Every finding on record at The Cottages at Garden Grove, A Skilled NRSG Comm

Based on record review and interviews, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one of five residents (Resident #153) reviewed. Specifically, Resident #153 developed a Stage 2 pressure ulcer (partial thickness tissue loss) to the coccyx (tailbone) and there was no documented evidence that wound care orders were clarified to determine if the treatment was daily or every three days; and there was no documented evidence of regular pressure ulcer assessments between [DATE] and [DATE]. Subsequently, the resident's pressure ulcer deteriorated to an unstageable (full thickness tissue loss in which the base of the ulcer is covered with dead tissue) area. This resulted in actual harm to Resident #153 that was not Immediate Jeopardy.Findings include: Resident #153 had diagnoses including stroke, protein-calorie malnutrition, and pressure ulcers. The [DATE] Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, was dependent on staff for all mobility and functional abilities, weighed 80 pounds, was at risk for developing pressure ulcers, did not have any unhealed pressure ulcers, had pressure reducing devices for chair and bed, had nutrition/hydration interventions, and received application of nonsurgical dressings and ointments/medications. The [DATE] at 8:42 AM Registered Nurse #15 progress note documented the resident had a new Stage 2 pressure area on the gluteal cleft (groove between buttocks) measuring 1 centimeter by 0.5 centimeters by 0.2 centimeters. New orders were to cleanse with normal saline, apply Triad paste (a zinc wound paste) and cover with Allevyn (wound dressing). The resident was on comfort measures. The resident's weight fluctuated between 70-80 pounds during the past year. Previous orders were in place to protect the gluteal cleft with Allevyn as the boney prominence of the coccyx protruded and the resident had no fat for protection. The resident had an alternating pressure mattress and specialty cushion in place. The resident's child requested the resident sit up after dinner about 10 days ago and the extra time sitting up could have contributed to the skin on the tailbone breaking down. The resident would be placed back to bed after dinner to support skin integrity. The Comprehensive Care Plan dated [DATE] documented the resident had a pressure ulcer on the tailbone. Interventions included weekly skin evaluations, weekly wound measurements, and referral to the facility's wound care team. The [DATE] at 8:17 AM Nurse Practitioner #11 order documented apply Triad wound dressing paste (zinc paste) topically once daily and as needed. Cleanse gluteal cleft gently and apply Triad paste to open area, cover with Allevyn for protection every three days at 7:00 AM-3:00 PM. The order was entered by Registered Nurse #15. There was no documented evidence that the wound dressing order was clarified with Nurse Practitioner #11 to determine if the frequency of wound care was daily or every three days. The 01/2026 Treatment Administration Record documented apply Triad wound dressing paste topically once daily and as needed; cleanse gluteal cleft gently and apply Triad paste to open area, cover with Allevyn for protection with a start date of [DATE] and scheduled for administration every three days on [DATE], [DATE], [DATE], [DATE], and [DATE] from 7:00 AM-3:00 PM. On [DATE] Licensed Practical Nurse #28 documented the treatment was not completed as the resident was already up in the chair. The [DATE] Nurse Practitioner #11 order documented cleanse coccyx wound with normal saline, apply Aquacel Ag foam bandage (an absorbent dressing with silver) and cover with Allevyn (dressing) every other day from 7:00 AM-3:00 PM.There was no documented evidence of wound assessments from [DATE] through [DATE].The [DATE] Nurse Practitioner #11 progress note documented a Stage 3 (full thickness tissue loss) pressure ulcer to the coccyx measuring 1.4 centimeters by 1.0 centimeter by 0.5 centimeters. The plan documented to continue with same wound care treatment and monitoring until healed and continue with nutritional support. The progress note did not include the current treatment in place. The [DATE] Registered Nurse #3 progress note documented a deterioration of the resident's tailbone pressure ulcer, was unstageable, measured 3.0 centimeters by 2.0 centimeters by 0.5 centimeters, and was black with dead tissue.The [DATE] Weekly Skin Condition Monitor completed by Director of Nursing #2 documented a pressure ulcer on the coccyx measured 3.9 centimeters by 3.5 centimeters by 0.3 centimeters with 90% eschar (dry, dead tissue); the wound deteriorated and the treatment plan was changed to cleanse with normal saline, apply skin prep (protectant) to wound edges, apply Medihoney (medical grade honey wound treatment) to wound bed, and cover with Allevyn. Nurse Practitioner #11 orders documented:-[DATE] cleanse wound with normal saline, apply skin prep to wound border skin, apply Medihoney to wound bed, and cover with Allevyn daily from 7:00 AM-3:00 PM. -[DATE] cleanse wound to coccyx with Vashe 0.033% irrigation solution (wound cleanser), everyday and as needed with dressing changes to Stage 2 pressure ulcer on the buttock. The [DATE] at 8:32 PM Registered Nurse #15 progress note documented the coccyx wound measured 6.0 centimeters by 4.5 centimeters by 0.6 centimeters with 100% loose eschar. New orders to apply Santyl (an ointment used to remove dead tissue) daily and cover with Allevyn and change as needed. Requested head-to-toe assessment with wound team as this resident was at high risk for quick changes in skin integrity.The [DATE] Nurse Practitioner #11 progress note documented a [NAME] pressure ulcer (a pressure ulcer that develops rapidly and associated with the dying process) (location not documented) measuring 6.0 centimeters by 4.5 centimeters by 0.6 centimeters with 100% eschar. The wound was worsening.The resident expired on [DATE]. During an interview on [DATE] at 10:50 AM, Registered Nurse #15 stated they found out about Resident #153's pressure ulcer to the tailbone in early [DATE]. They stated the pressure ulcer became worse over the month of February 2026. They stated if a pressure ulcer treatment was ordered every day and was only done every three days, the wound might get worse.During an interview on [DATE] at 12:42PM, Wound Care Nurse #16 stated they assessed Resident #153's pressure ulcer every Tuesday on wound care rounds with the nurse managers and the nurse practitioner. These findings were documented in the electronic health record. Resident #153 was very frail and developed a pressure ulcer on their tailbone that started out as a Stage 2, progressed to a Stage 3, deteriorated to an unstageable ulcer, then advanced to a Kennedy ulcer. They stated they believed the treatment ordered on [DATE] of zinc oxide paste and silicone dressing should have been applied every day rather than every three days. They stated if the treatment was not done daily as ordered, the pressure ulcer may not have healed properly. Wound Care Nurse #16 could not locate Resident #153's wound care records in the electronic health record. Wound Care Nurse #16 stated there was no evidence that wound care assessments were completed between [DATE] and [DATE].During an interview on [DATE] at 1:58 PM, Nurse Practitioner #11 stated they did wound rounds with the wound care nurse. They stated when they ordered treatments daily, they should be provided daily and not every three days. They were not aware the wound treatments were only done every three days, and they were concerned this could have caused the pressure ulcer to increase in size and delayed healing, possibly causing harm to the resident.10 New York Codes, Rules and Regulations 415.12 (c)(1)

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of three (3) residents (Resident #35) and one (1) of 12 Cottages (Cottage 31) reviewed. Specifically, staff in Cottage 31 did not change their gloves or perform hand hygiene in between cleaning resident rooms; and Resident #35's urinary drainage tubing was laying directly on the floor. Findings include:The facility policy Hand Hygiene, revised 08/2024, documented all personnel were required to wash their hands after each direct or indirect resident contact for which hand washing is indicated by accepted professional practice. Additionally, alcohol-based sanitizer could be used on hands that were not visibly soiled after contact with inanimate objects within the vicinity of a resident and after removing gloves.1) Custodian #25 was observed on 04/28/2026 at the following times wearing the same pair of gloves and not performing hand hygiene:-At 1:52 PM entering room [ROOM NUMBER]. At 1:55 PM they exited the room carrying a bucket and a spray bottle then entered room [ROOM NUMBER]. They did not perform hand hygiene. -At 1:56 PM they exited room [ROOM NUMBER] and retrieved towels from the clean linen closet in the hallway then reentered room [ROOM NUMBER] and went into the bathroom. They did not perform hand hygiene or a glove change. Boxes of gloves were wall mounted and visible from the hall, and no gloves were retrieved by the custodian.-At 1:59 PM they exited room [ROOM NUMBER] with the bucket and spray bottle and entered room [ROOM NUMBER]'s bathroom. They did not perform hand hygiene or a glove change. Boxes of gloves were wall mounted and visible from the hall, and no gloves were retrieved by the custodian.-At 2:03 PM they exited room [ROOM NUMBER], knocked on room [ROOM NUMBER]'s door and entered the room with the bucket and spray bottle. Moments later they exited the room, entered the utility room, and exited seconds later with a bottle of hand wash and reentered room [ROOM NUMBER]. They did not perform hand hygiene or a glove change.-At 2:07 PM they exited room [ROOM NUMBER] and entered room [ROOM NUMBER]'s bathroom carrying the bucket and the spray bottle. Moments later they exited the room, entered the soiled utility room, exited the utility room seconds later and reentered room [ROOM NUMBER]. They did not perform hand hygiene or a glove change.-At 2:12 PM they exited room [ROOM NUMBER], removed their gloves and washed their hands at the sink located off the kitchenette.Custodian #26 was observed on 04/28/2026 at the following times wearing the same pair of gloves and not performing hand hygiene:-At 1:58 PM cleaning the floor in room [ROOM NUMBER].-At 2:01 PM, placing the mop rag in a bag located just outside the room, picked up the mop, dustpan and set them outside room [ROOM NUMBER], then took a yellow rag from a rolling bucket and began wiping the dresser and the windowsill with it.-At 2:05 PM they exited room [ROOM NUMBER], did not perform hand hygiene or a glove change, knocked on room [ROOM NUMBER]'s door, entered the room with a rag and began to wipe down the bedside table and dresser.-At 2:09 PM they exited room [ROOM NUMBER], moved the mop, broom, rolling bucket, and dustpan outside room [ROOM NUMBER] then entered the room. They did not perform hand hygiene or a glove change.During an interview on 04/28/2026 at 2:16 PM, Custodian #25 stated that day they cleaned the bathrooms and Custodian #26 cleaned the bedrooms and floors. Unless a resident was on specific precautions, they only had to wear gloves to clean rooms. Gloves were worn to protect themselves from germs and to prevent the spread of germs and should be changed in between cleaning rooms. Gloves should be removed prior to leaving a room, not worn outside the room. room. They usually, upon exiting a room, went right to the main sink by the kitchen to remove their gloves and wash their hands. They stated they did not change their gloves between cleaning all the rooms they just cleaned. They should have but did not because they wanted to make sure everything was clean and was a little too focused on other things.During an interview on 05/01/2026 at 11:35 AM, the Director of Environmental Services stated gloves should be removed before leaving a room and hands sanitized prior to entering the next room. The same pair of gloves should not be worn to clean multiple rooms.During an interview on 05/01/2026 at 11:43 AM, the Infection Control nurse stated housekeepers should be removing their gloves and performing hand hygiene prior to exiting a room to prevent the spread of infection. 2)Resident #35 had diagnoses including neurogenic bladder (lack of bladder control) and urinary tract infections. The 03/25/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact, had an indwelling urinary drainage device, and was dependent with activities of daily living.The comprehensive care plan dated 02/25/2026, documented the resident had an indwelling urinary drainage device related to neurogenic bladder. Interventions included monitor for signs and symptoms of urinary tract infection, always keep tubing off the floor, and keep the urine collection bag covered to maintain dignity.The following observations were made of Resident #35: -on 04/27/2026 from 10:15 AM to 11:05 AM sitting in a wheelchair with their uncovered urinary drainage bag under the wheelchair and tubing directly on the floor. At 11:10 AM the resident's foot was on the tubing.-on 04/29/2026 in a wheelchair. The covered urinary drainage bag was under the wheelchair. The tubing contained cloudy urine with sediment and was dragging on the floor.-on 04/29/2026 at 3:03 PM in a wheelchair. The partially covered urinary drainage bag was under the wheelchair, the tubing contained cloudy urine with sediment and was dragging on the floor.-on 04/30/2026 at 10:08 AM in a wheelchair. The fully covered urinary drainage bag was under the wheelchair. The tubing contained cloudy urine with sediment and was dragging on the floor.During an interview on 05/01/2026 at 12:06 PM Certified Nurse Aide #42 stated they could not remember if they had any facility training on managing indwelling urinary drainage devices. They should keep urinary collection bags and the tubing covered. They should notify the licensed practical nurse if there was a problem with the urinary drainage device.During an interview on 05/01/2026 at 12:15PM Licensed Practical Nurse #43 stated they verified the indwelling urinary drainage devices were clean, there were no kinks in the tubing, urine was flowing freely, and drainage bags were covered. Infection control practices included handwashing, wearing gloves, and proper resident hydration. Urinary drainage tubing should not be on the floor as this could cause urinary tract infections. Licensed Practical Nurse #43 stated keeping the tubing off the floor was part of the resident's care plan and that it was the licensed practical nurse's responsibility to follow the care plan.During an interview on 05/01/2026 at 11:43 AM, the Infection Control nurse stated urinary drainage device tubing should not be on the floor because the floor was dirty, and contamination could occur. 10 New York Codes, Rules and Regulations 415.19(a)(b)

Based on observations, record review, and interviews, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of quality of life for one (1) of one (1) resident (Resident #129) reviewed. Specifically, Resident #129's urinary catheter drainage bag (collects urine) was uncovered and visible to other residents, visitors, and staff. Findings include:The facility policy Notification of Rights, revised 05/23/2025, documented the facility would provide an environment where all residents would maintain dignity and quality of life while receiving care.Resident #129 had diagnoses including neurogenic bladder (lack of bladder control). The 04/12/2026 Minimum Data Set (a resident assessment tool) documented the resident had intact cognition, required partial/moderate assistance with toileting hygiene and showering/bathing, required substantial/maximal assistance with personal hygiene, and had an indwelling urinary catheter.The 01/21/2026 Comprehensive Care Plan documented the resident had an alteration in elimination related to the use of an indwelling catheter. Interventions included keeping the urinary drainage bag covered to maintain dignity and utilizing a leg drainage bag as appropriate. Resident #129 was observed at the following times:-on 04/27/2026 at 11:20 AM, sitting in their wheelchair near the doorway of their room with their urinary drainage bag clipped to the bottom of the wheelchair. The drainage bag was uncovered, 1/4 full of amber colored urine, and was visible to staff, visitors and other residents in the area. The resident stated the drainage bag was never kept covered but if it was an option they would like.-on 04/28/2026 at 12:44 PM, sitting in their wheelchair at the dining room table with their urinary drainage bag clipped to the bottom of the wheelchair. The drainage bag was uncovered, contained amber colored urine, and was visible to staff, visitors and other residents in the cottage.-on 04/28/2026 at 1:40 PM, sitting in their wheelchair in the common area with their urinary drainage clipped to the bottom of their wheelchair. The drainage bag was uncovered, the tubing was resting directly on the floor, and was visible to staff, visitors and other residents in the area.-on 04/29/2026 at 12:19 PM, sitting in their wheelchair at the dining room table with their urinary drainage bag clipped to the bottom of the wheelchair. The drainage bag was uncovered, contained amber colored urine, and was visible to staff, visitors and other residents in the area.-on 04/30/2026 at 10:45 AM, sitting in their wheelchair in the common area with their urinary drainage bag clipped to the bottom of the wheelchair. The drainage bag was uncovered, 1/2 full of amber colored urine, and was visible to staff, visitors and other residents in the area.During an interview on 04/30/2026 at 1:28 PM, Certified Nurse Aide #22 stated they were unsure if the facility had privacy covers for urinary drainage bags. Resident #129's urinary drainage bag was never covered, and it was a dignity issue. During an interview on 04/30/2026 at 1:38 PM, Licensed Practical Nurse #23 stated they noticed Resident #129's urinary drainage bag was not covered. They should have spoken to the certified nurse aides about it or covered it themself. They were unsure if there were extra privacy bags in the cottage, but they were going to find one because it was a dignity issue and it should have been covered.During an interview on 05/01/2026 at 12:06 PM, Registered Nurse Manager #24 stated certified nurse aides were responsible for completing catheter care and ensuring urinary drainage bags had a privacy cover on them if the resident was not using a leg bag (a collection bag attached to the resident's leg and under clothing). Every cottage had privacy bags available and if they ran out staff should ask for more. It was not dignified for Resident #129's to be uncovered. 10 New York Codes, Rules and Regulations 415.5 (a)

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (2) of two (2) residents (Residents #18 and #131) reviewed. Specifically, Resident #18 did not receive their prescribed furosemide (diuretic medication) for 4 days, was not weighed daily as ordered, and there was no documented evidence the medical provider was notified; and Resident # 131 had an unwitnessed fall, and neurological checks were not completed as ordered. Findings include: The facility policy Medication Administration, last revised/ reviewed 09/17/2025, documented if a medication has not been delivered by pharmacy and/or is not available, the licensed practical nurse would check to see if the medication was in the automated dispensing system. If the medication is not in the automated dispensing system, the licensed practical nurse would report this to the supervisor/nurse manager and document in the electronic medical record. The supervisor/nurse manager will notify medical for further instruction and document response/intervention/substitution in the electronic medical record.The facility policy Monitoring Weights, revised 05/2022, documented if the resident had a 5 pound weight change the Registered Nurse Manager would requests any reweights to be obtained during morning huddle.The facility policy Neurological Evaluation Neuro Checks, last reviewed 06/07/2023, documented neurological evaluations will be initiated after an unwitnessed fall. Neuro checks will be done every 4 hours for the first 16 hours then every 8 hours for 48 hours. 1)Resident #18 had diagnoses including congestive heart failure (the heart does not pump well and can cause fluid buildup), chronic obstructive pulmonary disease (lung disease), and peripheral vascular disease (reduced blood flow to the limbs). The 01/18/2026 Minimum Data Set (a resident assessment tool) documented the resident had intact cognition, did not reject care, was dependent with transfers, weighed 112 pounds, had no weight changes at 1 or 6 months, and did not take a diuretic. WeightsPhysician orders documented:-01/12/2025 daily weights: notify medical with a weight gain of 2 pounds a day/ 5 pounds in a week. Licensed practical nurse to document weight daily on flow sheet on day shift 7:00 AM - 3:00 PM.-02/06/2026 furosemide 40 milligrams once daily for congestive heart failure. The 01/12/2026 revised comprehensive care plan documented the resident had congestive heart failure. Interventions included medications administered as prescribed by the physician, monitor weights as ordered, and notify physician of weight changes of 1-2 pounds in a day. The January 2026 Medication Administration Record documented daily weights, notify medical with a weight gain of 2 pounds a day or 5 pounds a week. Licensed practical nurse to document weight on daily weight flow sheet with a start date of 01/12/2026 at 5:28 PM. There was no documented evidence daily weights were obtained on 01/16/2026, 01/19/2026, 01/20/2026, and 01/25/2026.The February 2026 Medication Administration Record documented daily weights, notify medical with a weight gain of 2 pounds a day or 5 pounds a week. Licensed practical nurse to document weight on daily weight flow sheet with a start date of 01/12/2026 at 5:28 PM. There was no documented evidence daily weights were obtained on 02/04/2026, 02/14/2026, 02/15/2026, 02/17/2026, 02/18/2026, 02/21/2026, 02/22/2026, 02/23/2026, 02/24/2026, 02/27/2026, and 02/28/2026. The resident refused daily weights on 02/05/2026, 02/06/2026, and 02/20/2026. No weights were documented on 02/12/2026 no scale; and 02/13/2026 scale broken.The March 2026 Medication Administration Record documented daily weights, notify medical with a weight gain of 2 pounds a day or 5 pounds a week. Licensed practical nurse to document weight on daily weight flow sheet with a start date of 01/12/2026 at 5:28 PM. There was no documented evidence daily weights were obtained on 03/01/2026, 03/02/2026, 03/09/2026, 03/10/2026, 03/11/2026, 03/12/2026, 03/13/2026, 03/14/2026, 03/15/2026, 03/18/2026, 03/19/2026, 03/24/2026, 03/27/2026, and 03/28/2026. The resident refused daily weights on 03/03/2026, 03/06/2026, 03/16/2026, and 03/23/2026. No weight was documented on 03/29/2026 office visit and hospitalization. The April 2026 Medication Administration Record documented daily weights, notify medical with a weight gain of 2 pounds a day or 5 pounds a week. Licensed practical nurse to document weight on daily weight flow sheet with a start date of 01/12/2026 at 5:28 PM. There was no documented evidence of daily weights were obtained on 04/07/2026, 04/08/2026, 04/12/2026, 04/16/2026, 04/20/2026, 04/21/2026, 04/25/2026, 04/26/2026, and 04/28/2026.The April 20206 Medication Administration Record on 04/17/2026 Licensed Practical Nurse #21 documented the resident weighed 99.6 pounds. On 04/18/2026 Licensed Practical Nurse #9 documented the resident weighed 102.5 pounds (2.9-pound weight gain in 1 day). There was no documented evidence a medical provider was notified the resident had a weight gain of 2 pounds or more in 1 day.FurosemideOn 03/29/2026 at 12:17 PM, Registered Nurse Supervisor #7 documented they were notified the resident was restless. Upon assessment, the resident was found lying in bed in respiratory distress. The resident was noted to be bradycardic (abnormally slow heart rate) with a heart rate of 30 beats per minute. Their blood pressure was 160/80 millimeters of mercury (high), temperature of 98.2 degrees Fahrenheit (normal), oxygen saturation 92% on 4 liters of oxygen via nasal cannula, and respiratory rate of 28 breaths per minute (high). Medical was notified and an order was received to transfer the resident to the hospital for further evaluation and management. The resident was transferred to the hospital at 11:00 AM.The 04/02/2026 Hospital Discharge Summary documented the resident was treated for acute respiratory failure secondary to chronic obstructive pulmonary disease with possible concurrent pneumonia. Medications on discharge included 40 milligrams of furosemide daily in the morning.The 04/02/2026 at 3:03 PM, Registered Nurse Manager #8 progress note documented the resident returned to the facility from the hospital and home medications would be continued.The 04/03/2026 Nurse Practitioner #11 progress note documented the resident was seen at the request of nursing due to chronic pulmonary disease exacerbation. The resident was sent to the emergency room after being in respiratory distress and was readmitted to the facility. Their plan included continue furosemide for congestive heart failure. The 04/06/2026 Nurse Practitioner #1 order documented furosemide 40 milligram tablet once daily for congestive heart failure. The April 2026 Medication Administration record documented furosemide 40 milligrams once daily at 8:00 AM. On 04/03/2026, Licensed Practical Nurse #9 documented the medication was not provided due to not being in the medication cart; on 04/04/2026, Licensed Practical Nurse #9 documented the medication was not in from the pharmacy; on 04/05/2026, Licensed Practical Nurse #9 documented the medication was not available; and on 04/06/2026 Licensed Practical Nurse #9 documented the medication was not in from the pharmacy. The facility's Automatic Medication Dispensing System active inventory list documented furosemide 40 milligram tablets was included in the inventory. On 04/06/2026 at 10:35 AM, Registered Nurse Manager #8 documented they followed up with the pharmacy and the resident's furosemide medication would be delivered that day. There was no documented evidence the resident was assessed following four (4) missed doses of furosemide; if the medication omission was reported to the medical provider; or if the medication was available in the automated dispensing system. The facility's 04/27/2026 in progress investigation documented Licensed Practical Nurse #9 had a major medication error. Licensed Practical Nurse #9's written statement documented on 04/03/2026 - 04/06/2026 the resident's furosemide medication was not administered because it was not in the medication cart, and they did not retrieve the medication from the automatic medication dispensing system. They ordered the medication from the pharmacy. The investigation documented Licensed Practical Nurse #9 was educated on what to do if a medication was not available.During an interview on 04/29/2026 at 3:01 PM Certified Nurse Aide #13 stated the nurse would tell the certified nurse aides who needed to be weighed. The certified nurse aides obtained the resident's weight and told the nurse. If the resident refused to be weighed, they would reapproach the resident and tell the nurse. If the resident refused to be weighed the nurse should document the refusal in the chart. Resident #18's weight was supposed to be obtained daily, and the resident did refuse to be weigh a lot. They told the nurse when the resident refused. During an interview on 05/01/2026 at 10:19 AM, Licensed Practical Nurse #12 stated weights were listed in the computer when they were to be obtained. If a resident refused to be weighed, they would reapproach them and if they continued to refuse, they would document the refusal in the chart. Resident #18 was on daily weights and if there was a 2 pound weight change from the previous day the medical provider should be notified. The resident was on daily weights due to their medical condition of congestive heart failure. The resident did not refuse to be weighed when they worked with them. If they had a weight gain greater than 2 pounds in one day or 5 pounds in a week the nurse should tell the supervisor who notified medical of the weight gain.During an interview on 05/01/2026 at 11:02 AM, Registered Dietitian #14 stated daily weights were monitored by the Registered Nurse Manager or Nursing Supervisor and the Registered Nurse Manger or Nursing Supervisor notified medical of any changes per the order. Resident #18 sometimes refused weights. They were ordered for daily weights related to their diagnosis of congestive heart failure. They did not review the residents' weights daily to see if they were obtained but reviewed them weekly to monitor weight trends. The interdisciplinary team reviewed weights weekly during the weight meeting.During an interview on 05/01/2026 at 11:21 AM, Registered Nurse Unit Manager #8 stated they were unaware the resident was not being weighed daily as ordered and medical was not notified when the resident had greater than a 2 pound weight gain in 1 day. They stated if the resident did have a weight gain greater than 2 pounds in 1 day or 5 pounds in a week, staff should obtain a reweight to confirm the weight was accurate and then notify the registered nurse or Nursing Supervisor who would notify medical. The resident missed 4 days of furosemide because the nurse did not retrieve the medication from the automatic dispensing system when the resident was readmitted from the hospital and did not tell anyone the medication was unavailable. Once the facility was made aware of the incident during a family meeting an investigation was started. The nurse was written up for the medication error.During an interview on 05/01/2026 at 1:30 PM the Director of Nursing stated when a resident was readmitted to the facility the admitting nurse reviewed the discharge summary from the hospital to ensure all medications and treatments were current. If the resident had a medication ordered that was not in the medication cart the facility had an automatic medication dispensing system the nurse could retrieve medication from. All the nurses had access to the automatic medication dispensing system. They should also tell the nurse supervisor the medication was not in the cart, and it needed to be removed from the automatic medication dispensing system. The facility was alerted Resident #18 did not receive their ordered 40 milligrams furosemide for 4 day during a family meeting last week. Once they were aware of the situation an investigation was started. Licensed Practical Nurse #9 received a written warning and education on what to do when medications were not available. Resident #18 had a diagnosis of congestive heart failure and should have received the medication as ordered. This was considered a major medication error.During an interview on 05/01/2026 at 1:58 PM, Nurse Practitioner #11 stated Resident #18 had an order for daily weights related to a diagnosis of congestive heart failure. If they had a weight gain greater 2 pounds in 1 day or 5 pounds in a week, they should be made aware so they could evaluate the resident. The nurse managers or nursing supervisors were responsible for notifying the medical team of any significant weight changes. They were notified following a family meeting last week, the resident missed several doses of furosemide. They expected the nursing staff to notify them if any medications were not provided. The resident had a history of congestive heart failure, and their weights should be monitored and medication provided to prevent possible fluid overload.Interviews were attempted with Licensed Practical Nurses #9 and #10 return telephone calls were not received prior to survey exit.2)Resident #131 had diagnoses including left sided paralysis. The 03/12/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition, had no falls, and was dependent for most activities of daily living. The comprehensive care plan, initiated 12/18/2025, documented the resident was at risk for falls. Interventions included investigate and meet needs regarding frequent falls. The 04/13/2026 Accident and Incident Report documented at 8:38 AM on 04/13/2026 the resident had an unobserved fall in their room resulting in bruising to their forehead and a skin tear to their left elbow; neurological checks were initiated. The 04/13/2026 at 10:29 AM physician order documented a neurological evaluation template in a progress note would be completed every 4 hours for 16 hours then every 8 hours for 48 hours. The April 2026 Treatment Administration Record documented the resident was scheduled to have neurological checks on:-04/13/2026 at 10:30 AM, 2:30 PM, 6:30 PM, and 10:30PM-04/14/2026 at 10:30 AM and 6:30 PM-04/15/2026 at 2:30AM, 10:30 AM and 6:30PM Nursing progress notes did not document neurological checks were completed as scheduled on:-04/13/2026 at 6:30 PM or 10:30 PM-04/14/2026 at 10:30 AM or 6:30PM-04/15/2026 at 6:30PM During an interview on 05/01/2026 at 10:02 AM, Licensed Practical Nurse #43 stated neurological checks were done for unwitnessed falls. A check was done at the time of the fall and was documented in the computer. The registered nurse entered the order for the neurological checks. When due, it would come up on the treatment administration record for the nurses to complete. The nurse then completed the prepopulated form and initialed the administration record as complete. If they were unable to complete their documentation, they should let the supervisor know. During an interview on 05/01/2026 at 11:43 AM, Registered Nurse Unit Manager #8 stated when a resident fell a registered nurse did an assessment which included a neurological check. They entered the order for further neurological checks, and the times were auto populated. Resident #131had an unwitnessed fall that resulted in significant bruising. They were not aware Resident #131 did not have all their neurological checks completed. If a nurse was unable to complete the neurological checks, they should report it to the supervisor. 10 New York Code Rules and Regulation 415.12 (k) (1)

