Every finding on record at Terence Cardinal Cooke Health Care Center

Based on interviews and record review, the facility failed to ensure that medical records are maintained in accordance with accepted professional standards and practices to be complete and accurately documented. This was evident for one (Resident #5) of one resident investigated for medication error. Specifically, Registered Nurse #5 failed to accurately document the time Resident #5 received hydromorphone and Registered Nurse #5 failed to document that Resident #5 received a second dose of hydromorphone approximately two and a half hours later. The findings include:The facility policy titled, Administration of Medications, dated 01/01/2025, documented that the nurse is to immediately chart medications administered in the proper time and date square via initials and identifies initials by signature in the designated space on the administration record.Resident #5 was admitted with diagnoses that included diabetes mellitus, psychoactive substance use, and arthritis. The Minimum Data Set (MDS) (a resident assessment tool) assessment dated [DATE] documented that Resident #5 had intact cognition. The Minimum Data Set Assessment also documented that Resident #5 required partial assistance for activities of daily living. A physician's order dated 07/10/2025 documented hydromorphone two milligram tablets to be given as six milligrams (three tablets) by mouth every four hours as needed for pain greater than a pain scale level of six. A review of the Controlled Drug Administration Record for hydromorphone two milligram tablets, dated 06/28/2025, revealed that three tables were used on 07/11/2025 at 6:00 AM and again at 8:45 AM. There is no documented evidence of any other tablets removed on 07/11/2025 and if any tablets were wasted or returned. A review of the Medication Administration Record from 07/11/2025 documented hydromorphone was given on 07/11/2025 at 7:13 AM for a pain level of zero. There is no documented evidence that a second dose of hydromorphone was given to Resident #5 around 8:45 AM. A review of a nursing note dated 07/11/2026 at 10:20 AM, by Registered Nurse Manager #1, revealed that Registered Nurse Manager #1 called to the unit regarding a community nurse's concern for Resident #5 having received an additional dose of hydromorphone. Resident #5 was assessed and found to be in no acute distress.During an interview on 07/31/2026 at 8:10 AM, the complainant (a community outreach nurse known to Resident #5) stated they were visiting Resident #5 at the facility on 07/11/2025 at around 8:00 AM. The complainant stated they observed Resident #5 receive medications 8:00 AM and 9:00 AM. They further stated that Resident #5 said they had received a second dose of hydromorphone. The complainant stated they approached the nurse who administered the medication to report what Resident #5 had stated, and that was when the nurse realized the hydromorphone was administered a second time. The complainant stated they reported the incident to the nurse manager. During an interview on 07/31/2026 at 9:15 AM, Registered Nurse #4 stated that they received report, logged into the computer, and then entered Resident #5's room to ask for their pain level. Registered Nurse #4 stated that Resident #5 has reported a pain level of eight. Registered Nurse #4 stated that they reviewed the medication administration record and noted that the resident did not receive any hydromorphone that morning. They further stated that if the medication had been documented at 6:00 AM, they would have been alerted that hydromorphone was not available to be administered. Registered Nurse #4 stated after administering the hydromorphone, they were unable to document the administration as they saw it was charted as given at 7:13 AM. Registered Nurse #4 stated they conducted the narcotics count that morning without Registered Nurse #5. They also stated that they did not discuss Resident #5's pain medication administration with Registered Nurse #5 either. During an interview on 07/13/2026 at 10:45 AM, Registered Nurse #5 started they administered hydromorphone to Resident #5 on 07/11/2026 at around 6:00 AM. Registered Nurse #5 further stated they should have immediately documented that the medication had been administered on the Medication Administration Record but did not provide a reason why they did not. Registered Nurse #5 stated that made note of the list of residents' names and times of narcotic medications they had administered to chart it later. They further stated that they documented hydromorphone has been administered to Resident #5 at 7:13 AM on 07/11/2025. Registered Nurse #5 also stated that they did not report to the oncoming shift nurse that hydromorphone was given to Resident #5. During an interview on 07/31/2026 at 11:20 AM, Medical Doctor #6 stated that hydromorphone may be ordered as needed or as a standing order, depending on a resident's pain level and tolerance. Medical Doctor #6 further stated that hydromorphone would usually be dozed based on the pain scale of the resident and that the four-hour parameter is dependent on the resident's tolerance. Medical Doctor #6 stated that Resident #5 had pain low tolerance. They further stated that if doses were given too close, the resident may experience lethargy and respiratory failure and would need to be assessed by the medical provider. During an interview on 07/31/2026 12:05 PM, the Director of Clinical Operations stated they are responsible for education for all nursing staff. They further stated that the expectations of the nurses include first making rounds on their assigned units to determine resident safety and head count. The leaving nursing is expected to give report to the incoming nurse about any issues of concerns or activities that transpired during their shift. The medication administration pass expectation is to first see the resident, identify oneself and explain any procedure that is planned, and ask about their pain level. Let them know that you will be coming back once their meds are prepared. The nurse is to check the medical orders, and then the medication administration record, to ensure the medications are scheduled for administration. Once any medication is administered, the sign off is to be done immediately after. This is done to avoid any medication errors and prevents another nurse from administering the medication at the wrong time. During interviews on 07/29/2026 at 1:46 PM and 07/31/2026 at 2:24 PM, the Chief Nursing Officer stated that the expectation for all nurses who administer medications to residents is to check the medical orders against the medication administration record and again the labeling on the medication itself for accuracy. Once medications are administered, charting of those medications is to be done immediately afterwards. They further stated that hydromorphone was administered to Resident #5 at 6:00 AM and again at 8:45 AM. The medical order documented that hydromorphone is to be given four hours apart, but Resident #5 received the medication 2.5 hours apart instead. The Chief Nursing Officer stated that this incident would not have happened if charting and communication had been done. During an interview on 07/31/2026 at 1:47 PM, the Administrator stated their role includes ensuring that nursing staff have appropriate training and competency to carry out their roles functions and confirming that staff have adequate resources to perform their duties. The expectation is for all nurses is to follow all protocols under Resident Rights for medication administration. The Administrator further stated that medication nurses are to sign off immediately after medication administration to avoid any medication errors. 10 New York Codes, Rules and Regulations 483.70 (i)

Based on observation, record review, and interviews conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident in 2 (Resident #208 and Resident #269) of 4 residents reviewed for Infection Control out of 37 total sampled residents. Specifically, 1.) Licensed Practical Nurse #6 failed to perform hand hygiene and glove changes while performing wound treatment for Resident #208 and 2. ) Enhanced Barrier Precautions were not maintained when Licensed Practical Nurse #5 flushed Resident #269's indwelling urinary catheter. In addition, Licensed Practical Nurse #5 failed to clean / sanitize the Resident's bedside table after using it for the procedure. The findings are: 1. ) The facility policy titled Pressure Ulcer Protocol with a revision date of 03/2020 documented that the purpose of the policy is to promote the healing of pressure ulcers that are present including prevention of infection to the extent possible. Resident #208 was admitted to the facility with diagnoses that included Multiple Sclerosis, Functional Quadriplegia and Diabetes Mellitus Resident #208's physician's orders dated 08/24/2024 included wound care treatment on the day shift to sacral pressure ulcer, to cleanse wound with normal saline, pat dry, apply calcium alginate with honey to the wound bed, then apply skin prep to the edges of the wound & apply bordered foam. A comprehensive care plan for Stage 4 sacral pressure ulcer stage 4 was initiated for Resident #208 on 06/24/2024. The documented goal was for the pressure ulcer to not deteriorate and that the wound will be free of signs and symptoms of infection. The facility interventions include daily wound assessment during treatment care and to apply local treatments as ordered by the physician. On 10/25/2024 at 12:32 PM, Licensed Practical Nurse #6 was observed administering treatment to Resident # 208's Stage 4 sacral pressure ulcer, assisted by Certified Nurse Assistant #13. Licensed Practical Nurse #6's failed to perform hand hygiene and did not change their gloves after removing the old dressing. The Licensed Practical Nurse then took a pen and wrote the date on the new dressing, and then applied the new dressing on the wound, while wearing the same gloves. In addition, Licensed Practical Nurse #6's gown was not properly secured and was falling off from their shoulder, with part of the gown, touching Resident #208's lower leg. On 10/25/2024 at 12:57 PM, Licensed Practical Nurse #6 was interviewed and stated they forgot to wash their hands after removing the soiled dressing. They stated they broke the infection control practice by not washing their hands after removing the soiled dressing and by not properly securing their gown while doing the treatment. On 10/28/2024 at 12:03 PM, the Infection Preventionist, who was also the Administrator, was interviewed and stated they will conduct in-service education for staff on infection control practice, especially when doing treatment for pressure ulcer. 10/28/2024 at 02:05 PM, the Director of Nursing was interviewed and stated in-service education are being done to all staff regarding infection control and preventions and they will conduct audits to ensure the staff is doing appropriate treatment to all pressure ulcers. 44864 2.) The facility policy titled Enhanced Barrier Precautions with a last reviewed date of 03/28/2024 documented that Enhanced Barrier Precautions expand the use of personal protective equipment and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi drug resistant organisms to staff hands and clothing. The policy further stated that nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with multi drug resistant organisms. Resident #269 was admitted to the facility with diagnoses that include Neurogenic Bladder and Quadriplegia. The Quarterly Minimum Data Set ( a resident assessment tool) dated 09/10/2024 documented Resident #269's cognition was intact. The Minimum Data Set further documented that Resident #269 was dependent on staff for eating, bed mobility, transfers, and toilet use and had an indwelling catheter. The physician's orders dated 03/31/2024 had documented orders for Enhanced Barrier Precautions and to flush Foley catheter with 60 milliliters normal saline every shift. On 10/24/2024 02:55 PM, Licensed Practical Nurse #5 was observed flushing Resident #269's Foley catheter. Licensed Practical Nurse #5 entered the room with supplies in their hands and placed them on the Resident's bedside table. Licensed Practical Nurse #5 then washed their hands, donned a pair of gloves, and told Resident #269 that they were going to flush their urinary catheter. Licensed Practical Nurse #5 then moved the bedside table closer to the right side of the bed opened the package, placed a drape under the Foley catheter, and proceeded to flush the Foley catheter using the pistol syringe. Licensed Practical Nurse #5 then discarded the supplies in a bag and rested it on the table. Licensed Practical Nurse #5 disposed the plastic bag and took off their gloves and placed it in the garbage bag in the resident's room. Licensed Practical Nurse #5 washed their hands, then placed the bedside table in front of the Resident#269 and turned off the Resident's overbed light. Licensed Practical Nurse #5 washed their hands and left the Resident's room. Licensed Practical Nurse failed to don a gown prior to the procedure and failed to clean Resident #269's bedside table after the procedure. On 10/24/2024 at 03:05 PM, Licensed Practical Nurse #5 was interviewed and stated that they probably should have worn a gown when flushing Foley catheter. The Licensed Practical Nurse also stated that Resident #269 does not use their bedside table, so they do not need to clean the bedside table after use. On 10/24/2024 at 3:35 PM, the Clinical Administrator was interviewed and stated that nurses must use personal protective equipment when flushing a resident's Foley catheter. The Clinical Administrator also stated that tables must be lined before using it for the procedure and must be cleaned after use. On 10/28/2024 at 04:06 PM, the Chief Clinical Officer was interviewed stated that Enhanced Barrier Precautions is to be used for wounds and for procedures involving Foley Catheters. They stated that any area that is used for preparing, must be sanitized before and after, and that a clean barrier or drape should have been used for the bedside table. 10 NYCRR 415.19(a)(1-3)

