Every finding on record at The Pearl Nursing Center of Rochester

Based on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 2655452 and NY00386123/571480) completed on 12/11/2025, for three (3) (first, second, and third floors) of three (3) resident sleeping floors, the facility did not provide maintenance services necessary to maintain a safe, comfortable, and homelike environment. Specifically: ambient temperatures were not maintained between 71 and 81 degrees Fahrenheit ( F), supplemental heating devices in resident rooms were not functional and damaged, and automatic door opening features for handicap use were not functional. The findings are:Record review of the facility policy titled: 'Homelike Environment' included the policy statement that residents are provided with a safe, clean, comfortable and homelike environment. The policy also included facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting to include comfortable safe temperatures (71 F - 81 F).On 11/05/2025 at 1:22 PM the Administrator provided the surveyor with a vendor service report and repair quotes that were dated 09/25/2025 and signed by the facility 10/17/2025. The service report listed multiple boiler accessory and support components that needed attention, including but not limited to the following: the main controller for the boilers and pumps loop control system has burned out and not operable to control the system. Boiler #1 is leaking exhaust fumes via a small leak, has burners that are excessively dirty along with its heat exchangers, and has a failed supply water temperature sensor. Boiler #2 has leaks in its drain and exhaust lines and will continue to corrode; several valves and fittings in the piping have developed small leaks due to corrosion and age and could reduce the hot water. Pump #1 is making a grinding noise indicating a need to replace the bearing assembly and if it fails, it leaves Pump #2 as the only one to circulate hot water for heat throughout the building. Pump #2 needs a new starter contactor to run continuously without issue. Several spots on the gas lines have been taped/shut off it appears due to signs of past leaks. There was no documentation provided by the facility at that time to show the repairs had been made or scheduled.Observations on 11/07/2025 at 9:25 AM included a staff member struggling to pull a resident in a wheelchair through the two sets of double doors at the main entrance on the first floor. Further observations included the blue push buttons (marked 'push to open') for the automatic handicap door opening feature did not work when pressed. During an interview at this time, the Administrator stated the doors (automatic opening function) have not worked since they started. During another observation on 11/07/2025 at 11:15 AM a vendor was struggling to bring a mobile medical cart and screen through the main entrance double doors and the automatic door opening feature was not operational.During an interview on 11/07/2025 at 9:36 AM the Administrator stated they were not aware of any heating problems and had recently signed off for some repairs to be done on the boilers.Observations on 11/07/2025 from 9:45 AM to 10:45 AM included the following temperatures were measured using an [NAME] brand digital thermocouple in resident rooms on the second and third floors: #309 - 67.6 F, #305 - 69.2 F, #303 - 66.1 F, #313 - 66.5 F, #314 - 65.9 F, #315 - 65.0 F, #317 - 65.5 F, shared bathroom for #315/#317 - 63.3 F, #208 - 67.7 F, shared bathroom for #206/#208 - 64.4 F, #204 - 66.7 F, #200 - 67.9 F, #214 - 66.8 F, and #220 - 65.6 F.Further observations on 11/07/2025 from 9:45 AM to 10:45 AM included packaged terminal air conditioning (PTAC) units (wall mounted devices to provide supplemental heating and air conditioning) were damaged and/or not functional in the following resident rooms: room [ROOM NUMBER] - damaged, bent and pulled away from the wall, and was dispensing cold air into the room, room [ROOM NUMBER] - not functional, room [ROOM NUMBER] - unit dispensing cold air and control box painted shut, Room # 317 - unit dispensing cold air and control knob missing.Observations on 11/07/2025 at 10:00 AM included the temperature in resident room [ROOM NUMBER] (third floor) was 69.2 F, and a resident in bed closest to the door was fully wrapped in blankets from head to toe.During an interview on 11/07/2025 at 10:14 AM Licensed Practical Nurse #1 stated they have been having problems with the heat for about three to four weeks, and sometimes at night it gets really bad.During an interview on 11/07/2025 at 10:20 AM Registered Nurse Supervisor #1 (third floor) stated the heat in the resident rooms does not work and has not worked for a while, and the third floor is mostly dementia residents.During an interview on 11/07/2025 at 10:28 AM Resident #5 stated it is freezing in here and they caught pneumonia because of it. During another interview at 10:32 AM Resident #6 stated that it is always cold.On 11/07/2025 at 10:45 AM the surveyor's [NAME] brand digital thermocouple was checked for proper calibration using the ice point method and displayed 32.2 F.During an interview on 11/07/2025 at 11:30 AM the Director of Maintenance stated they use a heat gun to check temperatures in the building and they do not take them on the outside walls near windows in the rooms and at the ends of the hall because those areas are colder. The Director of Maintenance stated they take temperatures later in the morning because things have probably warmed up by then and most of the packaged terminal air conditioning units do not work.During a phone interview on 11/07/2025 at 2:46 PM the Administrator stated they had not yet implemented their plan for loss of heat.Observations on 11/08/2025 from 2:50 PM to 3:10 PM included the following temperatures were measured using an [NAME] brand digital thermocouple in the resident rooms on the second and third floors: #313 - 68.2 F, #315 - 67.8 F, 314 - 67.7 F, #323 - 68.2F, #301 - 69.5 F, #201 - 68.8 F, #212 - 68.9 F, #220 - 67.4 F, and #222 - 67.3 F.During an interview on 11/08/2025 at 3:04 PM Resident #7 stated a few days ago at night it was freezing, and they were shivering.Observations on 11/10/2025 from 9:12 AM to 9:26 AM included the following temperatures were measured using a [NAME] brand digital thermometer in resident rooms and common areas on the third floor: 3rd floor dining room - 67.5 F, third floor north hallway near the exit door - 67.6 F, room [ROOM NUMBER] - 67.7 F.10NYCRR: 415.29, 415.29(b), 415.29(h)(1,2), 415.29(j)(1),10NYCRR: 713-1.9(b)

