classified as having type 1 or type 2 diabetes. Clinical presentation and disease progression vary considerably in both types of diabetes. Occasionally, patients who otherwise have type 2 diabetes may present with ketoacidosis." (pg 2) "Two primary techniques are available for health providers and patients to assess the effectiveness of management plan on glycemic control: patient self-monitoring of blood glucose (SMBG) or interstitial glucose, and A1c." Glucose monitoring recommendations included; SMBG should be carried out three or more times daily for patients using multiple insulin injections or insulin pump therapy; For patients using less-frequent insulin injections, noninsulin therapies, or medical nutrition therapy alone, SMBG may be useful as a guide to management. (pg 12) Resident # 1: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident was transferred to the hospital on [DATE] and was readmitted on [DATE] with the [DIAGNOSES REDACTED]. Resident was alert and oriented with short term memory loss according to the Nursing Admission assessment dated [DATE]. Hospital History Physical Exam dated 9/2/13 documented [DIAGNOSES REDACTED]. Assessment and plan included risk of acute [MEDICAL CONDITION] with a history of CKD. The patient has had a greater than 25% change in his Glomerular filtration rate (GFR), we will monitor this and consider avoiding nephrotoxic medications should his renal function worsen over the course of this day. Type 2 DM, we will put him on sliding scale and monitor his finger-sticks. Initiate hyperglycemic protocol. Hospital Transfer Summary dated 9/9/13 documented [DIAGNOSES REDACTED]. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] From 71 to 180 give dose 0 units, from 181 to 250 give dose 2 units, from 251 to 300 give dose 4 units, from 301 to 350 give dose 6 units, from 351 to 400 give dose 8 units. Also included [MEDICATION NAME] 6 units sq daily at bedtime. Nurse progress note dated 9/9/13 at 4:33 pm and signed by a Registered Nurse (RN) documented, in reviewing patient's transfer summary and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Call to hospitalist who verified that he was on [MEDICATION NAME] in the hospital however he was having lower sugars and he is not to be on it in the rehab. He also stated that fingerstick's are not needed. Facility Physician admission orders [REDACTED]. Documented under treatment Diabetes Mellitus protocol, there were no orders to monitor blood sugar finger sticks. laboratory results dated as 9/10/13 documented glucose level of 302 (normal range 70-110), HbA1c (blood test used to determine how high your blood sugar has been in the past few months) level 6.9 (normal range <6.5). Physician documentation dated 9/10/13 at 10:00 am documented [DIAGNOSES REDACTED]. Entry for most recent blood sugar was blank. Entry under Endocrine,blood sugars were check marked. There was no mention of the recent discontinuance of insulin while in the hospital, or monitoring of blood sugar finger sticks. Resident care plans dated 9//9/13 included potential for transfer trauma, use of enablers to aid in turning while in bed, alteration in comfort related to (r/t) back pain, potential for falls, there was no careplan entitled DM. Nurse progress note dated 9/13/13 at 9:45 am and signed by an RN documented significant change noted in patient, increased lethargy, foul smelling urine, unable to ambulate with rehab. New order to obtain urinalysis (u/a) and urine culture and sensitivity (c&s). There was no mention of an assessment for [MEDICAL CONDITION] or fingerstick. Note documented physician assessed patient with increased lethargy, confusion, difficult to follow commands, new order to send to hospital emergency room for evaluation to rule out (r/o) [MEDICAL CONDITION] (TIA ), and confusion. There was no mention of assessment for [MEDICAL CONDITION]. Nurse progress note dated 9/13/13 at 9:37 pm documented hospital emergency room called, patient admitted with [DIAGNOSES REDACTED]. Hospital Transfer Summary dated 9/16/13 documented admitted [DATE], Resident presented at the hospital with headache and confusion. Admission work-up included blood work which revealed acute kidney injury with a creatinine of 2.4 and a potassium 5.3. Blood sugar was found to be elevated at 571. Arterial blood gas was significant for serum [MEDICATION NAME] being large. The patient was treated for [REDACTED]. During an interview on 9/19/13 at 10:30 am RN # 1 stated that frequently a call needs to be made to the hospital to get clear instructions in regards to admissions from the hospital. Then the facility physician is notified. RN spoke with the hospitalist who said the Resident had lower blood sugars in the hospital and did not need insulin. RN stated the hospitalist (hospital physician) got snippy when she asked about blood sugars and stated they did not need to be done. During an interview on 9/19/13 at 10:50 am the Registered Nurse Manager (RNM) stated that