Based on observation, record review, and interviews conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure that residents are treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was evident in 1 (Resident #28) of 1 resident reviewed for dignity. Specifically, Resident #28 was observed wearing the same outfit two days in a row. The findings are: The facility policy titled Resident [NAME] of Rights with a revision date of 02/24/2023 documented that residents have a right to be treated with consideration, respect, and full recognition of their dignity and individuality, including privacy in treatment and in care of their personal needs. Resident #28 was admitted to the facility with diagnoses that include Hypertension, Hemiparesis and Diabetes Mellitus. The Quarterly Minimum Data Set (a resident assessment tool) dated 09/29/2024 documented that Resident #28 had intact cognition and impaired vision. The Minimum Data Set assessment documented that Resident #28 required dependent level assistance with lower body dressing and putting on footwear and substantial assistance with upper body dressing. The Resident Property List dated 05/24/2024 documented that Resident #28 had 1 pajama, 2 slippers, 1 sweater / cardigan, 2 sweatpants, and 4 t-shirts. On 10/22/2024 at 10:39 AM, Resident #28 was interviewed and stated they did not have enough clothing and that the shirt they were wearing was for men's. They stated they did not have any shoes and that the few clothing they have were not comfortable. At the time, Resident #28 was observed wearing a multi-colored plaid button up shirt, light blue jeans, and yellow socks with no shoes on. On 10/23/2024, Resident #28 was observed, sitting in a wheelchair in the hallway close to the nursing station, wearing the same outfit that they were wearing on 10/22/2024. On 10/24/2024 at 02:42 PM, Certified Nursing Assistant #10 was interviewed and stated that they were aware that Resident #28 did not own many clothes. They stated that they attempted to get the Resident more clothing the weekend before by accessing the facility's donation closet, but that there was only one pair of pants that fit the Resident and that there were no shirts or shoes in the Resident's size. Certified Nursing Assistant #10 stated they had assisted the Resident with getting dressed in the morning of 10/23/2024. They stated that they obtained the clothing from the Resident's closet and was unaware that the Resident had worn those clothing the day before. On 10/24/2024 at 03:03 PM, Social Worker #2 was interviewed and stated that they were unaware that Resident #28 did not own enough clothing. They stated that Certified Nursing Assistants would typically be the ones to identify if a resident needed clothing due to their involvement in getting the residents dressed. They stated that if a Certified Nursing Assistant noticed that the resident did not have enough clothing, the procedure would be for the Certified Nursing Assistant to visit the facility's donation closet to obtain clothing. If there are not sufficient options in the donation closet, the facility's social workers would assist the resident with purchasing clothing items. Social Worker #2 stated they were unaware that Resident #28 was wearing clothing multiple days in a row but that it would be against their policy for a resident to wear clothing multiple days in a row without washing them unless it was the resident's preference. On 10/24/2024 at 03:15 PM with Resident #28's permission, Social Worker #2 and the State Surveyor made observations of the Resident's room and closet. The Resident's closet contained no clothing and no shoes. The laundry bin in the room contained unwashed clothing. Social Worker #2 stated that Resident #28 did not appear to own any shoes and did not have any clean clothing. On 10/25/2024, the Director of Social Services was interviewed and stated that they were not aware that Resident #28 did not own shoes and that Resident did not have an adequate supply of clothing until Social Worker #2 made them aware on 10/24/2024. They stated that clothing needs are identified through grievances filed by residents, quarterly care plan meetings, or staff members noticing that a resident does not have an adequate amount of clothing. The Director of Social Services stated that Certified Nursing Assistant #10 should have notified the nurse or social worker of the resident's lack of clothing when they observed it. They stated that they were not sure how Resident #28's lack of clothing was not rectified sooner but that they believed it was a breakdown in communication among staff. 10 NYCRR 415.5 (a)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00349557) Survey, the facility failed to ensure that a resident was free from sexual abuse. This was evident in 2 (Residents #447 and #463) of 6 residents reviewed for abuse out of 37 total sampled residents. Specifically, on 07/26/2024 at approximately 6:00 PM, Certified Nursing Assistant #4 observed Residents #447 and #463 lying in bed with no undergarments. Resident #447's hand was observed touching Resident #463's private area. The findings are: The facility policy titled Clinical, Resident Abuse Reporting and Investigation Protocol with a revision date of 06/27/2024 documented the facility will protect residents and ensure freedom from abuse, mistreatment, neglect, misappropriation of property, exploitation corporal punishment, and involuntary seclusion. The Accident/Incident Investigation Form dated 07/26/2024 at 6:00 PM documented that the Certified Nursing Assistant on duty found Resident #447 and Resident #463 both half-naked in bed, in Resident #447's room. Resident #447 was found touching Resident #463's private area. Resident #447 stated they did not do anything, while Resident # 463 was unable to relate the incident due to impaired cognition. A written statement by Certified Nursing Assistant #4 dated 07/26/2024 documented that at 6:00 PM, Certified Nursing Assistant #4 went to Resident #447's room to deliver the Resident's dinner and found Residents #447 and #463 half-naked. The written statement documented that Resident #447 was seen touching Resident #463's private area. A written statement by Licensed Practical Nurse #2 dated 07/26/2024 documented that they were called by Certified Nursing Assistant #4 to Resident #447's room and upon arrival, they observed Resident #447 fixing their clothes and went to the sink to wash their hands. Resident #463 was observed in bed, half-naked with their incontinent briefs and pants on the floor. Resident #447 stated I did not do anything. Resident #463 did not respond, was observed calm and with no visual discomfort. The facility's Internal Investigation dated 08/01/2024 completed by the Administrator concluded that based on their investigation, the incident was an interaction between 2 cognitively impaired residents with no negative outcome and there was no credible evidence of abuse, neglect, or mistreatment. The conclusion also documented that the interdisciplinary team confirmed that the incident was unpredictable and unprovoked between 2 cognitively impaired residents. Both residents were assessed by social work with no negative findings. Resident #447 had diagnoses which included Non-Alzheimer's Dementia, Chronic Obstructive Pulmonary Disease, and Essential Hypertension. The annual Minimum Data Set assessment dated [DATE] documented that Resident #447 had severely impaired cognition and behaviors of wandering which occurred 4 to 6 days but less than daily. The Minimum Data Set documented these wandering behaviors placed the resident at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy or activities of others. A comprehensive care plan dated 05/11/2024 and was last reviewed on 09/03/2024, documented Resident #447 was at risk for victimization. The facility interventions documented were to identify triggers for behaviors and develop interventions to address, to provide calm approach, talk in soothing manner, recognize that resident's cognitive status may inhibit understanding of behaviors exhibited and/or demonstrated towards them. A physician's progress note dated 07/27/2024 documented Resident #447 was seen and examined, and no injury was noted. Resident #447 denied any sexual action against anyone and does not know what they were talking about. A Psychiatry note dated 07/31/2024 documented Resident #447 was seen for significant issue of touching another resident. Resident #447 denied being in bed or touching Resident #463. Resident #447 was not manic or psychotic and behavior probably related to poor intellectual capacity and judgement. Resident was alert and oriented to self only and had diagnosis of Dementia secondary to medical condition of subdural hematoma and nontraumatic subarachnoid hemorrhage with behavioral disturbance. Resident #463 had diagnoses which included Non-Alzheimer's Dementia, Anemia, and History of Falling. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #463 had severely impaired cognition and behaviors of wandering daily. A comprehensive care plan dated 05/10/2024 and was last reviewed on 08/13/2024 documented that Resident #463 was at risk for victimization. The facility interventions documented were to involve in activities keeping with interests and providing emotional support. A physician's progress note dated 07/27/2024 documented that Resident #463 was seen and examined, and no injury was noted to genital area and there was no rectal bleeding or pain. A Psychiatry note dated 08/15/2024 documented Resident #463's insight and judgement was poor. Resident #463's ability to make decisions regarding health needs, discharge, and Power of Attorney was severely limited and Resident #463 was unable to understand and answer questions. During an interview on 10/25/2024 at 4:42 PM, Certified Nursing Assistant #4 stated that on the date of the incident, they were distributing meals to residents. They stated when they went to Resident #447's room, they saw Residents #447 and #463 in bed. They stated Resident #463 was naked from the waist down and that Resident #447 was not touching Resident #463. They stated they were not sure if Resident #447 was naked, but the Resident was pulling their pants while they were in bed. During a subsequent interview with Certified Nursing Assistant #4 on 10/25/2024 at 5:37 PM, the State Surveyor clarified the discrepancy between Certified Nursing Assistant #4's written statement and what they stated during the earlier interview. Certified Nursing Assistant stated they do not remember if Residents #447 and #463 were touching each other. They stated they remembered Residents #447 and #463 were lying in bed, Resident #463's incontinence briefs and pants were on the floor and that Resident #447 stood up pulling their pants when they entered the room. During an interview on 10/25/2024 at 6:25 PM, Licensed Practical Nurse #2 stated Certified Nursing Assistant #4 called them to Resident #447's room and when they arrived in the room, they observed Resident #447 standing and pulling their pants up. Resident #463 was calmly lying in Resident #447's bed naked from the waist down. During an interview on 10/25/2024 at 5:19 PM, Registered Nurse #1 stated they were the nursing supervisor for the evening shift on the day of the incident. Registered Nurse #1 stated they received a call from Licensed Practical Nurse #2 stating that Resident #463 was in Resident #447's bed. Registered Nurse #1 stated that the Certified Nursing Assistant reported that Resident #447 was touching Resident #463 in the genital area. They stated that the residents were immediately separated and that they assessed Resident #467's private area with no discharge or bleeding. Registered Nurse #1 stated they called the police and explained what happened to the physician. During an interview on 10/28/2024 at 10:13 AM, the Psychiatrist stated that both residents had prior consults pertaining to their capacity, but they did not assess Residents #447 and #463 for capacity to consent to sexual involvement. The psychiatrist stated that capacity to consent to sexual activity must be first requested before they assess residents for it. They stated they think the reason the facility did not request for capacity to consent to sexual activity was because the facility do not suspect sexual involvement. During an interview on 10/28/2024 at 2:28 PM, the Director of Nursing stated that the Certified Nursing Assistant reported that 2 demented residents were in the room, both with their incontinence briefs down, and that Resident #447's hand was close to Resident #463's perineal area. The Director of Nursing stated that they cannot conclude that Residents #447 and #463 had sexual intercourse. However, the Director of Nursing stated that touching another resident's private part was sexually inappropriate, but since Residents #447 and #463 were cognitively impaired, they would not say that it was abuse but rather an inappropriate behavior. During an interview on 10/28/2024 at 11:22 AM, the Administrator stated they received a call from Registered Nurse #1 on 07/26/2024 at about 6:45 PM stating that Residents #447 and #463 were in bed together. The residents were immediately separated. The Administrator further stated the psychiatrist determined neither resident has decision making capacity and there was no evidence based on Registered Nurse Supervisor #1's assessment that sexual activity occurred between Resident #447 and Resident #463. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interview conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure that a person-centered Comprehensive Care Plan was developed and implemented to meet the resident's goals, and address the resident's medical, physical, mental and psychosocial needs. This was evident in 1 (Resident #28) of 2 residents reviewed for care planning out of 37 total sampled residents. Specifically, Resident #28 who had a diagnoses and was receiving treatment for Glaucoma, had no comprehensive care plan developed to address the Resident's impaired vision. The findings are: The facility's policy titled Comprehensive Care Plan with a revision date of 06/23/2020 documented that the comprehensive care plan will include measurable objectives and timetables to meet the resident's medical, nursing, psychosocial needs, cultural, and trauma informed care if appropriate that are identified from the comprehensive assessment. The policy documented that the comprehensive care plan will be initiated by the interdisciplinary team members on admission and quarterly, readmission, significant change or any change in resident's plan of care. The policy documented that all disciplines are responsible for reviewing the comprehensive plan of care and documenting interventions. Resident #28 was admitted to the facility with diagnoses that include Hypertension, Diabetes Mellitus, and Glaucoma. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #28 had intact cognition and impaired vision. The Physician's Order dated 05/25/2024 and was renewed on 09/30/2024 documented that the Resident #28 had orders to take Latanoprost 0.005%, instill 1 drop into both eyes at bedtime for bilateral absolute glaucoma. A review of Resident #28's comprehensive care plan revealed that a care plan was not developed to address the Resident's impaired vision and diagnosis of Glaucoma. On 10/24/2024, the Director of Nursing was interviewed and stated that the admission nurse is responsible for creating care plans relevant to concerns present on admission. They stated that if there was a change in condition requiring a new care plan, the nurse working that shift with the resident would be responsible for completing that care plan. The Director of Nursing stated that a care plan for impaired vision should have been completed for residents with visual impairments. The Director of Nursing was unable to confirm which nurse would have been responsible for creating this care plan for Resident #28. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews conducted during the Recertification Survey from 10/21/2024 to 10/28/2024, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences. This was evident in 1 (Resident #841) of 3 residents reviewed out of 37 total sampled residents. Specifically, Resident #841, who had a documented allergy to fish and fish containing products, received a lunch tray containing fish. The findings are: The facility policy and procedure titled Special Food Needs, Swallowing/chewing difficulties, and Food Allergies with a revision date of 01/2024 documented that all food and beverages served will be assessed and determined safe for residents with special dietary needs, including those with food allergies. The policy documented that all new residents, diet order changes, and allergy information is printed via the network printer to the diet office. The Diet Clerk is responsible for entering the resident's name, room number, diet, and allergies into GeriMenu. A meal ticket should be printed prior to the next meal to ensure all residents receive a tray with the correct room number, diet, and allergy information. Resident #841 had diagnoses of Type 2 Diabetes Mellitus, Hypertension, and Anxiety. The 10/18/2024 physician progress notes documented that Resident was alert and oriented to person, place, and time. The Admission Nutrition Risk assessment dated [DATE] documented that Resident #841 had food allergies to fish and fish containing products. A care plan on allergies was initiated for Resident #841 on 10/21/2024. The facility interventions include alerting appropriate discipline for any drug and food allergy. On 10/21/2024 at 12:43 PM, Resident #841 was observed in their room refusing a lunch tray that contained fish on it, stating that they cannot eat fish. The lunch meal ticket dated 10/21/2024 included with the tray documented that the tray included fish seasoned with lemon and pepper. On 10/24/2024 at 02:19 PM, Certified Nursing Assistant #11 was interviewed and stated that they worked with Resident #841 on 10/21/2024 during the day shift. They stated that their job responsibilities included serving residents trays during mealtime and that on 10/21/2024, they brought Resident #841 their lunch tray. They stated that when serving meals, Certified Nursing Assistants are responsible for reading the meal ticket to ensure that all food on the tray is safe for residents to consume based on the allergies listed on the tray. Certified Nursing Assistant #11 stated that they did read the ticket prior to serving the tray to Resident #841, and that as soon as they placed the tray in front of the resident, the resident notified them that the tray contained fish, which they could not eat. Certified Nursing Assistant #11 stated that they removed the tray from the resident's room and notified the kitchen of the error and requested a new meal for the resident. On 10/24/2024 at 2:32 PM, Registered Dietician #2 was interviewed and stated that their job responsibilities include interviewing residents upon admission to confirm any food allergies that they have, inputting dietary orders, and inputting care plans related to nutrition. They stated that they completed Resident #841's admission nutrition assessment, and that Resident #841 is allergic to fish and fish products. They stated that the allergies inputted in the electronic medical record is connected to the system used by the kitchen staff, and it would be the kitchen staff's responsibility to ensure that the information appeared on the meal tickets. On 10/25/2024 at 11:32 AM, the Clinical Nutrition Manager was interviewed and stated that they were aware that Resident #841 had received fish on 10/21/2024 despite them having a documented allergy to fish. They stated that meal tickets are printed through the computer system, GeriMenu. They stated that the diet clerk was responsible for reviewing the allergies placed by the admission nurse or dietician in the electronic medical record and transmitting those allergies into Geri Menu. They stated that the diet clerk failed to transfer the allergy information from the electronic medical record to GeriMenu and that is what led to the food services staff to serve the Resident fish. The Clinical Nutrition Manager stated that the diet clerk who was responsible for inputting this information was unavailable to be interviewed by the surveyor. On 10/28/2024 at 1:51 PM, The Director of Nursing was interviewed and stated that the allergies are printed on each unit and posted in the nursing station. They stated that residents' allergies are also printed on their meal tickets. The Director of Nursing stated that in this situation, Resident #841's allergies were not listed on the meal ticket and although the Certified Nursing Assistant verified with the resident, the lunch tray should have not reached the Resident's room. 10 NYCRR 415.14(d)(4)