Based on interviews, and record review conducted during an Abbreviated Survey (Intake ID: NY00371613/571460) completed on 12/11/2025, the facility did not ensure services were provided to meet professional standards of quality for one (1) (Resident #1) of one (1) resident reviewed. Specifically, Resident #1 had medical orders for care of a peripherally inserted central catheter (used for long term intravenous (administered directly into the bloodstream through a vein) medication administration) and vital signs monitoring that were not documented on numerous opportunities, and the facility was unable to provide evidence these required services were completed as ordered.The findings include:The undated facility policy, Central Venous and Midline Catheter Flushing included, but was not limited to, flush catheters at regular intervals to maintain patency, an insertion site assessment should be done as part of the flushing process to monitor for complications, and to record in the resident's medical record the date, time and amount of flush administered, and the signature and title of the person recording the data.Resident #1 had diagnoses including sepsis due to streptococcus group B (a common bacteria that can cause serious infections), diabetes with a foot ulcer, and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated 02/03/2025, included the resident was cognitively intact, had an active diagnosis of septicemia (a severe bloodstream infection), was taking an antibiotic, had intravenous access, and received intravenous medications. Review of the Comprehensive Care Plan dated 02/11/2025, revealed Resident #1 had a central venous access device in their left upper arm. Interventions included to ensure the dressing was clean, dry and intact and to change the dressing weekly and as needed. Review of Resident #1's medical orders included the following: Assess the peripherally inserted central catheter site every shift, document, and call the medical provider (dated 01/31/2025); Change the peripherally inserted central catheter dressing weekly every Thursday day shift (dated 01/31/2025); Change caps on the peripherally inserted central catheter every three (3) days and as needed with bloodwork (dated 01/31/2025); Normal Saline Flush Intravenous Solution 0.9% use three (3) milliliters intravenously every day and evening shift (dated 01/31/2025); and Vital signs every shift for seven (7) days, then weekly on Monday (dated 01/29/2025).Review of Resident #1's Treatment Administration Record from 01/30/2025 to 02/14/2025 revealed no documented evidence (missing nursing signatures) the peripherally inserted central catheter site was assessed every shift on 19 of 43 opportunities; the peripherally inserted central catheter caps were changed on 3 of 5 opportunities, and the peripherally inserted central catheter dressing was changed on 1 of 2 opportunities.Review of Resident #1's Medication Administration Record from 01/30/2025 to 02/14/2025 revealed no documented evidence the peripherally inserted central catheter was flushed on 14 of 29 opportunities and vital signs were monitored on 5 of 24 opportunities. Additional review of Resident #1's progress notes did not include evidence that missed documentation in the Medication and Treatment Administration Records from 01/30/2025 to 02/14/2025 for the peripherally inserted central catheter assessments, flushes, dressing change, and vital signs had been addressed. During an interview on 11/10/2025 at 1:23 PM, Licensed Practical Nurse #1 stated registered nurses were the only nurses who could perform tasks on peripherally inserted central catheters and were expected to assess the site and flush the catheters. Licensed Practical Nurse #1 stated licensed practical nurses should check the resident's vital signs every shift as ordered, especially if the resident was on an antibiotic. During an interview on 11/10/2025 at 12:29 PM, the Director of Nursing stated it was important for the peripherally inserted central catheter to be flushed as ordered to ensure the access is maintained. During a follow-up interview at 1:36 PM, the Director of Nursing stated a registered nurse should sign the medication or treatment administration record each time they administer medication or flush a peripherally inserted central catheter. They stated if it is not signed for, there is no way to verify it was done. During an interview on 11/12/2025 at 11:07 AM, Licensed Practical Nurse Manager #1 stated nurses had been trained to document when tasks were completed, either by signing in the Medication/Treatment Administration Record or entering a nursing progress note. Licensed Practical Nurse Manager #1 stated if there were several blanks (missing nursing signatures) on the Medication/ Treatment Administration Record, they would consider the tasks incomplete. During an interview on 11/12/2025 at 11:45 AM, the Director of Nursing stated all newly admitted resident should receive vital signs every shift for seven (7) days and if there were no vital signs documented, the task was not completed. The Director of Nursing stated they would expect if a nurse was unable to complete a dressing change during their shift, the nurse should communicate to the oncoming shift so the task could be completed the same day as ordered.10 NYCRR 415.11(c)(3)(i)

Based on observations and interviews conducted during an Abbreviated Survey (ACTS Reference Number: NY00370341, Intake ID: Complaint 571451) from 09/08/2025 to 09/10/2025, the facility did not ensure each resident received and the facility provided food and drink that was palatable and at a safe and appetizing temperature for one (1) of one (1) test tray. Specifically, food and beverages during the lunch meal on 09/09/2025 were served at sub-optimal temperatures. This is evidenced by the following:During a tray line and lunch time observation on 09/09/2025, the tray delivery cart was loaded in the main kitchen and sent to Residential Unit 1 at 12:13 PM. The final meal tray was passed to a resident on the unit at 12:39 PM and test tray temperatures were taken at that time by a New York State Department of Health Surveyor, with the Food Services Director present, using the surveyor's calibrated thermometer. The findings included:Roasted potatoes: 101.3 degrees FahrenheitHoney ham: 110.6 degrees FahrenheitCooked asparagus: 101.8 degrees FahrenheitBlack coffee: 127.3 degrees Fahrenheit During an interview on 09/09/2025 at 12:44 PM, the Food Services Director stated they did not know the food would cool down that much between setting up the trays in the kitchen and passing them to residents on the units. They stated the food was cold and it was not okay. During an interview on 09/09/2025 at 1:17 PM, Resident #12 stated food that should be hot is sometimes served cold. 10 NYCRR 415.14(d)(1) Subpart 14-1.40(a)