Based on observations, interviews, and record review the facility did not ensure a resident with limited range of motion received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for one (1) of two (2) residents (Resident #66) reviewed. Specifically, Resident #66 had an order for a thoracolumbar sacral orthosis (a back brace used to keep the spine extended after a fracture) and was observed without the brace and there was no documented evidence the provider was notified of resident refusals. Findings include: The 03/2028 facility policy Devices and Equipment, documented residents with limited mobility would receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility was unavoidable.Resident #66 had diagnoses including compression fracture in their back. The 04/03/2026 Minimum Data Set assessment documented the resident had severely impaired cognition, no rejections of care, required moderate assistance with most activities of daily living and received occupational and physical therapy.The 04/01/2026 physician order documented thoracolumbar sacral orthosis brace when out of bed or sitting upright; could remove when lying down or sleeping.There was no documented evidence the comprehensive care plan included the spine fracture or use of the back brace.The 4/15/2026 Occupational Therapist #4's Treatment Encounter note documented a discharge summary was initiated and the resident was wearing and compliant with the back brace.During the following observations Resident #66 was not wearing the back brace:-on 04/27/2026 at 11:27 AM while sitting upright in their wheelchair. The back brace was sitting on the floor in their room. -on 04/29/2026 at 9:45 AM while sitting upright in their wheelchair. The back brace was sitting on the bedside table in the resident's room.-on 04/30/2026 at 11:47 AM while sitting upright in their wheelchair. The back brace was draped over the back of a chair in their room. The April 2026 Treatment Administration Record documented thoracolumbar sacral orthosis brace when upright and out of bed with a start date of 04/03/2026. During the 7:00 AM-3:00 PM shift the brace was not administered due to resident refusal on: 04/04/2026, 04/07/2026, 04/09/2026, 04/11/2026 -04/13/2026, 04/18/2026, 04/19/2026, and 04/21/2026 - 04/30/2026 (on 04/27/2026 by Licensed Practical Nurse #6, and 04/29/2026 and 04/30/2026 by Licensed Practical Nurse #12).There was no documented evidence the provider or therapy was notified the resident refused to wear the back brace. During an interview on 05/01/2026 at 8:47 AM, Certified Nurse Aide #5 stated braces and splints were on the care instructions and if a resident refused, they were supposed to report it to the nurse. Resident #66 had a back brace. The resident did not like the brace. They took care of the resident on 04/30/2026 during the day shift and the resident refused to put the brace on. They did not report the refusals but should have. They stated they likely got caught up in something and forgot to do so. During an interview on 05/01/2026 at 9:16 AM, Occupational Therapist #4 stated if a resident was not compliant with a device they should provide education, explore why the resident was refusing and possibly implement other devices the resident might comply with. Resident #66 was supposed to wear a back brace when out of bed due to a spine fracture. The brace was to promote healing and prevent twisting or bending of the spine. When discharged from therapy on 04/15/2026, the resident was compliant with the brace, and it was not reported to them the resident was refusing it. They would like to be notified because they could have gotten involved and maybe the resident would have responded better to someone else. During an interview on 05/01/2026 at 9:44 AM, Licensed Practical Nurse #6 stated usually the certified nurse aides applied the splints/braces, and the nurses documented it. Resident #66 refused the brace most of the time because they complained about related pain. They reported the refusals to whichever registered nurse was covering that cottage and was unsure what happened after that. During an interview on 05/01/2026 10:10 AM, Registered Nurse Manager #3 stated if a resident refused their brace or splint it was documented in a progress note and the provider and therapy should be notified. They were not aware Resident #66 refused their back brace and was unsure if the other managers who helped cover that cottage were aware. They did not see any progress notes related to the physician or therapy being notified of the refusals. 10 New York Codes, Rules and Regulations 415.12(e)(2)

Based on observations, record review, and interviews (iQIES Intake 2628724) the facility failed to ensure adequate supervision to prevent accidents for one (1) of seven (7) residents (Resident #151) reviewed. Specifically, Resident #151 required a mechanical lift for transfers and Certified Nurse Aide #37 transferred the resident using a gait belt resulting in a fall. Findings include: Resident #151 had diagnoses including encephalopathy (a brain disorder) and epilepsy (seizure disorder). The 09/11/2025 Minimum Data Set assessment documented the resident had intact cognition and was dependent for transfers. The comprehensive care plan, initiated 09/05/2025, documented the resident was at risk for falls and had a self-care deficit. Interventions included lifted mechanically with two (2) people for transfers. On 09/12/2026 the resident was lowered to the floor by certified nurse aide during an attempt to stand. The 09/05/2025 Registered Nurse Unti Manager #3's Fall Assessment documented Resident #151 was at high risk for falls. The 09/12/2025 Accident and Incident Report completed by Registered Nurse Unit Manager #3 documented at 10:30 AM on 09/12/2025 the resident convinced Certified Nurse Aide #37 they could stand and walk into the bathroom. When Certified Nurse Aide #37 stood the resident after applying a gait belt, the resident's legs gave out resulting in the resident being lowered to the floor. There were no injuries. The care plan was not followed; the resident was care planned for a mechanical lift. The root cause was the aide should not have listened to the resident. The aide was instructed to follow the care plan at all times. During an interview on 04/30/2026 at 1:43 PM, Certified Nurse Aide #37 stated they received education on activities of daily living when they were hired, and they reviewed the residents' care instructions daily. They could not remember all the details of Resident #151's fall but did recall using a gait belt to transfer them and having to lower them to the floor. They were written up but did not recall any related education. During an interview on 05/01/2026 10:35 AM Registered Nurse Unti Manager #3 stated when a resident fell, the nurse who assessed the resident at the time of fall should ensure the care plan interventions were in place and if it was observed that the care plan was not followed there would be a conversation with and education provided to that staff member about following care plans. Resident #151 convinced Certified Nurse Aide #37 they could walk but they required assistance of two (2) and a mechanical lift for transfers. Certified Nurse Aide #37 did not follow the care plan but knew they were supposed to. They stated they provided Certified Nurse Aide #37 with education. 10 New York Codes, Rules and Regulations 415.12(h)(1)

Based on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents (Residents #134) reviewed. Specifically, Residents #134 had behavioral symptoms related to dementia and did not have a person-centered care plan that included and supported their dementia care needs. Findings include:The facility policy Behavior Management Policy, last reviewed 9/2025, documented the nursing staff would conduct an assessment when a behavior occurs. Contributing factions such as pain, infection, environment, and emotional needs must be evaluated. The interdisciplinary team reviewed behavioral incidents and patterns. Interventions included preventative measures, communication, de-escalation, and maintaining safety. Psychotropic medications were only to be used when clinically necessary and ordered by a licensed prescriber. Non-pharmacological strategies must be attempted and documented first. Ongoing monitoring for effectiveness and adverse effects was required. All behavioral episodes, interventions, and outcomes must be documented in the medical record and updates to care plans will be recorded. The facility policy Behavioral Interventions, last reviewed 05/23/2025, documented the social worker will document on the behavior care plan, the interventions being utilized, and explore alternatives to medications with the interdisciplinary team. If a resident had increased behavioral issues requiring as needed or increased use of psychotropic medication the social worker would provide increased psychosocial support to the resident, work with the interdisciplinary team to develop non-pharmacological interventions and document the effectiveness of the interventions in a weekly progress note. The facility policy Dementia Care, last reviewed 03/2025, documented the facility would involve the resident or family/representative in discussions about the potential use of any specific approaches to their care. The resident's care should be tailored to personal care approaches, meal service, and activities to the individual by paying close attention to past life history, as well as current functional and cognitive levels. Staff were to respond to any behavior of distress/emotional as an unmet need versus attention to prevent an increase in agitation or behaviors. Resident #134 had diagnoses including dementia with psychotic disturbance, Parkinson's disease (a progressive neurological disease), and anxiety. The 4/17/2026 Minimum Data Set documented had severely impaired daily decision making skills, fluctuating inattention, wandered 1-3 of 7 days, required supervision for mobility, and utilized antipsychotic medication on a routine basis. The comprehensive care plan documented:-02/12/2025 cognitive deficits and short-term memory loss related to dementia and Parkinson's disease. Interventions included orienting the resident frequently to their surroundings and daily routine, maintaining a quiet environment, approaching in a calm slow manner, engaging in appropriate social conversations, providing reminders, cues and regular supervision, allowing time to respond, reducing decision making that caused stress, and encouraging participation in self-care. 02/13/2025 behavioral symptoms including exhibiting physically aggressive behaviors towards staff and others. Interventions included to identify a behavior pattern, remove resident from the situation triggering their behavior, evaluate their comfort level and medicate as necessary, administer medications as ordered, refer to a psychiatrist, orient to their daily routine, redirect negative behaviors, encourage participation in their activities of daily living, social services evaluation and follow up, record all behavior episodes, notify the medical provider of behavioral changes, allow time to de-escalate if agitated, offer one-to-one interaction for comfort, and offer their favorite snacks. -03/11/2025 was at risk for wandering and elopement due to impaired cognition with poor decision-making skills and ability to ambulate self with aimless wandering and exit seeking behaviors. Interventions included providing increased supervision during periods of increased wandering or agitation, providing and encouraging activities for diversion, notifying the supervisor if increased wandering was noted, and approaching in a calm manner. The undated care instructions documented the resident had behaviors and to provide one-to-one interaction for reassurance and comfort, offer snacks while giving choices, and encourage to watch movies. The resident also loved popcorn. The resident was on a puree diet with nectar thick liquids. The 03/19/2025 physician order documented to inject 2 milliliters (12.5 milligrams) of Risperdal (antipsychotic) extended release every 2 weeks on Wednesday with an end date of 04/28/2026. The 04/28/2026 physician order documented to inject 2 milliliters (25 milligrams) of Risperdal extended release by intramuscular route every 2 weeks on Wednesday. The 02/17/2026 Psychiatric Periodic Evaluation by Nurse Practitioner #40 documented the resident was seen for a follow-up psychiatric evaluation and medication review following prior medication change. The resident was noted to be sitting in the common area in a chair, awake, and alert to person, with baseline confusion. Per the nursing staff, there were no acute behavioral disturbances following Buspar (an antianxiety medication) gradual dose reduction in January 2026 from 20 milligrams twice a day to 15 milligrams twice a day. The resident was eating and sleeping fairly well. The resident could be socially inappropriate and sometimes tried to eat food from other residents' plates but was able to be redirected. The recommendation was to continue to monitor the resident's behavior, prioritize nonpharmacological interventions, continue to establish a routine, ensure all needs were met, evaluate for discomfort, and continue to reorient to surroundings. The 04/17/2026 Psychiatric Periodic Evaluation by Nurse Practitioner #41 documented the resident was observed to be comfortably sitting in the common area. They remained nonverbal for the encounter. Their affect appeared surprised and fixed without restlessness or agitation. They did not appear to be internally preoccupied or responding to internal stimuli. Per the chart review, they displayed behaviors including wandering around the cottage, pushing occupied wheelchairs without the consent of other residents, and trying to exit the side door. They had not been physically aggressive and there were no other identified concerns. There was no gradual dose reduction recommended at the time with a recommendation to utilize the antipsychotic medication with caution due to sudden cardiac death risk. It was recommended to prioritize nonpharmacological interventions and to have follow ups on a routine basis. The certified nurse aide behavior documentation documented:-the day shift (7:00 AM to 3:00 PM) on 04/23/2026 the resident was wandering, and their behavior was not easily altered.-the evening shift (3:00 PM to 11:00 PM) on 04/23/2026 the resident had insomnia, had wandering that was not easily altered, had socially inappropriate/disruptive behavior of being threatening that was not easily altered, and was resistive to care but was easily altered.-the evening shift on 04/24/2026 the resident had repetitive physical movements, wandering, verbally abusive behavior, physically abusive behavior, socially inappropriate behavior, and was resistive to care. All the resident's behaviors were easily altered.-the day shift on 04/25/2026 the resident was wandering and was resistive to care; both were easily altered. -the day shift on 04/26/2026 the resident was wandering which was not easily altered.-the day shift on 04/28/2026 the resident was wandering which was not easily altered.-the evening shift of 04/28/2026 the resident was wandering which was not easily altered and had socially inappropriate/disruptive behavior which was not easily altered. Nursing behavior notes documented the following:-on 04/24/26 at 9:36 PM by Licensed Practical Nurse #38 the resident wandered and was socially inappropriate. The resident continued to randomly enter rooms and disturb other residents. They checked off on the pre-populated list they provided a calm structured environment, checked the resident for unmet needs, provided direction in positive manner, initiated a psychiatric consult and gave psychiatric medications as ordered. The behavior was still present.-on 04/27/2026 at 2:24 PM by Licensed Practical Nurse #12 the resident always wandered and was easily redirected.-on 04/27/2026 at 9:41 PM by Licensed Practical Nurse #38 the resident was wandering and was socially inappropriate. They checked off on the pre-populated list that they provided a calm structured environment, checked the resident for unmet needs, redirected the resident and engaged them in diversional activities, and provided direction in a positive manner. The behavior was still present.-on 04/28/2026 at 10:11 PM by Licensed Practical Nurse #38 the resident continued to enter random rooms without an invitation and was annoying to other residents. They checked off on the pre-populated list that they provided a calm structured environment, checked the resident for unmet needs, redirected the resident and engaged them in diversional activities, and provided direction in a positive manner. The behavior was still present. The 04/09/2026 Registered Nurse Manager #20 progress note documented the certified nurse aides and other residents were noticing the resident had increased wandering episodes into other resident rooms and was displaying inappropriate behaviors. The resident was going into other resident rooms and pulling down their pants. The resident also went into another resident's room and laid down in bed with the other resident. Redirection was provided. The stop signs located on the doorways were not working to stop the resident from wandering into other residents' rooms. The resident's Buspar was decreased. The medical provider was notified of recent behaviors and advised changing the Buspar dose back to the original dose. The order was placed. Staff were to continue to monitor behaviors. The 04/22/26 at 2:51 PM Registered Nurse Manager #20 progress note documented the certified nurse aides notified them the resident was having increased behavioral episodes including climbing into other resident beds, wandering into other resident rooms to use their bathroom and stripping down. The behavior was going on for a couple of weeks. The resident was frequently going into other resident rooms and using their bathrooms. Medical was made aware and orders for a urinary analysis to rule out urinary tract infection was ordered. Staff were unable to get a sample, so a straight catheter was ordered to obtain the sample. The 04/28/26 at 11:40 AM Registered Nurse Manager #39 progress note documented the resident had increased behaviors of wandering into other resident rooms. The resident's urinalysis came back negative for a urinary tract infection. The medical provider was made aware and advised increasing the resident's dose of Risperdal to 25 milligrams. The order was transcribed and initiated. The 04/28/2026 Physician #48 progress note documented Resident #134's behaviors were progressively getting worse over the last week or two. The resident was wandering into other resident rooms and was more agitated. The plan was to discuss with the resident's family about considering increasing the resident's Risperdal to 25 milligrams daily. There were no documented social services progress notes regarding the resident's behaviors, increased wandering, or increases in psychotropic medication. The following observations of Resident #134 were made:-on 04/28/2026 at 12:15 PM moving with a shuffled quick gait to the recliner chair in front of the television after lunch was cleared. At 12:16 PM they moved to a different chair in the common area, then down the hall to a different chair, then into their room, then out into a chair in the hallway next to their room. At 12:17 PM they moved back to the chair in the lounge area, then to a different chair in the area and then back to the original chair. At 12:22 PM, they moved back to the dining room table. At 12:31 PM, Certified Nurse Aide #44 stated there they go as the resident went to a stationary chair in the lounge area then went to a stationary chair in the hallway. At 12:33 PM the resident went back to the stationary chair in the lounge area with their feet up on an ottoman. At 2:57 PM, they were brought into the lounge area by Certified Nurse Aide #45 and the resident got up from the chair and went back to the hallway chair. At 2:58 PM, Certified Nurse Aide #45 brought them back out to the lounge area and got bingo supplies. At 3:03 PM, the resident was holding up the bingo numbers for the other residents playing at the table. Certified Nurse Aide #44 stated it was the first time they had seen the resident hold the cards for bingo, but the resident had gone to the cabinet that morning and had gotten them out on their own. -on 04/29/2026 at 3:29 PM in the darkened hallway in a chair outside their room looking around. At 3:35 PM, the resident came out to the lounge area. Certified Nurse Aide #46 asked what the resident was doing as they went from one seat to another. They took the resident's hand and led them back down the hallway. At 3:36 PM Certified Nurse Aide #47 walked the resident back to the lounge area. At 3:39 PM the resident left the common area and went back down the hallway toward their room. At 3:40 PM, they came back to the lounge area, sat in a chair then got up quickly and went back down the hallway. At 3:44 PM Certified Nurse Aide #46 stood across from where the resident was seated on a chair in the darkened hallway and informed the resident where their room was then walked away. At 3:46 PM the resident opened the door to resident room [ROOM NUMBER] then closed it and went into resident room [ROOM NUMBER]. The female resident in room [ROOM NUMBER] told the resident to leave and the resident left the room and sat back in the chair down the hallway. At 3:47 PM, the resident went and sat in the common area. Certified Nurse Aide #46 asked the activity personnel in the lounge area where the resident was. Upon seeing the resident, they stated they did not want the resident going into other resident rooms. At 3:49 PM, the resident went into resident room [ROOM NUMBER] and then exited, shutting the door upon exit while Certified Nurse Aide #46 was charting in the lounge area. -on 04/30/2026 at 10:25 AM they went into resident room [ROOM NUMBER] towards the bathroom and then walked out. They went into resident room [ROOM NUMBER], had a hand on the other resident's walker and was told by the female resident they could not be in there. The resident calmly left and went back to resident room [ROOM NUMBER]. They were stopped by Certified Nurse Aide #45 who guided the resident to the lounge area and got the resident some juice as the resident sat in the recliner. At 10:40 AM the resident was calmly sitting in the lounge area drinking from their cup. During an interview on 04/30/2026 at 1:39 PM, Certified Nurse Aide #45 stated they received dementia care training once a year on an online platform. They knew what interventions to utilize for a resident with behaviors by contacting the nurse manager to ask what to do. Resident #134 had wandering behaviors which were sometimes redirected by getting the resident to sit down with something else like bingo. The resident's behaviors had remained consistent and had not increased lately to their knowledge. Usually after lunch was when the resident's behaviors were worse. It was hard to determine what the resident liked to do because they did not talk. The resident seemed to enjoy bingo though. During an interview on 04/30/2026 at 4:05 PM Certified Nurse Aide #47 stated they received dementia care training at the end of the year on an online platform. The interventions to use when a resident had behaviors were to reapproach and redirect. They tried to do things like an activity, offer food or drinks and move them away from other residents. Resident #134 had behaviors of wandering. It was non-stop with the resident going in and out of other resident rooms. They tried to redirect the resident to keep them out of other resident rooms and their personal space. Occasionally they turned on the resident's television and asked them to lie down and that worked. They also offered the resident a drink or snack at night and put on a movie. The resident had increased wandering for the last 3 weeks, particularly after dinner. The resident liked bingo and sometimes magazines. During a phone interview on 05/01/2026 at 10:48 AM Licensed Practical Nurse #38 stated they did not recall having dementia care training at that facility. They did not know if behavioral interventions were on the care plan as they had not looked. Resident #134 had behaviors of wandering into other resident rooms and through any open or accessible closed door. They also got into other residents' beds and pulled their clothes off while in other residents' rooms. The resident had not been aggressive or had any violent behavior. The resident had been on 12.5 milligrams of Risperdal, but it was increased to 25 milligrams because the resident was wandering into other resident rooms. The resident had increased behaviors which was why they did a urinary analysis on them, but it came back negative. They often sat the resident down and gave them pudding or ice cream; they liked to eat. Turning on the television to a channel the resident liked also helped; they liked sports. The resident just needed to be kept busy as they did not sit still for long. They were unaware of any new interventions put in place besides the medication increases with the resident's increased wandering. During an interview on 05/01/2026 at 11:09 AM Registered Nurse Manager #20 stated dementia care training was done yearly through online academy training. Interventions for resident behaviors were on the care plan. They, as the nurse manager, completed the care plans. Care plans should be personalized, and diversional activities should be specified for what worked for each resident. Resident #134 had behaviors including wandering into other resident rooms, but they were very easily redirected. Recently the resident had stripped down in other resident rooms. The resident had no episodes of aggression toward themselves or others. Due to the increase in wandering and new behavior of stripping down in other resident rooms, they got a urine sample on the resident. When it was negative for infection, they adjusted some of the resident's psychotropic medications. The resident liked to go on walks, participated in activities for a limited period but liked to sit and watch them, and they gave the resident a pudding or a drink. The resident's Risperdal was increased due to the increased wandering behavior and the stripping down in other resident rooms. During a phone interview on 05/01/2026 at 11:35 AM Physician #48 stated they recently increased Resident #134's Risperdal due to an increase in behaviors. The resident was going into other resident rooms at night and there were other things that occurred. Wandering was not an indication for Risperdal, but they had some behaviors prior to starting Risperdal, so they were trying an increase in dose. They expected the staff to utilize nonpharmacological interventions prior to medication adjustments. The nonpharmacological care plan interventions should be personalized to the resident. During a phone interview on 05/01/2026 at 12:01 PM Nurse Practitioner #41 stated when they last saw the resident, they had been displaying behaviors or wandering, trying to exit the side door and pushing occupied wheelchairs. It was hard to engage the resident as they were non-verbal. Wandering was not an indication for Risperdal, and they did not agree with the method the resident was receiving the Risperdal currently; however, they were new to the resident and the facility. They were not made aware when the facility increased psychotropic medications for the residents. They were not aware the resident recently had an increase of their intramuscular Risperdal dose and did not agree with the increase if it was due to the resident's wandering as that was not an indication for use. Resident #134 should have personalized nonpharmacological interventions on their care plan. Nonpharmacological interventions should always be prioritized over medication. During a phone interview on 05/01/2026 at 12:32 PM Social Worker #49 stated their involvement with residents who had behaviors was minimal. They did the mood care plan and made sure the psychiatric services saw them. They coordinated with the nurse manager to make sure they were aware of the behaviors. The psychiatric nurse practitioner was typically involved in psychotropic medication changes and approving those changes. They were aware of Resident #134's increased behaviors but did not have any involvement besides knowing the resident had behaviors. 10 New York Codes, Rules, and Regulations 415.12