Based on observation, interviews, and record review conducted during an Abbreviated Survey (NY00303407), the facility did not ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency, New York State Department of Health (NYSDOH). This was evident in 1 out of 3 residents reviewed (Resident #1). Specifically, on 10/05/22 at approximately 8:20PM, two Police Officers showed up at the facility to speak Resident #1 regarding an allegation of abuse. The facility initiated the investigation on 10/05/22 and reported the abuse allegation to NYSDOH on 10/06/22. The allegation of abuse was not reported within two hours. The findings are: The facility Policy and Procedure for Clinical, Resident Abuse Reporting and Investigation Protocol most recent review date 06/2022, documented that it is the policy of this facility that abuse allegations (verbal, mental, sexual, or physical abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Resident #1 was admitted to the facility with diagnoses including Autistic Disorder and unspecified Paranoid Schizophrenia Irritability, and Anger. A nurse's note, written by RN #1 dated 10/06/2022 at 4:04PM, documented that on 10/05/2022 at around 9:20PM, writer was called by the unit nurse to check on Resident #1. The police were on the floor to speak with Resident #1. Resident #1 reported to the police that the staff was harassing them. Resident #1 refused to tell the police who the staff were, and that Resident #1 would speak with the police later. Resident #1 was smiling while Resident #1 was talking to the police. The medical doctor was notified. The Accident Report dated 10/05/2022 documented that a complete body assessment was done, and no visible injury was observed, and Resident #1 had no complaints of pain. Two Police Officers arrived on unit and spoke to the Resident #1. Resident #1 explained that a staff threatened them but refuses to give the staff name to the Police Officers. No arrests were made. Resident #1 was in no distress, no changes in their skin status, no complains of pain. The Medical Doctor ordered Psychiatry consult. The investigation revealed that no one witness the alleged incident. The facility concluded that abuse, neglect, or mistreatment did not occur. A Webform submission form: Nursing Home Facility Incident Report documented that the facility reported the incident on 10/06/22 at 8:49AM. During an interviewed on 08/02/22 at 4:30PM, the Administrator stated that they did not receive a report about the incident involving Resident #1 until the morning of the next day (10/06/2022). The Administrator stated that the Nursing Supervisor (NS) #1 did not report the incident to them until 10/06/22. The Administrator stated that the Director of Nursing (DON) and RN #2 had submission right at the time of the alleged incident. The Administrator said that they don't know why the DON did not report the incident to the Administrator and does not know why RN #2 didn't report the alleged abuse allegation to NYSDOH in a timely manner. The former DON (was also RN #2) was not available for an interview. 10 NYC RR 415.4(b)