Based on observation, interviews, and record review conducted during an Abbreviated Survey (ACTS Reference Number: NY00370341, Intake ID: Complaint 571451) from 09/08/2025 to 09/10/2025, the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (1) (Resident #9) of three (3) residents reviewed. Specifically, Resident #9 was identified to be at risk for pressure ulcers, did not have care planned interventions in place to prevent skin breakdown, and later developed a pressure ulcer. Additionally, there was no documented evidence interventions to promote healing of the new pressure ulcer were implemented until three (3) days after the wound was first identified. This is evidenced by the following:The undated facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol included nursing staff and practitioners will assess and document each resident's risk factors for developing pressure sores such as immobility, recent weight loss, and a history of pressure ulcer(s). The physician will order pertinent wound treatments and help identify medical intervention for wound management. Resident #9 had diagnoses including a stage two (2) (a partial-thickness skin injury) pressure ulcer of the sacral region (bony area at the top of the buttocks), history of stroke with right-side paralysis, and severe malnutrition. The Minimum Data Set (a resident assessment tool), dated 10/08/2024, documented Resident #9's cognitive function was undetermined, they were incontinent of bowel and bladder, dependent on staff for toileting, bed mobility, and transfer assistance, were at risk for pressure ulcers, and had no unhealed pressure ulcers. The comprehensive care plan, dated 11/06/2024, identified the resident had a self-care deficit and limited physical mobility. Interventions included, but were not limited to, dependent on staff for transfers, toileting, eating, bathing, and personal hygiene. The care plan did not include measurable goals and/or interventions related to Resident #9's risk of developing pressure ulcers. Review of the current Kardex (care plan used by certified nursing assistants to direct daily care) included Resident #9 was dependent on staff for transfers, toileting, eating, bathing, and personal hygiene. The care plan did not address the resident's pressure ulcer risk or include interventions to assist with preventing skin breakdown. Progress notes reviewed from 11/01/2024 to 11/22/2024 revealed a nursing note, dated 11/19/2024, documenting Resident #9 had a reddened area on their bottom and a note was put in the medical provider book (used by nursing staff to communicate changes in a resident's condition to the medical team). In a wound care provider note, dated 11/20/2024, Physician #1 documented Resident #9 was seen for a wound assessment including a new deep tissue injury (a localized area of tissue damage that develops due to prolonged pressure on the skin) to their sacrum, measuring 3.0 centimeters in length, 5.0 centimeters in width, and no measurable depth. The surrounding skin had maceration (softening and weakening of the skin due to prolonged exposure to moisture) and erythema (redness). Treatment recommendations included to cleanse the wound with mild soap and water, apply a thick layer of TRIAD cream (wound treatment used to promote healing) to the wound and surrounding skin, and leave open to air every shift and as needed. Additional recommendations included, but were not limited to, offloading (reducing pressure on the affected area to promote healing), use of the facility pressure injury prevention protocol, a pressure redistribution cushion per facility protocol, and applying barrier cream three (3) times daily and after incontinence episodes. Review of Resident #9's Order Summary Report (medical orders) revealed a treatment order for the sacral wound dated 11/22/2024. There was no documented evidence preventative measures or treatment orders for the sacrum had been ordered prior to 11/22/2024. During an interview on 09/09/2025 at 1:52 PM, Certified Nursing Assistant #1 stated they would know if a resident was at risk for developing pressure ulcers and required skin prevention interventions by looking at the resident's Kardex. During an interview on 09/10/2025 at 9:27 AM, Licensed Practical Nurse #1, stated all residents at risk for skin breakdown should be repositioned every two (2) hours and if they identified new skin breakdown they would document it in the medical provider book. During an interview on 09/10/2025 at 9:14 AM, Registered Nurse #1 stated skin breakdown prevention interventions for residents would include to turn and reposition, encourage them to get out of bed, provide timely incontinence care, and promote good nutrition. They stated they would find instructions for turning and repositioning in the resident's medical orders. During an interview on 09/09/2025 at 9:38 AM, Licensed Practical Nurse Manager #1 stated if a resident had a new skin concern, they would have a registered nurse assess the resident and follow the facility's general wound care process or verbal orders until the resident was seen by the wound care provider on their weekly skin rounds. During an interview on 09/10/2025 at 9:58 AM, Medical Doctor #2 stated the Director of Nursing or nurse managers inform them of new wounds. Once a new wound has been identified, the resident is added to the list for weekly skin rounds and the medical providers will follow up. During an interview on 09/09/2025 at 11:25 AM, the Director of Nursing stated if a nurse identifies a new skin concern, they should contact the nursing supervisor, obtain general orders for treatment until the resident is seen by the wound care team, and write their findings in the medical provider book. The Director of Nursing stated upon identifying a new skin condition, they would expect nurses to document the description of the wound, any interventions, and who they notified.During a follow up interview on 09/10/2025 at 10:18 AM, the Director of Nursing stated staff can help prevent pressure injuries by providing timely incontinence care, promoting a resident's nutrition and hydration, and implementing preventative measures, such as applying a barrier cream. The Director of Nursing stated orders for preventative measures do not have to be in place for staff to provide them and certified nursing assistants should be turning and repositioning residents every two (2) to three (3) hours even if it is not documented in the resident's Kardex. They stated care plans are monitored and updated by nurse managers and should include wounds and appropriate interventions.10 NYCRR 415.12(c)(1-2)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: Complaint 2576858) conducted on 08/22/2025, it was determined for one (resident room [ROOM NUMBER]) of 72 resident rooms, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, there was mold and evidence of water leaks, wall, and floor damage in a resident bathroom. The findings are: Record review of the facility work order system from 05/01/2025 to 08/22/2025 revealed an entry for a ceiling tile that fell in the bathroom of resident room [ROOM NUMBER] on 07/02/2025 and was closed out on 07/03/2025. Additionally, there were entries for a clogged toilet in resident room [ROOM NUMBER] on 05/16/2025, 06/20/2025, and 08/14/2025. There were no other work order entries related to ceiling leaks in resident room [ROOM NUMBER] for this time period.During observations and interviews on 08/22/2025 at 1:30 PM, the ceiling tiles in the bathroom of resident room [ROOM NUMBER] (second floor two (2)-person occupied) were stained brown and spotted with a black material that appeared to be mold. Additionally in the bathroom, there was one (1) ceiling tile missing and there was an approximately one (1)-inch unsealed gap in the concrete slab separating the third floor (bathroom of resident room [ROOM NUMBER]) from the second floor. Further observations included the baseboard cove molding in the bathroom of room [ROOM NUMBER] was peeled off the wall exposing wall damage, there were multiple floor tiles that were missing or had come loose below the sink, and there was a strong odor of urine in the bathroom. During an interview that time, the Acting Director of Maintenance stated they were not aware of leaks in this room, but sometimes toilets overflow, and it goes down to the room below. Resident #1 stated there was a ceiling leak a few months ago. 10 NYCRR: 415.29, 415.29(i), 415.29(j)(1)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (NY00360750), the facility did not ensure there was a system, supported by policies and procedures, to ensure there was an adequate number of staff in the facility at all times who were properly trained and/or certified in cardiopulmonary resuscitation (CPR - life saving measures performed when the heart and or lungs cease functioning). Specifically, the facility did not maintain an updated list of staff currently certified and/or trained in Cardiopulmonary Resuscitation and did not maintain evidence of nursing staff education and training related to the facility's policy for Cardiopulmonary Resuscitation. This was evidenced by the following: The facility policy Emergency Procedure-Cardiopulmonary Resuscitation, revised February 2018, included to obtain and maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation for clinical staff members who will direct resuscitation efforts, including non-licensed staff. To provide periodic mock codes (stimulation of an actual cardiac/pulmonary arrest) for training purposes and select and identify a Cardiopulmonary Resuscitation team for each shift in case of an actual cardiac arrest. Resident #2 had diagnoses that included failure to thrive, dementia, and Parkinson's disease. The Minimum Data Set Resident Assessment, dated [DATE], documented the resident had severe impairment of cognitive function. Review of the facility investigation for an incident occurring on [DATE] included the Licensed Practical Nurse Supervisor had documented they were notified at 7:20 AM on [DATE] that Resident #2 was not breathing. On arrival to the resident;s room, the Licensed Practical Nurse Supervisor initiated cardiopulmonary resuscitation and 911 was called. During record review on [DATE], the facility was unable to provide a list of all nursing staff in the facility and their current cardiopulmonary certifications on file. During an interview on [DATE] at 11:18 AM, Licensed Practical Nurse #2 stated they had lost their cardiopulmonary card. During an interview on [DATE] at approximately 11:00 AM, the Registered Nurse Manager stated they were cardiopulmonary resuscitation certified and were unaware of how many staff who were certified in cardiopulmonary resuscitation were required in the facility at any one time. During an interview on [DATE] at 2:55 PM, the Corporate Infection Control Registered Nurse stated they could not provide any documentation of education for staff regarding emergency preparedness/cardiopulmonary resuscitation. They also stated they were working on a list of current cardiopulmonary resuscitation certified staff, but could only provide documentation to verify two nurses (including Licensed Practical Nurse Supervisor and one other nurse) working in the facility on [DATE] when the incident occurred who were currently certified in cardiopulmonary resuscitation. 10 NYCRR 415.11 (c)(3)(i)

Based on interviews and record review conducted during an Abbreviated Survey (NY00360750), the facility was not administered in a manner that enabled it to use its resources efficiently and effectively. Specifically, the facility did not have a system in place to monitor and maintain a list of facility staff who were currently certified in cardiopulmonary resuscitation (CPR [life saving measures performed when the heart and or lungs cease functioning]). This is evidenced by the following: The facility policy Emergency Procedure-Cardiopulmonary Resuscitation, revised February 2018, included to obtain and maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation for clinical staff members who would direct resuscitation efforts, including non-licensed staff. Provide periodic mock codes (stimulation of an actual cardiac arrest) for training purposes and select and identify a cardiopulmonary resuscitation team for each shift in case of an actual cardiac arrest. Review of the Facility Assessment, dated [DATE], included staff training and competencies including advanced directives and emergency preparedness. The Facility Census Report, dated [DATE], revealed the resident census on [DATE] was 100 residents. Review of the Order Listing Report (a report of all residents and their advanced directive wishes), dated [DATE], revealed 51 residents were identified as full codes (wished to receive cardiopulmonary resuscitation in the event of acute cardiac or pulmonary arrest). During an interview on [DATE] at approximately 11:00 AM, the Registered Nurse Manager stated they had been at the facility for two weeks and had not received any training on emergency preparedness. The Registered Nurse Manager also stated they were cardiopulmonary resuscitation certified and were unaware of how many staff certified in cardiopulmonary resuscitation were required to be in the facility for each shift. During an interview on [DATE] at 2:55 PM, the Corporate Infection Control Registered Nurse stated they could not provide documentation of any education provided to staff for emergency preparedness (including cardiac or pulmonary arrest). They also stated they were working on a list of current staff who were certified in cardiopulmonary resuscitation, but could only provide documentation to verify that two nurses (the two nurses who were working in the facility on [DATE] when a cardiac arrest incident occurred) were currently certified in cardiopulmonary resuscitation. The Corporate Infection Control Registered Nurse stated all of the organization's facilities were supposed to have uploaded copies of staff's cardiopulmonary resuscitation cards into the system utilized by the corporation, but this facility was on their third facility educator/trainer in the past year. 10 NYCRR 415.26