Based on observations, record review, and interviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for two (2) of 13 kitchens (Cottages 10 and 11 kitchens). Specifically, Cottage 10 kitchen had undated and expired food items; and Cottage 11 had expired food in the pantry refrigerator and food was out of acceptable temperature range. Findings include:The facility policy Food and Supply Storage, last revised 01/2026, documented all food and non-food items and supplies used in food preparation would be stored in such a manner to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Food would be discarded past the use-by or expiration date. Cottage 10: The following observations of the Cottage 10 kitchen were made on 04/27/2026 at 10:21 AM: -the refrigerator contained one opened 21-ounce carton of honey thick milk with a best used by date of 01/14/2026. -the refrigerator contained one undated tin foil covered cardboard carton of wilted salad was in the refrigerator. -Two unopened 32-ounce cartons of honey thick milk with a best used by date of 01/14/2026 and 04/04/2026 were on the shelf in the storage area. -Two unopened 46-ounce cartons of honey thick apple juice with a best used by date of 04/07/2026 and 04/26/2026 were in the panty area. During an interview on 04/27/2026 at 10:39 AM, Food Service Aide #34 stated the cook was responsible for ensuring all items were labeled and dated and the dietary department was responsible for removing expired items. During an interview on 04/27/2026 at 10:50 AM, [NAME] #35 stated it was the cook's responsibility to ensure all food items were labeled and dated and they were supposed to check at the beginning of their shift. During an interview on 04/28/2026 at 12:21 PM, Dietary Supervisor #36 stated the best used by date meant the item needed to be used by that date and it was expired if it was kept past that date. Nursing staff were responsible for dating open drinks, monitoring dates and removing drinks that were expired. Dietary staff were responsible for dating food items, monitoring dates, and removing food items that were expired. All items should be checked daily and removed if they were not dated or labeled. Cottage 11 The April 2026 pantry refrigerator log for Cottage 11 documented the following: -On 04/02/2026 at 9:00 AM the refrigerator was at 43 degrees Fahrenheit with no follow up temperature at 2:00 PM. -On 04/15/2026 the refrigerator was at 46 degrees Fahrenheit at 9:00 AM and 52 degrees Fahrenheit at 2:00 PM. Management was informed. -On 04/18/2026 the refrigerator was at 44 degrees Fahrenheit at 9:00 AM. -On 04/19/2026 the refrigerator was at 53 degrees Fahrenheit at 9:00 AM. -On 04/21/2026 the refrigerator was 50 degrees Fahrenheit at 8:00 AM. -On 04/26/2026 the refrigerator was at 45 degrees Fahrenheit at 7:30 AM. -On 04/27/2026 the refrigerator was in defrost mode at 9:00 AM. The following observations were made in Cottage 11 on 04/27/2026: -At 11:03 AM the resident refrigerator in the kitchen had boiled eggs, turkey, and ham lunch meat in the drawer with an expiration date of 04/26/2026. -At 11:11 AM the large, prepped meal refrigerator in the entrance alcove to the kitchen read 55 degrees Fahrenheit on both the external refrigerator thermometer and the independent thermometer inside. The refrigerator contained a tray of hot dogs, a tray of baked beans, a tray of carrots, a yogurt container, and a 2 liter bottle of soda. -At 11:18 AM the small refrigerator under the ice machine had a container of apricots with an expiration date of 03/06/2026. During an observation and interview on 04/27/2026 at 11:08 AM [NAME] #50 stated no residents consumed the boiled eggs, turkey, or ham out of the refrigerator that morning. The items were supposed to be discarded on the day they expired. The large, prepped meal refrigerator had been having problems holding temperature. It was logged on the temperature sheet, reported and management was aware. They were unsure how long the carrots, hot dogs, and baked beans were in the refrigerator as they were dropped off at different times. The baked beans and hot dogs were for dinner, and the carrots were for lunch. They were placed in the refrigerator frozen and were then heated up prior to meal service. [NAME] #50 took the temperature of the tray of carrots with a thermometer after removing them from the 55-degree Fahrenheit fridge. The carrots measured 62 degrees Fahrenheit. They stated they did not believe the apricots expired on 03/06/2026 but they should not have been in the refrigerator with that date. During an interview on 05/01/2026 at 12:56 PM the Director of Environmental Services stated maintenance requests were able to be made at any time, and the kitchen had its own sign on for the system. Food service was responsible for checking the refrigerator temperatures and reporting any issues. Monday, 04/27/2026 was the first time they were informed Cottage 11 had issues with the refrigerator. During an interview on 05/01/2026 1:06 PM Assistant Director of Food Service #52 stated they were covering for the current Director of Food Service for the day. They stated all the food that came out of the main kitchen had orange labels with the date and time it was prepared and the date the product expired/should be discarded. Everything in the refrigerators should either have an orange label or a handwritten label. The food should be discarded at the end of the day of the labeled discard date. There should not be expired items from the previous day still in the refrigerator or items with an expiration date of March 2026. During a phone interview on 05/01/2026 at 1:11 PM the Food Service Director stated the management team did weekly rounds and they checked the refrigerators and the temperature sheets. An out-of-temperature refrigerator should be reported as soon as it was noticed. They usually recommend the staff wait 30 minutes to see if the temperature drops back into the appropriate range. If it did, they kept an eye on the refrigerator. If it did not, a work order was submitted. Staff should be checking the refrigerator temperature prior to putting food in it and they should not be putting food into a refrigerator that was 55 degrees. They were aware the refrigerator was in and out of temperature, but it always dropped back into the correct temperature range. They were not aware the temperature was 55 degrees on Monday until they were notified, and they could not recall any other 50 and above temperatures that happened back-to-back in a day. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations, record review, and interviews (iQIES #2655817) the facility failed to ensure residents were free of any significant medication errors for two (2) of four (4) residents (Residents #109 and #75) reviewed. Specifically, Resident #109 was administered a crushed medication crushed despite instructions that crushing was contraindicated; and Resident #75 was administered all crushed medications together via their gastrostomy tube (enteral tube, a feeding tube directly into the stomach).Findings include:The 09/2024 facility policy Medications Through Eternal Tubes, documented delivering medications correctly to ensure their effectiveness. The policy did not document that medications should be given separately.The 03/2024 facility policy Medication and Treatment Administration documented a physician, nurse practitioner, or physician assistant order must be obtained to crush any medications. Nurses could only crush medications that could be crushed. They may not crush extended release, delayed release, or enteric coated medications.The United States Food and Drug Administration guidelines documented to administer each dose of potassium chloride extended-release tablets without crushing, chewing or sucking the tablets.The 2026 American Society for Parenteral and Enteral Nutrition Clinician's Guide to Medication's via Enteral Feeding Tubes documents do not mix medications together in order to prevent drug-drug interactions which can interfere with the intended therapeutic response or form precipitates that may clog feeding tubes. 1) Resident #109 had diagnoses including low potassium (a mineral required for nerve signals, muscle contractions, and heartbeat) levels. The 02/25/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact and had a history of low potassium levels.The 04/15/2026 physician order documented potassium chloride extended-release tablet 20 milliequivalents by mouth once daily. Do not crush or chew.The following observation was made during medication administration on 04/29/2026 at 10:01 AM with Licensed Practical Nurse #30. Licensed Practical Nurse #30 handed the surveyor all the medications they were about to administer for verification of the drug, dose, route of administration, and time of administration. This included the potassium chloride extended release 20 milliequivalent tablet. Licensed Practical Nurse #30 crushed the potassium chloride extended-release tablet and mixed it with other crushed medications in apple sauce. They entered Resident #109's room and administered the crushed medications.The April 2026 Medication Administration Record documented on 04/29/2026 at 10:00 AM Licensed Practical Nurse #30 administered 20 milliequivalents of potassium chloride extended-release tablet by mouth.During an interview on 04/30/2026 at 3:10 PM Licensed Practical Nurse #30 stated the electronic medication administration record for Resident #109 documented not to crush the potassium chloride extended-release tablet. They stated they should not crush extended-release tablets, but the facility's pharmacy had approved crushing them if that was the only way the resident would take the medication.2) Resident #75 had diagnoses including right sided paralysis. The 03/26/2026 Minimum Data Set assessment documented the resident's cognition was not assessed, they were dependent on most activities of daily living and had a feeding tube.The comprehensive care plan initiated 01/15/2026 and revised 03/09/2026 documented nutritional risk due to tube feeding. Interventions included medications per physician order.Physician orders documented the following:-50 milliliter water flush before and after medication pass.-hydroxychloroquine (used for autoimmune disease) 200 milligram tablet: give 1.5 tablets by gastrostomy tube once daily.-lisinopril (for blood pressure) 20 milligram tablet: give 1 tablet by gastrostomy tube once daily.-calcium 600 milligrams-vitamin D3 (nutritional supplement) 5 micrograms (200 unit) tablet: give 1 tablet by gastrostomy tube once daily.-metoprolol tartrate (for blood pressure/heart failure) 25 milligram tablet: give 0.5 tablet (12.5 milligrams) by gastrostomy tube twice daily.-aspirin 81 milligram chewable tablet: give 1 tablet by gastrostomy tube once daily.-atorvastatin (lowers cholesterol) 40 milligram tablet: give 1 tablet by gastrostomy tube once daily.-venlafaxine (antidepressant) 37.5 milligram tablet: give 1 tablet by gastrostomy tube twice daily; -baclofen (muscle relaxant) 10 milligram tablet: take 0.5 tablet by gastrostomy tube 3 times a day.During a medication administration observation on 04/30/2026 at 9:45 AM Licensed Practical Nurse #12 crushed the following medications: venlafaxine, metoprolol tartrate, lisinopril, hydroxychloroquine, calcium plus vitamin D3, baclofen, atorvastatin, and aspirin. At 10:20 AM Licensed Practical Nurse #12 mixed the above medications together with approximately 20 milliliters of water and administered them all at once via the gastrostomy tube followed by approximately 20 milliliters of water. During an interview on 04/30/2026 at 10:51 AM, Licensed Practical Nurse #12 stated they did not know if all the resident's medications could be administered together. They usually only separated liquids and powders from the crushed medications.During an interview on 05/01/2026 at 10:21 AM, Registered Nurse Unit Manager #3 stated when giving medications via a gastrostomy tube the medications could be crushed and administered all together unless the order specified otherwise.During an interview on 05/01/2026 at 11:30 AM, the Director of Nursing stated when giving crushed medications through a gastrostomy tube, all the medications could be given together unless otherwise stated in the order. If a medication order documented do not crush, then it should not be crushed. Instead, an alternative should be found. If a resident preferred to have it crushed, they had that right, but there should be physician notification, a note and maybe an order to cover that.During an interview on 05/01/2026 at 12:24 PM, Pharmacist #31 stated crushed medications were part of their reviews. Resident #109's orders had an entry of crush but neither yes nor no was checked off. If not checked as being a yes for crush, then it would not be in their system, and they would not have noted that in the review. Their potassium could be mixed with water to create a slurry but could not be crushed. They were unsure of the clinical implications if it was administered crushed. There was a liquid alternative to the tablet form. They stated when administering crushed medications through a gastrostomy tube, the medications should be administered one at a time and flushed with water in between to prevent clogging of the tube. That was more of a nursing standard.During an interview on 05/01/2026 at 2:03 PM, Nurse Practitioner #11 stated an order was required to crush a medication. They expected to be notified if staff were crushing medication without an order because some medications could not be crushed or might be incompatible with other medications. They expected potassium not be crushed if there were instructions to not crush as it could cause abnormal heart rhythms and be fatal. They were not aware Resident #109's potassium was being crushed. They should be notified because they would have directed to stop doing so. They stated when administering medications via a gastrostomy tube, they should be given one at a time unless otherwise indicated. Giving all the medications together could reduce their effectiveness. They would want to know if medications were being given all together because they would give directives to not do so. They were not aware Resident #75's medications were being administered together. 10 New York Codes, Rules and Regulations 415.12(m)(2)

Based on observations and interviews, the facility failed to ensure the results of the most recent Federal and State surveys were posted in a place readily accessible where individuals who wished to examine the survey results did not have to ask for them for 5 of 13 cottages (Cottages 10, 11, 21, 31, and 77). Specifically, the facility State survey results binders in Cottages 10, 11, 21, 31, and 77 were on a mantle shelf that was not readily accessible to residents in wheelchairs or were partially obscured by other items and not able to be easily seen by residents and families without asking for assistance. Findings Include:The New York State Department of Health Your Rights as a Nursing Home Resident in New York State documented residents had the right to read the results of the most recent State and Federal inspection survey and the facility's plan to correct any violations. During an anonymous resident group meeting on 04/27/2026 at 2:07 PM, four (4) residents stated they had never seen any previous survey results and did not know where they were located.The following observations were made of the facility State inspection binders:-In Cottage 10 on 04/28/2026 at 12:14 PM, the binder was on top of the mantle shelf behind the sign that documented the survey binder was on the lower shelves below and on 05/01/2026 at 1:35 PM, it was on the top mantle shelf against the back wall with a sign in front of it indicating the binder was on a lower shelf. -In Cottage 11 on 04/28/2026 at 12:44 PM, the binder was on top of the mantle shelf cabinet above average standing head height against the wall to the right of the television not accessible to residents in wheelchairs without assistance; and on 05/01/2026 at 11:01 AM it was on the top mantle shelf not at a wheelchair accessible level.-In Cottage 21 on 04/28/2026 at 12:50 PM, the binder was on the top mantle shelf above average head height and not at a wheelchair accessible height. It was partially blocked by a sign that indicated the State inspection binder was on the shelves below. On 05/01/2026 at 11:26 AM, the binder was on the top mantle shelf not at an accessible level for residents in wheelchairs. -In Cottage 31 on 04/28/2026 at 1:35 PM the binder was on the top mantle shelf behind a sign that documented the survey results were in a binder on the bookshelf below. The sign was obstructed by a vase of artificial flowers, and the binder was behind the sign. On 05/01/2026 at 1:29 PM, the binder was on the top mantle shelf, not within accessible reach, and behind the sign that stated it was on the lower shelf. -In Cottage 77 on 04/29/2026 at 10:54 AM, the binder was on the shelf inside of a closed cabinet 4 feet up from the ground. During an interview on 05/01/2026 at 9:57 AM, Certified Nurse Aide #19 stated they did not know where the State inspection binder was. Upon observing where the binder was located on the top shelf above average head height, they stated they did not believe it was accessible to residentsDuring an interview on 05/01/2026 at 11:09 AM, Registered Nurse Manager #20 stated the previous State inspections were posted in the common area of the cottage. The binder was kept around the mantle area, and the residents could ask to see it. The book was not at typical resident accessible height, and they would have to ask someone to see the results. During an interview on 05/01/2026 at 1:50 PM, the Administrator stated the most recent State inspections were in a binder in each cottage accessible to the residents. The State inspections should be kept on the bookshelf within reach of the residents or by the activity area. They were unaware the State inspection binders were kept on the top mantle shelf and not at a wheelchair accessible level. 10 New York Codes, Rules and Regulations 415.3(1)(c)(1)(v)

Based on observations, record review, and interviews, the facility failed to ensure a process was in place for residents to have their grievances addressed for 138 of 138 residents residing in the facility. Specifically, information on how to file a grievance and grievance forms was not available to the residents and the facility did not have a process for residents to file an anonymous grievance in 13 of 13 Cottages; and three (3) of three (3) anonymous residents present at the resident group meeting stated they did not know if there were grievance forms or where they were located, their right to file grievances anonymously, who the Grievance Officer was, and there was not always follow up on how their concerns were addressed. Findings include:The facility policy Grievance Management, last reviewed 04/2025, documented residents would be advised of their right to voice a complaint and the process for doing so upon admission and the information would also be posted throughout the facility. Complaints may be communicated orally or in writing to any member of the staff. For each complaint received the staff member was to complete a Complaint Record documenting the date of the complaint, name of the individual, the relationship with the resident, the resident, the nature of the complaint including a request for a written response, requested action sought, and the preferred method of response. The staff would give it to their immediate supervisor who would then forward it on to the Grievance Officer. The Grievance Officer would log and track the resolution and distribute the complaint to the Administrator, Director of Nursing and appropriate members of management who would complete the investigation within 5 business days. The Grievance Officer would notify the complainant in the manner requested. If the complaint could not be resolved within 5 business days, the management staff member was to contact the complainant to let them know additional time was needed. The 2025 Grievance Log documented seven (7) grievances for the year. There were no documented grievances for 2026. During a resident group meeting on 04/27/2026 at 2:07 PM, three (3) anonymous residents stated the facility listened to their concerns, but they did not tell the residents what they were going to do or were doing to address their concerns. They did not know if there was a grievance process, if there was a formal process to write down a concern, how to file a grievance, or who the Grievance Officer was. The following cottages were observed to have no signs on the process for filing a grievance, who the Grievance Officer was, grievance forms available to residents, or a way to file a grievance anonymously:- Cottage 11 on 05/01/2026 at 1:23 PM- Cottage 21 on 05/01/2026 at 1:26 PM- Cottage 31on 05/01/2026 at 1:29 PM- Cottage 10 on 05/01/2026 at 1:35 PM During an interview on 05/01/2026 at 9:57 AM, Certified Nurse Aide #19 stated they did not know what the grievance process was for the facility or who the Grievance Officer was. During an interview on 05/01/2026 at 9:48 AM, Licensed Practical Nurse #32 stated they did not know what facility's grievance policy was or how to file a grievance for a resident or family member's concern. They also did not know who the Grievance Officer was. During an interview on 05/01/2026 at 11:09 AM, Registered Nurse Manager #20 stated if a resident complained to a certified nurse aide the certified nurse aide should notify the nurse manager. They should obtain as much information as they could about their concern and give it to the social worker. The social worker would then complete the investigation. They did not know if there was a way to file a grievance anonymously. They were unsure if there were grievance forms for residents and/or families to fill out, but they did not have copies in the cottage. If they had forms, it was likely on the facility's electronic share drive. During an interview on 05/01/2026 at 12:46 PM, the Director of Resident Services stated any concern brought up was supposed to be written up on a grievance form and the investigation was completed by the appropriate department. The Grievance Officer should ensure it was completed, and a resolution was given to the resident. All staff had access to the grievance form through the electronic share drive. There was not a way for residents or families to file a grievance anonymously. Residents and families did not have access to the grievance form without asking staff. They were not aware it was a resident right to be able to file a grievance anonymously. There were no signs posted in the cottages regarding the grievance process, how to file a grievance, and who the Grievance Officer was but some cottages had a binder on resident rights. During an interview on 05/01/2026 at 1:50 PM the Administrator stated there was a grievance form that residents, families, or staff could fill out if there was a concern or issue. If a staff member completed a grievance for a resident or family they should start the investigation. If it could not be resolved, the grievance was forwarded up to a higher level. If a resident requested a grievance form staff could make them a copy of the form. Some of the clinical care offices in the cottages kept a copy of the grievance forms. There was a binder in each cottage before the pandemic, but they were removed. The residents and families could also contact the Ombudsman with any concerns. A resident could file an anonymous grievance by asking for a form, leave their name off when filling it out and leave it in the clinical care office. They were aware it was a resident right to file a grievance and to be able to file one anonymously. 10 New York Codes, Rules, and Regulations 415.3(C)(1)(ii)

Based on record review and interviews, the facility failed to provide the resident and their representative with a summary of their baseline care plan that included initial goals, a summary of medications and dietary instructions, and services and treatments to be administered for one (1) of one (1) resident (Resident #14) reviewed. Specifically, there was no documented evidence Resident #14 and their representative were informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. Findings include:The facility policy Comprehensive Care Plans, revised 04/2025, documented each resident would have an individualized interdisciplinary plan of care completed within 48 hours of admission. Resident #14 was admitted to the facility on [DATE] with diagnoses including left hip fracture. The comprehensive care plan, initiated 04/06/2026, documented the resident was alert and oriented and was independent in decision making. Interventions included encourage their involvement in the care planning process. During an interview on 04/28/2026 at 1:27 PM, Resident #14 stated they and their two children had a meeting with several other staff members in the past month, but they did not recall receiving a copy of their care plan or their physician orders. During an interview on 04/28/2026 at 2:32 PM, Registered Nurse Manager #3 stated care plans were initiated on admission by the nurse managers, and they held 72-hour care plan meetings. They never provided residents with a copy of their baseline care plan and were never told they had to. They did not give Resident #14 a copy of their baseline care plan. Their first care plan meeting was 04/20/2026; they did not have a 72-hour care plan meeting due to a family death. During an interview on 05/01/2026 at 11:26 AM, the Director of Nursing stated the facility did not complete baseline care plans. They had been at the facility for 5 years and during that time baseline care plans were not printed and given to the residents. They were not aware that should happen. 10 New York Codes, Rules and Regulations 415.11

Based on observation, record review, and interviews conducted during the abbreviated survey (iQIES #2643653) the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 did not receive timely treatment or interventions when they did not have bowel movements for more than three (3) days. Additionally, the medical provider was not notified of the resident's bowel status and when a bowel medication was not available to administer. Findings include:The facility's 03/2014 policy Bowel Protocol documented:- Certified nursing assistants would record the bowel movement of residents every shift on bowel movement worksheets.- Licensed nursing staff would monitor residents' bowel patterns by reviewing the bowel movement worksheet daily and apply the bowel protocol as ordered. - If a resident failed to have a bowel movement within three (3) days, by the evening of the third day, licensed nursing staff were to administer Milk of Magnesia at bedtime; on day four (4) additional medication, suppository and enema were to be given if the resident continued to have no bowel movements; on day five (5), clear liquid diet, notify the physician, and a registered nurse would complete a rectal exam to check for presence of stool but not to digitally remove stool. - If this protocol was ineffective, the physician was to be notified. - Documentation included certified nursing assistant to record the residents' bowel pattern each shift on the bowel movement worksheet; licensed nursing staff would review the bowel movement worksheet at the beginning of each shift, determine the appropriate intervention, record the medication on the Medication Administration Record, and document in the nursing progress note the medication given and the results. Resident #1 had diagnoses including Parkinson's Disease, constipation, irritable bowel syndrome. The 07/28/2025 Minimum Data Set assessment documented the resident's cognition was intact. They required substantial/maximal assistance to dependence on staff for all activities of daily living tasks except for eating when they needed supervision or touching assistance. The 07/22/2025 admission nursing progress note documented the resident's last bowel movement was on 07/21/2025, prior to admission. The 07/22/2025 physician admission orders for bowel medications included:-Docusate sodium (a stool softener used to prevent constipation commonly called Colace) 100 milligram capsule, two capsules orally two times a day, hold for loose stools.-Linzess (for irritable syndrome and chronic constipation) 145 microgram capsule orally once daily. The 07/2025 Medication Administration Record documented Linzess was not administered/not available from 07/22/2025 to 07/25/2025. There was no documented evidence the medical provider was notified the medication was not administered. There was no documented evidence the resident had a bowel movement from 07/22/2025 to 07/26/2025. There was no documented evidence of bowel interventions. The 07/26/2025 at 4:14 PM nursing progress notes by Licensed Practical Nurse #6 documented the resident was on the no bowel movement list. Linzess was delivered and started. The resident had four (4) ounces of prune juice. They were assessed by the registered nurse and the resident stated they wanted to wait to have anything more to promote a bowel movement The 07/26/2025 at 9:47 PM nursing progress notes by Licensed Practical Nurse #6 documented the resident continued with no bowel movement and the registered nurse was aware. A suppository was ordered and given at 2:00 PM with no bowel movement reported. The resident was assessed for bowel sounds by the evening registered nurse. The 07/27/2025 at 10:41 PM nursing progress note by Registered Nurse #10 documented the resident was without documented bowel movement since 07/22/2025 and received a suppository without results. They were assessed for bowel sounds which were hypoactive. Their bowel medications required an evaluation, and they may need an x-ray in the morning. There was no documented evidence the medical provider was notified when Resident #1 was without a bowel movement from 07/22/2025 to 07/27/2025. There was no documented evidence the resident had a bowel movement from 08/05/2025 to 08/09/2025 and no documented evidence of bowel interventions. The 08/09/2025 at 2:04 PM the nursing progress note by Licensed Practical Nurse #6 documented a suppository was given per nursing order with no bowel movement in more than nine (9) shifts and the registered nurse was aware. As of 5:32 PM the resident was pending results from the suppository. There was no documented evidence the resident had a bowel movement from 08/09/2025 to 08/11/2025 and no further documentation related to the resident's bowel medication or results from the 08/09/2025 suppository. There was no documented evidence the medical provider was notified the resident was without a bowel movement for seven (7) days and with no results from the suppository. The 08/11/2025 at 2:57 PM nursing progress note by Unit Manager Registered Nurse #1 documented the resident had chest pain and was diaphoretic (excessive sweating). The resident was transferred to the hospital. The 08/11/2025 Emergency Department encounter note and Hospital After Visit Summary documented the resident had a past medical history of Parkinson's disease and constipation. They reported cramping in their chest and feeling clammy but denying any cardiac symptoms. They were noted to be constipated for the past few days. An abdominal x-ray showed constipation. They had a mineral oil enema rectally at 4:45 PM with minimal stool evacuated, a disimpaction with mild stool, a soapsuds enema and Senna was last given at 8:57 PM. Clinical impressions included constipation unspecified. The 08/12/2025 at 9:58 AM nursing progress note by Registered Nurse Unit Manager #1 documented the resident returned from the hospital at 9:30 AM with the diagnosis of fecal impaction. The resident's comprehensive care plan initiated 07/22/2025 through discharge on [DATE] did not list constipation as a focused/problem area and therefore there was no plan for the resident's continued constipation. During an interview on 10/17/2025 at 10:57 AM, Registered Nurse Unit Manager #1 stated when a resident was on the No Bowel Movement list the licensed practical nurse would notify them, and at three or four days they would assess the resident for bowel sounds and look for an upper ileus (the muscle stops working and cannot pass stool). If there were no bowel sounds then a Kidney, Ureter and Bladder x-ray was ordered. During an interview on 10/28/2025 at 10:25 AM and 10/30/2025 at 10:18 AM the Assistant Director of Nursing #7 stated they were aware the facility bowel movement protocol was outdated and needed revising which they were in the process of completing. The facility did not have a paper bowel movement form the certified nursing assistants filled out manually as referred to in the protocol. It was discovered on 10/28/2025, during the abbreviated survey, bowel movement data from the certified nurse aide electronic documentation was not consistently transferring the correct data to the No Bowel Movement report. For Resident #1, the reports did not match the certified nurse aide documentation. The No Bowel Movement report was the primary report utilized to determine if bowel interventions were needed for residents. This form was printed out at 12:00 AM nightly by the supervisor and brought to each unit for the day shift licensed practical nurse to review The Assistant Director of Nursing stated if no entry was made on the certified nurse aide documentation, it was considered a no bowel movement for that shift. If a medication was not available, the nursing staff should notify the registered nurse or supervisor who will notify the medical provider and document they did so. During an interview on 10/28/2025 at 1:30 PM and on 10/30/2025 at 9:40 AM Licensed Practical Nurse #6 stated they received the No Bowel Movement list daily which was usually left on the medication cart by the night supervisor. They were not sure if the lists were accurate. When they gave Resident #1 a suppository on 08/09/2025, they pulled up the dashboard report in the computer and saw the resident went more than nine (9) shifts without a bowel movement. When they saw a resident needed a bowel intervention, they notified the registered nurse for further instructions. A small bowel movement was not counted as a bowel movement. They did not look at the facility's Bowel Protocol for guidance. They needed an order for bowel interventions if there was not one in place. When they gave a suppository, they communicated that to the next shift. The next shift was to monitor and if no results, they communicated that to the oncoming shift to intervene. They did not document they informed the next shift. They do not call the medical provider, as the registered nurse was the one who was to make the notifications. During a phone interview on 10/30/2025 at 1:19 PM Nurse Practitioner #8 stated they expected to be notified when a bowel intervention was done and the expected outcome did not occur. If a resident's bowel movements were not monitored adequately and interventions not implemented, the resident could have a negative outcome such as bowel obstruction or ileus. They were not aware Resident #1 had any indication of a small bowel obstruction or ileus. They were not notified of any concerning gastrointestinal symptoms that would have caused them to intervene. 10 NYCRR 415.12