Based on record review and interview conducted during the Recertification and Abbreviated survey (NY00295603) from 9/29/2022 to 10/6/2022, the facility did not ensure that the designated representative was immediately notified of a change in resident's condition. This was evident for 1 (Resident #597) of 4 residents reviewed for Notification of Change out of 38 sampled residents. Specifically, the designated representative of Resident #597 was not notified upon the resident's transfer to the hospital. The findings are: The facility policy titled Clinical, Acute Change in Condition, System Wide revised 6/27/22 documented the appropriate and proper identification of a change in condition of the patient/resident and the appropriate follow-thru by means of proper notification of the appropriate person. The New York State Department of Health Complaints Tracking System documented on 8/25/22 a complainant reported Resident #597 was transferred to the hospital after resident complained of blurry vision and severe headaches and the complainant was not made aware by the facility. Resident #597 had diagnoses of lung cancer and schizophrenia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #597 was cognitively intact. The physician's order dated 7/29/22 documented transfer of Resident #597 to acute care for imaging post altercation and complaints of headache. The Nurse Practitioner (NP) transfer note dated 7/29/22 documented Resident #597 was transferred to, and call placed to the emergency room to inform of resident's arrival. The nursing note dated 7/29/22 documented Resident #597 was transferred to the emergency room . There was no documented evidence Resident #597's designated representative was made aware of the resident's transfer to the emergency roiagnom on [DATE]. On 10/4/22 at 9:37 AM, Registered Nurse (RN) #3 stated they are responsible to notify designated representative of any changes in a resident's condition and documents notification in the electronic medical record. Resident #597's designated representative was informed when the resident had an altercation the day before their hospitalization and should have been notified immediately when resident was being transferred to the hospital on the following day. On 10/6/22 at 12:43 PM, an interview was conducted with the Administrator who stated they could not explain the reason Resident #597's designated representative was not notified of the resident's transfer to the hospital. 415.3(e) (2) (ii) (b)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure the accuracy of a resident's assessment. This was evident for 1 (Resident #77) of 7 residents reviewed for Accidents out of 38 total sampled residents. Specifically, the Minimum Data Set 3.0 (MDS) assessment documented Resident #77 had wandering behavior and using a Wander/elopement alarm. The findings are: The facility policy titled MDS last reviewed 07/2017 documented interdisciplinary (IDT) members must verify the accuracy of assessment and the MDS is signed, certifying completion and accuracy. Resident #77 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #77 was cognitively intact, wandered daily, ad used a Wander/elopement alarm daily. On 10/3/22 at 12:50 PM and 10/6/22 at 11:14 AM, Resident #77 was observed in their room or sitting in the dayroom. Resident #77 was not observed with wandering behavior and did not have a wander/elopement alarm in place. There was no documented evidence Resident #77 had wandering behaviors or used a Wander/elopement alarm. The MDS Coordinator was interviewed on 10/5/22 at 11:35 AM and stated they were responsible for completing Resident #77's MDS assessment. The wandering behavior and alarm must have been a data entry error. Resident #77's MDS assessment will be modified and resubmitted. The MDS Coordinator does check assessments for accuracy. 415.11(b)

Based on record review and staff interviews conducted during a Recertification Survey from 09/29/22 to 10/06/22, the facility did not ensure that the resident and their representative were provided with a written summary of the Baseline Care Plan (BCP). This was evident for 1 resident of 1 resident reviewed for Tube Feeding, and 1 of 5 residents reviewed for Unnecessary Meds, out of 38 sampled residents. (Residents #170 and #387) The findings are: The facility policy titled Baseline Care Plan effective November 2017 and reviewed 07/2021 documented that the facility provides the Resident and the Representative with a written summary of the Baseline Care Plan .The Team Members evaluate Resident within 48 hours of admission, completes initial assessment, develop initial care plan based on identified concerns .if CP reviewed via telephone, will be sent via certified mail to the family, certified return receipt placed in resident's medical record. 1). Resident #170 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Significant Change in Status Minimum Data Set (MDS) dated [DATE] documented that the resident had intact cognitive status. The MDS also documented that the resident participated in the assessment and family and significant other did not participate in the assessment. The Baseline Care Plan (BCP) was documented as created on 06/07/2022; with goals that included: Resident will continue to state preferences, accept care, and remain in the facility x 30 days. Interventions included provide a copy of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes 06/07/22-10/05/22 revealed no documented evidence that the resident and/or designated representative had been provided with a copy of or had signed the baseline care plan. 2). Resident #387 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented the resident had moderately impaired cognition, makes self-understood, and understands others. The MDS further documented the resident and family or significant other participated in the assessment. On 09/30/22 at 09:06 AM, Resident #387 stated they had not been given a copy of base line care plan. The Baseline Care Plan (BCP) was documented as created on 09/10/22; with goals that included Resident will continue to state preferences, accept care, and remain in the facility x 30 days, and interventions which included provide a copy of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes 08/16/22-10/04/22 revealed no documented evidence that the resident and/or designated representative had been provided with a copy of or had signed the baseline care plan. On 10/06/22 at 10:38 AM, the Social Worker (SW) #1 was interviewed. SW #1 stated that Resident #170 was met by the Social Worker within 72 hours of admission; Nursing is in charge of initiating the base line care plan and giving the written summary to the resident. SW #1 also stated that they did know whether or not a copy of BCP was given to the resident and could not recall the nurse at the time of the resident's admission. On 10/06/22 at 10:47 AM, the Social Worker (SW) #2 was interviewed. SW#2 stated that Resident #387 was seen during re-admission and had the initial Social Services assessment with the resident in September. SW#2 stated that the BCP was done by nursing within 48 hours when the resident came in, but they are not sure if the written summary of BCP was given to the resident. On 10/06/22 at 11:03 AM, an interview was conducted with the Director of Clinical Operations (DCO). The DCO stated that when the resident comes in, the nurse reviews the base line care plan with the resident, and within 48 hours the Interdisciplinary team members gather to discuss the plan of care with the resident and provide a copy of written summary of the base line care plan to the resident/resident's representative. The DCO#1 is unable to explain why there was no documented evidence in the residents' charts that a copy of written summary of BCP was provided to the residents or their representatives. 415.11 (c)

Based on observations, staff interview and record review conducted during a Recertification and Complaint survey (NY 603) from 09/29/22 to 10/06/22, the facility did not ensure that a person-centered care plan with measurable goals, time frames and interventions were developed and implemented to address resident concerns, consistent with the resident rights to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, 1). a Comprehensive Care Plan (CCP) was not developed and implemented for a resident with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evident for 1 of 1 resident reviewed for [CONDITION(S)]/Catheter and 1 of 1 resident reviewed for Skin Conditions out of 38 sampled residents (Residents #417 and #6). The findings are: The facility policy and procedure titled Comprehensive Care Plan dated September 1st, 2007 and last revised on September 28th 2022 documented the Comprehensive Care Plan should include measurable objectives and timetables to meet a Resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment. 1). Resident #417 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident with intact cognitive status. Required limited assist of one staff person for bed mobility and transfer, extensive assist of 1 staff person for dressing and toilet use, extensive assist of 2 staff people for personal hygiene. The nurse's progress note dated 7/26/22 documented that the resident came to the nurse's station and said that something is falling out of their vagina. The resident was examined and a mass extending past the vaginal lips was observed. The nursing progress note further stated that the resident was referred to the primary MD. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The primary MD further stated that it is relatively a new problem causing more discomfort. No history of birthing children. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician further stated that the Uterine prolapses when the resident is in supine position and retracts when the resident lies down. On 10/04/22 at 3:02 PM, Physician #2 was interviewed and stated that the resident has Uterine prolapse. It appears in supine position. Resident has an appointment with the Gynecologist on 3/3/2023. Physician #2 further stated that the resident has no bleeding, no infection, no emergency. On 10/06/22 at 12:45 PM, RN #4 was interviewed and stated that a resident's care plan is initiated by an RN as soon as they discover a problem with the resident. She further stated that the goal is reviewed in 30 days to see if it is working. There was no documented evidence that a care plan addressing the care or management of a resident with Uterine prolapse was developed. 2). Resident #6 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) assessment dated [DATE] documented resident's cognition was moderately impaired. The MDS also documented the resident had infection of the foot and treatments included application of nonsurgical dressings, nonsurgical ointments/medication, application of dressing to feet, pressure reducing device for chair and for bed. The hospital discharge summary dated 11/24/21 documented resident was admitted to the hospital for [CONDITION(S)] secondary to LLE ulcer with surrounding [CONDITION(S)]. During the hospital course resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon discharge, resident was to follow up for vascular surgery appointment in 2 weeks. The nursing skin assessment dated [DATE] documented resident with wound on left big toe anterior. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound consult note dated 11/29/2021 documented the resident was noted to have a wound on the left first toe and was referred for wound care evaluation and treatment. The wound was located left first toe measuring 1.0 centimeters (cm) x 1.0 cm and progress was undetermined because it was first visit. The treatment to continue topical wound dressing with Iodosorb gel and Calcium Alginate. The vascular surgery note dated 12/6/21 documented resident was seen for post op LLE [MEDICATION(S)] with angioplasty of popliteal/AT vessels on left side. Recommended to continue course of PO antibiotics, Santyl/[MEDICATION(S)] to Left great toe with sterile dressing, [MEDICATION(S)]/[MEDICATION(S)] and will follow up in 2 weeks for wound check. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Attending Physician (AP) note dated 12/8/21 documented resident followed up by vascular surgeon on 12/6/21. Recommendations included apply small amount of Santyl [MEDICATION(S)] to left great toe wound daily, skin prep on left ankle daily, and follow up in two weeks with the vascular surgeon. A review of the CCP created 11/27/21, revised 12/29/21 reveals that there was no documented evidence the facility developed a care plan for resident's ulcer/wound care treatment or interventions to reduce/prevent infection of the skin and lower extremity amputation The Licensed Practical Nurse (LPN#3) was interviewed on 10/3/2022 at 9:41 AM and stated that unit nurse will initiate baseline care plans when resident is admitted and the RN Manager will develop and revise the CCP. LPN#3 also stated that CCP related to Resident #6's impaired skin integrity and wound on the left toe should have been developed with appropriate goals and interventions upon admission since resident was admitted with the wound but LPN#3 did not know why it was not initiated. LPN #3 further stated facility switched to the new electronic medical record system in 10/2021 therefore, it may be possible that documentation was not completed because staff did not know how to navigate through the new system. Registered Nurse (RN#2) was interviewed on 10/3/22 at 10:31 AM and stated the resident's CCP is initiated by unit nurse or unit RN manager. If the resident is admitted in the afternoon, the CCP should be initiated by the afternoon admitting nurse and completed by unit nurse or unit RN manager. If the resident has new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 further stated that they were not aware that resident did not have a CCP related to impaired skin integrity and that a CCP should have been created for Resident #6. On 10/4/22 at 9:47 AM, the Wound Care Nurse (WCN) was interviewed and stated that the unit RN managers are responsible for initiating and revising CCPs. Once a wound was identified, the unit RN manager should conduct a skin assessment, notify the interdisciplinary team including the attending physician, obtain appropriate treatment order and notified wound care team for wound consultation. RN#1 also stated a CCP for the care of the actual wound and interventions to prevent infection of the wound should have been developed and implemented when the wound was first identified. 415.11(c)(1)