Based on observations and interview conducted during the Recertification Survey, the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment was not maintained in proper working condition. The findings are: Observations in the basement laundry room on 6/25/24 at 8:40 AM included one of two dryers and one of three washing machines were not functional. When interviewed at this time, a housekeeping/laundry staff member stated that all of the laundry is done in-house, and it would help to have them all working. 10 NYCRR: 415.29, 415.29(b), 415.29(c)

Based on interviews and record review conducted during the Recertification Survey, for two (1st and 2nd floor units) of three residential care units reviewed, the facility did not ensure that an accurate reconciliation of all controlled substances (narcotic medications) was consistently completed. Specifically, the narcotic count logs which included reconciliation of narcotic medications at the end of each shift were not consistently signed to indicate the count had been done and the correct count of narcotic medications had been verified by two nurses. This was evidenced by the following: The facility policy Medication - Controlled Substances, dated April 2019, included that narcotics would be counted with two professional nurses and documentation that the count was completed and accurate would be completed at the beginning and end of each shift. Any discrepancy in a shift-to-shift count must be immediately communicated to the Director of Nursing. 1. Review of the second-floor south medication cart on 6/27/24 at 10:30 AM revealed that the Controlled Substance Inventory logs dated 4/1/24 to 5/18/24 (the only sheets provided when prior three months requested) had numerous (greater than twenty) missing signatures, including multiple days in a row, to verify that the controlled substance count had been completed and was accurate, and that the shift-to-shift narcotic count had been completed by two nurses. When interviewed at the time, Licensed Practical Nurse #2 said that the narcotic sheets should be signed as a legal document that included how many drugs/pills were received and how many were left. When completed, the sheets should be sent to medical records. The Controlled Substance Inventory logs include the date, time, resident's name, and medication given and total counts were done at the end of each shift. When asked the whereabouts of the inventory log from the prior day, Licensed Practical Nurse #2 stated they were unaware and that the night shift nurses most likely did not sign off for the narcotic count being completed. 2. Review of the first-floor south medication cart on 6/27/24 at 11:05 AM the Controlled Substance Inventory logs for the previous three months contained numerous missing signatures (greater than 30) to verify that the shift-to-shift narcotic count had been completed. When interviewed at this time, Licensed Practical Nurse #4 stated that the yellow sheet comes with the blister packs (of narcotics from pharmacy). We fill out date, time, tablets given, how many we started with and then what was left. The Controlled Substance Inventory log is filled out with each resident's name, date, and time, with medication and prescription number. At the end of the shift a count is done with the nurse coming on and the nurse going off and both should sign as to the accuracy of the count. In addition, both should sign the narcotic sheet for the receiving nurse and the surrendering nurse (of the narcotic keys). Licensed Practical Nurse #4 stated that doing the narcotic count at the end of the shift is done to make sure the correct medication was given and that the count (of medications left) is correct. When interviewed on 6/27/24 at 11:45 AM, Licensed Practical Nurse Manager #2 stated that all nurses know to sign out on the narcotic sheets with the outgoing and incoming staff signatures and to inform a nursing supervisor if there are missing signatures. Licensed Practical Nurse Manager #2 said that the purpose of the count was to keep track of the narcotic (medications) count and who has the narcotic keys and that the narcotic sheets from earlier this week were missing signatures. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observations, interviews, and record review conducted during the Recertification Survey for one (Resident #42) of six residents reviewed, one of one basement laundry room and nine (Resident Rooms #106, 108, 111, 120, 122, 208, 220, 306, and 307) of nine resident rooms reviewed, the facility did not ensure the environment remained free from accident hazards. Specifically, for Resident #42, who was known to vape in their room, the facility did not ensure the resident was assessed for and care planned for the use of electronic cigarettes in the facility. The basement laundry room had a significant buildup of lint behind dryers creating a fire hazard and multiple resident rooms had water temperatures above 120 degrees Fahrenheit at points of use. This is evidenced by the following: 1. During an observation on 6/24/24 at 1:30 PM, there was significant buildup of lint behind the dryers in the basement laundry room. The lint was approximately one to two-inches thick and covered the top and rear surfaces of two natural gas-powered dryers, the walls, the floors, electrical wires, and motors. Additionally, lint was coming out of an open junction in the exhaust duct work while the dryer was running. During an observation and interview on 6/24/24 at 3:05 PM, there was a smell of smoke and a light haze in the basement corridor outside the laundry room. The Director of Maintenance stated they were cleaning the lint behind the dryers and a spark from the dryer ignited the lint. They immediately used a fire extinguisher to put out the fire and turned off all electricity to the room. 2. During an observation on 6/26/24 at 10:56 AM, the in-line temperature gauge at the mixing valve for outgoing water located in the basement boiler room displayed 132 degrees Fahrenheit. During an observation on 6/26/24 at 11:40 AM, the sink water temperature in resident room [ROOM NUMBER] was 127.9 degrees Fahrenheit. The surveyor's digital thermometer was checked for proper calibration at that time using crushed ice and water and displayed 32.5 degrees Fahrenheit. Review of water temperature logs provided by the facility revealed the following temperatures exceeding 120 degrees Fahrenheit and did not include any documented corrective action: - On 4/23/24, resident room [ROOM NUMBER] was documented as 124 degrees Fahrenheit - On 5/14/24, resident room [ROOM NUMBER] was documented as 130.1 degrees Fahrenheit - On 6/05/24, resident room [ROOM NUMBER] was documented as 125.4 degrees Fahrenheit - On 6/13/24, resident room [ROOM NUMBER] was documented as 122.1 degrees Fahrenheit - On 6/17/24, resident room [ROOM NUMBER] was documented as 125.6 degrees Fahrenheit - On 6/18/24, resident room [ROOM NUMBER] was documented as 123.8 degrees Fahrenheit - On 6/24/24, resident room [ROOM NUMBER] was documented as 125.4 degrees Fahrenheit - On 6/25/24, resident room [ROOM NUMBER] was documented as 122.4 degrees Fahrenheit - On 6/26/24, resident room [ROOM NUMBER] was documented as 127.4 degrees Fahrenheit During an interview on 6/28/24 at 2:48 PM with the Regional Director of Operations, the Corporate Infection Control Nurse, and the Regional Director of Clinical Services, the Regional Director of Operations stated they were aware of issues related to the physical environment and were waiting to hear back from a vendor with a quote to evaluate the hot water. Review of the facility policy, Water Temperatures, Safety of, dated May 2024, revealed the policy included: water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas would be set to temperatures of no more than 120 degrees Fahrenheit, maintenance staff were responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log, and if at any time water temperatures felt excessive to touch, staff would report findings to the immediate supervisor. 3. Resident #42 was admitted to the facility approximately two and a half years ago and has diagnoses including, arthropathy (a disease of the joints often causing muscle weakness), and peripheral vascular disease. The Minimum Data Resident assessment dated [DATE] revealed the resident was cognitively intact, dependent on staff for all activities of daily living and under tobacco use, the assessment was blank. Review of the undated facility policy, Tobacco-Free Environment Policy, revealed the facility prohibited the use of tobacco and tobacco products, including but not limited to, electronic cigarettes by residents, employees, and others entering the facility premises. There would be no designated smoking areas on the premises unless specifically identified for the use of residents admitted to the facility before implementation of the policy. For current residents that smoked prior to the policy implementation, residents were allowed to use tobacco or tobacco products in a designated area outside and were required to have a smoking assessment completed to determine the level of supervision to be provided and interventions to mitigate (to reduce the occurrence of a severe outcome) the risk of injury. The employee's responsibilities in enforcing the policy included, but were not limited to, reporting witnessed violations immediately to the Executive Director, Director of Nursing, Nurse Manager, or Nurse Supervisor. Residents would be asked to immediately comply with the facility policy and any tobacco products found would be confiscated and returned upon discharge from the facility. Review of an Admission Agreement, dated 1/4/21 and signed by Resident #42, revealed that smoking was never allowed in any area inside the facility, the facility did allow outdoor smoking for residents within specific smoking times, and if a resident would like to smoke, they would sign and adhere to the rules outlined in the facility smoking policy. Review of the current comprehensive care plan, revealed Resident #42 was non-compliant with the facility smoking/vaping policy and hoards vapes in their room (private) which they refuse to surrender to staff when requested. Interventions included to offer smoking cessation information, to ensure resident was aware of the facility policy, and to document refusals to turnover possession of vaping materials. Review of current physician orders included two (2) liters oxygen via nasal cannula (a device that delivers oxygen through the nose) on at bedtime and off in the morning. Review of a progress note, dated 9/27/23 at 10:04 AM, Social Worker #1 documented the interdisciplinary team met for Resident #42's annual care conference and the resident was present. Nursing addressed that Resident #42 should not be vaping in the facility and the interdisciplinary team would implement weekly meetings to ensure this was not happening. Resident #42 was offered a nicotine patch (used for smoking cessation) but declined. Review of nursing progress notes from 5/4/24 to 5/19/24 revealed frequent documentation regarding either Resident #42 holding a vape pen, smoking a vape pen, or the presence of a vape pen in their room. Progress notes revealed Resident #42 frequently refused to give the vape pen to staff upon their request, and often became agitated and verbally combative and administration staff were notified. The facility was unable to provide any Incident/Accident Reports related to Resident #42's smokeing a vape pen in their room or any assessement done for the safe use of a vape pen in their room. During an observation and interview on 6/24/24 at 10:26 AM, a vape pen was laying on top of Resident #42's bedside table. When asked what it was, Resident #42 stated it was a BIC pen used for writing and asked, are you going to tell on me? During an interview on 6/26/24 at 1:31 PM, Certified Nursing Assistant #2 stated their were a few residents in the facility who smoked and Resident #42 vaped. They had not seen Resident #42 vaping but had seen the vapes on their dresser. During an interview on 6/27/24 at 4:28 PM, Resident #42 stated they did vape in their room and that they had been offered nicotine patches but they made them sick. Resident #42 stated they needed to quit smoking and would try other methods of smoking cessation. During an interview on 6/28/24 at 11:37 AM, Licensed Practical Nurse Manager #2 stated there should be no smoking or vaping at the facility because they were a non-smoking facility. If residents were observed smoking, staff should conduct a search of their room and if materials were found an incident and accident report should be completed. Licensed Practical Nurse Manager #2 stated they had received frequent complaints of Resident #42 vaping in their room and was not sure how the resident kept getting the vapes. The facility had offered Resident #42 smoking cessation products and made transfer referrals to other facilities, but a smoking assessment had never been done because they were a non-smoking facility. Licensed Practical Nurse Manager #2 stated that frequent checks for materials were not done for Resident #42 and checks were only done when staff reported a concern. During an interview on 6/28/24 at 12:49 PM, the Regional Director of Clinical Services stated the facility was non-smoking and residents signed an agreement not to smoke upon admission. Smoking assessments were not done because it was a non-smoking facility. The Regional Director of Clinical Services stated that smoking cessation could be offered, but most residents decline. Resident #42's continued vaping was an issue of non-compliance with their care plan and staff should be keeping a record of the non-compliance. The Regional Director of Clinical Services stated Resident #42 required ongoing monitoring to ensure their safety and that of other residents. During an interview on 6/28/24 at 2:48 PM with the Regional Director of Operations, the Corporate Infection Control Nurse, and the Regional Director of Clinical Services, the Regional Director of Operations stated they were not aware Resident #42 had been vaping in their room and if found an incident report should be completed, and smoking cessation offered. The Regional Director of Clinical Services stated staff were not consistently documenting or completing incident reports when they became aware of the resident vaping in their room. 10 NYCRR 415.12(h)(1-2)

Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00319773), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for two (Residents #30 and #42) of five residents reviewed. Specifically, the facility could not provide evidence that physician-ordered wound care treatments were provided as ordered. This is evidenced by the following: 1. Resident #30 had diagnoses including chronic ulcers of left leg, chronic obstructive pulmonary disease (COPD-disease of the lungs causing difficulty to breath), and diabetes. The Minimum Data Set Resident assessment dated [DATE] documented that Resident #30 was cognitively intact and had a skin ulcer that required a dressing. Current Physician orders for Resident #30's left leg wounds included to clean the wounds with wound cleanser, apply zinc oxide to the macerated skin, cover it silver alginate (wound treatment often used for infected wounds), apply an absorbative non-bordered dressing, wrap in gauze, secure with tape, and change daily and as needed. The orders also included to wrap the resident's leg with an ace wrap in the mornings and remove it in the evenings. During observations on 6/26/24 at 12:35 PM and 6/27/24 at 1:38 PM, Resident #30 was not wearing any ace wraps to the left leg. In an observation of wound care on 6/26/24 Licensed Practical Nurse #2 completed Resident #30's wound care (silver dollar sized venous ulcer) as ordered. An ace wrap was not applied as ordered following the dressing change. Review of Resident #30's June 2024 Treatment Administration Record revealed documentation that the dressing had been completed on both 6/26/24 and on 6/27/24. Additionally, review of the June 2024 Treatment Administration Record revealed missing documentation (dressing not signed off by nursing as completed for 8 out of 27 opportunities related to the left anterior wound dressing change). During an interview on 6/27/24 at 1:37 PM, Resident #30 stated that they used to have an ace wrap on the wound but that the wound nurse had said a few weeks ago to leave them off and let the wound dry. During an interview on 6/27/24 at 2:00 PM, Licensed Practical Nurse #2 stated the wound order was confusing and that they were not aware that there was a separate order for ace wraps (which was signed off as completed on the Treatment Administration Record). During an interview on 6/28/24 at 11:39 AM, Licensed Practical Nurse Manager #2 stated that the way the order was written, Resident #30's ace wraps should have been written as a second order and not included with the dressing change order. During an interview on 6/28/24 at 12:49 PM, the Acting Director of Nursing stated that nursing should follow the physician's order as written. If the order was confusing or not understood, staff should clarify the order. 2. Resident #42 had diagnoses including diabetes, morbid obesity, and a recent surgical abdominal wound. The Minimum Data Set Resident assessment dated [DATE] documented that Resident #42 was cognitively intact. Physician orders dated 6/7/24 for Resident # 42's abdominal wound included to clean the wound with wound cleanser, apply skin prep (protective skin treatment) around the wound, apply calcium alginate (an absorbent wound treatment) to the wound, cover it with an absorbent dressing, and change it three times a week every Monday, Wednesday, Friday and as needed. On 6/20/24, the Physician changed the abdomen dressing to daily and as needed. Review of Resident #42's Treatment Administration Record from 6/7/24 to 6/27/24 revealed that on 4 of 14 opportunities there was no documentation that the wound care had been provided as ordered. There was no documented evidence that the resident had refused any dressing changes. Review of a wound care note dated 6/19/24 revealed Resident #42's abdominal wound was 7 centimeters by 15 centimeters and on 6/25/25 the wound care note included the wound was improved with a size of 6 centimeters by 14 centimeters. In an interview on 6/28/24 at 9:59 AM, Medical Provider #1 stated orders should be acted on (as ordered). Medical Provider #1 stated that if a resident refused a treatment, nursing staff would notify the medical team. During an interview on 6/28/24 at 12:49 PM, the Acting Director of Nursing stated they would expect nursing staff to carry out (provide) wound treatments as ordered and if unable to complete for any reason, they should contact the medical provider. The Acting Director of Nursing said a blank box on the Medication (or Treatment) Administration Record indicated the medication (or treatment) was not signed off or not given (done). 10 NYCRR 415.12 46526