Based on observations, record review, and interviews during the abbreviation survey (NY00373359), the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 was care planned for two staff for care, a staff member provided care alone, and the resident sustained skin tears. The resident also sustained a fracture and it was not able to be determined if the fracture occurred during the care, or following the incident. Findings include: The 2/5/2024 facility policy Comprehensive Care Plan, documented residents and their representatives would play an active role in the implementation of the resident's care plan. The plan would address the resident's needs. Resident #2 had diagnoses including Alzheimer's dementia, atrial fibrillation (abnormal heartbeat), and Myelodysplastic syndrome (abnormal blood cells affecting bone density). The 12/12/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, used a walker or wheelchair, was dependent for bed mobility/transfers/toileting, required moderate assistance with personal hygiene, was always incontinent of urine and occasionally incontinent of bowels, and received psychotropic medications and a diuretic (water pill). The 12/19/2024 comprehensive care plan documented the resident was at risk for falls, was at risk for impaired skin integrity, had the potential for excess bruising/bleeding, was incontinent of bowel and bladder, had accusatory behaviors, had anemia, and had self-care deficits. Interventions included 2 staff at all times to act as witness, call bell in reach at all times, inspect skin every shift, maximal assistance with dressing, protect extremities during care, change/toilet with 2-staff assist every 2-3 hours, ensure gentle handling is provided at all times, dependent for transfers with mechanical lift, and dependent with bed mobility. The 2/24/2025 incident report documented an injury of unknown origin at 4:43 PM. Staff reported the resident had no recent falls and did not hit their elbow on anything. The resident reported falling although there were inconistencies noted in their report. An x-ray of the left upper arm was ordered due to reports of pain and swelling. The x-ray showed a left elbow fracture. The findings documented the resident had risk factors of bones breaking easily due to Myelodysplastic syndrome that they felt caused the fracture. The family did not want the resident sent to the hospital for evaluation until the next morning. The report documented the facility did not find that abuse, neglect, or mistreatment had occurred. The following witness statements were included in the report: - Certified Nurse Aide #9's statement documented on 2/22/2025, the aide provided care at about 5:00 PM by themselves, held the resident by the shoulder and leg to turn them, and completed care. When attempting to provide care again at about 9:00 PM, the aide was unable to turn the resident in bed and obtained help from Certified Nurse Aide #10. The staff noticed skin tears to the resident's left shoulder and elbow, which were not there previously. - Certified Nurse Aide #7's statement documented the resident had no pain or injuries on 2/22/2025 day shift. The next morning on day shift, the resident had pain in their left arm. The resident told the aide they had fallen out of bed and had a fight (arguement) with the person grabbing their arm the night before. The aide called the supervisor to report the pain. The aide's written report documented the resident had no skin tears on 2/21/2025. - Certified Nurse Aide #9 was called and reiterated the previous statement and stated the resident had not hit their head or elbow on anything. - Certified Nurse Aide #10 stated Certified Nurse Aide #9 asked for help as they could not turn Resident #2 on their own. The resident's shirt was already off, and the skin tears were evident with fresh blood. - The report documented the resident had inconsistencies with their version of events. The 2/22/2025 at 9:54 PM Registered Nurse #16 progress note documented the resident was turned to their left side in bed for incontinence care. When the resident was rolled back, staff noted a skin tear to the left shoulder and elbow with a scant amount of bleeding. Steri strips were applied, and the family and provider were made aware. The 2/23/2025 at 6:59 PM Registered Nurse #16 progress note documented the resident's left arm was assessed and the steri-strips were in place on the left shoulder and elbow. The elbow joint was red and warm to touch and swollen from elbow down. There were 3 separate areas of bruises on the left forearm. Staff were instructed the resident was 2-assist with care. The 2/24/25 Nurse Practitioner #12 progress note documented the resident was seen due to reports of left arm pain and swelling. There were no reported recent falls. X-rays and an ultrasound were ordered. The 2/25/2025 hospital discharge summary and left arm x-rays reports documented the resident stated they had fallen on 2/23/2025 and struck their head. The resident complained of head, neck, and left arm pain. The x-ray documented the resident had thin bones and an acute mild fracture of the left elbow. A splint was placed. The 2/25/25 Nurse Practitioner #13 progress note documented the resident was evaluated due to mild left arm pain. An x-ray confirmed multiple fractures. There were questionable reports of the resident falling. The resident was to be sent to the hospital. The 2/26/25 Nurse Practitioner #12 progress note documented the resident returned from the hospital on 2/25/25 with a left arm splint due to a fracture. During an interview on 3/19/2025 at 3:00 PM, the Assistant Director of Nursing #3 stated resident specific care was documented in the care instructions and care plans. Staff were expected to follow those plans and instructions. Certified Nurse Aide #9 failed to follow the resident's plan of care by not having another staff member present during care. The reason the resident was to have 2 staff were due to false accusations in the past regarding staff. The facility believed the resident sustained the skin tears due to not following the plan. The facility did not believe the arm fracture occurred at this time as they felt the fracture was due to brittle bones. The aide received disciplinary actions. During a telephone interview on 3/20/2025 at 1:03 PM, Certified Nurse Aide #7 stated staff were to follow resident specific care located in the care instructions, otherwise a resident could get hurt. Resident #2 was known to have falsely accused staff members of things in the past and therefore was 2-assist at all times. The resident did not complain of arm pain the day before. The resident told the aide that they got into a fight with staff, and they pulled the resident's arm. The aide stated they were not on duty at the time of the incident. During an interview on 3/20/2025 at 1:40 PM, Certified Nurse Aide #10 stated staff were to follow the resident specific care located in the care plans and care instructions. Resident #2 was to have 2 staff for all care and was very hard to turn in bed. Certified Nurse Aide #9 was attempting to provide care by themselves on 2/22/2025, was unable to do so, and called Certified Nurse Aide #10 for assistance. While turning the resident, the aides noted a skin tear on the resident's upper arm and shoulder. The supervisor was called, and the resident was assessed. There were no complaints of pain before, during, or after the supervisor's assessment. During an interview on 3/20/25 at 3:40 PM, the Director of Nursing stated the aides were expected to review each assigned resident's care instructions at the beginning of the shift. Staff were expected to follow those instructions. Certified Nurse Aide #9 did not follow the resident's care plan of 2 assist and was disciplined for that. The resident had an arm fracture, but the facility was unable to determine through the investigation as to when it occurred. The facility determined the fracture was caused by the resident's comorbidity and brittle bones. They could not determine when the fracture occurred, and did determine the aide caused the skin tears. During an interview on 3/20/2025 at 3:59 PM, Nurse Practitioner #13 stated the facility determined the arm fracture was not caused by this incident, and they were unable to determine when it occurred but was due to brittle bones from comorbidities. Myelodysplastic Syndrome caused the bone density to be very thin and weak. It would not take much to fracture a bone. During an interview on 3/20/25 at 4:09 PM, Certified Nurse Aide #9 stated on 2/22/25 at about 5:00 PM, they went to provide incontinence care to Resident #2 by themselves. There were no issues at that time. The aide went to provide care at about 8:00 PM, and the resident's bed was wet with urine. The aide went to get help as the resident was 2-assist. When turning the resident in bed, both noticed a shoulder cut and told the supervisor. The aide stated they had provided care to the resident by themselves and should not have. The aide stated they reviewed each resident's care instructions daily. The aide did not remember the resident complaining of arm pain that night. 10 NYCRR 415.12(h)(l)

Based on record review and interview during the abbreviated survey (NY00325983), the facility did not promote and facilitate the resident's right to self-determination through support of resident choice, including the resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 refused incontinence care and staff continued to provide care following multiple refusals. Findings include: The March 2014 facility policy Notification of Rights, documented each resident would be provided with an environment allowing them to maintain dignity and quality of life. The 6/24/2014 Certified Nurse Aide Job Description documented to adhere to Resident's Rights regulation and promote resident's autonomy in decision making and honor their choice. Resident #1 had diagnoses including history of sacral and upper pubic fractures, seizures, depression, high blood pressure, and inner ear disorder. The 9/17/2023 Minimum Data Set assessment documented the resident had highly impaired hearing, had full cognition, required limited assist with most activities of daily living, required extensive assist of 1 with toilet use, used a walker, was occasionally incontinent of bowel and bladder, and received an antipsychotic, antidepressant, and an opioid. The 6/14/2023 updated comprehensive care plan documented the resident was incontinent of urine. Interventions included: incontinence briefs, the resident did not require assistance from staff, and preferred not to be disturbed on the night shift (11PM-7 AM) unless they rang for assistance. The 10/13/2023 incident report documented that at 6:40 AM, Certified Nurse Aide #4 continued to provide incontinence care despite the resident refusing and stating they were not incontinent. The resident stated the aide proceeded to roll the resident in bed and pull down their incontinence brief for incontinence care despite the resident stating they were not wet. Certified Nurse Aide #4's statement documented the resident had been incontinent at night the previous two nights and allowed care. The aide went into the room to check to see if the resident was incontinent, the resident stated to the aide that they were not wet, and the aide continued to provide incontinence care. The care plan was followed. The employee was suspended pending investigation and disciplinary actions were taken by the facility. The social worker followed up with the resident twice post incident and the resident had no psychological concerns. The 10/13/2023 at 3:37 PM Assistant Director of Nursing progress note documented the resident stated at about 6:40 AM, Certified Nurse Aide #4 rolled the resident in bed. The care plan was updated that the resident did not want to be woken at night unless they rang their call bell. On 3/20/2025 at 12:30 PM, Resident #1 was sitting in a chair in their room dressed and groomed. The resident reitterated the statement given in the incident report and that the resident was initially upset, then became angry. The resident did not see Certified Nurse Aide #4 following the incident. The resident stated the aide continued to provide care against their wishes, after the resident stated they did not need to be checked for incontinence. During an interview on 3/19/2025 at 3:00 PM, the Assistant Director of Nursing stated resident specific care was located in each resident's care instructions. Each staff member was expected to look at all assigned resident instructions at the beginning of the shift and before providing care to a resident. Staff members were expected to follow each resident's plan of care. All staff were aware of this, and they received education during orientation. One of the resident's rights was to be able to refuse care. If a resident refused something, staff were to make sure the resident was safe, exit the room, and report the refusal to a nurse or supervisor. Refusals were to be documented in the resident's medical record. A progress note was to be written by the nurse. On 10/13/2023, Certified Nurse Aide #4 went to toilet the resident. The aide's rational was that the resident was incontinent of urine the previous two times they provided care and the resident allowed the aide to provide the care. When the aide went into provide care to the resident, the resident stated they did not need incontinence care. The aide turned the resident over to provide care, and the resident began banging the wall with their hand to get help. Certified Nurse Aide #4 was suspended pending investigation and was given a written disciplinary action. The facility investigation determined Certified Nurse Aide #4 violated the resident's rights. There was no negative outcome to the resident or harmful intent. During an interview on 3/20/2025 at 2:52 PM, the Director of Social Services stated all residents were given a copy of Resident Rights and Choice on admission. Each resident had a right to refuse any care, treatment, medication, or staff. Staff were to reapproach and abide by the resident's choice. There was an incident where Resident #1 refused incontinence care during the night and the aide did not abide by those wishes. The director stated they interviewed the resident that morning and again after the incident. There were no negative effects, although the resident was angry about the situation at the time. During an interview on 3/20/25 at 3:40 PM, the Director of Nursing stated resident specific care was in their care instructions. The expectation was for staff to follow those instructions. If not, the staff member received disciplinary actions. All staff received abuse, neglect, and resident rights training on at least an annually basis. Each resident received education on resident's rights and choice upon admission. Staff were not to provide care to a resident who refused, although they should reapproach the resident after the initial refusal. The aide violated the resident's rights by not abiding by the refusal, but there was no abuse, neglect, or harm. The aide was suspended pending investigation, was reeducated, and later terminated for attendance issues. 10 NYCRR 415.5(b)(1,3)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00340968, NY00316430, and NY00302422) surveys conducted 7/8/2024-7/16/2024, the facility did not ensure residents were given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living for 1 of 4 residents (Resident #61) reviewed. Specifically, Resident #61 leaned far to the right in their wheelchair and was not assisted with repositioning. Findings include: The 9/2014 facility policy Repositioning, documented elders would receive the required assistance for repositioning based on their assessment from the interdisciplinary team and that repositioning in bed/chair was assured for those elders who needed assistance. Resident #61 was admitted to the facility with diagnoses including unspecified dementia, multiple sclerosis (a central nervous system disease), generalized muscle weakness, and unspecified pain. The 5/17/2024 Minimum Data Set assessment documented the resident had severely impaired daily decision making skills, was rarely understood, had one fall, required moderate assistance with sitting to lying and transfers, and used a manual wheelchair. The 3/22/2023 Occupational Therapist #44 discharge summary documented the resident was able to maintain static (sitting still) sitting with contact guard assistance. Therapy provided to address standing tolerance and sitting balance. Recommendations included to perform activities of daily living in seated position as much as possible. The 1/29/2024 Physical Therapist #45 discharge summary documented the resident required stand by assistance to maintain static (with no movement) and dynamic (with movement) sitting. The comprehensive care plan revised 2/20/2024 documented the resident was at risk for falls due to balance impairment. Interventions included reposition in chair as needed. The comprehensive care plan revised 5/15/2024 documented the resident required set up or clean up assistance with eating. The care instructions dated 7/9/2024 documented, Dycem (non-slip material) in wheelchair at all times. Do not leave in wheelchair unsupervised. The resident was observed: -On 7/8/2024 at 5:35 PM, sitting in their wheelchair leaning far to their right side, using their right arm to eat and drink. Their food fell off their fork and the milk spilled to the floor when they tried to bring the utensil and cup to their mouth. -On 7/9/2024 at 9:56 AM, sitting in their wheelchair leaning far to their right. -On 7/10/2024 at 10:44 AM, sitting in their wheelchair leaning far to the right with their right underarm in direct contact with wheelchair arm rest. -On 7/10/2024 at 12:30 PM, sitting in their wheelchair leaning far to the right. Certified Nurse Aide #12 used the waist band of the resident's pants to straighten the resident. -On 7/10/2024 at 12:53 PM, sitting in their wheelchair leaning far to the right side, using their right arm to eat salad. Lettuce dropped off their fork onto the floor. -On 7/15/2024 at 12:56 PM, sitting in their wheelchair eating lunch, leaning to the far right. They were able to straighten their posture briefly, but immediately went back to a right leaning posture. During an interview on 7/16/2024 at 9:14 AM, Certified Nurse Aide #12 stated if they noticed a resident was leaning in a chair, they should realign the resident and report it to the nurse who could trigger a physical therapy evaluation. Resident #61 required the assistance of one for positioning and tended to lean to the side. During mealtimes they sometimes leaned with their food and the food dropped onto the floor. Therapy worked with the resident, but they did not believe anything was changed to help with positioning. During an interview on 7/16/24 at 9:37 AM, Licensed Practical Nurse #16 stated if there was a positioning concern with a resident, they would do whatever they could to make sure the resident was properly aligned. If they saw a resident was leaning in their chair and it was not ordinary behavior, they would call the Nurse Manager to assess. If the leaning affected the resident's ability to eat, they should straighten them and help them eat. Resident #61 sometimes needed help when sitting in their chair due to leaning and sitting to the side of the chair. They did not see the resident at mealtimes due to covering another cottage during mealtimes but did not think the resident required any assistance with eating. During an interview on 7/16/2024 at 11:15 AM, the Assistant Director of Nursing stated if staff saw a positioning issue with a resident, such as sliding or leaning in a chair, they should reposition the resident. If it was an ongoing issue, they expected a physical therapy evaluation to be triggered. They expected the same if the leaning occurred during mealtime. They were not sure what Resident #61's assistance level for positioning or eating was. They had not seen the resident lately, but the last time they did, the resident was self-propelling in their wheelchair and did not notice any abnormalities. Proper positioning was important for swallowing, comfort, safety, and for prevention of wounds. During an interview on 7/16/24 at 11:47 AM, Occupational Therapist #15 stated on admission residents were assessed for appropriate wheelchairs, cushions, and need for adaptive equipment such as lateral supports. If they noticed a change in a resident or received an alert from a Nurse Manager, they would reassess the resident. If a resident leaned in their wheelchair, they would reassess the wheelchair or the need for lateral supports to correct leaning. Resident #61 leaned to the right, but they had never worked with them. They thought lateral supports would agitate the resident due to their history of behaviors. Blankets might work if placed in the wheelchair for positioning because they could be removed by the resident, whereas the lateral supports could not. They did not believe lateral supports had been tried with the resident. Proper positioning was important to prevent skin breakdown as leaning could agitate the resident's underarm. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00302422, NY00316430, NY00340968) surveys conducted 7/8/2024-7/16/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 7 residents (Resident #100) reviewed. Specifically, Resident #100 was not assisted with removing unwanted facial hair and had unclean and untrimmed fingernails. Findings include: The facility policy, Standard of Care: Personal Hygiene/Grooming/Dressing/Eating- ADL Function/Rehab Potential, revised 9/2014 documented every elder should be encouraged and assisted as necessary to maintain personal hygiene for optimal physical and psychological well-being. Daily morning care would consist of shaving and fingernails would be cleaned and checked for trimming on showers days. Resident #100 had diagnoses including dementia and anxiety. The 5/20/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required partial/moderate assistance with personal hygiene, substantial/maximal assistance with showering/bathing, and did not refuse care. The comprehensive care plan initiated 2/6/2024 documented the resident had a self-care deficit related to dementia. Interventions included nail care and shaving assistance per customary routine preferences, showers on Wednesday and Saturday evening, and the resident required substantial/maximal assistance with bathing and general personal hygiene. The 7/2024 Certified Nurse Aide Resident Care Record documented the resident received a shower during the evening shift on 7/6/2024 and 7/10/2024 and received assistance with personal hygiene from 7/8/2024-7/14/2024 on both day and evening shifts. Resident #100 was observed at the following times: - On 7/8/2024 at 6:20 PM, seated in their wheelchair with thick black hair covering their upper lip, long gray/white hair under their chin, and their fingernails were long and unkept with brown debris underneath the fingernails. The resident stated they did not want facial hair. - On 7/9/2024 at 2:59 PM, seated in their wheelchair with thick black hair covering their upper lip, long gray/white hair under their chin, and their fingernails were long and unkept with brown debris underneath most of them. - On 7/10/2024 at 12:30 PM, seated in their wheelchair with thick black hair covering their upper lip, long gray/white hair under their chin, and their fingernails were long and unkept with brown debris underneath most of them. -On 7/15/2924 at 11:10 AM, seated in their wheelchair with thick black hair covering their upper lip and long gray/white hair under their chin. During an interview on 7/15/2024 at 1:52 PM, Certified Nurse Aide #34 stated they looked at a resident's care instructions to see how to properly care for the resident. Personal hygiene was completed every day and consisted of bathing, dressing, oral care, nail care, and shaving. They stated they documented all care provided and if a resident refused, they would document the refusal and notify the nurse so they could reapproach the resident. They were familiar with Resident #100, they did not refuse care, and they assisted with their care on the morning of 7/15/2024. They did notice Resident #100's facial hair earlier but did not have time to remove it. They planned on shaving the resident later that day. They stated long, unwanted facial hair and dirty fingernails were not dignified. During an interview on 7/15/2024 at 2:24 PM, Certified Nurse Aide #37 stated personal hygiene consisted of dressing, bathing, shaving, and nail care. They were familiar with Resident #100, assisted with their care earlier that day, and the resident did not refuse care. They did notice Resident #100's facial hair, but they were already up and, in their wheelchair, so they did not shave them. They planned on cutting Resident#100's fingernails. It was important to complete all personal hygiene including shaving and nail care daily so the resident would feel good and not cut themselves. During an interview on 7/16/2024 at 9:53 AM, Licensed Practical Nurse #29 stated staff looked at a resident's care plan or care instructions to tell how to properly care for the resident. Personal hygiene was completed each shift and consisted of washing a resident's face and body, nail care, hair care, shaving, and oral care. Nail care was also done on shower days. If a resident refused care, the certified nurse aides should document the refusal and notify the nurse. They had not been notified of any refusals by Resident #100. They stated it was important for the certified nurse aides to offer shaving and cutting fingernails to maintain Resident #100's dignity. During an interview on 7/16/2024 at 11:15 AM, the Assistant Director of Nursing stated personal hygiene consisted of bathing, oral care, shaving, nail care, and should be completed daily for each resident and as needed. If a resident refused any kind of care, the certified nurse aide should document the refusal and notify the nurse. If personal hygiene was signed off as completed, that meant it was done. They stated it was important to shave and provide nail care to Resident #100 to maintain their dignity. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review during the recertification and abbreviated (NY00316340 and NY00336542) surveys conducted 7/8/2024-7/16/2024, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #120) reviewed. Specifically, Resident #120 was not offered meaningful activities that included their interests and preferences. Findings include: The undated facility policy, Recreation Philosophy and Practice, documented the Recreation Department honored freedom of choice for their household members, and enabled elders/persons to either actively or passively participate in leisure experiences to enhance quality of life via groups or one to one endeavors targeted to provide experiences for success. The facility Admission Agreement dated 5/2024 documented covered services included an activities program and would provide a varied schedule of activities to meet resident physical, psychological, spiritual, and individual needs. Resident #120 had diagnoses of peripheral vascular disease (poor circulation), diabetes, and chronic kidney disease. The 1/29/2024 Admission Minimum Data Set assessment documented the resident's cognition was moderately impaired, they felt down, or depressed, and daily preferences included listening to classical music, attending religious services, and going outside for fresh air when weather permitted. The comprehensive care plan initiated 2/7/2024 documented a focus of therapeutic recreation. Interventions included to ensure the resident had an activities calendar in their room, invite to programs of interest such as music, exercising, watching sports of interest, reading, spiritual time, reminiscing, and spending time outdoors when the weather permitted. The July 2024 activity schedule for Cottage #87 was posted on a white board in the common area and was placed on top of the fireplace hearth. The board sat in the corner of the hearth and wall and was approximately 6 feet from the floor and not highly visible. Activity times were listed as AM and PM and included: - On 7/8/2024 AM church, PM good news. - On 7/9/2024 AM cow craft, PM milk/cookies. - On 7/10/2024 AM exercise, PM manicures. - On 7/11/2024 AM exercise, PM musical. - On 7/12/2024 AM BINGO, PM snacks/chats. - On 7/15/2024 AM church, PM strolls. - On 7/16/2024 AM exercise, PM gardening. The July 2024 activity attendance record for Resident #120 did not document attendance for music, spiritual services, or going outdoors per the resident's preferences. There were no documented activity progress notes for Resident #120. During an observation and interview on 7/8/2024 at 1:48 PM, Resident #120 was sitting in their room on their bed. There were no personal effects in their room. A July 2024 activity calendar was hanging on a bulletin board to the right of the door and was not visible from the main part of the room. The resident stated they loved classical music but did not have means to listen to it. They enjoyed socializing with other people of the same sex, but they were the only cognitive one of their sex in their building. They loved to spend time outdoors. They were only invited to attend BINGO which they did not like. During an observation on 7/10/2024 at 12:31 PM, the resident was sitting at a dining room table with a cognitively impaired resident. There was no interaction between the residents. During an observation and follow-up interview on 7/15/2024 at 10:47 AM, Resident #120 was observed self-propelling in their wheelchair near the exit door of the Cottage and asked to go outdoors or sit on the porch. Certified Nurse Aide # 25 told the resident they could not go outside. Resident #120 propelled themself over to the dining room window and sat and looked outside. The resident became tearful and stated they had rules to follow so what could they do? They stated they were a practicing Roman Catholic and had only spoken to a priest one time but would love to attend church. They felt lonely, and they wanted to socialize with other residents of the same sex. During an interview on 7/15/2024 at 11:35 AM, Recreation Specialist #2 stated they were responsible for activity programs for three Cottages, including Resident #120's. Resident #120 liked music, going outdoors, and socializing. They tried to incorporate those preferences into their programs but often did not have enough time. They had played a 50-minute church service on the television in Resident #120's cottage so they could run over to a different cottage and finish up those resident activities. Resident #120 was not invited to the church service. There were no social groups, but they tried to bring residents to other buildings to socialize. Outside vendors did not come to provide activities due to the facility requirement of background checks and paperwork that took too long to process. They had not brought Resident #120 to any other buildings for socialization. They stated the resident had not been outside lately and did not have any classical music in their room to listen to. During an interview on 7/16/2024 at 8:48 AM, the Director of Therapeutic Recreation stated they had a full caseload and was responsible for activity programs in Cottages #31, #51 and #61. They stated the facility had not had any outside vendors come to the facility since COVID-19. They had a priest come only when needed and did not have any Catholic mass services. They did not have social groups except for Resident Council and a cooking group. They had not had outdoor activities such as cookouts in a long time. They were not set up for those types of events. Residents were not allowed to go outside if the temperature was 85 degrees Fahrenheit or higher for safety reasons. 10NYCRR 415.5(f)(1)

Based on observation, record review, and interview during the recertification and abbreviated (NY00316430) surveys conducted 7/8/2024-7/16/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 6 residents (Residents #125 and #7) reviewed. Specifically, Resident #125 did not have an alternating pressure overlay (a specialty mattress overlay that provides air flow to relieve pressure) in place as ordered, and Resident #7's wound treatments were not completed as ordered. Findings include: The facility policy, Skin Care, dated 3/2014 documented residents with pressure ulcers would receive the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. The Nurse Manager would assess all residents with any staged pressure ulcers weekly, collect data, and document on the skin tracking worksheet. Depending on the statistics, continuing education would be given on prevention and treatments. The facility policy, Alternating Pressure Mattress Overlay, revised 3/2022 documented an order would be obtained from the provider. The licensed practical nurses would check the function and comfort mode of the mattress every shift, sign off on the Treatment Administration Record, and report any unresolved issues to the Nurse Manager or Supervisor. 1) Resident #7 had diagnoses including an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) of the right heel, protein-calorie malnutrition, and local infections of the skin and subcutaneous (below the surface) tissue. The 5/15/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject, had one Stage 3 pressure ulcer (full thickness tissue loss), had a pressure reducing device for their bed, and received pressure injury care. The 5/15/2024 at 8:52 AM physician treatment order documented Medi Honey paste (a medical grade honey product used for wound healing) apply 1 applicator by topical route once daily. Wash right heel pressure ulcer with soap and water, pat dry, apply skin prep (skin protectant) around the wound, apply Medi Honey to the wound base, and cover with adhesive foam dressing. Change daily and as needed. The Comprehensive Care Plan initiated 6/24/2022 documented the resident had skin breakdown related to pressure on their right heel. Interventions included to assess characteristics of wound during treatment care and document weekly; elevate heels off bed with pillow supplied by therapy; turn and position every 2-3 hours as needed; foot cradle on end of bed, alternating air mattress set to middle firmness and use pressure relieving devices in bed or chair as indicated. The July 2024 resident care instructions documented use pressure relief mattress, elevate heels off the bed with therapy supplied pillow; use extra caution when ambulating, dressing and repositioning due to new blood thinner order; turn and position every 2 to 3 hours and as needed. The 6/4/2024-6/18/2024 Nurse Practitioner #35 progress notes documented the resident had a Stage 3 pressure ulcer measuring 1.5 centimeters by 0.5 centimeters by 0.1 centimeters on 6/4/2024 and measured 1.2 centimeters by 0.8 centimeters by 0.1 centimeters on 6/18/2024 and was improving. A 7/2/2024 at 10:13 AM Assistant Director of Nursing #21 progress note documented the resident had a healing Stage 3 pressure ulcer to the right heel measuring 1.9 centimeters x 1.5 centimeters and containing 100% pale pink tissue. No signs or symptoms of infection were noted. There was a moderate amount of serosanguinous (mixture of serum and blood) drainage on the old dressing. The 7/2024 Treatment Administration Record documented to wash right heel pressure ulcer with soap and water, pat dry. Apply skin prep around wound and allow to air dry. Apply Medi Honey 100% topical paste, apply 1 applicator to wound base. Cover with gauze, cover with abdominal pad (absorbent dressing), and wrap with elastic gauze every day during the 3:00 PM- 11:00 PM shift and as needed. The Treatment Administration Record documented Licensed Practical Nurse #36 did not complete the treatment to their right heel on 7/8/2024, 7/9/2024, and 7/10/2024 due to not having supplies. During an interview on 7/15/2024 at 9:32 AM, Licensed Practical Nurse #20 stated the resident's treatment to their right heel was scheduled for the 3:00 PM-11:00 PM shift. If supplies were not available, nurses should notify their supervisor. During a treatment observation and follow-up interview on 7/15/2024 at 2:32 PM, Licensed Practical Nurse #20 applied Medi Honey topical paste to the wound and covered the right heel with an abdominal gauze pad and Kerlix bandage. The wound appeared to be a clean Stage 3 ulcer with some maceration (moisture damage) around the perimeter. The 7/15/2024 at 4:04 PM Assistant Director of Nursing #21 progress note documented a late entry from the 7:00 AM-3:00 PM shift. The resident's wound care supplies were noted to be unavailable per the licensed practical nurse documentation and after consult with the wound care nurse the treatment was changed. During an interview on 7/16/2024 at 9:16 AM, Assistant Director of Nursing #21 stated they were responsible for ordering wound care supplies. They stated the nurses would write down what was needed, and they would order them. Supplies were delivered every Wednesday. They stated the resident's lack of wound care supplies triggered on the 24-hour report and they became aware on 7/15/2024 the treatment was not completed for 3 days. They stated it was unacceptable for the resident's treatment not to be completed by Licensed Practical Nurse #36 due to a lack of supplies; the Registered Nurse Supervisor should have been notified and the resident's pressure ulcer could have gotten worse or infected. During an interview on 7/16/2024 at 9:59 AM, Infection Preventionist #46 stated also functioned as the wound care nurse for the facility. They stated Resident #7 had a stage 3 pressure ulcer to their right heel and arterial ulcers to the surface of their toes. They stated they were not aware the resident's treatments were not completed until 7/15/2024 when the Assistant Director of Nursing approached them and asked for an alternate treatment. The Infection Preventionist stated it was unacceptable for the resident to not have their wound care for 3 days and could lead to infection of the wound or it could worsen. Voicemail messages were left with Licensed Practical Nurse #36 and no return calls were received. 2) Resident #125 had diagnoses including dementia, Stage 2 (partial thickness skin loss). pressure ulcers of the right and left heels. The 6/21/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, did not exhibit behaviors, did not reject care, required partial/moderate assistance for bed mobility and transfers, was at risk for developing pressure ulcers, had two Stage 2 pressure ulcers that were not present on admission, and received pressure ulcer care. The comprehensive care plan initiated on 5/20/2024 documented the resident had impaired skin integrity related to a Stage 2 pressure ulcer on their right and left heel. The interventions included alternating pressure overlay on the bed, apply treatments as ordered, assess skin every shift, elevate heels off the bed, and turn and position every two hours while in bed. The 6/26/2024 physician order documented alternating pressure overlay on the bed, set to middle firmness, and check inflation every shift. Resident #125 was observed at the following times: - On 7/8/2024 at 1:26 PM, sitting in their wheelchair with a regular mattress on their bed. The alternating pressure overlay was rolled up on the floor next to the dresser and the pump was lying on top of the dresser. - On 7/9/2024 at 9:58 AM, sitting in their wheelchair with a regular mattress on their bed. The alternating pressure overlay was rolled up on the floor next to the dresser and the pump was lying on top of the dresser. - On 7/10/2024 at 6:23 AM, lying on their back in bed, on a regular mattress. The alternating pressure overlay was rolled up on the floor next to the dresser and the pump was lying on top of the dresser. - On 7/11/2024 at 7:16 AM, lying on their back in bed, on a regular mattress. The alternating pressure overlay was rolled up on the floor next to the dresser and the pump was lying on top of the dresser. The July 2024 treatment administration record documented alternating pressure overlay checks every shift. Check functioning/inflation and set to middle firmness. The alternating pressure overlay was documented as checked: - On 7/8/2024 by Licensed Practical Nurse #28 from 7:00 AM- 3:00 PM; by Licensed Practical Nurse #30 from 3:00 PM- 11:00 PM; by Licensed Practical Nurse #32 from 11:00 PM- 7:00 AM. - On 7/9/2024 by Licensed Practical Nurse #29 from 7:00 AM- 3:00 PM; by Licensed Practical Nurse #30 from 3:00 PM- 11:00 PM; by Licensed Practical Nurse #32 from 11:00 PM- 7:00 AM. - On 7/10/2024 by Licensed Practical Nurse #28 from 7:00 AM- 3:00 PM; by Licensed Practical Nurse #28; by Licensed Practical Nurse #30 from 3:00 PM- 11:00 PM; by Licensed Practical Nurse #32 from 11:00 PM- 7:00 AM. - On 7/11/2024 by Licensed Practical Nurse #29 from 7:00 AM- 3:00 PM; by Licensed Practical Nurse #31 from 3:00 PM- 11:00 PM; by Licensed Practical Nurse #33 from 11:00 PM- 7:00 AM. During an interview on 7/15/2024 at 1:59 PM, Certified Nurse Aide #34 stated they thought Resident #125 had pressure ulcers on their heels and was supposed to be on an alternating pressure overlay, be turned and positioned frequently, and have their heels elevated while in bed. These tasks were listed on Resident #125's care instructions. The nurses were responsible for the mattress settings, and ensured it was in place and functioning. They stated they did not notice if the mattress was in place, and they would notify a nurse if there were any issues. They stated it was important for the alternating pressure overlay to be in place and working to prevent Resident #125's pressure ulcers from getting worse. During an interview on 7/16/2024 at 9:41 AM, Licensed Practical Nurse #29 stated all direct care staff were responsible for checking to ensure alternating pressure overlays were in place and functioning. The nurses had to sign off every shift that the overlay was functioning correctly, and the settings were correct. They did not recall the last time they checked Resident #125's alternating pressure overlay, but if they signed it off in the treatment administration record it meant they observed it working. They stated it was important to check the alternating pressure overlay as ordered because if it was not in place or working properly it could put Resident #125 at risk for further skin breakdown on their heels. During an interview on 7/16/2024 at 11:07 PM, the Assistant Director of Nursing #21 stated staff looked at a resident's care plan to tell them how to properly care for the resident. All alternating pressure overlays needed a physician order, and the order would include the correct setting. The licensed practical nurses had to sign off every shift that it was working properly and set correctly. They expected the alternating pressure overlay to be in place if the licensed practical nurses were signing off on it and would expect the staff to notify a manager or provider if it was not in place. They stated they had heard from staff it was on the floor all week and not being used. Any nurse could have placed it on the bed and turned it on because there was an order for it. They stated it was important to ensure Resident #125's alternating pressure overlay was in place and working to prevent further skin breakdown. 10NYCRR 415.12(c)(1)(2) 48675