Based on observations, record reviews and interviews conducted during the Recertification survey from 9/29/2022 to 10/6/2022, the facility did not ensure that resident's Comprehensive Care Plan (CCP) was reviewed and revised to accurately reflect the current residents status. Specifically, 1). Activities of Daily Living and a respiratory care plan was not reviewed and revised in a timely manner, and 2). A comprehensive care plan was not reviewed and revised for a resident with a history of a fall. This was evident for 1 of 1 resident reviewed for Respiratory Care and 1 of 7 residents reviewed for Accidents out of 38 sampled residents (Residents #83 & Resident #332) The findings are: The facility policy and procedure title Comprehensive Care Plan dated 09/01/2007 and last revised on 09/20/2022 documented that a written comprehensive care plan is developed and maintained for each resident to attain or maintain the resident highest practicable physical, mental, and psychosocial wellbeing. The Comprehensive Care Plan shall be reviewed and revised as needed at least quarterly, annually, and whenever there is a change in the Resident's medical condition, functional status etc. 1). Resident #83 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/04/22 at 12:34 PM, resident was observed in bed. Able to talk to surveyor with a [CONDITION(S)] collar on. The Quarterly Minimum Data Set (MDS) 3.0 dated 07/07/2022 documented resident had intact cognitive status. The MDS also documented that the resident required extensive assistance of 2 staff members for bed mobility and transfer, and dependent assist of 2 staff members for dressing, toilet use and personal hygiene. In addition, the MDS documented that the resident was receiving Oxygen Therapy, Suctioning and [CONDITION(S)] care. The nursing progress notes dated 9/5/22 stated [CONDITION(S)] in place and patient's suction done numerous time on tour with thick whitish secretion. PRN nebulizer treatment administered, tolerated well. Resident was encouraged to practice deep breathing and cough secretion. No shortness of breath noted, denies pain and discomfort. Will continue to monitor. The Comprehensive Care Plan (CCP) titled Ineffective airway clearance with the effective of 1/25/2022 had a goal for the resident to mobilize secretion with effective secretion removal and improve strength to cough. Intervention included evaluate the breath sound pre and post treatment. The CCP titled Resident requires assistance with ADL's task performance dated 12/18/2021 included a goal for the resident to remain clean, neat, and free of body odor. The intervention included to identify the resident's preferences on ADL's care. There was no documented evidence that the care plans were reviewed after the quarterly assessments dated 4/13/22 and 7/7/22 were completed. On 10/06/22 at 11:20 AM, Registered Nurse (RN) #3 was interviewed and stated that care plans are updated when there is a change and quarterly. 2). Resident #332 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data set 3.0 (MDS) assessment dated [DATE] documented that the resident has intact cognition and required supervision and set up for bed mobility, transfer and eating and limited assistance of one staff for dressing, toilet use and personal hygiene. The MDS also documented that the resident had not had a fall. A CCP titled Falls was created on 3/14/22 and included a goal that the resident will be free of injury with an intervention to encourage resident to wear well fitted shoes. Care Plan Notes by Problem dated 3/15/22 documented that resident had a fall on 3/14/22. There was no documented evidence that the CCP was reviewed and revised after 3/14/22. On 10/06/2022 at 12:45 PM, RN #2 was interviewed and stated that as soon that the resident has a problem, a care plan is initiated. The care plan is reviewed in 30 days to see if the goal is working. If the goal is not working, the goal is changed. If the goal is working, the care plan needs to be updated from 30-90 days. On 10/06/22 at 3:02 PM, the Director of Nursing (DON) was interviewed and stated that care plans need to be reviewed quarterly and as needed. 415.11(C)(2)(i-iii)

Based on interviews and record review conducted during the Recertification and Complaint survey (NY00295603) from 9/29/2022 to 10/6/2022, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan and the resident's choices. Specifically, Resident #6, a resident admitted with a vascular ulcer on the left great toe, did not receive appropriate and timely assessment, treatment, and monitoring to prevent wound worsening and infection. This was evident in 1 of 3 residents reviewed for Skin Conditions out of a total sample of 38 residents. (Resident #6) The findings are: The facility policy and procedure titled Wound Management, Pressure Ulcer Care and Prevention revised 7/1/21 documented to assess/observe all residents for the risk of pressure ulcer and to have an appropriate interdisciplinary preventative care plan implemented when indicated. Residents with existing pressure ulcers will be evaluated and managed in accordance with the system's established clinical practice guidelines. On 9/29/22 at 3:04 PM, Complainant was interviewed via phone and stated their mother who is a resident in the facility, had her toe amputated in January 2022. Complainant visited the resident on 12/27/21 and observed that resident was extremely malodorous. When the complainant removed the resident's sock, he/she observed ulceration on the resident's toe. Staff had no knowledge of their mother's foot ulceration and were reluctant to transfer the resident to ER. Complainant expressed that it could have been avoidable only if staff were competent and necessary treatments/tests were all done and completed in a timely manner. Resident #6 was admitted with diagnoses that include Diabetes Mellitus, Peripheral Arterial Disease, Non-Alzheimer's Dementia and Cellulitis of left lower limb. The annual Minimum Data Set (MDS) assessment dated [DATE] documented resident's cognition was moderately impaired. The MDS documented the resident had infection of the foot and treatments included application of nonsurgical dressings, nonsurgical ointments/medication, application of dressing to feet, pressure reducing device for chair and for bed. The hospital discharge summary dated 11/24/21 documented resident was admitted to the hospital for sepsis secondary to LLE ulcer with surrounding cellulitis. During the hospital course resident underwent angioplasty to restore circulation and started on antibiotic regimen. Upon discharge, resident was to follow up for vascular appointment in 2 weeks. The nursing skin assessment dated [DATE] documented Resident #6 had a wound on the left big toe anterior. The physician's orders dated 11/27/2021 documented to apply skin prep to left ankle daily at 10 AM and to review skin integrity every 7 days. There were no treatment orders for the left big toe wound upon admission A review of the Comprehensive Care Plan (CCP) created 11/27/21, revised 12/29/21 reveals that there was no documented evidence the facility developed a care plan for resident's ulcer/wound care treatment or interventions to reduce/prevent infection of the skin and lower extremity amputation. The wound consult note dated 11/29/2021 documented the resident was noted to have a wound on the left first toe and was referred for wound care evaluation/treatment. The wound on the left first toe measured 1.0 centimeters (cm) x 1.0 cm. The progress was undetermined because it was the first visit. The treatment plan was to continue topical wound dressing with Iodosorb gel and Calcium Alginate. There was no documented evidence the resident had treatment orders for the left first toe prior to the wound consult on 11/29/21, and the topical wound dressing with Iodsorb gel and Calcium Alginate was not ordered after the wound consult on 11/29/21. The vascular surgery note dated 12/6/21 documented resident was seen for post-operative appointment. It documented that resident's LE ulcer improved with antibiotic therapy and s/p angioplasty. Recommended to continue course of PO antibiotics, Santyl/Bactroban to Left great toe with sterile dressing, Eliquis/Plavix and will follow up in 2 weeks for wound check. The physician's orders dated 12/6/21 documented to clean the left great toe with Normal Saline (NS) and apply Santyl and Bactroban at 8 AM daily for wound care treatment and scheduled vascular consult follow up in 2 weeks on 12/20/21 at 2:45PM. The Attending Physician (AP) note dated 12/8/21 documented resident followed up by vascular surgeon on 12/6/21. As per vascular surgeon, resident to start ASA 81 mg, apply small amount of Santyl Bactroban to left great toe wound daily, skin prep on left ankle daily, and follow up in two weeks with the vascular surgeon. The nursing progress note dated 12/20/21 documented resident out on pass for vascular follow up but was late to vascular appointment as per escort. There was no documented evidence that resident was seen and evaluated by vascular surgery. Per the medical record, Resident #6 received weekly wound assessments on 11/29/21 and 12/6/21. There was no documented evidence that wound assessments were conducted on the following weeks: 12/13/21 and 12/20/21. Further review of the nursing progress notes from 12/1/21 to 12/27/21, revealed no documentation of wound treatment/dressing change, assessment or shift monitoring of resident's left great toe, or documented rationale of the worsening of the left toe. The Treatment Administration Record (TAR) for December 2021 documented the resident did not receive the daily Santyl Bactroban dressing to the left toe for 13 days/opportunities out of 24 days/opportunities, and the resident did not receive the daily skin prep dressing to the left ankle for 14 days/opportunities out of 30 days/opportunities. There was no documented evidence the resident refused the dressings. In addition, the resident's weekly skin check was not completed on 12/25/21. The AP intramural transfer note dated 12/23/21 documented that Resident #6 was transferred to AP #1's care. The note documented resident's overall medical summaries and care management plans. There was no documentation regarding Resident #6's left great toe wound in the transfer note. The AP note dated 12/27/21 documented that resident's left foot was evaluated at this tour with the resident's daughter present. Management plans were to obtain repeat XR left foot and Arterial Doppler of LE to ascertain that circulation of left foot is still intact and to provide IV antibiotic coverage. The physician's orders dated 12/27/21 and 12/28/21 documented X Ray of left foot and Arterial Doppler. A review of radiology report dated 12/28/21 documented 3 views of left foot X Ray revealed no radiographic evidence of osteomyelitis. There was no documented evidence that Arterial Doppler was completed. The physician's order dated 12/28/21 documented wound care consult to assess cellulitis with vascular ulcer L great toe. The wound consult note dated 12/29/21 documented that resident has a wound found on the left 1st toe, measuring 0.8 cm x 0.8 cm, decreased in size but noted signs of infection: inflammation, erythema, pain, and warmth. Resident is currently on antibiotic and recommended to transfer to the hospital for further evaluation and possible amputation. The Attending Physician note dated 12/29/21 documented resident's left great toe had massive tense edema, intense erythema, lifting of nail plate, blood oozing, cyanotic hue, warm to touch. Resident started IV antibiotics for recurrent cellulitis left great toe. XR left foot showed some erosive changes but not definitive for osteomyelitis, CT or MRI recommended. Arterial doppler LE not done. Resident with worsening cellulitis left great toe, now concern for limb jeopardy. Resident to transfer to ER. Daughter made aware. The physician's order dated 12/29/21 documented transfer to acute hospital, diagnosis of severe cellulitis L great toe with possible ischemia. The Licensed Practice Nurse (LPN#4) was interviewed on 10/6/2022 at 4:41 PM and stated that he/she no longer working for this facility. LPN #4 stated that he/she does recall this resident but does not remember about resident's skin condition. LPN#4 stated any new admitted residents are physically assessed upon admission. If resident was observed with an ulcer/wound, wound care team was consulted for wound care management. The wound care team does weekly rounds and visits those observed with ulcers/wounds. The wound care team will complete weekly evaluation and prescribe the treatment orders in the system. The treatment will be provided by the treatment nurse on the unit. However, the treatment nurse was not consistently available on the unit, and the med pass nurse had to pick up the treatment. LPN#4 stated they informed the unit manager if they were not able to provide care/treatment. The Unit Manager was understanding because staffing issues were common during that time. LPN#4 stated they could not recall why there were missing signatures in the TAR. LPN#4 further stated significant changes to the ulcer would be documented in nursing progress notes. LPN#4 stated that the unit manager is responsible for developing and updating the CCP. The Registered Nurses Manager (RN#2) was interviewed on 10/3/22 at 10:31 AM and stated that the unit nurse and the unit manager who were responsible for Resident' #6's care are no longer working in the facility. RN#2 could provide information regarding the missing wound care signatures or why the care plans were not created for the resident's ulcer because they were not working on the unit at that time. RN #2 further stated that it is unit manager's responsibility to ensure that unit nurses/CNAs are completing required documentation in the electronic medical record. She stated skin assessment is completed for all new residents and wound consult is ordered when resident was noted with skin breakdown/wounds or if at risk for skin breakdown. The CCP is initiated by admission nurse and it is updated by unit nurse/RN supervisor. The Wound Care Nurse (RN #1) was interviewed on 10/4/22 at 9:47 AM and stated that he/she works with a Physician Assistant (PA) who does all wound care management in the facility. RN #1 stated that their responsibilities consist of completing wound assessment of newly admitted resident with an ulcer/wound, treating, and evaluating wound treatment in a weekly basis. RN#1 stated Resident #6 was assessed for the left toe wound on 11/29/21. Resident #6 was provided a dressing change at the initial visit, and the Physician Assistant (PA) recommended a topical wound dressing should continue for Resident #6's wound management. RN #1 stated they were not aware the dressing was never ordered. RN#1 stated Resident #6 was scheduled to be seen again on the following Monday dated 12/6/21 as per the wound round schedule, but Resident #6 was not seen by the wound care team on 12/6/21 because outpatient vascular surgery was following the resident. RN #1 stated the resident's left toe wound was evaluated and monitored by vascular surgery. RN#1 stated facility's wound care team did not see Resident #6 until 12/29/21 as per physician's order for wound consultation. RN#1 reviewed MAR, TAR and CCP effective dated 11/27/21 to 12/29/21 and stated wound care treatment and preventative treatment administration records were blank and without signatures on multiple days, CCP addressing resident's skin condition was not found. The Wound Care Physician Assistant (PA) was interviewed on 10/6/22 at 4:55 PM and stated that he/she does not remember about the resident's ulcer and its condition. PA stated resident's ulcer/wound is assessed upon admission and when consulted. PA will most likely follow vascular surgery's recommendation and does not usually intervene in resident's wound management if resident is followed by vascular surgery. The RN Unit Manager who worked on the unit at the time was not available for interview. The Attending Physician (AP #1) was interviewed on 10/06/22 at 10:20 AM and stated Resident #6 was admitted to the facility and was initially under another physician's care. Resident #6 was transferred the unit AP#1 oversees. AP #1 stated they receive the resident's medical information through record review and a verbal report from the unit nurse at the time of transfer. AP #1 could not recall when they were first was made aware of the resident's wound on the left great toe. 415.22(a)(1-4)