Based on observations and interviews conducted during the Recertification Survey, for three (first, second, and third floors) of three resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically: exhaust ventilation was not functional, plumbing fixtures were not maintained and/or working properly, hot water temperatures were not maintained between 90 and 120 degrees Fahrenheit ( F), lighting was not functional, light lenses and covers were missing, there were cracked and damaged tiles, doors and walls were damaged, a resident room lacked a means for securing valuables, there were resident care items stored on the floor, and there was an accumulation of bugs in stairwells. The findings are: Observations during the initial tour of the facility on 6/24/24 from 8:50 AM to 1:30 PM included the following: a) The exhaust ventilation in the following areas were observed to not be drawing air out of the rooms: in the ceiling of the bathroom in room [ROOM NUMBER], the shower room across from the 2nd floor staff bathroom, the first-floor soiled utility room, the janitor's closet next to room [ROOM NUMBER], and the shared bathroom for rooms [ROOM NUMBERS]. b) The light lenses in the corridor outside room [ROOM NUMBER] (3rd floor), in the 3rd floor soiled utility room, and in the shower room were cracked and broken. c) The hand wash sink in the 3rd floor shower room only discharged a small trickle of water and would not shut off using the valve handles. d) The floor tiles near the sink in room [ROOM NUMBER] were cracked with small sections missing. e) The janitor's closet next to room [ROOM NUMBER] contained a floor sink and the room did not have functional exhaust. f) There were multiple missing ceiling tiles in the shower room near room [ROOM NUMBER] (first floor). g) The hopper (flushing rim fixture) in the first-floor soiled utility room was clogged with a brown liquid and a sign nearby read: do not flush. h) There were resident care supplies including a brush, shampoo, ointment, and bed pans stored on the floor inside the first-floor supply closet next to room [ROOM NUMBER]. Additionally, a shelf in this room was tipped and coming off of the wall. Observations on 6/25/24 at 8:40 AM included a mechanical exhaust fan attached to duct work located near the ceiling above the washing machines in the basement laundry room that was not functional and heavily coated with dust. Further observations included a large open circular duct above the dryers that was improperly vented across the hallway into the generator room. During an interview at this time, the Director of Maintenance stated that a vendor was contacted to evaluate/troubleshoot the issue but would not come out to the facility because they are owed money. Observations on 6/25/24 at 8:45 AM included no hand washing sink in the basement laundry room. Observations on 6/25/24 at 9:00 AM included the plate warmer (lowerator) in the main kitchen had a frayed cord with exposed wires near the plug. During an interview at this time, the Dietary Manager stated that they had put in a maintenance order to get it fixed but the new maintenance director just started yesterday. Observations on 6/25/24 from 9:39 AM to 9:55 AM included the tops and bottoms of the emergency exit stairwells of the north and south stairwells had a large accumulation of dead bugs and spiderwebs. Further observations included the doors at the tops of each stairwell were open approximately 1/2- to 1-inch. During an interview at this time, the Director of Maintenance stated that they were told that there were no keys for the roof doors. Observations on 6/25/24 at 11:00 AM included the refrigerator in the 2nd floor dining room had a sign posted on the door that it was broken. When interviewed, the 2nd floor Licensed Practical Nurse Manager stated that it broke last Friday and they did send a work order to Maintenance but does not know if they have started working on it. Observations on 6/25/24 at 10:28 AM included the sink drainpipe was disconnected in resident room [ROOM NUMBER] and there was a sign on the sink that read: Do not use broken sink. Observations on 6/26/24 at 11:15 AM included the sink faucet in resident room [ROOM NUMBER] was very loose and water could not be shut off using the valve handles. Further observations included the cabinet near the window bed had a lockable drawer that was open and unlocked. During an interview at this time, Resident #34 stated someone had been stealing and they did not have nor were they offered a key to the cabinet drawer. Observations on 6/27/24 at 9:13 AM included pooling water on the floor in the basement boiler room from a leaking pipe above the boilers. 10 NYCRR: 415.29, 415.29(c), 415.29(d), 415.29(g), 415.29(h)(1), 415.29(i)(1,2), 415.29(j)(1)

Based on observations and record review conducted during the Recertification Survey, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: On 6/24/24 at approximately 9:00 AM, a carbon monoxide detector was observed in the basement kitchen above the prep sink area, and the kitchen was also observed to contain a natural gas-powered range. Further observations in the basement included natural gas boilers in the boiler room and a natural gas-powered generator in the generator room. Observations on 6/26/24 from 10:46 AM to 11:05 AM included carbon monoxide detectors located on the walls in the corridor on the second floor outside resident rooms [ROOM NUMBERS]. On 6/26/24 at 10:39 AM, the surveyor requested a list of documentation from the facility via email including documentation of testing of carbon monoxide detectors. There was no documentation provided by the facility of the locations of all carbon monoxide detectors within the facility or any documentation of monthly inspection and testing of carbon monoxide detectors. The 2015 edition of the International Fire Code (IFC), requires carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance. Additionally, carbon monoxide alarms shall be maintained in accordance with NFPA 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer's published instructions at least monthly. 10 NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.1, 915.1.4, Section 1103.9, 2012 NFPA 720: 8.7.1