Based on observations, record review, and interviews during the recertification survey conducted 7/8/2024-7/16/2024, the facility failed to ensure all allegations of abuse, neglect, and mistreatment were thoroughly investigated or reported to the New York State Department of Health as required for 1 of 1 resident (Resident #77) reviewed. Specifically, Certified Nurse Aide #1 had a physical altercation with Resident #77 causing a skin tear (a wound caused when layers of skin separate or peel back) to the resident's arm and Certified Nurse Aide #1 was not immediately removed from direct resident care pending investigation. Additionally, the facility did not conduct a thorough investigation to rule out abuse and neglect and did not report the incident to the New York State Department of Health as required. Findings include: The facility policy, Dementia Care, dated 3/2024, documented upon admission all resident's cognitive status would be reviewed for an assessment of care needs; basic care approaches were to approach in a soft, low voice, re-direct whenever possible from a high stress environment, allow the resident to remain in a preferred location/environment if safe, and re-approach resident later if they expressed/chose to remain, recognizing that this was a preference/choice even in someone who had dementia. The facility policy, Abuse, reviewed by the facility 5/2024 documented all employees would be trained on appropriate interventions to deal with aggression and/or catastrophic reactions of residents; all staff were required to monitor staff for inappropriate behaviors including swearing, rough handing, or ignoring a resident's needs and report it to their supervisor and appropriate actions would be taken. The Nursing Supervisor was required to complete a Resident's Accident/Incident report if they became aware of any injury sustained by the Resident, and the Director of Nursing would investigate for any potential of abuse in accordance with New York State Department of Health's Investigative Guidelines for Allegations of Abuse/Neglect in Long-Term Care Facilities. Residents involved in allegations of abuse would be protected from harm during the investigation of reported abuse. If the Director of Nursing had reason to suspect the employee abused or mistreated a resident, options included: suspension of suspected employee until the investigation was complete; reassignment of suspected employee to another unit, change of assignment to prevent the involved employee contact with the involved resident; and termination. The facility policy, Resident Abuse Reporting, reviewed by the facility 5/2024, documented witnessed or suspected incidents of abuse were to be reported to the Department of Health when reasonable cause was established. The Supervisor would be responsible for notifying the Administrator/Director of Nursing of the witnessed or suspected incident of abuse. Upon receiving an allegation of abuse, the Nurse Manager/Designee would place the accused employee on immediate temporary suspension pending investigation and ensure that staff had correctly and accurately completed an incident report. Together, the Director of Nursing and Administrator would review the internal investigation to determine reasonable cause. The Nurse Manager/Designee would submit the Incident/Accident to the Department of Health within 24 hours and after reviewing with the Administrator and Director of Nursing. Resident #77 had diagnoses of restlessness and agitation and mild dementia with anxiety. The 5/20/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, used a wheelchair, had highly impaired hearing, responded adequately to simple, direct communication, had behavioral symptoms not directed toward others 1-3 of 7 days, did not reject care, required moderate assistance for most activities of daily living, and did not have any skin tears. The 5/14/2024 admission assessment completed by Registered Nurse #17 documented Resident #77 was alert and oriented to person, place, time, and situation, made their own healthcare decisions, required extensive assistance with bed mobility and transfers and had multiple bruises on the right arm caused by multiple blood draws during hospitalization . The Comprehensive Care Plan documented: - on 5/14/2024 the resident had potential risk for impaired skin integrity related to limited mobility. Interventions were to inspect skin every shift for evidence of redness, excoriation, or breakdown; keep skin clean and dry; lubricate dry skin as needed, provide treatments as needed, and monitor lab work and report abnormalities as needed. - on 5/14/2024 the resident was at risk for falls due to impaired judgement and balance/coordination impairment. Interventions included keep in high visibility areas as applicable. - on 5/14/2024 the resident had a hearing deficit with interventions including staff should speak slowly, clearly, and loudly while facing the resident; approach the resident from the front and use gentle touch to get attention. - on 5/21/2024 the resident received buspirone (used to treat anxiety) related to diagnosis of agitation. Interventions included assess behavior pattern daily and assess effectiveness of medication. The buspirone was increased on 5/23/2024 due to agitation/anxiety in the evening. - on 5/22/2024 the resident had altered mood state as manifested by motor tension, autonomic hyperactivity, apprehensiveness, and hypervigilance. Interventions included encourage verbalizations of feelings, explore positive coping strategies, reduce environmental stimuli, and provide reassurance and emotional support. A 5/21/2024 Physician #6 order documented psychiatric consultation for behaviors. Document progress note every shift on the behaviors presented by the resident, any non-pharmacological interventions, and the result of the interventions. The 7/2024 resident care instructions documented the resident used a walker and a wheelchair, required partial/moderate assistance with transfers, and had verbally abusive behaviors and negative statements. The instructions did not include interventions for behavioral symptoms. The 7/7/2024 at 8:19 PM Registered Nurse Supervisor #2's nursing progress note documented Resident #77 was reportedly being combative with Certified Nurse Aide #1 during the shift. The resident punched Certified Nurse Aide #1 several times and Certified Nurse Aide #1 grabbed Resident #77's arm when the resident swung at them a fourth time, resulting in a 2.5-inch skin tear to the resident's left arm. The skin tear was covered with Suresite (a transparent film dressing). The family was notified, and a message was sent to the social worker and the Director of Nursing. There was no documented evidence an investigation was initiated to rule out abuse and neglect or that Registered Nurse Supervisor #2 immediately removed Certified Nurse Aide #1 from providing resident care. The 7/7/2024 Certified Nurse Aide Documentation Record documented the resident refused to bath or eat during the evening shift (3:00 PM-11:00 PM) and was signed by Certified Nurse Aide #1. There were no behaviors documented. A 7/7/2024 Physician #6 order documented cleanse left forearm skin tear with normal saline. Pat dry and apply Suresite dressing every 3 days. Monitor for signs and symptoms of infection and report to registered nurse. During an observation and interview on 7/8/2024 at 5:28 PM, Resident #77 was observed with a bandage and bruising to their left arm. Resident #77 stated Certified Nurse Aide #1 grabbed and cut their arm. The resident was able to answer screening questions appropriately. The facility Accident/Incident Report signed by Registered Nurse Supervisor # 2 on 7/11/2024 (four days after the incident) documented on 7/7/2024 at 7:21 PM an incident occurred in the living room of the resident's cottage. The resident was aggressive and had reportedly hit the certified nurse aide (unidentified). After multiple strikes the resident attempted to hit the certified nurse aide again. In an attempt to protect themself, the certified nurse aide grabbed the resident's arm which resulted in a skin tear due to the resident's fragile skin. The resident had an order for a psychiatric evaluation already in place due to agitation and anxiety and was seen 7/11 with recommendations for management of anxiety and symptoms. The offense was not reportable. The section First Accused Perpetrator had N/A written through it. The conclusion documented the investigation did not support the allegation of abuse, mistreatment, neglect. The report was signed by the Administrator and the Director of Nursing on 7/11/2024. There was no documented evidence how the facility concluded abuse or mistreatment did not occur or that Certified Nurse Aide #1 was suspended pending investigative outcome. Certified Nurse Aide #1's timecard documented the following hours worked: - on 7/7/2024 6:56 AM- 9:13 PM - on 7/8/2024 6:57 AM-10:33 PM - on 7/10/2024 7:04 AM- 9:04 PM - on 7/11/2024 7:04 AM-3:03 PM - on 7/12/2024 7:03 AM (survey exited prior to the end of Certified Nurse Aide #1's shift). During an interview on 7/11/2024 at 12:02 PM, Resident #77 stated Certified Nurse Aide #1 wheeled them to the dining room area (unsure of the date) and locked their wheelchair wheels so they could not move. They attempted to move in their chair and Certified Nurse Aide #1 repeatedly grabbed their wheelchair and stopped them from returning to their room. Certified Nurse Aide #1 grabbed their arm and when the resident pulled away, their arm was cut. During an interview on 7/11/2024 at 11:57 AM, Certified Nurse Aide #1 stated they worked on 7/7/2024 during the evening shift from 3:00 PM-9:00 PM. Licensed Practical Nurse #3 and they put the resident in their wheelchair and brought them to the common area. The resident later wanted to go back to their room, was combative, and struck them (Certified Nurse Aide #1). They grabbed the resident's arm to stop them from hitting and the resident sustained a skin tear. They thought it was appropriate to grab the resident's arm due to the resident's combative behaviors. They and Licensed Practical Nurse #3 reported the incident to Registered Nurse Supervisor #2 that evening. During a telephone interview on 7/11/2024 at 12:49 PM, Licensed Practical Nurse #3 stated they worked on 7/7/2024. They were administering medications in the resident's cottage. At approximately 6:00 PM- 6:30 PM, they were advised by Registered Nurse Supervisor #2 had arrived due to Resident #77 hitting Certified Nurse Aide #1 but had no knowledge of the incident only that the resident had a skin tear and they cleaned it and covered it with gauze. During a telephone interview on 7/11/2024 at 2:26 PM, Registered Nurse Supervisor #2 stated they worked on 7/7/2024 and were alerted Resident #77 had a skin tear to their left arm. They stated when they arrived, Certified Nurse Aide #1 informed them the resident had been combative and they grabbed the resident's arm to stop them from hitting them. Registered Nurse Supervisor did not think it was abuse and the only prevention implemented was the certified nurse aide was prevented from doing further care. Registered Nurse Supervisor #2 stated they were unaware if a full investigation was completed. During an interview on 7/11/2024 at 2:30 PM, the Director of Nursing stated the facility had not started a full investigation of the incident that occurred on 7/7/2024 because the New York State Department of Health entered the facility for the recertification survey on 7/8/2024. They stated Resident #77 was combative, their family was notified, and the resident had been seen by Social Services and progress notes would be added. On 7/11/2024 at 3:59 PM, the Director of Nursing submitted an Investigative Report to the New York State Department of Health, 4 days after the incident occurred. During a follow-up interview on 7/12/2024 at 9:23 AM, the Director of Nursing stated they were not made aware of the incident with Resident #77 and Certified Nurse Aide #1 until they completed rounds on the morning of 7/8/2024. They stated Registered Nurse Supervisor #2 had completed an incident report and abuse was not suspected. They asked Certified Nurse Aide #1 and Registered Nurse Supervisor #2 about the incident and concluded there was no abuse and did not notify anyone else. They stated they would investigate now that they were aware. During an interview on 7/12/2024 at 9:41 AM, the Administrator stated they were not aware of an incident between Certified Nurse Aide #1 and Resident #77 until the New York State Department of Health requested a full investigative report. They stated they were responsible for investigating to rule out abuse but had accepted the Director of Nursing's statement that abuse was unfounded. The Administrator stated they knew what incidents needed to be reported to the New York State Department of Health but did not do so as they thought abuse was ruled out; if abuse was ruled out, they did not send the accused home. During an interview on 7/12/2024 at 10:14 AM, Physician #6 stated they were familiar with Resident #77 who had diagnoses of dementia and anxiety and had seen them on 7/10/2024. They were not advised of any incidents between Certified Nurse Aide #1 and Resident #77 and was not aware the resident had a skin tear. They thought it was appropriate for Certified Nurse Aide #1 to grab Resident #77's arm if it were done in self-defense. 10NYCRR 415.4(b)

Based on record review, observation, and staff and resident interviews conducted during the post survey visit, it was determined the facility did not ensure unsafe smoking practices were thoroughly investigated and did not reassess plans of care to prevent unsafe smoking for 1 of 2 sampled residents (Resident #8) reviewed with a history of smoking. Specifically, when Resident #8 was found with smoking materials on more than one occasion, a full investigation was not conducted to determine the source of these materials, whether the resident was able to use these smoking materials, and how the resident's non-compliance with the facility's non-smoking policy would be effectively addressed. Additionally, Resident #8's comprehensive care plan (CCP) was not evaluated by the interdisciplinary team for its effectiveness and was not revised to address unsafe smoking practices. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. THIS IS A REPEAT DEFICIENCY FROM THE 6/20/13 RECERTIFICATION SURVEY. Findings include: The facility's Smoking Policy was last revised on July 1, 2013. The policy specified signs would be posted at entrances that to inform all individuals entering or occupying the facility that smoking is not permitted. All residents and visitors "share in the responsibility" for adhering and enforcing" the smoking policy. "It is the responsibility of all management/supervisory personnel to ensure compliance with the smoke-free policy for all residents...". The policy did not address how residents would be monitored to prevent their possession and/or access to smoking materials. Resident #8 had [DIAGNOSES REDACTED]. The resident also has chronic obstructive pulmonary disease (COPD) and diabetic neuropathy. The resident's Minimum Data Set (MDS) assessment, dated 4/29/2013, documented the resident's cognition was intact and did not use tobacco products. The resident was readmitted on [DATE] from a hopsital-based behavioral unit after treatment for [REDACTED]. The physician's admission history and physical note, dated 7/23/2013, documented the resident "shows poor insight and judgment". The physician noted the resident "smokes around 1 pack (of cigarettes) a day and has been doing so for 40+ years; and has a history of alcohol use, as well." On 8/2/2013 at 3:30 PM, a nursing note documented the resident had taken cigarettes and a lighter out of her purse and "stated she wanted to smoke a cigarette." The resident initially refused to give a staff member the cigarettes and lighter, but "threw the cigarettes" at the nurse and began using foul language towards the staff. The nurse was "unsuccessful" when she attempted to re-direct the resident. The social worker "was made aware." Review of the resident's comprehensive care plan (CCP), updated 8/20/2013, revealed no documentation of the resident's smoking history, nor was the incident documented when she was found in possession of smoking materials. A nursing progress note, dated 8/26/2013 at 1:45 AM, documented a certified nurse aide (CNA) found a cigarette in the resident's bed. The note specified the resident had been spoken to by nursing and social services about the non-smoking policy and "continued to be uncompliant". The nursing note documented the supervisor was notified and the nurse manager would be informed. Review of the 24 hour supervisor's report for 8/26/2013 revealed no documentation that a cigarette was found in the resident's bed. On 8/27/2013 at 3 PM, a nursing progress note, documented a CNA found a lighter in the resident's bed. The CNA took the lighter from the resident. The 24 hour supervisor's report for 8/27/2013 did not document that a lighter was found in the resident's bed on that date. The Resident Plan of Care (CNA care instructions), dated 9/3/2013, documented the resident attempts to smoke. There were no further care instructions that pertained to the resident's smoking attempts on that plan of care. This information was not on the resident's comprehensive care plan. The resident was observed on 9/3/2013 at 12:30 PM in her room sitting in a wheelchair with a Wanderguard attached. The surveyor observed an open make-up bag on the resident's lap that contained one loose cigarette and a red cigarette pack. The resident then proceeded to ask the surveyor "Can you take me out for a cigarette?" The CNA assigned to the resident was interviewed on 9/3/2013 at 3:40 PM. He stated the resident occasionally asked to go outside to smoke. He was aware that cigarettes and a lighter were found in the resident's possession but, could not recall the date. He was unaware of any plan to ensure the resident did not have smoking materials. The licensed practical nurse (LPN) was interviewed on 9/3/2013 at 3:50 PM. She stated the resident often begged to go out to smoke. She said she was on duty on 8/26/2013 when the CNA gave her the cigarette found in the resident's room. The LPN stated she notified the shift nursing supervisor and left a note for her nurse manager. She said she was unaware of any plan to ensure the resident did not have smoking materials. On 9/3/2013 at 4:00 PM, the registered nurse (RN) Manager was interviewed and stated she was aware the resident had smoking materials in her possession on 8/26/2013 and 8/27/2013. She said she attempted to review the smoking policy with the resident but said the resident became angry. The RN Manager stated the resident refused to use smoking cessation methods. She also said the unit social worker and social work supervisor were aware the resident was found with cigarettes in early August, but she was not sure if they were aware the resident had smoking materials on 8/26 and 8/27/2013. She stated there was no plan in place to ensure the resident did not have smoking materials. When interviewed on 9/3/2013 at 4:15 PM, the Social Work Supervisor stated she was aware the resident had cigarettes and a lighter in early August (2013) after she was readmitted from the behavioral unit. She said she had reviewed the facility no smoking policy with the resident and provided her with a copy. The social worker stated the resident understood the policy and was offered smoking cessation materials but she refused. The Social Worker Supervisor said she was unaware the resident was found with smoking materials on 8/26/2013 and 8/27/2013. She stated this information should have been communicated to her through the shift report. She said she thinks another resident's family member gave the cigarettes to the resident. There were no documented interventions on the resident's CCP to help prevent the resident's access to smoking materials. The resident's unit social worker was interviewed on 9/3/2013 at 5:10 PM. She stated she was aware the resident had cigarettes on 8/2/2013, but was not aware the resident had smoking materials on 8/26/2013 and 8/27/2013. The social worker stated she should have been notified through shift report or when she was on the unit. She talked to the resident about getting on a smoking cessation program but the resident declined. On 9/3/2013 at 4:15 PM, the Quality Assurance (QA) Coordinator was interviewed regarding the facility's plan for monitoring unsafe smoking practices. He stated they were auditing facility grounds for cigarette butts to ensure compliance. He did not address any monitoring systems in place for residents who may have smoking materials in their possession. 10NYCRR 415.12 h(1) (2)

Based on record review and staff interview conducted during the extended and abbreviated surveys, (Complaints # NY 962, NY 881, and NY 708), it was determined the Administration failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of 51 residents in the facility identified at risk for elopement including (Residents #1, 10, 13, 14, 28, 32, 33, 34, and 36). This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of residents at risk for elopement. The Immediate Jeopardy situation was removed on 6/20/2013, prior to the survey exit. Findings include: Refer to F323 for 9 of 12 residents reviewed for accidents (Residents #1, 10, 13, 14, 28, 32, 33, 34, and 36) reviewed for accidents/elopement. On 6/13/2013 at 12:50 PM, the Administrator stated in an interview, she did not feel there was a problem with the facility's elopement policy, she felt that the problem was with staff member's non-compliance with implementing the policy. She stated she "wouldn't be surprised if our staff closed there eyes knowing someone wanted to leave." She stated she believed the facility policy would work if staff adhered to it. She stated the direct care staff were responsible for knowing which residents had Wanderguards (a device used to detect wandering) and ensuring they were in place. She did not know if there was a system in place for checking the function of Wanderguards. She stated besides Resident #14, she was not aware of any residents leaving undetected or attempting to leave the facility undetected in the last 6 months. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on 6/20/2013 based on the following corrective actions taken by the facility: - Wanderguard placement was checked for all residents with Wanderguards and a system was implemented to check placement on a routine basis. - The functioning of Wanderguards and Wanderguard alarmed doors were checked and a system was implemented to check the functioning on a routine basis. - The policy and procedure was revised to ensure residents who refused Wanderguards were adequately monitored to prevent elopement/unsafe wandering. - Staff were provided with training on policies and procedures related to elopement and wandering. - Plans of care were updated to ensure direct care staff were aware of residents at risk for elopement. 10NYCRR 415.26

Based on record review and staff interview conducted during the extended and abbreviated surveys, (Complaints # NY 962, NY 881, and NY 708), it was determined the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents for the 51 residents in the facility identified at risk for elopement including 9 of 12 residents reviewed for accidents (Residents #1, 10, 13, 14, 28, 32, 33, 34, and 36). This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of residents at risk for elopement. The Immediate Jeopardy situation was removed on 6/20/2013, prior to the survey exit. THIS IS A REPEAT DEFICIENCY FROM THE June 18, 2013 AND THE December 13, 2013 SURVEYS. Findings include: Refer to F323 for 9 of 12 residents reviewed for accidents (Residents #1, 10, 13, 14, 28, 32, 33, 34, and 36) reviewed for accidents/elopement. On 6/13/2013 at 12:50 PM, the Quality Assurance (QA) Coordinator stated the facility was not currently conducting any audits or QA related to elopement. He stated once at morning meeting recently, the team discussed one resident who refused to wear a Wanderguard (a device used to detect wandering). He stated this was not discussed at a QA meeting as well. On 6/13/2013 at 12:50 PM, the Administrator stated in an interview, in response to Resident #14 eloping in May 2013 and walking to the hospital, the facility planned to implement an audit on elopements to be started at the QA meeting at the end of June 2013. In an interview on 6/13/2013 at 3:10 PM the Medical Director stated there was a policy related to resident wandering and elopement. He said he was not familiar with the policy or how it was being implemented. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on 6/20/2013 based on the following corrective actions taken by the facility: - Wanderguard placement was checked for all residents with Wanderguards and a system was implemented to check placement on a routine basis. - The functioning of Wanderguards and Wanderguard alarmed doors were checked and a system was implemented to check the functioning on a routine basis. - The policy and procedure was revised to ensure residents who refused Wanderguards were adequately monitored to prevent elopement/unsafe wandering. - Staff were provided with training on policies and procedures related to elopement and wandering. - Plans of care were updated to ensure direct care staff were aware of residents at risk for elopement. 10NYCRR 415.27(a-c)