Based on observation, record review, and interview, the facility did not ensure a resident who is fed by enteral means received appropriate treatment and services to prevent complications of enteral feeding. This was evident for 1 of 1 resident reviewed for Tube Feeding. (Resident #170). Specifically, Resident #170 was observed doing self-administration of tube feeding, and there was no documented evidence the resident was assessed or educated regarding self-administration of tube feeding. In addition, the staff were not aware the resident was doing self-administration of tube feeding or monitoring the tube feeding completed by the resident to prevent complications. The finding is: Resident #170 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Significant Change in Status Minimum Data Set (MDS) dated [DATE] documented that the resident had intact cognitive status. The MDS also documented the resident required supervision with no set up with walking, was total dependent on staff for eating and required extensive assistance of staff for other Activities of Daily Living. The MDS further documented that the resident is on tube feeding, and the proportion of total calories resident received through tube feeding is 51 % or more. Sig Change MDS also documented that resident experienced a weight loss of 5% or more in one month or 10% or more in 6 months and was not on a physician-prescribed weight-loss regimen. The resident's weights were documented as follows: 6/7/22 8:31pm = 105 pounds (lbs) 7/6/22 1:45 pm = 94 8/5/22 5:40pm = 97.6 9/1/22 = 93.9 The resident had a significant weight loss of 10.66% between June and September. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/29/22 at 11:15 AM, Resident #170 was observed in bed with a Gastrostomy tube placed in the stomach. Three (3) full packs and 1 empty pack of [MEDICATION(S)] HN feed was observed on the overbed table. Resident #170 was interviewed immediately and stated that they had been self-administering the feeds at 8:00 AM, 12 PM, and 6 PM. On 10/03/22 at 11:54 AM, Resident #170 was observed self-administering the feeding via tube; Resident opened the tube, took the uncovered syringe that had been placed on the overbed table, inserted it in the tube and poured the feed. Hand hygiene was not performed before or after the feeding. There was no nursing staff present at the bedside to monitor or supervise the resident, and Resident #170 stated that they had been doing this themselves for a long time. On 10/05/22 at 08:54 AM, Resident #170 was observed in bed, alert and awake, and stated that they had self-administered the morning feed at about 8 am. Two (2) full packs of [MEDICATION(S)] feed were observed on the overbed table, and 1 empty pack was observed in the garbage can on the left side of the resident. There was no documentation noted in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that resident was evaluated, trained, and monitored for self-administration of tube feeding. There was no Comprehensive Care Plan regarding the resident's ability to conduct self-administration of tube feeding. On 10/05/22 at 09:38 AM, an interview was conducted with the Certified Nursing Assistant (CNA) #2. CNA #2 stated that they had been taking care of the resident periodically since the resident was admitted . CNA #2 also stated that they had seen the tube feeding on the resident's table, but thought the nurse gave the feeding to the resident. On 10/05/22 at 09:57 AM, the Licensed Practical Nurse (LPN) #2 was interviewed. LPN #2 stated that resident is given bolus feeds at 8, 11, and 2 pm daily, and it is administered by the nurse. LPN # 2 also stated that when they went to give resident the feeding this morning, resident stated they were full. LPN #2 further stated that they had been and did not know who placed the two bottles of the feed on the resident's overbed table. On 10/05/22 at 10:16 AM, an interview was conducted with the unit Licensed Practical Nursing Supervisor (LPNS). The LPNS stated that they are not sure if the resident is expected to self-administer the feeding. LPNS also stated that the resident's admission record documented that the resident had been self-administering the Tube Feeding (TF) in the community for the past 2 years prior admission to the facility, but there was no note documenting that resident was assessed on admission as being able to self-administer the TF. LPNS further stated that upon investigation, resident confirmed that the nurses have been delivering the feeds to the room for self-administration, however the resident could not recall the names of the nurses. LPNS stated that when resident and the family was updated of the current weight, resident agreed that the nursing should be administering the feeding for now, resident will be monitored daily, and re-assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/05/22 at 01:56 PM, an interview was conducted with the Registered Dietician (RD). The RD stated that the resident was seen for assessment on 7/27/22 when triggered for weight loss, resident's chart was reviewed and noted that the total amount of feeding estimated and ordered for the resident is adequate to provide for the resident's needs so no further change was made then based on the estimate. The RD further stated that the bolus feed is supposed to be administered by the nurses, and they were not aware that resident was self-administering the tube feeding. The RD stated that the feeds seen on the resident's overbed table must have been given to the resident by the nursing staff, as the feeds are always kept in the unit storage that is only accessible to the nursing staff. On 10/06/22 at 01:02 PM, the Speech Therapist (ST) was interviewed. ST stated that resident was seen and evaluated when admitted in June, resident declined speech therapy and also declined to be on PO intake; Resident stated he/she has been on tube feeding for 2 years and has been self-administering the feed in the community for the past 2 years. ST stated that no further speech pathology was offered to the resident. ST further stated that they could not recall if the resident was assessed by the nursing for ability to safely self-administer the feed. On 10/06/22 at 02:13 PM, the Administrator was interviewed. The Administrator stated that they were not aware that the Resident was self-administering the tube feeding without proper assessment and care planning. 415.12(g)(2)

Based on observation, record review and staff interviews conducted during the Recertification and Complaint survey (NY 603) from 9/29/2022 to 10/6/22, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices. Specifically, there was no documented evidence in the Treatment Administration Record (TAR) that Resident #6 and Resident #212 received their wound care treatment and preventative treatment as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #6 and Resident #212) The findings are: The facility policy and procedure titled Medication Administration dated 12/2021 documented medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must initial the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . If a drug is withheld, refused, or given at another time other than the scheduled time, the individual administering the medication shall initial and circle the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 1). Resident #6 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) assessment dated [DATE] documented resident's cognition was moderately impaired. The MDS also documented that the resident had infection of the foot and treatments included application of nonsurgical dressings, nonsurgical ointments/medication, application of dressing to feet, pressure reducing device for chair and for bed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Treatment Administration Record (TAR) for December 2021, revealed there is no documented evidence that Resident #6 received or refused the daily wound treatment and dressing change on 13 of 24 days and that daily skin prep was provided to resident's left ankle on 14 of 30 days. 2). Resident #212 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS assessment dated [DATE] documented Resident #212 had intact cognition, required extensive assistance or dependent assistance of staff for Activities of Daily Living and was at risk of developing pressure ulcers/injuries with treatments that included pressure reducing device for chair and for bed and turning/repositioning program. On 9/30/22 at 12:42 PM, Resident #212 was interviewed and stated that they were seen by a wound care doctor a month ago for an open ulcer located on the back of their thigh and was prescribed skin prep daily. Resident #212 also stated treatment was not given consistently and was only given when the regular full-time nurse was on duty. Resident #212 stated that they had to ask the floating nurses for the treatment, but it was still not getting done. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Right posterior thigh: cleanse with NSS, pat dry and apply skin prep to edges, apply honey to wound then Alginate and cover with [MEDICATION(S)] daily. Review of Treatment Administration Record (TAR) for August 2022 and September 2022, revealed no documented evidence that Resident #212 received or refused the daily wound care treatment on 22 of 31 days in August 2022 and 15 days of 29 days in September 2022. On 10/3/2022 at 9:41 AM, the Licensed Practice Nurse (LPN) #3 was interviewed and stated that the facility switched to a new Electronic Medical Record system in October of 2021; therefore, staff still had difficult time trying to navigate through the system. LPN#3 also stated that it may be possible that residents received treatments, but the staff missed the documentation in the electronic medical record because staff had technical issues with the new system, or that they were busy and forgot to complete the documentation. LPN#3 further stated the administration record for medication and treatment should have been completed daily or even as a late entry if it was forgotten on the day. Registered Nurse (RN) #2 was interviewed on 10/3/22 at 10:31 AM and stated that the unit nurse and the unit manager who were responsible for documenting and maintaining Resident' #6's clinical record for 12/2021 are no longer working in the facility. RN #2 also stated they could not determine if the wound care treatment was administered to Resident #6 on the dates with missing signatures on the TAR for 12/1/21 to 12/29/21. RN #2 further stated it is the unit manager's responsibility to ensure that unit nurses are providing all treatments as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 stated that they run a report at the end of every shift to ensure clinical records are completed by the shift nurses and CNAs. The Wound Care Nurse (WCN) was interviewed on 10/4/22 at 9:47 AM and stated that unit nurses are responsible for documentation of treatments. The WCN reviewed Resident #6's TAR and stated wound care treatment and preventative treatment administration records were blank and without signatures on multiple days. The WCN further stated they were not aware that Resident #212 did not receive skin prep treatment daily. 415.22(a)(1-4)