fingerstick blood sugars were not done because the A1c was normal, and that the Resident was placed on the Diabetic Protocol. There was no fingerstick done on admission, and there was no shift to shift report of the Resident being a diabetic with insulin recently being discontinued. RNM stated that nursing judgment should have been to order fingersticks to monitor. During an interview on 9/19/13 at 11:30 am the physician stated the hospitalist said the blood sugars were low while in the hospital and no insulin or fingerstick's should be continued. The blood glucose would have been monitored weekly with the weekly laboratory work. In hindsight fingerstick blood sugars should have been done, but that they went by the labs and thought perhaps he was diet controlled. The physician stated that the resident's A1c was normal when when told of the glucose level of 302. During an interview on 9/19/13 at 11:45 am RN # 2 stated that on 9/13/13 the Resident was in therapy having difficulty and she was called to assess him. Thought he was having a TIA, his symptoms seemed cardiac and he was leaning over to one side. The physician came in and said to send him to the emergency room and she did not ask for a blood sugar. RN stated that knowing he was a diabetic I should have checked his fingerstick. During an interview on 9/19/13 at 1:25 pm the Director of Nursing (DON) stated they (meaning the nursing staff) were told they did not have to monitor the blood sugars by the hospital physician. A nurse can use their judgment to take a fingerstick, it does not require a physician order. A resident should be monitored when certain medications are discontinued, and fingerstick's should have been monitored following the Resident's insulin being discontinued. DON stated sometimes we give hospital physicians more credit, and the problem is we get a false sense of security with what they say. We need to remember as nurses not to forget the basics; basic knowledge, nursing standards because it is our responsibility and our liability. 10NYCRR415.12

Based on medical record review and staff interviews during a complaint investigation (Case # NY 742) it was determined that the facility did not ensure that care and services were provided to maintain the highest practicable physical, mental and psychological well being for one (Resident # 1) of two residents reviewed. Specifically, the facility did not ensure the resident received appropriate and timely medical care when the resident's right arm/hand was noted to be red, warm and painful on 11/30/10 at 6:43 am. The hand/arm continued to develop increased swelling, redness, warmth and pain (described as a 10 out of 10 by the resident) until 12/1/10 when the resident was sent out to the local emergency department at the request of the family and admitted to the hospital for seven days with a [DIAGNOSES REDACTED]. Additionally, a nurse practitioner, after seeing and assessing the resident on 12/1/10 did not notify the attending physician (MD) and did not document her findings in the resident's medical record; and when the MD did not return a call to a nurse who had attempted to contact him to inform him of the resident's worsening condition, a second call was not placed to the MD for approximately 10 hours. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have moderately impaired cognitive ability with the ability to understand others and to make herself understood. A nurses note dated 11/27/10 at 5:29 am, documented that the resident was found on the floor in the doorway of her room. The resident sustained [REDACTED]. The resident had no complaints of pain and the plan was to monitor the resident. The nurses notes in the Resident's medical record documented the progression of the wound as followed: on 11/30/10 at 6:43 am, the resident's right hand is red and warm to touch. The resident was medicated for pain described as a 10 out of 10. The resident was more anxious than usual because of the pain; on 11/30/10 at 7:39 am, the resident is having pain in the right hand and it is swollen and reddened; on 11/30/10 at 1:12 pm, the resident continues to complain of pain and an x-ray was done; on 11/30/10 at 10:19 pm x-ray shows there is no fracture or dislocation. The resident continues to complain of pain and her hand is swollen, sensitive and warm to touch. On 11/30/10 at 11: 23 pm, the nurse attempted to call the MD about the resident. The physician did not return the phone call. The nurses notes on 12/1/10 at 6:41 am, documented the resident was restless all shift, complained of pain in the right hand, temperature was 99.8 and the hand is swollen and warm to touch. The right forearm is red and swollen up to and above the elbow. On 12/1/10 at 2:01 pm the resident is anxious. The right hand and arm remain swollen and warm to touch and a new order was received for [MEDICATION NAME] three times a day for two days. On 12/1/10 at 10:22 pm the resident's family is very concerned that the swelling