Based on interviews and record review conducted during the Recertification Survey, the facility did not ensure that services were provided and/or arranged for the accepted standards of quality that should have been provided for two (Residents #9 and #70) of five residents reviewed. Specifically, lab services were not provided as recommended by pharmacy and ordered by the Physician. This is evidenced by the following: When requested, the facility was unable to provide any policies related to obtaining lab work or a blood draw protocol. 1. Resident #70 had diagnoses that included dysphagia (difficulty swallowing), pneumonitis (inflammation of lung tissue), and diabetes. The Minimum Data Set Resident assessment dated [DATE] documented the resident was moderately impaired cognitively and did not exhibit behaviors or refusals of care at that time. The current Comprehensive Care Plan revised on 2/16/24 revealed Resident #70 required tube feeding related to dysphagia and could not have foods or fluids by mouth. Nursing interventions included obtaining and monitoring labs and diagnostics as ordered and reporting the results to the medical provider as indicated. Review of Resident #70's Medication Regimen Review dated 3/14/24 revealed that the pharmacist recommended a Basic Metabolic Panel (a blood test that measures the body's chemical balance and metabolism) due to receiving Lasix (a diuretic medication commonly known as a water pill that can cause multiple side effects such as electrolyte imbalances). Physician #1 agreed with the recommendation and signed the Medication Regimen Review on 3/16/24. Review of Resident #70's electronic medical record revealed no evidence that the lab work had been completed as recommended by the Pharmacist and the Physician or that the resident had refused any lab work. 2. Resident #9 had diagnoses that included diabetes, chronic kidney disease, and schizoaffective disorder (form of mental illness). The Minimum Data Set Resident assessment dated [DATE] documented the resident was moderately impaired cognitively and did not exhibit any refusals of care at that time. Review of Physician orders dated 3/8/24 revealed orders for a hemoglobin A1C (blood work used to monitor blood glucose levels) and a lipid panel (blood work used to monitor cholesterol). Review of the Medication Regimen Review for April 2024 revealed the Pharmacist's recommendation for a lipid panel and a hemoglobin A1C due to Resident #9's medication regimen. Physician #1 agreed, signed the Medication Regimen Review on 4/18/24 and again ordered a lipid panel and a hemoglobin A1C . Review of Resident #9's electronic medical records revealed no evidence that the lab work had been completed as ordered by the Physician or that the resident had refused lab work. During an interview on 6/27/24 at 12:16 PM, Registered Nurse Manager #1 said that when the provider (Physician) orders lab work, the nurses are supposed to collect the blood draws in-house on Tuesdays and Thursdays, call the hospital for the labs to be picked up, and within 24 hours the lab results should be available. Registered Nurse Manager #1 said a paper copy of the labs would come through via fax and be reviewed by a nurse and the provider before being scanned into the resident's electronic health record. During an interview on 6/27/24 at 4:40 PM, the Registered Nurse/wound care/infection control nurse stated that the labs for Residents #9 and #70 were not done as ordered and that they reached out to the medical team to see if they still wanted the labs done and they had replied yes. During an interview on 6/28/24 at 9:42 AM, Physician #1 said Resident #9 and #70's labs should have been drawn as ordered unless it was a difficult blood draw or the residents refused. In which case, Physician #1 said there should be a note in the chart, and they should have been notified as to why the labs were not completed. During an interview on 6/28/24 at 10:17 AM, the Acting Director of Nursing said the Director of Nursing was responsible for reviewing the Medication Regimen Reviews, but they had not reviewed any since they had been in their role effective 6/1/24. Additionally, the Acting Director of Nursing said they did not have an answer for why the labs were overlooked, but they would expect the nurses to document any refusals. The Acting Director of Nursing said it had not been brought to their attention that either resident had refused lab work. 10 NYCRR 415.20

Based on interviews and record review conducted during the Recertification Survey and complaint investigation (NY00313302), it was determined that for one (Resident #10) of six residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors. Specifically, there was no documented evidence that Resident #10 had received their antipsychotic medication (medications used to treat mental illness) on multiple days. This is evidenced by the following: Resident #10 had diagnosis that included paranoid schizophrenia (a type of mental illness), Crohn's disease (an inflammatory bowel disease), and diabetes. The Minimum Data Set Resident assessment dated [DATE] documented the resident had moderate impairment of cognitive function and no refusals of care or behaviors at that time. Physician orders dated 12/15/23 through 3/22/24 included clozapine 300 milligrams to be given at bedtime for chronic paranoid schizophrenia. Physician orders dated 1/2/24 included blood work for complete blood count, clozapine panel, and absolute neutrophil count for monitoring the use of clozapine. These tests were again ordered on 1/8/24. Review of the Medication Administration Record revealed that on 12/30/23, 12/31/23 and 1/3/24 the clozapine was documented as on hold. On 1/1/24 and 1/4/24 clozapine was documented as refused. On 1/6/24, 1/7/24, and 1/9/24 the Medication Administration Record documented that the clozapine was not administered due to either nausea or that resident was hospitalized . The clozapine was documented as given on 1/2/24, 1/5/24, and 1/8/24 (despite the prescription not being refilled by pharmacy). Review of Resident #10's electronic medical record revealed no evidence that the Physician ordered the medication to be held on 12/30/24, 12/31/24 and 1/3/24, no evidence that the resident refused the medication on 1/6/24, 1/7/24 and 1/9/24, no evidence that the resident had been hospitalized during that time and no evidence that the lab work had been completed following the physician orders on 1/2/24. In a nursing progress note dated 1/7/24, Registered Nurse #2 documented that they were notified by a unit Licensed Practical Nurse that Resident #10 remained out of clozapine. The progress note included that the pharmacy required a provider to update the Risk Evaluation and Mitigation Strategy program (a requirement for monitoring the severe risk for neutropenia [abnormal white blood cell count] prior to refilling clozapine prescriptions). In a medical progress note dated 1/8/24, Nurse Practitioner #2 documented that they had been working on getting Resident #10 reapplied to the Risk Evaluation and Mitigation Strategy program since late December and that the blood work would be reordered. During an interview on 6/27/24 at 12:16 PM, Registered Nurse Manager #1 said that when the provider (Physician) orders lab work, the nurses are supposed to collect the lab draws in-house on Tuesdays and Thursdays, call the hospital for the labs to be picked up and within 24 hours, the lab results should be available. Additionally, Registered Nurse Manager #1 said a paper copy of the labs would come through a fax and be reviewed by a nurse and the provider before being scanned into the resident's electronic health record. During an interview on 6/28/24 at 9:49 AM, Physician #1 stated that they were not sure what happened with the clozapine medication for Resident #10 between 12/30/23 and 1/10/24 and stated that the pharmacy would not fill the prescription until blood tests were completed. Physician #1 stated that clozapine was an antipsychotic medication and that it was an important medication for Resident #10 for behaviors and psychiatric issues. During an interview on 6/28/24 at 11:39 AM, Licensed Practical Nurse Manager #2 stated that Resident #10 was on a different unit at that time and that they were unaware of the circumstances of what occurred other than the medication was not refilled due to the bloodwork not being done and that the Nurse Manager at that time was no longer at the facility. In an interview on 6/28/24 at 12:49 PM, the Acting Director of Nursing stated that the medical providers should be responsible for a resident's required blood work and that all residents taking clozapine should have a standing order for blood work. The Acting Director of Nursing did not know who at the facility was responsible for the Risk Evaluation and Mitigation Strategy Assessments. 10 NYCRR 415.12(m)(2)