Based on observation, interview, and record review conducted during the extended and abbreviated surveys (Complaints # NY 962, NY 881, and NY 708), it was determined for the 51 residents in the facility identified at risk for elopement including 9 of 12 residents reviewed for accidents (Residents #1, 10, 13, 14, 28, 32, 33, 34, and 36), 2 of 2 residents reviewed for swallowing concerns (Residents #24 and 33), 2 of 7 residents reviewed for falls (Resident #11 and 20), and 1 resident outside of the sample (Resident #38), the facility did not ensure residents received the proper supervision and assistance devices to prevent accidents and the resident environment remained free of accident hazards. Specifically: - the facility failed to have an effective system in place to ensure the safety of the 51 residents identified at risk for elopement including Residents #1, 10, 13, 14, 32, 33, and 34; - the facility failed to consistently implement care plans of residents identified at risk for elopement including Residents #1, 10, 13, 14, 32, 33, and 34; - the facility failed to thoroughly investigate all incidents of exit-seeking behavior for Residents #1, 10, 14, 13, and 34; - the facility failed to reassess residents' elopement risk and revise care plans when needed and communicate care plan changes to staff for Residents #1, 10, 13, 14, 32, 33, and 34; and - the facility failed to develop and implement a system to monitor the placement and operation of Wanderguards (a device used to detect wandering) for Residents #10, 13, 14, 33, and 34. In addition, the facility did not ensure unsafe smoking practices were thoroughly investigated and did not reassess plans of care to prevent unsafe smoking for Residents #10, 28, and 36. The facility did not implement aspiration precautions as planned for Residents #24, 33, and 38. The facility did not implement timely changes to Resident #11's plan of care following a fall with a fracture, and to Resident #20's plan of care following 3 documented falls. This resulted in no actual harm, with potential for serious harm, that was Immediate Jeopardy and Substandard Quality of Care to resident health and safety for the 51 residents at risk for elopement including Residents #1, 10, 13, 14, 32, 33 and 34 and was no actual harm with potential for more than minimal harm that was not immediate jeopardy for Residents # 11, 20, 24, 28, 36, and 38. The facility implemented corrective measures to remove the Immediate Jeopardy prior to survey exit on 6/20/2013. THIS IS A REPEAT DEFICIENCY FROM THE June 18, 2013 AND THE December 13, 2013 SURVEYS. Findings include: ELOPEMENT 1) Resident #14 was admitted to the facility in 11/2012 with [DIAGNOSES REDACTED]. For Resident #14 the facility failed to: thoroughly investigate all incidents of exit-seeking behavior; thoroughly investigate all incidents of exit-seeking; reassess residents' elopement risk and revise care plans when needed and communicate care plan changes to staff; develop and implement a system to monitor the placement and operation of Wanderguards. The admission Elopement Risk assessment dated [DATE], documented the resident was not at risk for elopement. A note added to the assessment dated [DATE], documented the resident was ambulating on the unit and would "look at elevator." Staff were concerned the resident would get on the elevator, so Wanderguard bracelet was applied to the resident. On 11/26/2012 nursing documented in a progress note, the resident was upset, crying and stated she did not want to be "here." The comprehensive care plan (CCP) initiated in 11/2012 and updated on 3/18/2013 documented the resident had inappropriate behavior described as "crying outbursts." The CCP did not document the resident was at risk for eloping and used a Wanderguard. The MDS dated [DATE] documented the resident was severely impaired cognitively, and displayed verbal behavioral symptoms toward others, daily. The MDS recorded the resident did not wander and was independent with transferring and ambulation. Between 3/20/2013 and 4/28/2013 nursing documented the resident exhibited agitation, weepiness, and was "tearful and distraught." The resident made statements she was "sick of being here", did not "want to be in this place any longer", wanted to "get out of this place" and wanted to die. The resident was placed on 15 minute monitoring from 4/4/2013 - 4/8/2013 and on 4/26/2013. On 4/29/2013, the resident was transferred to the hospital, for a psychiatric placement, for escalating behaviors with suicidal ideations. There was no documented evidence, in the resident's medical record, the resident's elopement risk was reassessed from admission in November 2012 until discharge to the hospital in April 2013. There was no documentation related to the presence of the Wanderguard. Nursing progress notes dated 5/20/2013 at 1:30 PM, documented the resident was readmitted to the facility. The resident was described as weepy due to "missing a male patient" at the hospital. The resident was observed wandering in the halls and visiting with other residents. A readmission elopement assessment dated [DATE] documented the resident was an elopement risk. The CCP dated 5/20/2013 documented the resident wandered on the unit, and was at risk for elopement, as the resident verbalized wanting to leave. The plan included providing a Wanderguard. An undated entry on the CCP documented the resident "refused to keep Wanderguard on." The certified nurse aide (CNA) plan of care dated 5/20/2013 documented the resident had a Wanderguard and was "currently" an inpatient at the hospital. There was no documented evidence the plan of care was updated following the resident's return on 5/20/2013. CNA #10 was interviewed on 6/11/2013 at 12:25 PM and stated when the resident returned on 5/20/2013, she started talking about leaving. CNA #10 said she, and other staff, informed the registered nurse (RN) Manager the resident needed a Wanderguard. She stated the resident was not provided with a Wanderguard at that time. Nursing progress notes described the resident as pleasant and in no distress on 5/20/2013 and 5/21/2013. On 5/22/2013 at 11 AM, nursing documented the resident was pleasant had "crying episodes" and "wants to get out of here" as she "can't take it anymore." The licensed practical nurse (LPN) documented the resident would be monitored, and a note would be left for the resident's physician to increase the resident's antipsychotic medication. The CNA plan of care dated 5/21/2013 through the day shift on 5/22/2013 documented the resident was "currently an inpatient" in a behavioral unit, and the plan was not updated after the resident was readmitted on [DATE]. The CNA plan of care dated 5/23/2013 documented the resident was to be monitored for outbursts. The nursing notes dated 5/24/2013 on the 7 AM to 3 PM shift, documented the resident was having crying episodes, increased anxiety and stated she "wants to get out of here and be with family." The notes recorded the plan was to continue to "monitor." The registered nurse (RN) progress note dated 5/25/2013 at 1 PM documented the facility was notified by telephone the resident was at the emergency room at a local hospital. After searching, the resident was not found at the facility. The hospital contact person stated the resident was being brought back by their security. The RN note dated 5/25/2013 at 1 PM, documented the resident "adamantly" refused to allow placement of a Wanderguard bracelet and was placed on 15 minute checks. An addendum to the note documented, the resident stated the previous Wanderguard was "pricking my skin" and she was not having another one. The LPN note dated 5/25/2013 at 2 PM documented the RN was informed the resident needed a Wanderguard as she "eloped" to a hospital (2 to 3 blocks away from the facility). A Wanderguard was placed on the resident at 2 PM. An addendum to the note documented the resident refused the Wanderguard and the RN was notified. An RN note dated 5/25/2013 at 4:59 PM documented she was informed by a CNA, the resident "just removed" the second Wanderguard. The resident refused to state where she disposed of the Wanderguard and staff was unable to locate it. A Resident/Visitor Event Report dated 5/25/2013 documented the morning prior to the incident the resident stated she wanted to go outside, refused lunch and went to her room. The report did not address if the resident had the Wanderguard on before she eloped and did not address how the resident was able to exit the building undetected. The follow up steps documented, the Wanderguard was attempted, the resident refused and was placed on 1:1. The CCP dated 5/25/2013 documented the resident was placed on 1 to 1 supervision after she eloped. The Visual Monitoring Sheets documented the resident was observed every 15 minutes during the evening shift on 5/25/2013 and 5/26/2013, and on the night shift and day shift on 5/27/2013. Per the documentation, it was unclear if the resident was being observed on a 1:1 or every 15 minutes, during this time period following the incident. The CNA plan of care documented: - on 5/26/2013 both 15 minute checks and "1;1 watch"; - on 5/27 and 5/28/2013 the plan did not document the resident's need for 1:1 monitoring; - on 5/29/2013, the day shift documented the resident was on "constant observation has eloped, removes Wanderguard" and the night shift the plan did not document the resident was at risk for elopement and on constant observation; and - from 5/30/2013 - 6/11/2013 the plan included "watch near elevator" due to elopement risk, and on constant observation. On 6/11/2013 at 12:30 PM, CNA #10 stated in an interview, the resident was on 15 minute checks "over the weekend" of 6/8 - 6/9/2013. CNA #10 said the resident was on 1 to 1 supervision "yesterday" 6/10/2013 and was on 15 minute checks "today." At 3 PM on 6/11/2013, during the evening shift report, a nursing staff member was heard stating the resident was on 15 minute checks during the day shift because they did not have enough staff for 1 to 1 supervision. The staff member said since there were five CNAs on the evening shift, one would be assigned 1 to 1 supervision of the resident. On 6/12/2013 at 9:30 AM, CNA #12 stated in an interview, the resident was "happy" when she returned to the facility on [DATE], and became agitated before dinner wanting to "get out of here." She said she reported that to the LPN. CNA #12 said on 5/21/2013, she reported, to the nurse, that she was concerned about the resident wanting to leave. She said no changes were made to the resident's plan of care, and the resident was not placed on 15 minute checks, until after eloping on 5/25/2013. The LPN was interviewed on 6/12/2013 at 3 PM,and stated residents who wore Wanderguards were checked every shift for placement of the Wanderguards. She said when she checked for a resident's Wanderguard and did not see one, she documented in the treatment record, and informed the nurse manager, or the nursing supervisor, who would then order more. She said it sometimes took a day or two to get the new Wanderguard. The LPN stated she left a note for the RN Managers on 6/9/2013 requesting an updated list of residents with Wanderguards. She said the resident was no longer on 1 to 1 supervision and was on 15 minute checks. She said she did not know when or why it changed and stated the surveyor would have to ask the RN Manager. During an interview on 6/12/2013 at 3:10 PM the RN Manager stated the night shift checked resident Wanderguards to ensure they were working. She said she was not aware of any documentation regarding this. The RN stated Wanderguard assessments were done every 3 months, were kept in the nursing progress note section of the residents' records, and that was where the information was located, regarding which residents had Wanderguards. The treatment administration record (TAR) for March 2013, April 2013 and May 2013 did not include any documentation regarding the resident's Wanderguard. The TAR for June 2013 recorded the resident's Wanderguard was to be checked every shift. On 6/1/2013 and 6/2/2013 the night nurse documented the resident had a Wanderguard and the day and evening nurses documented she did not have one. From 6/3/ - 6/12/2013 the TAR documented the resident did not have a Wanderguard. On 6/4 and 6/11/2013, the LPN documented the resident refused the Wanderguard. On 6/14/2013 at 9 AM the resident was observed seated at the table in the dining room. The resident was no wearing a Wanderguard bracelet. A CNA assisting the resident, stated to the surveyor, the resident did not have a Wanderguard, as she refused it. At 12 PM on 6/14/2013 both RN Managers were interviewed and one of the RN's said she was "pretty sure" the resident had a Wanderguard before she was sent to the hospital in May 2013. The RN said the Wanderguard was placed on the resident when she returned from the hospital and the resident "kept it on for a few days." The RN stated she could not "vouch" for when the resident last had the Wanderguard on before eloping on May 25, 2013. There was no documentation in the resident's medical record regarding whether the resident had a Wanderguard in place prior to her hospitalization or how long she had one after she returned from the hospital. Following the resident's elopement, on 5/25/2013, there was no documented evidence in the medical record a reassessment was completed for the resident's elopement risk. 2) Resident #1 had [DIAGNOSES REDACTED]. For Resident #1 the facility failed to: thoroughly investigate all incidents of exit-seeking behavior; thoroughly investigate all incidents of exit-seeking; and reassess residents' elopement risk and revise care plans when needed and communicate care plan changes to staff. An elopement risk assessment dated [DATE] documented the resident was not at risk for eloping. There were no nursing progress notes documented from 3/28/2013 - 4/2/2013. The resident's comprehensive care plan (CCP) dated 4/3/2013, documented the resident had cognitive impairment, usually understood, required cues and supervision, had impaired judgement, made poor decisions and had a history of [REDACTED]. A nursing note dated 4/3/2013 documented the care plan team reviewed the resident's CCP the "wander care plan" was continued. There were no nursing notes between 4/4/2013 and 5/5/2013. The Resident Sign Out/In Sheet dated 5/ - 5/11/2013 did not document the resident was off the unit. The Sign Out/In sheet dated 5/12/2013 documented the resident signed himself off the unit to an illegible destination. There was no documentation the resident signed back in to the unit. There were no nursing notes in the record from 5/6/2013 through 5/14/2013. Nursing documented on 5/15/2013 at 9:55 AM, the resident had been at the front desk requesting to go to the store. The resident did not go outside, and was redirected to speak with activities regarding shopping trips. The note recorded the resident stated, "I want to buy shampoo." The resident was placed on 30 minute visual monitoring for one day. The note recorded to "monitor for resident leaving unit." A visual monitoring sheet dated 5/15/2013 documented the resident was on both 15 and 30 minute checks. The form documented the resident was monitored every 30 minutes from 10 AM to 3 PM, every 15 minutes from 3 PM to 9:30 PM, and every 30 minutes from 8:45 PM to 10:45 PM. There was no rationale documented, in the resident's medical record, for the changes in the frequency of monitoring. The registered nurse note dated 5/16/2013 at 12:30 PM, documented the resident was on 15 and 30 minute visual monitoring. The resident showed no signs of leaving the unit or the facility, and activities would take the resident to the next shopping trip. The note recorded to "monitor resident." The Sign Out/In sheet dated 5/16/2013 documented the resident was signed out by a staff person at 2:40 PM for social hour. The sheet did not document the resident signed back in. The Sign Out/In sheet dated 5/17/2013, at an illegible time, documented the resident signed himself off the unit for "outside." There was no documentation the resident signed back in to the unit. There were no nursing notes documented between 5/17/2013 and 5/21/2013. Licensed practical nurse (LPN) #7's note dated 5/22/2013 at 2:40 PM, documented a certified nurse aide (CNA) found the resident outside the "S" (service) level by the visitor parking lot in the door way. The resident stated he was waiting for a bus and as long as he signed out he could go on the bus. The LPN documented she told him signing out meant he could go within the building or outside with someone. The nurse manager was made aware and 30 minute visual monitoring was started. The Sign Out/In sheet did not document the resident was off the unit on 5/22/2013. A visual monitoring sheet dated 5/22/2013 documented 30 minute checks of the resident started at 2:45 PM. The form did not consistently document 30 minute monitoring of the resident for the evening shift. A visual monitoring sheet dated 5/23/2013, documented 30 minute checks of the resident were completed from 7 AM to 1 PM, and did not document the signature of the person who performed the monitoring. Registered nurse (RN) #4's note dated 5/23/2013 at 1 PM, documented the resident's 30 minute checks were discontinued. The RN recorded the resident was present on the unit, and stated he did not want to leave. There was no documentation, in the resident's medical record, the resident's elopement risk was reassessed on 5/23/2013. There were no documented nursing notes between 5/24/3013 and 5/28/2013. An elopement risk assessment dated [DATE], documented the resident was not at risk for elopement. The CCP dated 5/28/2013, documented the resident was at risk for elopement as evidenced by the resident requesting to leave building to buy items, and attempts to leave "ADHS" room. The plan included: - to provide a Wanderguard bracelet at all times while in the "ADHS" program; - take photographs of the resident to facilitate identification of resident; - reevaluate resident risk factors semi annually and as needed; and - monitor the resident's attendance in the building at all times through next review. There were no documented nursing notes between 5/29/2013 and 6/1/2013. The resident's plan of care (RPOC) used by the CNAs dated 6/1/2013, documented the resident was an elopement risk, and he refused to wear a Wanderguard. There were no nursing notes documented between 6/2/2013 and 6/5/2013. The RN note dated 6/6/2013 at 3 PM, documented the resident was seen, for a routine visit, by the nurse practitioner, and there were no new orders. There were no nursing notes documented between 6/7/2013 and 6/10/2013. The CCP dated 6/10/2013 documented the resident refused to wear a Wanderguard. There was no documentation of changes to the CCP or monitoring related to the residents refusal. The resident's Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired, the resident did not exhibit wandering behavior, and was independent with most activities of daily living (ADL). Observations of the resident on 6/11/2013 included: - at 8:57 AM in the dining room, very talkative with other residents; - at 11:44 AM the resident was walking independently down the hall heading to the nurses station; - at 11:55 AM the resident was walking down the hall past the elevator; - at 12 PM the resident was in the dining room; and - from 3:20 PM to 3:45 PM the resident was seated at a dining table with the surveyor. During an interview with the resident, on 6/11/2013 at 4:05 PM, he stated he liked to go for walks and the last time he went was "just the other day" when he went to the store. He stated he wanted to look at some shampoo, and the store was just up over the hill, not that far away. He did not tell them (the facility) he was leaving and when he got back they yelled at him and told him not to go anywhere. He stated but, "I'm [AGE] years old." He said he used to be a runner, enjoyed cross country and used to run 5 miles a day. He said he had not taken a bus, but he'd like to, as he used to a lot in the past. During an interview with CNA #6 on 6/12/2013 at 10:40 AM, she said she heard about the resident going outside, "maybe a week ago", when he went to social hour and then went out front. He was placed on 15 or 30 minute checks for a "couple" of days. CNA #6 said the resident eloped awhile ago, and on that occasion he was in the lobby by the front door. She said the resident sometimes wanted to get new soap, so she would get it for him so that he would not go out to get it. She said they placed a Wanderguard on the wheel chair, but once they put it on the wheel chair the chair disappeared. She said that they were supposed to keep "tabs" on him by checking the bathroom, bedroom, and other areas, which was difficult to do when they were short staffed. During an interview with CNA #9 on 6/12/2013 at 11:30 AM, she said that resident elopements were a big problem on Units 2, 5, and 6. She stated the resident was an elopement risk, and he left the facility to buy sneakers, at a store up the street, not long ago. The unit received a call to go get him from the store. CNA #9 stated when the resident returned there were no changes made to his plan. During an interview with CNA #10 on 6/12/2013 at 11:50 AM, she stated the resident left the faciity on approximately 5/23/2013, to go buy sneakers, and that he was at a bus stop. During an interview with LPN #7 on 6/12/2013 at 1:45 PM, she stated she wrote the nursing note dated 5/22/2013. She stated she could not recall which CNA notified her the resident was in the parking lot by the service elevator. All she knew was what was written in her note. LPN#7 said the resident was placed on 30 minute visual checks, and she was responsible for passing that information on to the next shift. The resident remained on 30 minute checks through the next day in order to monitor him through the night. She stated the resident left the building in the past and she was not aware of the specifics. LPN #7 stated the resident would sign out and go to programs in the building. During an interview with CNA #11 on 6/13/2013 at 8:40 AM, she stated she was assigned to care for the resident that day. She said she was not aware of a plan for the resident at this time, related to elopement risk. She stated she did not know if the resident attempted to leave the facility recently, but knew the resident had a history of [REDACTED]. She stated the resident did not like to wear the Wanderguard. CNA #11 said it was difficult to keep track of the resident especially if staff were assisting other residents in their rooms. At one moment he could be there and the next time they checked, he would be gone. She stated there was not always enough staff to monitor residents. During an interview with the RN Manager on 6/13/2013 at 9 AM, she stated the resident was considered to be at risk for elopement. She stated the resident did not act on it. The residents were checked throughout the day, and if she felt a resident was going to try to leave the facility she would implement 15 or 30 minute checks. The LPNs were responsible for completing the checks, and the documentation was kept in the residents' record. The resident was asked to sign out before he left the unit. She stated she was told by another RN the resident was found by the street and told staff he was going to buy shampoo. She stated the front desk called and notified her he was in the lobby, and she went down to discuss this with him. The RN said the resident was compliant, and she placed him on 30 minute checks for 48 hours. She removed the checks after the resident told her he did not have any desire to leave the facility. She did not complete an incident report as the resident did not leave the facility grounds. She stated this was her only incident with the resident, and he was not placed on monitoring checks in the past. The RN stated Elopement risk assessments were completed with resident quarterly reviews. During an interview with RN #2 on 6/13/2013 at 9:35 AM, she stated the resident lived in the facility since 2010, and he would go sit on the patio. She said he did not leave the facility grounds. She said she questioned the resident's ability to sign in and out. The Director of Nursing (DON) stated on 6/13/2013 at 10:40 AM that she provided the surveyors with all of the facility's accident incident reports and investigations. During an interview with the DON on 6/13/2013 at 12:40 PM, she stated she did not know the resident was by the street or attempted to cross the street, but if this occurred she should have been made aware. She stated the resident was able to walk around the building. The DON stated she was not aware of any comments the resident made about wanting to leave the facility or go to the store. She stated she gave all accident/incident reports to the surveyors and she did not have any more. The DON said elopement risk assessments were to be completed by RNs quarterly. If an incident occurred, or a resident had a history of [REDACTED]. When considering discontinuing visual monitoring checks, staff were to be looking at resident assessment and behaviors. During a phone interview with the Medical Director on 6/13/2013 at 12:55 PM, he stated he was familiar with the resident, as the resident sought him out for conversation. He said he did not know the resident was by the street or attempted to cross the street. He was made aware the resident was found outside the facility on 5/22/2013, as staff contacted him following the incident. He stated he did not talk to the resident about the incident, and did not write a progress note. He knew the resident refused to wear a Wanderguard, and he did not recall any past visual monitoring checks or attempts to leave. He stated if visual monitoring was initiated for the resident, 15 or 30 minute checks would be reasonable. He was not aware of the current plan for the resident, and said the resident should not leave the floor unless he was with a staff member. During an interview on 6/14/2013 at 9:05 AM, RN #2 stated that she was originally told the resident was outside at the picnic tables, then learned the resident was at the bus stop down the street. RN #2 stated she found the resident across the street at the bank, she could not recall when and knew the weather was warm. She stated she was concerned about the lack of monitoring within the facility, that the resident had dementia and was not safe to be out of the facility alone. During an interview with the Assistant Director of Nursing (ADON) on 6/18/2013 at 9:19 AM, she stated she was not aware of anything, in regards to the resident's incidents of elopement. 3) Resident #33 had [DIAGNOSES REDACTED]. For Resident #33 the facility failed to: thoroughly investigate all incidents of exit-seeking behavior; reassess residents' elopement risk and revise care plans when needed and communicate care plan changes to staff; and develop and implement a system to monitor the placement and operation of Wanderguards. The 3/28/2013 elopement risk assessment documented the resident was not at risk for elopement. The assessment documented the resident was occasionally disoriented, complacent, had very limited mobility, was ambulatory with 1 assist, and took medications that altered his mental status. The comprehensive care plan (CCP) dated 3/28/2013 did not document the resident was at risk for elopement or that he had a Wanderguard.. The 6/7/2013 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, did not exhibit behaviors including wandering, and moved about the unit with limited assistance in a wheelchair. The 6/7/2013 RPOC (resident plan of care, care instructions) documented the resident had a Wanderguard. On 6/11/2013 between 9:30 and 9:50 AM, licensed practical nurse (LPN) #2 stated in an interview, the resident did not have a Wanderguard and was not at risk for elopement. The 6/11/2013 RPOC documented the resident had a Wanderguard. On 6/11/2013, the registered nurse (RN) Manager (RN #3) stated in an interview, there were 7 residents on the unit who wore Wanderguards, including Resident #33. She stated all 7 residents wore the Wanderguards on their person, their wheelchair, or their walker. On 6/13/2013 at 9 AM, RN #4 (who worked as a building Supervisor) stated in an interview, when residents had Wanderguards, the RNs periodically checked to make sure they had them on. She stated the function of the Wanderguards were checked when a resident got too close to the elevator and the alarm sounded. On 6/13/2013 at 12:50 PM, the Administrator stated in an interview, she was not aware whether the facility had a system for checking the function of the Wanderguards. She stated the elevators alarmed when residents with Wanderguards got close to them. She stated the direct care staff should check the placement of the Wanderguards every shift as listed on the RPOCs. She stated those checks were not documented, and the certified nurse aides (CNAs) were responsible for providing all care listed on the RPOCs. On 6/13/2013 at 8:40 PM, the resident was asleep in bed and a Wanderguard was observed on a wheelchair in the room. On 6/13/2013 (LPN) #3 stated in an interview, on some of the nursing units Wanderguard placement was checked and documented on the Treatment Administration Record (TARs) and on some units it was not. She stated to her knowledge, the Wanderguard placement was documented on the TARs on Unit 6 and not on Unit 3 which was where Resident #33 resided. On 6/14/2013 at 9:45 AM, the Administrator stated in an interview, a staff member went through the facility last night and checked the function of every Wanderguard. She stated the resident's Wanderguard was not functional and was replaced. The CCP was updated on 6/14/2013 and documented the resident was at risk for elopement as evidenced by wandering. The CCP specified the resident made attempts to leave the unit and "wanders frequently." He was to wear a Wanderguard device. UNSAFE SMOKING: 4) Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to admission, the resident was hospitalized from [DATE] through 4/22/2013. The hospital history and physical dated 3/27/2013 documented the resident had a long history of smoking and was a current smoker. The social services social history dated 4/22/2013 documented the resident's hobbies and interests included smoking, she was a current smoker, and the smoking policy was not reviewed with the resident. The initial nursing progress note dated 4/22/2013 documented the resident told registered nurse (RN) #3 she was going outside to smoke and RN #3 stated that smoking was not permitted at the facility. RN #3 documented she attempted to apply a Wanderguard bracelet (a device used to detect wandering) to the resident, to prevent her from going outside to smoke, and the resident refused. The comprehensive care plan (CCP) dated 4/22/2013 did not document the resident's smoking history or the fact that she refused a Wanderguard upon admission. The 4/23/2013 physician's progress note documented the resident smoked a pack of cigarettes per day for at least [AGE] years. The 4/29/2013 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and did not use tobacco products. The RN Supervisor's (RN #6) note dated 5/18/2013 at 7:30 PM, documented the resident made multiple trips off the unit, was found outside smoking, and a Wanderguard was placed on the resident's wheelchair. RN #6 documented he explained to the resident that smoking was not permitted at the facility. There was no documented evidence an incident and accident report was completed