Based on observations, record review, and staff interviews conducted during the Recertification survey from 9/29/22 to 10/6/22, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident receiving Tube feedings was not properly monitored and supervised to ensure that proper infection control measures were maintained to prevent the development and transmission of infections. This was evident for 1 of 1 resident reviewed for Tube Feeding out of 38 sampled residents. (Resident #170) The findings are: The facility policy and procedure titled Gastrostomy Tube Feedings, dated 04/2015, last revised date 11/2020 documented: .Wash hands .Don gloves .Rinse bulb syringe after each use .Place bulb and syringe on clean paper towel . Resident #170 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Significant Change in Status Minimum Data Set (MDS) dated [DATE] documented that the resident had intact cognitive status. The MDS also documented the resident required supervision with no set up with walking, total dependent of staff for eating and Extensive Assistance of staff for other Activities of Daily Living (ADL). The MDS also documented that resident is on tube feeding, proportion of total calories resident received through tube feeding is 51 % or more. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Two Cal HN five times a day, Route: G-Tube, Strength: Full, give 1 bottle (237 ml) 5x/day On 09/29/22 at 11:15 AM, Resident #170 was observed in bed with a Gastrostomy Tube (GT) placed in the stomach. Three (3) full packs and one empty pack of 'TWO CAL HN feed was observed on the overbed table, placed next to a urinal container. The bulb syringe and the irrigation cup, not dated and not labeled, were also left on the table uncovered. On 10/03/22 at 11:54 AM, the resident was observed self-administering the feed via the feeding tube; Resident #170 opened the tube, took the uncovered syringe that had been placed on the overbed table, inserted it into the G tube and poured the feed. A urinal containing urine was observed on the overbed table next to the feed. Resident #170 did not perform hand hygiene before or after the feeding. There was no nursing staff available at the bedside to monitor/supervise the resident. Resident #170 stated that they have been doing this by themselves for a long time. There was no documented evidence that education on infection control practices when administering tube feedings had been provided to Resident # 170. On 10/05/22 at 09:38 AM, an interview was conducted with Certified Nursing Assistant (CNA) #2. CNA#2 stated the resident needs extensive assistance for care, uses a urinal and is assisted in emptying the urinal as often as resident voids in it. The urinal is always placed on the overbed table by the resident. CNA #2 also stated that they have seen the feed on the resident's table but was not sure who placed the feed there. CNA #2 further stated that they know that the feed and urinal are not supposed to be on the same table and they will find another table for the resident to place the urinal on. On 10/05/22 at 10:16 AM, an interview was conducted with the unit Licensed Practical Nursing Supervisor (LPNS). The LPNS stated that they were not sure who placed the urinal and the feed on the resident's overbed table. The LPNS also stated that the CNAs are supposed to be assisting the resident in emptying the urinal and ensuring that it is not kept together with the resident's feeds. The LPNS further stated that whenever rounds are made and the urinal is noted on any of the resident's table, they are removed and properly placed. On 10/05/22 at 12:43 PM, an interview was conducted with the Infection Control Preventionist (ICP). The ICP stated that the nurses on the units, the supervisor and the ICP are responsible for ensuring that staff are observing infection control practices when giving care to the residents. The ICP also stated that the problem was brought to their attention today, and they will ensure that the resident and staff are re-educated on proper infection prevention protocols. On 10/05/22 at 01:35 PM, the Executive Director (ED) was interviewed and stated that the facility is trying to investigate a better and more appropriate way of placing resident's urinal within reach rather than hanging it on bed side rails or placing it on the overbed tables that are being used for other resident's personal items. The ED also stated that placing the urinal on the same table containing other resident's items is an infection control issue which will be addressed. 415.19 (a)(1-3)

Based on record review and interview during the Recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. This was evident for 13 of 16 residents reviewed for the Resident Assessment facility task (Resident #s 12, 7, 13, 11, 19, 17, 6, 16, 10, 14, 15, 4, and 20). Specifically, comprehensive assessments for Resident #s 12, 7, 13, 11, 19, 17, 6, 16, 10, 14, 15, 4, and 20 were not transmitted and submitted to QIES within 14 days of their completion date. The findings are but not limited to: The facility's policy titled Completion of MDS Assessments revised 8/15/17 documented interdisciplinary team (IDT) will complete an MDS on all residents on admission and as mandated by the regulatory agencies. The MDS schedule and oversight of the completion of the process is the responsibility of the MDS Coordinator. (1) Resident #12 had a Quarterly Assessment with an assessment reference date (ARD) of 8/11/22 and completion date of 8/25/22. The assessment was submitted more than 14 days after the completion date on 10/2/22. (2) Resident #7 had a Quarterly Assessment with an ARD of 8/9/22 and completion date of 8/23/22. The assessment was submitted more than 14 days after the completion date on 10/2/22. (3) Resident #16 had Annual Assessment with an ARD of 8/20/22 and completion date of 8/27/22. The assessment was submitted more than 14 days after the completion date on 10/2/22. On 10/5/2022 at 02:40 PM, the Director of MDS (DMDS) was interviewed and stated MDS assessments are completed within 14 days of ARD and submitted to QIES within 14 days of the completion date. The facility's new software directly transmits MDS data to ASAP system and confirms the acceptance. The software showed that the batch of MDS assessments were submitted on 9/2/22 and the DMDS did not know that there were not accepted into ASAP system. The DMDS did not check the final validation report because the software showed the MDS assessments were submitted to the ASAP system. 415.11

Based on record review and staff interviews conducted during an abbreviated survey (NY 076), the facility failed to ensure that an alleged violation involving sexual abuse was reported within a timely manner to the New York State Department of Health (NYSDOH). Specifically, on 11/23/2020, the facility received a report on an alleged resident to resident sexual abuse. The facility reported the allegation to the NYSDOH on 12/04/2020, eleven days after the incidents occurred. The findings include: The facility's Policy and Procedure, titled Clinical Resident Abuse Reporting and Investigation Protocol Policy last revised on July 2021, stated that all reports of resident abuse shall be reported immediately to the Administrator and to the New York State DOH in accordance with State Laws. Resident #1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, dated dated dated [DATE], identified that Resident #1 's cognitive status was severely impaired. Resident #1 required supervision and set up help with activities of daily living. Resident #2 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, dated dated dated [DATE], identified that Resident #2 's cognitive status as intact. Resident #2 required supervision and set up help with activities of daily living. The facility's Incident Report dated 11/23/2020, documented that on 11/23/2020 at 7 PM, Resident #1 was observed with Resident #2 in a compromise position in her room. Resident #2 was naked from the waist down and Resident #1 has his head in between her legs as reported by staff. Both Residents later denied the incident when questioned by the nurse. Psychiatry note dated 11/24/20, documented that Resident #1 lacks capacity to make sexual decisions. Psychiatry note dated 11/25/20, documented that Resident #2 has poor capacity to make decision regarding sexual relations. The Facility's investigation report dated 11/25/20, documented that the facility determined that both residents were alert and oriented. They were found in Resident #2's room engaging in what appeared to be a sexual relationship. Both Residents were counseled by Social Work #1 on the importance on maintaining safety in exhibiting their sexuality. There is no credible evidence of abuse, neglect of mistreatment. During an interview on 03/31/22 at 01:30 PM, the Administrator #1 stated that all incidents regarding Residents abuse must be reported to the NYSDOH within 24 hours days. If the residents sustain any injuries, the allegation must be reported within two hours. the Administrator #1 also stated that the incident occurred on 11/23/20 and was investigated and concluded that both residents were consenting adults and abuse did not occur. The facility concluded its investigation on 11/25/20. The Psychiatrist saw both residents days later and determined that both residents do not have the capacity to make decisions about sexual relations. Once the Psychiatrist determined that they were not fit to make decisions about sexual relations; they reported the incident to DOH. On 12/4/20 the incident was reported to NYSDOH. During a telephone interview on 07/15/22 at 10:30 AM, the Administrator #1 stated that the Director of Nursing #1 did was investigate this allegation. The Administrator stated that the allegation was not reported to NYSDOH because the residents were consenting adults. The residents were subsequent evaluated days later by the Psychiatrist who documented that the residents did not have capacity to consent. The allegation was then reported to NYSDOH eleven days later. 10 NYCRR 415.4(b)

Based on observation, record review and interview conducted during the Focused Infection Control Survey conducted on 3/15/21, the facility did not ensure that an infection prevention and control program was maintained to help prevent the development and transmission of COVID-19. Specifically, a massage therapist was noted performing services in a resident's room where contact and droplet precautions were required without wearing the appropriate Personal Protective Equipment (PPE). This was evident for random observations on 1 of 15 units (1st Floor- Hospital North). The findings are: The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of their COVID-19 status. Health Care Professionals (HCP) and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. The facility policy on Conservation of Personal Protective Equipment effective 12/30/2020 documented Personal Protective Equipment (PPE) should only be worn when necessary and required for the care of the patient or resident and to protect the healthcare providers. Gown should be worn during care of the residents or patients with COVID-19 or a person under investigation (PUI) will be a priority. The policy also documented that healthcare providers, facility staff, visitors and residents must wear a face mask while in the facility. Healthcare providers providing care to patients in their home must always wear a mask and face shield/goggles while in the home. A masks and face shield/goggles should be worn when on a COVID unit or where there are PUI. Eye protection should be used for contact with potentially infectious residents/patients and when on the COVID-19 unit. A yellow sign posted on the door at the unit entrance indicated the unit had been placed on contact/droplet precautions. A sign posted on the resident's door indicated special droplet precautions, enhanced precautions and special contact precautions. The sign instructed staff to don PPE which included gowns, gloves, surgical masks, and face shields. A fully stocked PPE bin with yellow gowns and gloves was observed opposite the resident's room door. On 03/15/2021 at 11:20 AM, a Massage Therapist (MT) was observed in Resident #1 room massaging the resident's skin through clothing and protective heel boots. The Massage Therapist was wearing a surgical mask and personal glasses and was not wearing a gown, gloves, or face-shield/goggles. The MT performed hand hygiene in the resident's room using hand sanitizer after he completed the task and exited the room and entered the nurse's station. On 03/15/2021 at 11:26 AM, an interview was conducted with the Massage Therapist (MT). The MT stated that they were familiar with the PPE they were supposed to wear, donning/doffing, COVID-19 and was in-serviced in February 2021. The MT also stated that he was wearing his personal glasses and will wear a face shield sometimes. The unit was currently on precautions due to someone testing positive. PPE should be used for hands on care; however, he did not wear gloves as it interferes with providing massage. The MT also stated if he observe staff wearing gowns, he will do the same. The MT further stated he should have been wearing gloves, gown and a N95 mask as they have access to PPE needed. On 03/15/2021 at 11:40 AM, an interview was conducted with unit Registered Nurse (RN) #2. RN #2 stated that when staff are providing direct care, they should be wearing face shield, gown, mask, and gloves for all residents. RN #2 also stated are no active COVID-19 cases on the unit. The unit is on precautions with full PPE required due to possible exposure from a resident who tested positive to COVID-19 and was transferred to the COVID-19 dedicated unit. On 03/15/2021 at 1:43 PM, an interview was conducted with the Administrator. The Administrator stated that staff should be wearing mask, eye protection and gown when providing direct care. The Administrator also stated Massage Therapy staff should have been wearing mask, gown, gloves, and face shield since they were touching the resident. The Administrator stated that the therapist is on a set schedule and he has always seen him in the correct PPE. 415.19 (a)(1-2); 400.2