is much worse than yesterday (11/30/10). The nurse spoke with the hospice nurse and the MD and the resident was transferred to the hospital via ambulance. A nurses note in Resident #1's medical record dated 12/1/10 at 8:30 am, signed by the Registered Nurse Unit Manager (RNUM) and titled " Late Entry " (the note was actually entered into the computer on 12/2/10 at 12:17 pm) documented that the MD was called and it was reported to him that the resident's right hand was noted to have significant redness, swelling and pain, and the "right hand skin tear area" had signs of infection. The note also documented that the option of antibiotic treatment was reviewed with, and the x-ray report was read to the MD at that time. A hospital emergency department record dated 12/1/10 at 11:30 pm indicated the resident is being admitted to the hospital for treatment with intravenous antibiotics for a [DIAGNOSES REDACTED]. During an interview on 12/8/10 at approximately 1:00pm, the RNUM stated when she arrived at work on 11/29/10 at approximately 6:45 am, she was informed that Resident # 1 had fallen over the weekend and had sustained a skin tear to the right forearm. She assessed the resident and noted a dressing covering the skin tear. The RNUM saw the resident's arm again on 11/30/10, early in the shift (approximately 7:15 am) and noted the arm was swollen and the resident was now complaining of pain. At that time, the resident asked if she should have an x-ray of her arm. The MD was notified and an x-ray was taken that afternoon. When the RNUM arrived at work on 12/1/10 at approximately 6:45 am, the facility night supervisor and the unit night shift charge nurse (LPN#2) asked her to look at Resident # 1's arm. The RNUM stated that both nurses were concerned that the resident might have a [MEDICAL CONDITION] of her arm and hand. When the RNUM assessed the resident's arm that morning, she noted increased swelling, redness, warmth and pain and asked the nurse practitioner to look at the resident's arm. The RNUM reported that after looking at the resident's arm, the NP asked if she was sure the resident didn't have a fracture. When the NP was told the resident's x-ray were negative, she stated the resident might benefit from [MEDICATION NAME] antibiotics. The RNUM called the MD during the morning on 12/1/10 and reported that the pain, swelling, redness and warmth of the resident's arm had all increased and that it looked like the resident had a [MEDICAL CONDITION]. The RNUM stated that she also informed the MD that the nurse practitioner had looked at the resident's arm and hand and thought the resident could benefit from antibiotics. The MD gave an order to give the resident two additional doses of [MEDICATION NAME] that day and stated that he would look at the resident's arm when he made rounds the following morning on 12/2/10. During an interview on 12/8/10 at 4:15 pm, a licensed practical nurse (LPN#1) stated she was working the 3:00pm to 11:00pm shift on 11/30/10 and around 6:00pm she placed a call to the evening registered nurse supervisor (RNS) and asked her to look at Residents # 1's hand and fingers because they were quite swollen. The RNS assessed the resident and told LPN#1 to watch the resident for increased swelling. Later in the shift, at around 10:30pm, LPN # 1 again called the RNS and requested that she come back and recheck the resident because the swelling to the hand and fingers had increased and they were now warm to touch. The RNS assessed the resident's hand and instructed LPN #1 to call the MD and describe the swelling and redness of the resident's fingers, hand and arm and to mention that the x-ray done earlier in the day was negative for fracture. LPN # 1 placed a call to the MD but he had not returned her call when she left at the end of her shift (11:00pm). LPN #1 stated that the night-shift charge LPN (LPN #2) was present when the call was placed to the MD and therefore LPN #2 was aware that the MD had not returned her call. On 12/8/10 at approximately 4:15 pm, the RNS stated she was called on 11/30/10 around 6:00pm by LPN #1, who asked her to come and look at Resident #1's arm because it was swollen and painful. The RNS stated when she saw the resident's arm there was a dressing wrapped around it and the arm and hand were swollen. The RNS removed the dressing, thinking perhaps it was tight and causing the resident's arm to swell. She then told LPN #1 to keep an eye on the resident's hand and arm. The RNS was called again at the end of the shift by LPN #1 and asked to come back and look at the resident's hand. The RNS noted at that time that the resident's arm and hand were now red and warm to touch and more swollen than earlier. The RNS was concerned and told LPN#1 to call the MD and let him know about the arm (pain, swelling, warmth and redness) and to let him know that the x-ray taken earlier in the day was negative. The RNS left the unit and didn't see the resident again until the next