Based on observation, record review, and interview with staff and residents conducted during the extended survey, it was determined for 8 of 16 residents (Residents #15, 31, 32, 33, 34, 37, 39, and 47), reviewed for swallowing concerns, 2 of 9 residents (Residents #16 and 43), reviewed for falls and 1 of 30 sampled residents (Resident #44), the facility did not ensure adequate supervision and assistance devices to prevent accidents. Specifically: - for Residents #15, 31, 32, 33, 34, 37, 39, and 47 the facility failed to have a system in place to ensure an effective care plan was developed, communicated with direct care staff, and implemented to assist residents who were at risk for aspiration (taking foreign matter, such as food, into the lungs); - for Residents #31, 32, 33, 34, and 39, the facility failed to implement supervision as planned for those residents, at risk for aspiration, who ate in their rooms; - for Residents #15, 34, 37, and 39, the facility failed to ensure residents were positioned properly while being fed; and - for Residents #34, 39, and 47, the facility failed to develop and implement a system to educate and monitor family and visitors who fed residents who were at risk for aspiration; - for Resident #47, the facility failed to reassess the resident following a choking incident. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Residents #15, 31, 32, 33, 34, 37, 39, and 47. - For Resident #16 the facility did not reassess the plan of care when a low bed was not available; - for Resident #43 the facility did not ensure the chair alarm was implemented and planned; and - for Resident #44 the facility did not ensure the room was free from accident hazards. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #16, 43, and 44. The facility implemented measures to remove the Immediate Jeopardy on December 13, 2012. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS OF June 18, 2012, October 14, 2011, and January 1, 2011. Findings include: The facility procedure titled "Meal Captain" dated December 2012 documented the designated meal captain responsibilities include: ensuring residents receive correct food/fluid consistencies; ensuring room trays are correct, all items are on the tray, and food/fluid consistencies are correct; assigning a staff member to supervise resident's eating in their rooms, ensuring residents receive adaptive equipment as on the meal ticket; ensuring resident are positioned correctly for meals, assigning staff to resident rooms who require assistance and who are on aspiration precautions. The Nurse Manager ensures residents being fed by family are fed in a safe manner, family must be trained by speech therapy, and demonstrate correct techniques and knowledge before feeding the resident. The facility procedure titled "Thickened Liquids/Aspiration precautions dated November 2012, documented pre-thickened fluids are used, thickened liquids are supplied to the nursing units from dietary, except for pudding thick liquids and soup. Once a new liquid consistency order is written the staff will fax the order to the pharmacy and dietary. "The Speech Language Pathologist is responsible for the training of staff on thickening of items." The facility policy titled "Dining Experience" dated November 28, 2011 documented for resident's with feeding strategies staff will refer to the Resident Plan of Care sheets for the specific requirement. Residents who require supervision for meals, regardless of time of day, or day of week, will not be allowed to eat meals unsupervised in their rooms. All of these residents will be required to eat their meals in the dining room. Interventions to use when a resident is at risk for aspiration include: feed the resident slowly; position in an upright position during meals and for 15 - 30 minutes after meals and ensure food and fluid consistency is correct. CONCERNS WITH FEEDING 1) Resident #39 had [DIAGNOSES REDACTED]. The September 12, 2012 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, fed herself after meal set-up, did not have signs/symptoms of a possible swallowing disorder, and received a mechanically altered diet. The November 15, 2012 speech language pathologist (SLP's) evaluation documented the resident was coughing when eating. The recommendations included a ground consistency diet, with nectar thick liquids and no bread. The evaluation documented the resident was able to have thin liquids via a Provale cup (specialized cup that delivered a specific amount of fluid for each swallow). The modified barium swallow evaluation report dated November 21, 2012 documented the resident had aspiration after swallow with thin liquids and silent aspiration with nectar consistency liquids. The evaluation recorded the resident was able to tolerate nectar thick liquids given 1/2 teaspoon at a time, and thin liquids in a 5 cubic centimeters (cc) Provale cup. The SLP note dated November 26, 2012 documented the resident was trialed on Honey consistency via a cup. She documented she would check with the modified barium swallow therapist to ensure it was safe for the resident to have honey consistency liquids in a cup. The November 27, 2012 physician's orders [REDACTED]. The SLP progress note dated November 28, 2012 documented the resident was tolerating honey consistency liquid well. The comprehensive care plan (CCP) dated December 1, 2012 documented the resident's diet order was ground consistency with honey thick liquids. The Resident Plan of Care (RPOC, used to direct care) dated December 4, 2012 documented the resident's diet order was soft consistency with nectar thick liquids and no bread products. The RPOC did not document the resident's current diet order of ground and liquid consistency of honey. On December 5, 2012 at 6:05 PM, the resident was observed in bed being fed supper by a friend. The resident's meal included 2 ground chicken patties served on buns. The resident's menu slip documented the resident was not to receive bread. In an interview on December 5, 2012 at 6:05 PM the resident's friend stated she fed the resident once a week, in the evening. The friend stated the resident did not eat usually eat bread as she had no front teeth and bread "sticks to her teeth." She said she was going to feed the resident the ground chicken without the bun. She stated the only time she fed the resident bread was when sloppy joes were served, as the meat made the bread soggy, and the resident could then eat it. On December 6, 2012 at 5:45 PM, the resident was observed sitting in her bed, being fed by a family member, and the head of the bed was not elevated to 90 degrees. The resident had 3 juices that were nectar thick consistency and ice cream on her supper tray. The resident's meal ticket documented she was on honey thick consistency, and did not include ice cream. In an interview with the resident's family member on December 6, 2012 at 5:45 PM, she stated she fed the resident supper twice a week. She said she knew the head of the resident's bed should be elevated higher, but the resident did not like to sit upright, when she ate. The family member stated the resident could not eat bread as she "chokes on it." She stated on occasion, the resident was given bread, such as a hot dog roll, depending on the dietary server. She said on occasion, she requested a tuna or peanut butter sandwich from dietary and noticed when she cut the crust off, the resident was able to eat them. She stated the resident liked to have ice cream for dessert. On December 6, 2012 at 5:50 PM, the registered dietitian (RD) stated in an interview, the resident was not served bread because she had a swallowing issue. She stated the resident should not have been given ice cream as that was not honey thick consistency. She said the resident's drinks should have been honey thick consistency. On December 6, 2012 at 6 PM, licensed practical nurse (LPN) #8 Supervisor, stated in an interview, she was told by dietary staff that the resident's daughter may have put the juices on the resident's tray and that was why she received the incorrect consistency fluids. She stated she did not know if the non-staff members who fed the resident received training. On December 7, 2012 at 10 AM, the SLP stated in an interview, the resident's meal ticket documented no bread as the resident could not properly chew it. She stated the resident should not receive any bread or bread products. The SLP stated ice cream was not safe for residents on honey thick consistency diets. The SLP said residents should be positioned upright at 90 degrees when eating and minimally at 70 degrees. On December 10, 2012 at 1:25 PM, certified nurse aide (CNA) #6 stated in an interview, the resident's visitors bought in food for her and stored it in a cabinet in her room. She stated she thought the resident had fruit cups and soup in her room at present. On December 10, 2012 at 1:35 PM, CNA #7 stated in an interview, she was aware visitors fed the resident in the evening and at times brought in food for her. She stated one family member brought in milkshakes and they were safe for the resident if she drank them right away. On December 10, 2012 at 1:45 PM, CNA #8 stated in an interview the resident ate supper in her room every evening and was fed by visitors. On December 10, 2012 at 2:10 PM, the RN Manager stated in an interview, she was not aware the resident was fed supper by visitors most evenings. The RN said she was not aware the resident had food visitors brought in stored in her room. Observations made on December 10, 2012 at 2:20 PM showed fruit cups, pudding, and Jello cups were in a cabinet in the resident's room. On December 7, 2012 at 10 AM during the interview with the SLP, she stated the facility recently implemented new standards for altered consistency diets. The facility's undated Thickened Liquid Consistency Guide documented Jello was a thin liquid. In summary, for Resident #39, the facility: - failed to provide the resident with the consistency food and fluid as ordered by the physician; - failed to ensure the resident was properly positioned when being fed; - failed to ensure non-staff members who fed the resident were trained and supervised; and - failed to ensure the food brought in by non-staff members was monitored for the appropriate consistency. UNTIMELY FOLLOW-UP AFTER A CHOKING INCIDENT 2) Resident # 47 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely impaired cognitively. The resident required limited assistance of one person for eating and was on a mechanically altered diet. The comprehensive care plan (CCP) dated August 15, 2012 documented the resident was to be fed and did not specify if the resident could be fed by a family member. The physician orders [REDACTED]. The Nutrition Care Plan Review Evaluation dated September 5, 2012 documented the resident was fed by staff. The evaluation documented the resident had swallowing problems per the speech language pathologist's (SLP) evaluation of May 5, 2012. Nursing progress notes dated September 7, 2012 documented the resident "had sandwich and tater tots" for supper. The resident tried to cough up large amounts of food particles and when she was unable to do so, the resident was suctioned. An Event Report dated September 7, 2012 documented at 6:30 PM, after eating supper, the resident began to cough. She brought up small pieces of food, continued to cough and was unable to clear her airway. The resident's oxygen saturation was 87 percent, and she was suctioned for a moderate amount of food particles. The report documented the resident's cough was less frequent but wheezing developed in the lungs. The resident was given a nebulizer breathing treatment and her oxygen saturation level was 99 percent afterwards. The report did not document if the resident received the correct consistency food. The nursing progress notes dated September 7, 2012 documented the resident was suctioned deeper, a second time, for a couple pieces of food. The physician was notified and ordered a chest x-ray, nothing by mouth except clear liquids "tonight", a nebulizer treatment every 4 hours until morning and an antibiotic. On September 8, 2012 the physician documented the resident had an "episode of aspiration" the previous day. The resident was eating her meal "being fed by her husband" and the episode of aspiration was reported to include food "such as tater tots." The physician's orders [REDACTED]. The CCP dated September 18, 2012 documented the resident was to receive pureed food with honey thick liquids and was on aspiration precautions. The CCP did not document specific strategies to be implemented when feeding the resident. On September 18, 2012, the dietitian documented the resident's swallowing evaluation was pending. The SLP Swallowing Evaluation, dated September 20, 2012, documented the resident was seen for overt signs and symptoms of aspiration due to oropharyngeal dysphagia. The SLP recommendations included: - changing the resident's fluid consistency to pudding thick; - alternating bites and sips; - siting upright at 90 degrees during meals and for 30 minutes after meals; - supervision at meals; and - oral care after meals. The SLP documented "aspiration precautions." The CCP did not document the feeding interventions as per the SLP's recommendations until an entry on December 10, 2012. The MDS assessment dated [DATE] documented the resident was on a mechanically altered diet and required extensive assistance with eating. On December 13, 2012 between 9:40 - 10 AM, the corporate registered dietitian (RD) and the supervising RD were interviewed. They said the SLP provided services on an as needed basis and that may have effected the timeliness of the resident's swallow evaluation. They said the resident's tater tots should have been pureed as per the physician's orders [REDACTED]. The Director of Rehabilitation Therapy was interviewed on December 13, 2012 at 9:55 AM and stated if she had been notified of the resident's physician order [REDACTED]. She said she had no documentation she was notified. The SLP was interviewed at 10 AM on December 13, 2012 and stated she performed the resident's swallowing evaluation as soon as she was aware of the order. She recommended pudding thick liquids and started the resident on speech therapy. The SLP stated she did not know the resident was being fed by her husband. She said she did not educate or train him to safely feed the resident. In summary, for Resident #47: - the facility failed to ensure the resident was evaluated by the SLP, as ordered by the physician, in a timely manner. - the facility failed to ensure an effective care plan was developed, communicated with direct care staff, and implemented to assist the resident who was at risk for aspiration; and - the facility failed to develop and implement a system to educate and monitor family and visitors who fed residents at risk for aspiration. UNSAFE POSITIONING DURING MEALS 3) Resident #37 had [DIAGNOSES REDACTED]. The speech language pathologist's (SLP) evaluation dated March 31, 2011 documented the resident was at risk for choking and aspiration when not seated upright at meals. The SLP documented the resident did not like to be seated upright at meals. The recommendations included positioning the resident upright at meals with support, and leaving the resident upright for a half an hour after eating for safe swallowing completion. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognitive skills for daily decision making were moderately impaired and the resident did not reject care. The resident required total assistance with eating and had impairments in range of motion (ROM) of his arms and legs. A physician's progress note dated September 24, 2012 documented the resident "does require extensive amount of nursing support in terms of his activities of daily living (ADL) in light of his [DIAGNOSES REDACTED]." A nursing quarterly assessment dated [DATE] documented the resident did not have swallowing difficulty. The resident's comprehensive care plan (CCP) dated October 4, 2012 documented; "feeding strategies per SLP recommendations." (The CCP did not list the specific strategies to be used when feeding the resident.) The physician's orders [REDACTED]. A nursing progress note dated November 27, 2012 documented, "Spoke to resident about current plan of care. Resident is in agreement." The resident's plan of care (RPOC, used to direct care), dated December 4, 2012, documented the resident was "noncompliant with out of bed" and "Torso/w/for meal only." There was no explanation of what "torso/w/for meal only" meant. The RPOC did not document the resident was on aspiration precautions when not seated upright for meals. Observations on December 5, 2012 showed: - At 12:55 PM, the resident was lying flat in the bed, the head of the bed was not elevated. He was being fed beef stroganoff and noodles by certified nurse aide (CNA) #9. - At 1:20 PM, the head of the resident's bed was elevated to less than 30 degrees. CNA #9 was feeding the resident, and stated to the surveyor the resident liked to lay flat in bed when he ate and the head of the bed was elevated as much as he allowed. On December 5, 2012, between 5:55 - 6:20 PM, the resident was observed lying in bed, with the head of bed elevated 30 degrees. The resident was being fed supper by CNA #10 and was chewing his food for an long time before swallowing. On December 6, 2012 at 8:45 AM, the resident stated in an interview, he did not mind sitting upright for meals and that some staff did sit him upright. On December 6, 2012 at 9:20 AM, the resident was observed lying in bed with CNA #6 feeding him. The head of bed was slightly elevated. On December 6, 2012 at 1:20 PM, the registered nurse (RN) Manager stated in an interview, she did not know how the resident was positioned at meals as she never observed him eating. On December 7, 2012 at 10 AM, the Director of Rehabilitation and the SLP stated neither were familiar with the resident. The SLP stated, in general, residents should be upright for meals and if 90 degrees was not possible, she would recommend 70 degrees. On December 7, 2012 at 11:30 AM, the registered dietitian (RD) stated in an interview, she was not familiar with how the resident was positioned when he ate as she never saw him eating. On December 10, 2012 at 9:36 AM, the RD stated in an interview, there was no list of residents on aspiration precautions. She stated the RPOC should document all residents who were on aspiration precautions. Review of the resident's RPOC, dated December 4, 2012, did not document he was on aspiration precautions when not seated upright at meals. On December 10, 2012 at 12:41 PM, the resident was observed lying in bed with the head of bed elevated to approximately 30 degrees. The resident was being fed a grilled cheese sandwich by a CNA. On December 10, 2012 at 1:45 PM, CNA #8 stated in an interview, the resident did not like to be upright when he ate. She said she did not know what "torso w/ meal only" meant on the RPOC. The CNA stated the resident was non-complaint with therapy recommendations. On December 10, 2012 at 3:15 PM, the Administrator stated in an interview, if a resident ate meals in their room daily it should be documented on the CCP. The Administrator stated she was not aware of the resident's preference to eat in a reclined position. On December 11, 2012 at 12:40 PM, the resident was observed lying flat in bed being fed lunch by a CNA. In summary the facility: - failed to ensure the resident was positioned safely while eating; and - failed to have a system in place to ensure an effective care plan was developed, communicated to direct care staff, and implemented to assist the resident to eat safely. UNSUPERVISED DINING 4) Resident #31 had a [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment. The resident was independent with eating, required assistance with setup and was on a mechanically altered diet. The physician order [REDACTED]. The swallowing evaluation dated November 7, 2012 documented the resident had mild oral dysphagia (difficulty swallowing) marked by no teeth or dentures and increased chewing time with some meats. The speech language pathologist (SLP) progress note dated November 7, 2012 recommended all meat and large pieces of food should be cut up and the resident was to alternate bites and sips. The physician order [REDACTED]. The physician ordered all meat and large pieces of food were to be cut up by staff. The resident plan of care (RPOC, used to direct care) dated December 7, 2012 documented the resident was on aspiration precautions and his meat and large pieces of food were to be cut up by staff. The comprehensive care plan (CCP) dated December 10, 2012 documented the resident had a swallowing problem and interventions included staff cutting meat into small pieces and the use of verbal cues to remind the resident to alternate solids and liquids. On December 10, 2012 from 1:30 - 1:49 PM, the surveyor observed the resident sitting on the side of his bed eating lunch. The resident's lunch included two hot dogs which were not cut up. The meal ticket documented meat and large pieces of food were to be cut up by staff. No staff entered the resident's room during the observation. When interviewed on December 10, 2012 at 1:45 PM, CNA #4 stated there was no one assigned to supervise residents who ate in their rooms. She said the CNAs walk by and make sure the residents are okay. She stated she was not aware of any resident on aspiration precautions. CNA #4 said aspiration precautions meant the resident could choke easily. Observations on December 10, 2012 at 1:50 PM, showed CNA #5 brought Resident # 31's meal tray out of his room. There was one hot dog on the tray. When interviewed on December 10, 2012 at 1:50 PM, CNA #5 stated she did not know who supervised residents who ate in their rooms. She stated when residents were on aspiration precautions it was documented on the RPOC and meant a resident could choke easily. In summary, for Resident #31, the facility: - failed to have a system in place to ensure an effective care plan was developed, communicated with direct care staff, and implemented to assist residents who were at risk for aspiration; and - failed to implement supervision, as planned, when the resident ate in his room. --------------------------------------------------------------------------------------------- The facility implemented measures to remove the Immediate Jeopardy situation on December 13, 2012, including: - developed an accurate list of residents on aspirations precautions; - developed a plan to supervise those residents, who were at risk for aspiration, who wished to dine in their rooms; - developed new policies and procedures to address families feeding residents; and - developed a plan to train family members on safely feeding residents. --------------------------------------------------------------------------------------------- ENVIRONMENTAL HAZARDS: 4) Resident #44 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognitive skills for daily decision making were severely impaired, and he was totally dependent on staff for most activities of daily living. A physician's orders [REDACTED]. These orders were discontinued on December 10, 2012. The resident's room was observed on December 10, 2012 at 12:17 PM, December 11, 2012 at 10:05 AM, and December 13, 2012 between 1:25 - 1:45 PM. During each observation, the piped in wall oxygen was running and there was no oxygen tubing or nebulizer attached to the oxygen. During an interview with the registered nurse (RN) Manager on December 13, 2012 between 1:25 - 1:45 PM, she stated she was not aware the oxygen was running in the resident's room, the resident was not currently using oxygen. On December 13, 2012 at 1:45 PM a maintenance staff checked the resident's wall oxygen and stated to the surveyor, it "sometimes does that" it just needs a plug. On December 13, 2012 between 1:45 - 2:36 PM, the Director of Maintenance stated he was aware maintenance staff checked the resident's wall oxygen unit that day. He said he did not have a record of being notified previously that there was a concern with the resident's wall oxygen unit running when it was not in use. In summary, the facility did not ensure the resident's environment was free of accident hazards as the resident's wall oxygen unit was continuously running when not in use. FALLS: 5) Resident #43 had [DIAGNOSES REDACTED]. The November 16, 2012 nursing assessment documented the resident was not at risk for falls, had no "specific safety concerns" and did not require "special safety equipment." The November 23, 2012 Minimum Data Set (MDS) assessment documented the resident was severely impaired cognitively, required limited assistance of one person for transferring and walking, and extensive assistance for toileting/personal hygiene/dressing/bathing. The MDS recorded the resident had fallen, since the last assessment, and had no injury. The November 23, 2012 nursing progress note documented the resident tried to stand up on his own and sat on the foot rests of the wheelchair. The November 23, 2012 Resident/Visitor Event Report documented the resident was counseled on ensuring his wheelchair breaks were locked when transferring himself. The comprehensive care plan (CCP) dated November 28, 2012 documented the resident had impaired judgment and balance and fell within the past 30 days. The CCP documented the resident had bed and chair alarms and did not specify the date the alarms were implemented. The November 29, 2012 nursing progress note documented the resident transferred, toileted and ambulated himself. The November 30, 2012 nursing progress note documented the resident was found on the floor between the bed and chair. The resident was educated on safety awareness with "little understanding." The Resident/Visitor Event Report of the same date documented a bed and chair alarm were implemented. A December 2, 2012 nursing progress note documented the resident was found on the floor after trying to transfer himself. The Resident/Visitor Event Report, of the same date, did not document whether the resident's bed or chair alarm were in use or functioning at the time of the fall. The Resident Plan of Care (RPOC, used to direct care) dated December 4, 2012 documented the resident at risk for falls and transferred with moderate assistance of 1 person. The RPOC did not document the resident used a bed or chair alarm. On December 5, 2012 between 11:10 - 11:40 AM, the registered nurse (RN) Manager stated in an interview, the resident had been falling frequently. The resident was observed on December 6, 2012 at 5:50 PM. He was outside the dining room, sitting in the wheelchair. He stood up on his own, no alarm sounded. The resident was unsteady, his wheelchair was not locked and began to roll backwards. The surveyor alerted a staff member. On December 13, 2012 at 9:30 AM, the RN Manager stated in an interview, the resident was care planned to have a bed/chair alarm on at all times. She stated he was accepting of the alarms. The staff member who assisted the resident back to his room on December 6, 2012 at 5:50 PM was not available for interview. In summary, Resident #43 was not consistently provided with bed/chair alarms as planned. 10NYCRR 415.12 h(1) (2)

Based on observation, record review, and staff and family interviews conducted during the extended survey, it was determined for 7 of 16 residents reviewed for swallowing concerns (Residents #11, 31, 32, 35, 36, 38, and 39), the facility did not provide food prepared in a form to meet individual needs. Specifically, the facility failed to provide Residents #11, 31, 32, 35, 36, 38, and 39 with their accurate food/fluid consistency or with assistive devices as planned and ordered by the physician. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety for Residents #11, 31, 32, 35, 36, 38, and 39. The facility implemented measures to remove the Immediate Jeopardy on December 13, 2012 prior to exit. Findings include: The facility procedure titled "Meal Captain" dated December 2012 documented the designated meal captain responsibilities include: ensuring residents receive correct food/fluid consistencies; ensuring room trays are correct, all items are on the tray, and food/fluid consistencies are correct; assigning a staff member to supervise resident's eating in their rooms, ensuring residents receive adaptive equipment as on the meal ticket; ensuring resident are positioned correctly for meals, assigning staff to resident rooms who require assistance and who are on aspiration precautions. The Nurse Manager ensures residents being fed by family are fed in a safe manner, family must be trained by speech therapy, and demonstrate correct techniques and knowledge before feeding the resident. The facility procedure titled "Thickened Liquids/Aspiration precautions dated November 2012, documented pre-thickened fluids are used, thickened liquids are supplied to the nursing units from dietary, except for pudding thick liquids and soup. Once a new liquid consistency order is written the staff will fax the order to the pharmacy and dietary. "The Speech Language Pathologist is responsible for the training of staff on thickening of items." The facility policy titled "Dining Experience" dated November 28, 2011 documented for resident's with feeding strategies staff will refer to the Resident Plan of Care sheets for the specific requirement. Residents who require supervision for meals, regardless of time of day, or day of week, will not be allowed to eat meals unsupervised in their rooms. All of these residents will be required to eat their meals in the dining room. Interventions to use when a resident is at risk for aspiration include: feed the resident slowly; position in an upright position during meals and for 15 - 30 minutes after meals and ensure food and fluid consistency is correct. 1) Resident #39 had [DIAGNOSES REDACTED]. The September 12, 2012 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, fed herself after meal set-up, did not have signs/symptoms of a possible swallowing disorder, and received a mechanically altered diet. The November 15, 2012 physician's orders [REDACTED]. The November 15, 2012 SLP's evaluation documented the resident was coughing when eating. The recommendations included a ground consistency diet, with nectar thick liquids and no bread. The evaluation documented the resident was able to have thin liquids via a Provale cup (specialized cup that delivered a specific amount of fluid for each swallow). The modified [MEDICATION NAME] swallow evaluation report dated November 21, 2012 documented the resident had aspiration after swallow with thin liquids and silent aspiration with nectar consistency liquids. The evaluation recorded the resident was able to tolerate nectar thick liquids given 1/2 teaspoon at a time, and thin liquids in a 5 cubic centimeters (cc) Provale cup. The SLP note dated November 26, 2012 documented the resident was trialed on Honey consistency via a cup. She documented she would check with the modified [MEDICATION NAME] swallow therapist to ensure it was safe for the resident to have honey consistency liquids in a cup. The November 27, 2012 physician's orders [REDACTED]. The SLP progress note dated November 28, 2012 documented the resident was tolerating honey consistency liquid well. The comprehensive care plan (CCP) dated December 1, 2012 documented the resident's diet was ground consistency, no bread, honey thick liquids and thin liquids via a 5 cc Provale cup with direct staff supervision. The Resident Plan of Care (RPOC, used to direct care), dated December 4, 2012 documented the resident's diet order was soft consistency with nectar thick liquids and no bread products. The RPOC did not document the current order for ground consistency, honey thick liquids, and thin liquids via a 5 cc Provale cup with supervision. On December 5, 2012 at 6:05 PM, the resident was observed sitting in her bed being fed supper by a friend. The resident's menu slip documented she was not to receive bread. The resident's supper included 2 ground chicken patties, served on buns. The resident's friend stated, in an interview at that time, she fed the resident supper once a week. She said the resident did not usually eat bread and the only time she fed her bread was when sloppy joes were on the menu. She stated the sloppy joes made the bread very soggy and the resident was then able to eat the bread. On December 6, 2012 at 5:45 PM, the resident was observed sitting in her bed being fed by her family member. The resident's supper was served and she received 3 nectar thick juices and ice cream. The resident's meal ticket documented she was on honey thick liquids, ice cream was not on the meal ticket. The resident's family member stated, in an interview at that time, she fed the resident supper 2 nights a week and the resident could not eat bread because she "chokes on it." She stated on occasion, the resident received bread with her meals, such as a ground hot dog on a roll, and that depended on which dietary server was working. She stated on occasion, she requested a tuna or peanut butter sandwich from dietary and noticed if she cut the crust off, the resident could eat the sandwiches. She stated the resident liked ice cream for dessert. On December 6, 2012 at 5:50 PM, the registered dietitian (RD) stated in an interview, the resident did not receive bread due to a swallowing issue. She stated the resident should not have been given ice cream because that was not a honey thick consistency item. She said the resident's drinks should have been honey thick consistency. On December 6, 2012 at 6 PM, licensed practical nurse (LPN) #8 Supervisor, stated in an interview, she was told by dietary staff that the resident's daughter may have gathered her beverages that evening and that was why she received the incorrect fluid consistency. On December 7, 2012 at 10 AM, the SLP stated in an interview, the resident had poor chewing skills and could not properly chew bread. She stated she should not receive any bread or bread products. The SLP stated ice cream was not safe for resident's on honey thick consistency liquids. On December 10, 2012 at 1:35 PM, certified nurse aide (CNA) #7 stated in an interview, she was aware visitors fed the resident in the evening and at times brought in food for her. She stated one family member brought in milkshakes and to her knowledge, they were safe as long as the resident drank them right away. On December 10, 2012 at 2:10 PM, the RN Manager stated in an interview, she was not aware the resident received the incorrect food consistency at 2 supper meals. In summary, for Resident #39, the facility failed to provide the resident with the food and fluid consistency as ordered by the physician. 2) Resident #11 had [DIAGNOSES REDACTED]. The August 29, 2012 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required set-up and supervision with meals. A nursing progress note dated September 20, 2012, documented a swallowing evaluation was needed as the resident refused to drink thickened liquids. The October 18, 2012 modified [MEDICATION NAME] swallow (a swallow study), documented the resident presented with decreased ability/ to chew and decreased tongue base retraction which led to the resident's dysphagia. The speech language pathologist's (SLP) final assessment recommended the resident receive a ground diet and either nectar thick liquids or thin liquids via a 10 cubic centimeters (cc) Provale cup (a specialized cup that delivered 10 cc per swallow). The resident plan of care (RPOC, used to direct care), dated December 5, 2012, documented the resident required a regular ground diet with thin liquids via a Provale cup, and did not include nectat thick liquids. Observations on December 5, 2012 at 5:50 PM, showed: - a certified nurse aide (CNA) encouraged the resident to come to the table and told him she would get his coffee and meal; - the CNA gave the resident coffee in a regular mug; - after a few minutes, the RN Manager took the mug of coffee away from the resident, and said to the surveyor "we're getting his cups that he uses now;" - the resident was given nectar thick apple juice, tasted it and said he did not want it; - at 6:15 PM, the RN Manager said to the surveyor she was calling the kitchen again for the resident's Provale cup; - at 6:21 PM, the Provale cup was delivered to the unit; and - the resident was no longer in the dining room. Observations on December 6, 2012 showed: - at 8:40 AM, a CNA gave the resident thin consistency orange juice, milk, and coffee in regular glasses; - the resident drank the coffee; - 12:40 PM, a CNA gave the resident thin water in a regular glass and coffee in a Provale cup; and - the resident drank the water and the coffee. On December 7, 2012 at 8:40 AM a CNA was observed giving the resident thin consistency water in a regular glass. At 9:20 AM the resident was observed in the dining room, with thin coffee in a regular mug. CNA #11, who was assisting the resident, was interviewed at that time and stated the resident had a [MEDICATION NAME] swallow evaluation "about a month ago" and "passed" and could now have thin liquids with supervision. The RPOC dated December 10, 2012, documented the resident was to receive a ground diet with thin liquids via a Provale cup. The RPOC recorded the resident required supervision and was on aspiration precautions. The RPOC did not specify what the aspiration precautions were. Observations on December 10, 2012 at 12:30 PM showed: - a CNA gave the resident thin consistency water, coffee, and chocolate milk in regular glasses; - the resident drank the coffee; and - a CNA brought the resident a second cup of coffee in a Provale cup, and left the chocolate milk and water in regular cups. Observations on December 11, 2012 at 8:40 AM, showed CNA #11 gave the resident thin consistency chocolate milk in a regular glass and coffee in a Provale cup. The resident drank the chocolate milk. During an interview on December 11, 2012 at 2:30 PM, the RN Manager stated Provale cups were sent from dietary with the resident's meal. She said the resident had been getting one Provale cup and she was not sure what beverages were being served in the Provale cup. The RN said she thought it depended on the resident's preference. In summary, the facility failed to provide the resident with the fluid consistency and assistive devices as planned and ordered by the physician. 3) Resident #31 had a [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment. The resident was independent with eating, required assistance with setup and was on a mechanically altered diet. A nursing progress note dated November 1, 2012 documented the resident choked on pineapple bits while in the dining room. A nutrition progress note dated November 6, 2012 documented the resident had a coughing episode on November 1, 2012. The note documented the resident stated "it hurts to swallow." The resident's diet was downgraded to ground consistency for safety precautions. The physician order [REDACTED]. The swallow evaluation dated November 7, 2012 documented the resident had mild oral dysphagia (difficulty swallowing) marked by no teeth or dentures, increased chewing time and difficulty with some meats. The speech language pathologist (SLP) note dated November 7, 2012 documented the recommendation to cut up the resident's meat and large pieces of food, and to alternate bites and sips. The physician order [REDACTED]. The physician ordered meat and large pieces of food were to be cut up by staff. The comprehensive care plan (CCP) dated November 8, 2012 documented the resident was at nutritional risk related to aspiration precautions. The CCP recorded meat and large pieces of food were to be cut up by staff. The resident plan of care (RPOC), used to provide care, dated November 30, 2012 documented meat and large pieces of food should be cut up by staff, and verbal cues given to the resident to alternate solids and liquids. The CCP dated December 10, 2012 documented the resident had a swallowing problem. Interventions were for staff to cut meat into small pieces and use verbal cues to alternate solids and liquids. On December 10, 2012 from 1:30 - 1:49 PM, the surveyor observed the resident sitting on the side of his bed eating lunch. The resident's lunch included two hot dogs which were not cut up. The meal ticket documented meat and large pieces of food should be cut up by staff. No staff entered the resident's room during this observation. When interviewed on December 10, 2012 at 1:45 PM, CNA #4 stated no one was assigned to supervise residents who ate in their rooms. She said the CNAs walked by and made sure the residents were OK. She stated she was not aware of any resident on aspiration precautions and was not aware of any resident who had recently choked. On December 10, 2012 at 1:50 PM, CNA #5 was observed removing the resident's lunch tray. There was one hot dog on the tray. When interviewed on December 10, 2012 at 1:50 PM, CNA #5 stated she did not know who supervised residents who ate in their rooms. She stated residents on aspiration precautions were listed on the RPOC sheets. She stated she was not aware of any resident who had recently choked. When interviewed on December 13, 2012 at 9:50 AM, the dietician stated she learned of the resident's November 1, 2012 choking episode by going through the progress notes on November 6, 2012. She stated she spoke to the SLP about getting a swallowing evaluation, which was done the next day. In summary, the facility failed to provide the the resident with food consistency as ordered by the physician. --------------------------------------------------------------------------------------------- The facility implemented measures to remove the Immediate Jeopardy on December 13, 2012, including: - trained staff on providing residents with food/fluid consistency and assistive devices as ordered by the physician; and - developed a plan to oversee meal service on the nursing units to ensure food/fluid consistency and assistive devices were provided as ordered by the physician. 10 NYCRR 415.14(d)(3)