Based on observations, record reviews, and interviews conducted during the third Focused Infection Control Survey (FICS) and Complaint Investigation Survey (#NY 029), the facility did not ensure that an alleged violation involving abuse was reported to the NYSDOH (New York State Department of Health) and ensure that the results of the investigation were reported to the Administrator or designated representative and other officials in accordance with State law, including to the State Survey Agency (NYSDOH), within five working days of the incident. Specifically (1.) There was no documented evidence that the facility reported to NYSDOH of the allegation of abuse within the time frame. (2) The results of the investigation concerning abuse/mistreatment of [REDACTED].#2) was not reported. This was evident for 1 of 2 residents investigated for abuse. The findings are: The Facility policy titled: Clinical, Resident Abuse Reporting and Investigation Protocol, Policy and procedure dated 06/27/2019 documented that the facility will ensure that all alleged violation involving abuse, neglect, exploitation, or mistreatment including injuries of an unknown source, misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause allegation do not involve abuse, and do not result in serious bodily injury, to the Administrator of the facility and to other officials ( including to the State Survey Agency, and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State Law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 dated 6/30/2020 documented that the resident has a Brief Interview for Mental Status (BIMS) Summary Score of 9/15 (moderate impairment). The resident displayed rejection of care 1 to 3 days during the assessment period. On 08/05/2020 at 2:30 PM, an interview was conducted with Resident #2. Resident #2 stated that the Licensed Practical Nurse (LPN)#1 came inside the room while Resident #2 was about to eat his breakfast and forced him to take his medication. The resident took the medication cup and set it aside, then the LPN hit his hand two times and pushed the medication cup back towards his mouth. The resident stated that he was starving and needed to eat first before taking his medication, but the LPN#1 insisted and grabbed his hand. After the resident took the medication, the nurse left the room. Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Quarterly MDS 3.0 dated 7/22/2020 documented that the resident has a BIMS summary score of 9/15 (moderate impairment). Resident # 3 did not exhibit any mood indicators nor adverse behaviors during the assessment period prior to MDS being completed. On 08/05/2020 at 2:35 PM, an interview was conducted with Resident #2 roommate (Resident #3). Resident #3 stated that on the day of the incident, he was inside the room, and the curtains were open. Resident #3 stated that the nurse came into the room and observed talking to Resident#2 disrespectfully and saw the nurse grabbed Resident #2 left hand and said, eat, eat'. Resident #2 hit the nurse's hand, and the nurse replied, don't hit me, don't hit me. The nurse left the room after. The Physician order [REDACTED]. by oral route once daily every day at 9 AM, Multivitamin tablet 1 table by oral route once daily every day at 9 AM and Memantine 5 mg tablet 2 tablets (10mg) by oral route 2 times per day every day at 10 AM. The Medication Administration Documentation Audit Detail Report dated 7/4/2020 at 10:28 AM documented that LPN #1 gave Resident #2 the following medications: [REDACTED]. The nursing progress notes dated 7/1/2020 to 8/4/2020 was reviewed and observed that there is no written evidence that the incident was reported by Resident #2 and Resident #3. On 8/5/2020 at 10:24 AM, the Director of Risk Management entered a nursing progress note as a late entry. The note documented that on 7/5/2020, the resident alleged he was hit on his hands by the nurse giving medications. The resident was assessed. No signs of injury were noted, and an investigation was initiated. Social Services progress note dated 07/09/2020 documented that the Social worker and 1199 delegate met with the resident regarding complaint made. The resident was interviewed and asked to identify the staff member, and the resident was unable to identify the staff from the photos provided. The resident's roommate was interviewed and stated he heard the staff member ask the resident not to grab her and heard a slap on the wrist following that as indicated by the example shown by the resident's roommate. The Comprehensive Care Plan (CCP) dated 7/5/2020 documented that the resident is at risk for physical abuse as the resident complains of the alleged abuse. Intervention includes identifying patterns of behavior, monitoring residents for complaints of abuse, neglect, and mistreatment. The Facility Occurrence Report dated 7/5/2020 documented that the alert resident, oriented with a BIMS score of 9 reported an alleged assault by the LPN who hit his hand. The alleged nurse was suspended with the pending outcome of the investigation. LPN Employee Disciplinary Action notice dated 7/4/2020 documented that Resident #2 stated that a Jamaican nurse hit his left hand when giving medication before breakfast. LPN #1 was immediately suspended from duty pending an investigation. The facility sent a letter to the alleged LPN dated 07/10/2020 documented that her employment at that facility has been terminated due to alleged resident abuse, jeopardizing the safety and welfare of a resident, and is an unacceptable work performance and unacceptable conduct. The termination was effective on 07/4/2020. A document titled; Confidential for Facility Risk Management Internal Investigation only, the final outcome dated 7/22/2020 documented that even though the resident and roommate were not able to identify the nurse involved, the nurse was terminated, and the staff was in serviced on abuse and neglect. On 8/5/2020 at 12:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Assistant Director of Nursing (ADON) #2 called her on 7/4/2020 when she was off regarding the incident. The DON directed the ADON to suspend the alleged LPN and start the investigation. The DON also stated that she was responsible for reporting the incident to NYSDOH, and it was her fault for not reporting the incident to NYSDOH. As per DON, in her absence, three people have access for NYSDOH, and those are the ADON #1, facility Administrator and the Executive Director. The DON stated that any alleged abuse, including Resident #2's incident should be reported to NYSDOH on a specific time frame. On 8/5/2020 at 12:50 PM, an interview was conducted with the ADON #2. The ADON stated that she had reported the incident to the DON, and the incident was immediately investigated. As per ADON #2, she did not report the incident since there was no credible evidence that there was abuse, and the LPN was terminated. The ADON #2 added that she does not have access to report the incident to NYSDOH but has already informed the incident to the DON. On 8/5/2020 at 1:17 PM, an interview was conducted with the Executive Director. The Executive Director stated all alleged abuse should be reported to NYSDOH. Still, we did not report the incident to NYSDOH since it appears that there is no inclusive evidence that the nurse hit the resident, there was no eyewitness, as though there was nothing conclusive that something happened. On 8/5/2020 at 12:50 PM, an interview was conducted with the facility Administrator. The Administrator stated that when an allegation is reported to nursing and the DON, it is investigated immediately and the person involved is suspended. The investigation is completed and sent to HR for review. There was no credible evidence that abuse occurred, so the incident was not reported to NYSDOH. 415.4

Based on observation, record review and interviews conducted during the abbreviated survey it was determined that the facility failed to ensure that all essential door alarm systems of stairwells were maintained in operable conditions. This was evident in one exit door out of four sampled door alarms. Specifically, the door alarm in stair "F" which egresses to 106th street malfunctioned. Subsequently, resident #1 eloped from the facility. This resulted in no actual harm to resident #1 and the potential for serious harm to all ambulatory residents on the discreet units of the Cohen Building that is Immediate Jeopardy to Resident Health and Safety. Complaint ID #NY 525 The Findings include: Resident # 1 is a [AGE] year old male admitted to the facility on [DATE] from the hospital. admitting [DIAGNOSES REDACTED]. Initial nursing assessment dated [DATE] documents that resident is alert and oriented times 3 and was able to make his needs known. An Elopement risk assessment dated [DATE] documented that resident # 1 was not considered an elopement risk. A nursing note dated 09/03/13 documents "resident # 1 noted to be wandering aimlessly around unit and off the unit. At this time, he was considered at risk for elopement and was placed on 30 minute monitoring and a wanderguard was placed on his lower leg. On 09/05/13 during the 30 minute check at 05:30 PM, the resident could not be located. The Charge Nurse was notified at 05:35 PM and a search was initiated. The facility determined that resident # 1 eloped undetected via stairwell "F" that leads to 106 th street. On further investigation by the facility low voltage alarm wire that connected the stairwell door had malfunctioned due to normal wear and tear and this resulted in the alarm not being transmitted to the main monitoring station. A review of the facility ' s maintenance logs revealed that the alarm systems were not included in any preventive maintenance program at the facility. In an interview with the Director of Engineering on 09/09/13 at 11:00 am, he stated that, minor cosmetic work of the pavement in the Mona Gold Garden was initiated and it was not clear if the vibrations from the tools and construction activities might have caused the wires to fail. He concluded that there was no accidental cutting of wires or deliberate attempt to disable the alarm wires. A review of the camera recording by the facility indicated that the resident exited from the facility door to the Mona Gold Garden on 9/5/2013. The facility door is an alarmed delayed egress door. There was no alarm system installed that connected the gate that allowed the resident to exit to the street either locally or remotely prior to the elopement. In an interview with the Administrator on 09/09/13 at 11:00 AM he stated that, initially after the elopement all stairwell doors and exit doors were checked and were found to be in good working order. On 09/05/13, the facility developed and implemented the following corrective actions prior to the arrival of the Department of Health personnel. A new policy and procedure was developed for "Perimeter Exit Search" and was implemented by the facility and it will include: All exit doors will be checked and tested for alarm function daily during the evening shift, Security will document if alarms are working and/or if re-set is required, and the Director of Engineering will be notified immediately if any alarm is not functional or requires re-setting. Observation on 09/09/13 with the Director of Engineering included testing of the stairwell alarms in "F", "G", Mona Gold door and the gate at the fifth avenue entrance. Also, installed in the proximity of stair "F" was a red indicator light which would become activated once the Mona Gold Gate is opened and it can only be reset at this location. Security officers were observed at the entrance way. On further monitoring of the Annex base station, all door systems were observed connected to an alarm light with a number that identified the location of the alarm as Stair F -26, Mona Gold gate - 25 and Stair G - 40. These alarms were checked with the Director of Engineering and all were functional and a maintenance check list has been put in place to ensure residents are safe. 415.29 (b)