day (12/1/10) when the evening RN charge nurse (RN #1) called her around dinnertime and requested that she look at the resident's arm. The RNS stated the arm looked worse than the evening before (11/30/10) and the resident's daughter was now insisting that the resident be seen in the emergency room . The RNS told RN #1 to call the MD and get an order to send the resident out to the emergency room . During an interview on 12/10/10 at 2:30 pm an LPN (LPN#2) stated that she worked the night shift from 11:00 pm on 11/29/10 to 7:00 am 11/30/10. When she checked on Resident #1 just after midnight on 11/30/10, the resident complained of pain in her arm and hand and was given Tylenol. At 3:30 am the resident complained of "severe pain" and described it as a "10 out of 10." LPN # 1 noted at that time that the resident's arm and hand were swollen and this was reported to a night shift supervisor and also the RNUM when she arrived for work at 7:00 am on 11/30/10. When LPN # 2 returned that night to work from 11:00 pm on 11/30/10 to 7:00 am 12/1/10, she received report from LPN #1 who explained that she had just placed a call to the MD to make him aware that the resident's hand and arm were swollen, red, painful and warm to touch and also to let him know that the resident's x-ray was negative. LPN # 1 reported to LPN #2 that she had placed a call to the MD but he had not returned her call. When questioned, LPN # 2 stated that she did not place a second call to the MD during her 11:00pm to 7:00am shift. She stated that she saw the resident shortly after report and noted the resident's arm, hand and fingers were warm, red, and very tender to touch and had increased swelling that now extended to above the elbow. She noted that the steri-strips that had been placed over the skin tear were pulled tight because of the swelling. She removed them, cleansed the wound and applied a dressing and reported all of this to the night shift supervisor who told her that the MD would probably order antibiotics in the morning. LPN #2 stated that the resident was awake all night because of arm and hand pain and worrying about her arm. LPN # 2 reported all of this to the RNUM when she arrived at work at 7:00am on 12/1/10. During an interview on 12/9/10 at approximately 8:00am, the MD stated he had been called during the day shift on 11/30/10 and told that the resident had fallen over the weekend and that her hand was swollen. Thinking there might be a fracture of her hand, he ordered an x-ray of the arm, hand and ribs. He received a second call on 12/1/10, late in the morning and was told the resident's x-rays from the day before were negative and there was a small opening in the skin on her arm and her hand was a little swollen. The MD stated that when he was told there was no fracture he then considered that the resident might have some type of [MEDICAL CONDITION] process going on that had caused the swelling. Because the resident was already on [MEDICATION NAME] each day for [MEDICAL CONDITIONS], the MD ordered two additional doses for that day and the next, and said he would see the resident the following morning (12/2/10). The MD stated that if someone had reported to him earlier, that the resident's hand was red, swollen, and painful, or if someone had suggested that she needed to go out to the hospital or that it looked like the resident had a [MEDICAL CONDITION], he would have sent her out to the ER immediately or he could have started IV antibiotics right there (in the nursing home). The MD stated the first he heard anyone say that her arm and hand were "red, swollen, warm and painful " was when he received a call during the evening on 12/1/10 and the caller described the resident's hand and said the resident's daughter thinks she should go out to the ER. The MD stated, "I don't recall that anyone ever said any of those things to me." The MD saw the resident the next day (12/2/10) at the hospital and he described the resident's hand and arm as "exquisitely painful" and with a [DIAGNOSES REDACTED]. During an interview on 12/9/10 at approximately 10:00am the nurse practitioner stated that she was asked to see Resident # 1 and assess her right arm on the morning of 12/1/10. She noted that the resident's arm was red, swollen and painful and the nurse had it elevated with an ice pack on it. The NP stated she had been told the resident had fallen and upon seeing the resident, her initial thought was that perhaps there should be additional x-rays taken to re-evaluate for a fracture. The NP mentioned to the RNUM that the MD might want to order antibiotics for a couple of days because of the open area on the resident's. When asked, the NP stated that she did not contact the MD after seeing the resident and did not enter a note in the resident's medical record because she had been asked to see the resident as a favor and did not normally see this resident. She assumed that the nurse would have followed up with the MD. 10 NYCRR 415.12