Based on record review and staff interview conducted during the extended survey, it was determined the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents for 77 residents on aspiration (taking foreign matter into lungs) precautions, including Residents #11, 15, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 47, who were reviewed for swallowing concerns. Specifically, the QA committee failed to identify concerns with providing adequate supervision during meals, failed to identify concerns with non-staff members feeding residents; failed to provide training and oversight to non-staff members who fed residents; failed to identify concerns with residents receiving inappropriate food/liquid consistency, failed to identify concerns with improper or inadequate use of adaptive feeding equipment, and failed to implement corrective measures. Refer to F323 and F365. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of Residents #11, 15, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 47. The Immediate Jeopardy situation was removed on December 13, 2012, prior to the survey exit. THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS OF June 18, 2012 and October 14, 2011. Findings include: The Administrator was interviewed on December 10, 2012 at 3:15 PM and stated she was not sure if audits were being conducted to monitor residents on aspiration precautions or the positioning of residents when eating. She stated prior to survey, she was not aware there were concerns with the manner in which residents were positioned when they were eating. The Director of Nursing (DON) stated in an interview on December 10, 2012 at 6:00 PM, nursing audited 10 residents per week on each unit during meals. She stated the audits did not identify concerns with residents' positioning at meals; did not identify concerns with residents receiving the incorrect consistency of food and fluid, and did not identify concerns with adaptive feeding equipment that would affect swallowing. In summary, the facility failed to ensure the QA committee identified concerns and implemented corrective measures for residents on aspiration precautions, providing supervision at meals, and providing the proper food/fluid consistency and adaptive feeding equipment. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on December 13, 2012 based on the following corrective actions taken by the facility: - developing an accurate list of residents on aspirations precautions; - developing new policies and procedures to address families feeding residents; - developing a plan to train family members on safely feeding residents; - developing a plan to supervise those high risk residents who wished to dine in their rooms; - training staff on providing residents with their ordered food and fluid consistency and assistive devices; and - developing a plan to oversee meal service on the nursing units to ensure the proper food consistency was served and residents had their ordered assistive devices. 10NYCRR 415.27(a-c)

Based on observation, record review, and staff interview conducted during the standard and abbreviated survey (#NY 903), it was determined the facility did not ensure 2 of 9 sampled residents (Residents #4 and 23) reviewed for pressure ulcers, received the necessary care and services to prevent the development of pressure ulcers and promote healing. Specifically, for Resident #4 who developed a Stage III pressure ulcer, staff were not aware of the Stage III pressure ulcer and did not implement preventative measures for pressure relief or treatment to prevent further pressure ulcers; For Resident #23, prior to developing a pressure ulcer staff did did not implement pressure relieving devices; and after developing a pressure ulcer staff used an incorrect product for treatments. This resulted in actual harm for Resident #4 and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #23. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF October 14, 2011. Findings include: 1) Resident #4 was admitted on [DATE], and readmitted from the hospital on May 21, 2012, with [DIAGNOSES REDACTED]. The Skin Condition Monitor form documented the resident returned from the hospital on May 21, 2012 with a Stage II pressure ulcer measuring 0.3 centimeters (cm) x 0.3 cm on the left inner knee. The readmission assessment, dated May 24, 2012, documented the resident had a pressure ulcer risk score of 18, with a score of 15 or higher meaning very high risk. The assessment documented the resident had a pillow between his legs, and a Gaymar (pressure relieving) overlay was placed on his mattress. The skin condition Monitor form dated May 24, 2012 documented the pressure ulcer on the resident's left inner knee was a Stage II that measured 0.6 cm x 0.5 cm x 0.1 cm with dry eschar in the woud bed. A physical therapy (PT) progress note, dated May 28, 2012, documented the resident had severe [DIAGNOSES REDACTED] and tightness of both hips, which was "causing pressure sores" between both knees. The recommendation was for a pillow to be placed between the resident's thighs and knees. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had normal cognition with no behavior issues. The MDS recorded the resident was non-ambulatory and was totally dependent for bed mobility and all other activities of daily living except eating. The MDS documented the resident had worsening of 1 pressure ulcer, was not on a turning and positioning program, and did not have pressure relieving devices for his chair or bed. The MDS recorded no impairment to the resident's range of motion of his legs. A PT progress note dated June 4, 2012, documented a recommendation, "reiterated to nursing," for the resident to have a pillow between both knees at all times due to "continuing worsening and spread of pressure areas" between both knees and thighs. The comprehensive care plan (CCP), last updated on June 5, 2012, documented: - The resident had: potential for impaired skin integrity related to bowel and bladder incontinence; a history of pressure ulcers; limited mobility; poor intake of food and fluids; weight loss; and severe pain. - On May 10, 2012, the resident had Stage I pressure ulcers on the left inner knee and left hip; a Stage II pressure ulcer on the left knee and an unstageable pressure ulcer on the left hip. - The CCP did not contain information about the number and stages of the resident's pressure ulcers after May 10, 2012. - The resident's potential for impaired skin integrity was "resolved" on June 5, 2012. The Skin condition Monitor form dated June 7, 2012 documented the left inner knee pressure ulcer was a Stage III, and measured 2.0 cm x 1.5 cm x 0.2 cm (depth). The recommendation on the form, documented by the occupational therapist was to use a t-shaped cushion between the resident's legs "for pressure relief while in bed and wheelchair - remove for hygiene." An occupational therapy (OT) progress note, dated June 11, 2012, documented precautions including; "pillow between legs in bed-skin breakdown." The OT progress note documented a t-shaped cushion for pressure relief between the resident's knees was trialed, and the resident refused it. The new recommendation, for pressure relief, was a Gaymar air (pressure relieving) wheel chair cushion between the legs for "pressure relief-utilizing contour seat cushion for pressure relief and position." On June 12, 2012 at 9 AM registered nurse (RN) #8 stated the resident had 5 pressure ulcers: Stage II pressure ulcers on the right and left inner knees; an unstaged blister on the right medial thigh; a Stage II pressure ulcer on the lower left knee; and a Stage IV pressure ulcer on the left hip. The Resident Plan of Care, dated June 12, 2012, did not document the resident was to have a pressure relieving device between his knees, and did not specify the resident was provided with a pressure-relieving mattress or overlay. At 2:30 PM on June 12, 2012, a surveyor observed the resident sitting in a wheelchair in his room. The resident stated he had 5 open wounds. A 4 inch circle of yellow drainage was observed on his pajamas over his inner left knee. His knees were touching, and there was no pressure relieving device between them. A blue T-cushion was observed on the dresser. The resident's unmade bed contained a standard pressure relieving mattress, without a Gaymar overlay. At 9:30 AM on June 13, 2012, the resident was observed lying on his right side, eating breakfast. Dressings were observed on both inner knees, and there was no pressure relieving device between his knees. The resident stated the t- shaped cushion (on the dresser) was used "a couple of times," and he did not like it because it was bulky and embarrassing. He stated he was supposed to have a gel pillow between his legs at all times, and he did not know where the pillow was. During an observation of a dressing change at 11:35 AM on June 13, 2012, the surveyor asked the licensed practical nurse (LPN) to roll the resident for observation of his buttocks. An open area covered by yellow slough (dead tissue) was observed on the resident's left buttock. The LPN stated to the surveyor this new open area had not been reported to her. At 11:40 AM on June 13, 2012, CNA #12 who was assigned to care for the resident stated the resident had no new open skin areas. At 11:45 AM on June 13, 2012 RN #8 assessed the open area on the resident's left buttock and stated to the surveyor the area was a Stage III pressure ulcer measuring 4.3 cm x 2.0 cm, with 50% slough in the wound bed. At 11:50 AM on June 13, 2012, CNA #12, who began work at 7 AM, stated she had not provided incontinence care to the resident that day. The CNA said she was unaware the resident had a new pressure ulcer on his left buttock. At 12 PM on June 13, 2012 RN #8 stated all of the resident's pressure ulcers should be documented on the CCP, and after reviewing the CCP and Resident Plan of Care (used by the CNAs to direct care), she stated she did not know if the resident was supposed to have a pressure relieving cushion between his knees. At 12:10 PM on June 13, 2012 RN #8 stated the resident told staff that a Gaymar cushion covered by a pillowcase was supposed to be positioned between his knees. At 12:15 PM on June 14, 2012, the RN unit manager stated she was unsure about the criteria for provision of pressure relieving mattresses. At 12:18 PM, the resident stated staff had placed an alternating pressure mattress (APM) on his bed at 5:30 PM on June 13, 2012. When re-interviewed at 12:20 PM on June 14, 2012, the RN unit manager stated the Assistant Director of Nursing had placed the APM on the resident's bed on the evening of June 13, 2012, and that in view of the resident's multiple open wounds, the APM should have been provided sooner. During an interview with the occupational therapist/Director of Rehabilitation at 3:15 PM on June 14, 2012, she stated therapy staff recommended use of a (Gaymar) pillow between the resident's knees at skin rounds, and she would have expected this recommendation to be included in the resident's care plan. In summary, the resident who was at very high risk for development of pressure ulcers, experienced harm as: - the interdisciplinary team did not provide comprehensive, timely care planning and individualized interventions to prevent worsening of existing pressure ulcers and development of new pressure ulcers; - the facility did not provide the recommended pressure relieving devices and the resident's wounds continued to worsen; - staff did not provide incontinence care as planned; and - the CCP did not accurately document the numbers and stages of the resident's pressure ulcers; 2) Resident #23 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident: - had severe cognitive impairment; - was non-ambulatory; - used a wheel chair with extensive assistance for transferring and mobility on the unit; - required extensive assistance with dressing and hygiene needs; - was always incontinent of bowel and bladder; - was not identified as being at risk for pressure ulcers; and - was not documented as having a pressure reducing device for her bed. The registered nurse (RN) Unit Manager was interviewed on June 18, 2012 at 10 AM and stated a nursing quarterly assessment including a "Pressure Ulcer Risk Assessment and Prevention Measures" should have been completed in February, 2012. Reviewing the resident record, the RN Unit Manager was unable to locate the assessment and stated she did not know if it was ever completed. The comprehensive care plan (CCP) dated March 12, 2012 documented the resident had potential for impaired skin integrity related to incontinence and limited mobility. The CCP included pressure relieving/reducing devices for the bed and chair as indicated. The CCP did not document if the devices were indicated or what devices would be used. A nursing progress note dated March 15, 2012 documented the staff reported an area on the resident's buttocks, that was superficial, reddened measuring 0.5 x 0.5 (no unit of measure recorded). The plan included turning and positioning the resident every 2 hours and applying Sensicare (a protective barrier creme). The registered dietitian (RD) documented on March 19, 2012 review of the skin book revealed the resident had an area on her left buttock "noted as excoriation" versus a Stage I pressure ulcer. A nursing progress note dated March 21, 2012 documented the resident's excoriated area had resolved and the resident had a new open area on her coccyx measuring 1.5 x 0.5 (no unit of measure recorded) that was a "Stage II." The note documented the skin care protocol "to include prevention" was put in place. Review of dietary and nursing progress notes, from March 21 - April 10, 2012, documented the resident continued to have a pressure ulcer on her coccyx. The notes recorded the pressure ulcer on the resident's buttocks had reopened and then resolved. The RN Unit Manager was interviewed on June 18, 2012 at 10 AM and stated the resident was given the APM (alternating pressure mattress) when the pressure ulcer developed in March, 2012. She stated she did not think the facility's regular mattresses were pressure relieving/reducing. The RN Unit Manager said she was unable to find documentation the resident had any type of pressure reducing mattress before developing the pressure ulcer in March 2012. She stated the resident should have been identified as high risk for developing a pressure area as she was unable to change positions independently and required a mechanical (Hoyer) lift for transfers. The RN Unit Manager said the resident had "always been" a Hoyer lift. The RN Unit Manager said the resident should have had a Gaymar (pressure relieving) mattress if assessed to be at risk, but was unable to say if she had one before developing the pressure ulcer on her coccyx in March 2012. On April 10, 2012, nursing progress notes documented the resident fell and was sent to the emergency room . The nursing note dated April 12, 2012 documented the resident returned from the hospital and had an open area on the coccyx. The note recorded the facility skin care protocol was to be followed. The RN's Pressure Ulcer Risk Assessment and Prevention Measures form dated April 12, 2012 documented the pressure ulcer on the resident's coccyx. The assessment documented the resident's risk score for developing pressure ulcers was 17, with 15 or greater being very high risk. Protocols set up by level of risk and preventive measures were documented to include an APM and a Gaymar mattress overlay. The MDS assessment dated [DATE] documented the resident had an unstageable pressure ulcer. The skin and pressure ulcer treatments included a pressure reducing device for the chair and bed. The MDS recorded the resident was on a turning and repositioning program, nutrition and hydration interventions were in place and the resident was receiving pressure ulcer care. The nurse practitioner (NP)'s orders dated June 12, 2012 documented the treatment to the pressure ulcer on the resident's coccyx as "cleanse with NS (normal saline), pat dry, and apply [MEDICATION NAME] (used to promote healing) and dry sterile dressing every day." The June 2012 Treatment Administration Record (TAR) documented the treatment as ordered by the NP. The licensed practical nurse (LPN) was observed on June 15, 2012 at 9:45 AM as he performed the resident's pressure ulcer treatment. The LPN applied [MEDICATION NAME] Ag (a dressing with an antimicrobial agent). The LPN, with the RN Unit Manager present, stated during an interview on June 15, 2012 at 10:09 AM, the TAR documented the type of treatment product to be used for the resident's pressure ulcer as [MEDICATION NAME], not [MEDICATION NAME] Ag. During an interview with RN Assistant Director of Nursing (ADON), who was the acting Director of Nursing (DON), on June 15, 2012 at 3:40 PM, she stated she provided oversight to the skin program. She stated [MEDICATION NAME] Ag had a silver component, that helped with bacteria, and [MEDICATION NAME] did not. She stated if the physician's orders [REDACTED]. She was not aware staff used [MEDICATION NAME] Ag for the resident's pressure ulcer treatment when [MEDICATION NAME] was ordered. In summary the facility: - did not identify the resident to be at risk for developing pressure ulcers; - did not document evidence the resident was provided with pressure relieving device in bed, in a timely manner, before developing skin breakdown; and - did not administer the pressure ulcer treatment as ordered. 10 NYCRR 415.12 (c)(1)

Based on record review and staff interviews conducted during an abbreviated survey (complaint # NY 223) it was determined for 3 of 230 residents reviewed for advanced directives, (Residents #1,2 and 5), the facility did not ensure residents' wishes regarding advanced directives were honored. Specifically, Resident #1 was resuscitated in conflict with his MOLST which documented he wanted to be a DNR and Residents #2 and #5 both had physician orders [REDACTED]. This resulted in actual harm that is not immediate jeopardy. Findings include: The facility policy #AD-A-,[DATE], titled, "Advanced Directives MOLST (medical orders for life sustaining treatment) Documentation" last reviewed [DATE], documented, "MOLST form-a document which translates resident's treatment preferences into physician's orders [REDACTED].The original pink MOLST form is intended to travel with the resident from institution to institution and go home with the resident after discharge." A "DNR order is initially written by MD on MOLST Form as previously described. After the completion of the MOLST form, the attending physician must re-write the DNR order on the usual MD order sheets. This confirms the order on the MOLST form, and triggers further steps to identify and track the resident's DNR status." 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge summary dated [DATE] documented the resident was a DNI/DNR (Do Not Intubate-Do Not Resuscitate). The admission History and Physical from the attending physician, dated [DATE], documented the resident was a full code (CPR, cardiopulmonary resuscitation). The resident's initial nursing admission assessment dated [DATE] documented the resident was a full code. The questions about the MOLST form and Health Care Proxy were left blank. The assessment also documents that the resident is understood by others and clearly comprehends the communication of others. Undated telephone admission orders [REDACTED]. On [DATE] a MOLST form was completed to document the resident's verbal request to a DNR order. The physician signed the MOLST on [DATE]. The social worker was interviewed on [DATE] at 10:30 AM. She stated that the resident was admitted on Friday, [DATE] and at the time of admission the resident told the nurse he wanted to be a full code. She stated that she approached the resident on Monday, [DATE] but he was sleeping. She stated that on Tuesday [DATE] the resident said he wanted to be a DNR. She talked to the resident and his son and daughter in law on Tuesday, [DATE] and they completed the MOLST paperwork to make the resident a DNR. The social worker stated she left the MOLST paperwork in the physician's notebook for the physician to the sign. The physician comes to the facility three times a week. The resident coded the following morning, [DATE]. The physician had signed the MOLST by that time but the MOLST was not filed back into the chart. It was in a separate folder. Progress notes dated [DATE] at 0516 written by the RN documented the resident was in full arrest without spontaneous respirations or pulse (carotid and radial). CPR was initiated at 0519. EMS was called and the chart was being copied. The chart was checked for a MOLST and none was present. An admission order for a full code was found and subsequent orders did not include a DNR order so CPR was initiated. The RN wrote, "that was this writer's rationale for initiating CPR." EMS arrived at 0524. The resident had a cardiac rhythm and palpable pulse at 0526 but no spontaneous respirations so EMS intubated and transferred the resident to the hospital. The Transfer Communication Form sent with the resident to the hospital on [DATE] documented that the resident did not have a DNR and did not have a MOLST. The hospital admission note from the emergency room physician documented that "while at the nursing home the resident was assisted to the bathroom by an aide, become unresponsive. CPR was started and EMS was called. When EMS arrived, they tried to determine the resident's code status. The nursing home staff indicated that the resident did not have a code status, therefore, was a full code. The patient was intubated and CPR was initiated. The resident soon had a pulse. When the resident arrived to the emergency room , he was found to be hypotensive. While in the emergency room we reviewed his records and found he was a DNR/DNI. The emergency room physician contacted the nursing home and they confirmed that they finally did find the paperwork indicating that he is a DNR/DNI, and they faxed us the paperwork. The family was then contacted and confirmed he is a DNR/DNI. The patient was kept comfortable and he expired." The Director of Nursing was interviewed on [DATE] at 9:30 AM. She confirmed the resident was wearing two bracelets at the time he arrested at the nursing home on [DATE]. She stated he was wearing a DNR bracelet from a prior hospitalization and he was wearing a full code bracelet from the nursing home. The nursing home physician was interviewed on [DATE] at 4:30 PM. He stated that when he signed Resident #1's MOLST it was in a separate folder and not in the resident's chart. He stated he didn't write a separate order regarding the change in the resident's code status from full code to DNR because the nurses always write the order for him. The physician was asked why he doesn't just write the order himself at the time he signs the MOLST. He stated "that's not the system." In summary, the facility did not honor the resident's right to be a DNR and he was resuscitated against his wishes when his MOLST was not executed properly. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The undated telephone admission orders [REDACTED]. The nursing admission assessment, dated [DATE], documented the resident was a full code. The questions regarding the MOLST and Health Care Proxy were left blank. The assessment also documented the resident understood others and was understood by others. On [DATE] the social worker completed a MOLST form documenting that the resident wanted a DNR order. The resident signed the MOLST on [DATE] and the physician signed the following day, [DATE]. On [DATE] a verbal order was taken at 1430 to change the resident's code status to DNR because of the MOLST initiated on [DATE]. In summary, from [DATE] to [DATE], when DOH was present in the facility, the resident's orders did not include an order regarding his desire to change his code status from full code to DNR. 3) Resident #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission form, from the resident's original admitted d [DATE], documented the resident was a full code. On February 10, 2012 the resident completed a MOLST form which documented she wanted to be a DNR. The physician signed the MOLST on February 10, 2012. A review of physician orders [REDACTED]. On [DATE] the physician called in a verbal order to have the resident's code status at DNR/DNI consistent with her MOLST. In summary, from February 10, 2012 to [DATE], when DOH was onsite at the nursing home, the resident's orders did not include an order regarding her desire to change her code status from full code to DNR. NYCRR 415.3(e)(1)(ii)

Based on observations, staff and resident interviews, and record reviews conducted during the standard survey and an abbreviated survey (#NY 587), it was determined the facility did not ensure the necessary care and services to maintain the highest practicable physical well-being in accordance with the comprehensive care plan (CCP) was provided for 2 (Residents #14 and 21) of 30 sampled residents. Specifically, the facility did not ensure there was timely assessment and follow-up treatment when Resident #14 had abnormal [MEDICAL CONDITION] hormone levels. For Resident #21, the facility did not document her bowel pattern as planned. This resulted in actual harm that is not immediate jeopardy for Resident #14, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #21. Findings include: 1) Resident #14 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP), dated September 15, 2010, documented the resident had [MEDICAL CONDITION] and was followed by a consulting physician. The consultant physician's note, dated September 28, 2010, documented the resident had Grave's disease, was on [MEDICATION NAME] [MEDICATION]), and noted his weight was down 10 pounds since his last visit. The consulting physician recommended a recheck of [REDACTED]. There were no nursing, physician, or nurse practitioner (NP) notes from September 28 until October 7, 2010, when the attending physician wrote a progress note. The physician's note documented the resident was followed by a consultant physician for his [MEDICAL CONDITION] and Grave's disease; and specified the resident's free [MEDICATION NAME] (a [MEDICAL CONDITION] hormone) was slightly low, with a normal TSH level. The physician renewed orders for [MEDICATION NAME] 20 mg daily. A lab report, dated October 15, 2010, documented the resident's TSH level was elevated to 14.23 (normal 0.36 - 4.17 ml/UL); the resident's T4 level was 0.49 (normal 0.76-1.46 NG/DL); and the results were "faxed to" the consultant physician, per handwritten note on the lab report. There were no physician or NP progress notes that addressed the resident's abnormal lab values on October 15, 2010. A verbal NP order, dated October 22, 2010, discontinued the resident's [MEDICATION NAME] medication, ordered tests for TSH and free T4 levels to be done on November 5, 2010, and to fax the results to a handwritten telephone number (consultant physician's number). The surveyor interviewed the registered nurse (RN) Unit Manager on December 14, 2010 at 12:50 PM. She stated she was the nurse who took the telephone order to discontinue the [MEDICATION NAME] (on October 22, 2010), and obtain repeat lab work. She stated she did not know the identity of the person from the consulting physician's office who gave her the order. The RN said the telephone order included the fax number to which the reports were to be sent. The RN said she notified the NP via telephone, and the NP approved the order to discontinue the [MEDICATION NAME]. There was no documentation from the NP dated October 22, 2010, that specified the rationale for the discontinuation of the resident's [MEDICATION NAME] medication. A laboratory (lab) report, dated November 5, 2010, documented the resident's T4 level was elevated to 5.03 (normal 0.76 - 1.46) and the TSH level was decreased to 0.013. The report documented a handwritten note by a licensed practical nurse (LPN) that specified a copy of the results were faxed to the consultant physician on November 10, 2011. The report's handwritten note specified the resident's [MEDICATION NAME] was discontinued on October 22, 2010. There were no physician or NP progress notes documented in the resident's medical record from November 5 until November 9, 2010 that addressed the resident's abnormal lab levels dated November 5, 2010 lab values. On November 9, 2010, the NP documented an order for [REDACTED]." There was no progress note documented by the NP to address these lab results. Nursing notes progress documented the following: - on November 13, 2010, the resident was lethargic and slow to respond, his heart rate was 83 beats per minute, his eyes were blood shot. - on November 14, 2010, the resident was more tired than usual, and his heart rate was 71. - on November 17, 2010 at 6:40 AM, the resident was diaphoretic (sweating), shaking, his blood pressure was 160/100, his heart rate was 144 beats per minute, his mental status was altered, he was unable to urinate, and he had increased thirst. The nursing note specified physician was notified and the resident was sent to the hospital for evaluation. The hospital's "General Emergency Department Prompt Care Discharge Instructions", dated November 17, 2010, documented the resident had [MEDICAL CONDITION] and [MEDICAL CONDITION], with "significantly" elevated T4 and T3 (another [MEDICAL CONDITION] hormone) levels. The recommended treatment was to increase the [MEDICATION NAME] to 20 mg daily. This discharge note documented the elevated lab levels were discussed with the consulting physician, and noted he would "call the order in." The symptoms of [MEDICAL CONDITION] were documented on the discharge instructions; and the instructions specified to seek immediate medical attention for any of these symptoms. Medical orders written by the NP and dated November 17, 2010, included an order to notify the consultant physician of the abnormal lab values from the hospital's emergency room . There were no changes made to the resident's [MEDICATION NAME] medication at that time. A nursing note, dated November 17, 2010, documented the resident started treatment for [REDACTED]. There was no documentation regarding notifying the consulting physician of the resident's lab values, as instructed on the NP orders. A verbal physician's orders [REDACTED]. The transfer form, dated November 18, 2010, documented the resident had not voided in 10 hours, had lower abdominal discomfort, and was "nervous." Nursing notes, dated November 18, 2010 (untimed), documented that after the family was notified of the need to send the resident for an evaluation at the emergency room , the family member expressed concern why the resident's [MEDICATION NAME] medication had been discontinued. Review of the resident's October 2010 and November 2010 Medication Administration Records (MARs) revealed the resident did not receive the medication [MEDICATION NAME] from October 23, 2010 until after his hospitalization on [DATE]. The hospital discharge summary, dated November 24, 2010, documented the resident was admitted with confusion and [MEDICAL CONDITION](rapid heart beat). The discharge [DIAGNOSES REDACTED]." Nursing notes dated November 24, 2010 at 1:45 PM, documented the resident was readmitted from the hospital. The surveyor observed the resident on December 14, 2010 at 12 PM, in his room watching television. He stated he was feeling better, and denied any discomfort. In an interview with the Medical Director on January 11, 2011 at 11:15 AM, she told the surveyor she reviewed the resident's record after the family expressed concern about his hospitalization . She stated there were new practices in place regarding communicating with consultant physicians. When the surveyor interviewed the NP initially on December 14, 2010, and re-interviewed on January 11, 2011 at 12:45 PM, she stated she did not notify the attending physician or the Medical Director of the resident's abnormally elevated laboratory values, or of the delay in response from the consulting physician regarding them. She said it was up to the consulting physician to address the resident's lab values. The attending physician did not return the surveyor's phone call request for an interview. In summary, the resident experienced harm, as he required hospitalization for a [MEDICAL CONDITION] crisis, when the facility did not ensure there was a timely medical assessment and follow-up treatment for [REDACTED]. 10 NYCRR 415.12