Based on observations and interview conducted during the Recertification Survey, it was determined that the facility did not properly dispose of garbage and refuse. Specifically, garbage and refuse were not contained within dumpsters and receptacles were not covered. The findings are: Observations during the exterior tour of the facility on 6/24/24 at 11:42 AM included three dumpsters with one uncovered located on the northwest corner of the property. Additionally, there was trash around and behind the dumpsters including, but not limited to: part of a lift chair, plastic gloves, various paper and plastic items, and an empty medication blister pack displaying a resident's name and drug information. During an interview following this observation, the Acting Director of Nursing was given the medication blister packet and stated that it should have been shredded, not put in the garbage. Observations on 6/27/24 at 9:24 AM included two of the three dumpsters were left with the covers open. 10 NYCRR: 415.29 (i)(1), 415.29(j)(6)(i), 415.14(h), Subpart 14-1.150

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined the facility did not ensure that resident-identifiable information was kept confidential. This was observed on two (second and third floor residential care units) of three units and outside the facility by the garbage receptacle. Specifically, there were several observations of empty medication blister packets (a way to package medications) with resident identifiable information on them in open bins on the units and accessible to all staff, residents, and visitors. Additionally, a medication blister packet with resident identifiable information on it was observed outside the facility on the ground next to a garbage receptable also accessible to the public. The facility's undated policy, Health Insurance Portability and Accountability Act Compliance and Resident Identification Information Destruction, documented that resident identification information included personal identification details and any other documents containing protected health information. The policy documented all items containing resident identification information must be disposed of using the designated bins (for shredding) located throughout the facility that will be collected and contents securely shredded by a certified document destructive service. Under no circumstances should items containing resident identification information be disposed of in regular trash or recycling bins. All employees were responsible for ensuring that documents containing resident identification information were placed in the bins immediately after they were no longer needed, and employees must not leave documents containing resident identification information in unsecured areas or unattended. During observation on 6/24/24 at 11:42 AM, an empty medication blister packet that had a resident's name and medication clearly visible on the front of the packaging was located on the ground near the garbage dumpsters. When interviewed at the time, the acting Director of Nursing stated that the medication packet should have been shredded, not put in the garbage. During an observation on 6/26/24 at 12:25 PM, on the third-floor residential care unit there were approximately 16 empty medication blister packets labeled with resident's names and medication information in an open recycling bin in the unsecured nurse's station accessible to residents, all staff, and visitors. When observed on 6/27/24 at 9:52 AM, the same bin continued to contain multiple medication blister packets all with resident's identifying information visible on them. During an observation on 6/27/24 at 10:30 AM, on the second-floor residential care unit, there were multiple medication blister packets labeled with resident's identifying information visible on the packets in a recycling bin in the unsecured nurse's station accessible to residents, all staff, and visitors. During an interview on 6/27/24 at 9:52 AM, Licensed Practical Nurse Unit Manager #1 stated the contents in the recycling bin located in the nurse's station were picked up by environmental services to go to another location for shredding from an outside company. During an interview on 6/27/24 at 9:56 AM, Licensed Practical Nurse #1 stated when the medication blister packets were empty, the tops should be removed (contains resident's name and medication information) and scratched off with a marker and then placed in the recycling bin. During an interview on 6/28/24 at 10:39 AM, the Environmental Service Supervisor stated that the bins located at the nurse's station contained important papers that have patient identifying information on them that should not be thrown out but should be placed in special bins to be shredded. Environmental Service Supervisor stated that the top of the medication blister packet (containing resident identifiers) should be given to the nurses to be placed in a bin for shredding and these bins were located on the first floor and in the Business Office. During an interview on 6/28/24 at 12:49 PM, the acting Director of Nursing stated that resident's medication labeled blister packets were considered resident identifiable information and the process for disposing them should be to remove the top portion that has resident-identifiable information on it and placed in a bin designated for protected health information, and the other part can be thrown into the garbage. The acting Director of Nursing stated this information should be in a concealed area and not in an open area that was accessible to residents and visitors and that there was a bin designated for protected health information, on the first floor. 10 NYCRR 415.22(c)

Based on interviews and record review conducted during the Recertification Survey for eight (Residents #9, 22, 32, 36, 70, 78, 102, and 112) of eight residents reviewed for Baseline Care Plans, the facility did not ensure that a Baseline Care Plan summary was provided to the residents and/or resident representatives. Specifically, the facility was unable to provide evidence that a written summary of their Baseline Care Plan (developed within 48 hours of admission and included minimum healthcare information necessary to properly care for the immediate needs of the residents and that they were able to understand) had been provided to any of the residents and/or their representatives. This is evidenced by, but not limited to the following: The facility's policy, Care Plans - Baseline revised in March 2022, documented: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. The resident and/or representative are provided a written summary of the Baseline Care Plan in a language that the resident/representative can understand. Resident #9 had diagnoses that included diabetes, chronic kidney disease, and schizoaffective disorder (a mental health condition). The Minimum Data Set Resident assessment dated [DATE], documented the resident was moderately impaired cognitively, and that it was very important to them to have their family involved in discussions pertaining to their care. Resident #70 had diagnoses that included dysphagia (difficulty swallowing), pneumonitis (inflammation of lung tissue), and diabetes. The Minimum Data Set Resident assessment dated [DATE], documented the resident was moderately impaired cognitively and able to understand others with clear comprehension. Resident #78 had diagnoses including diabetes, osteoarthritis of both hips (a degenerative joint disease), and a stage four (full thickness tissue loss) pressure ulcer of the sacral (the bottom of the spine) region. The Minimum Data Set Resident assessment dated [DATE], documented the resident was cognitively intact. Review of Baseline Care Plans for Residents #9, 70, and 78 revealed that a written summary had been developed following admission to the facility, but there was no evidence that a copy of it had been provided to any of the residents or their representatives. The area on the Baseline Care Plan designated for the resident's and/or their representative's confirmation that the summary had been reviewed and/or provided was blank for all residents reviewed. During an interview on 6/27/24 at 9:23 AM, the Director of Social Work said their process included that the resident and/or their representative would sign the Baseline Care Plan summary (after review) then they would print it and give them a copy of it. The Director of Social Work said they were only recently made aware that the Baseline Care Plans were part of the Social Worker's responsibility. During an interview on 6/28/24 at 10:09 AM, the Acting Director of Nursing said that Baseline Care Plans were the Social Worker's responsibility and that the resident and/or their representative should receive a copy of it. The Acting Director of Nursing said they had trained the Director of Social Work to enter a progress note showing they had provided a copy of the Baseline Care Plan to the resident and/or their representative and especially for the families who could not come into the facility. The Acting Director of Nursing said they were aware that the system was broken and needed fixing. 10 NYCRR 415.11

Based on interviews and record review conducted during an Abbreviated Survey (complaint #'s NY00321305, NY00322131, NY00312328), it was determined that for three of three residents reviewed, the facility failed to ensure that the residents were free from significant medication errors. Specifically, Resident #3 did not receive multiple doses of Zonisamide (anti-seizure medication) and levothyroxine (thyroid hormone replacement medication). Resident #5 did not receive multiple doses of multiple medications including but not limited to Bactrim (antibiotic), Seroquel (an antipsychotic medication) and levothyroxine. Resident #6 did not receive multiple doses of valproate (anti-seizure medication). This is evidenced by: The undated facility policy Prescribing and Ordering of Medications, documented that for new/re-admissions, hand write all orders utilizing pre-printed admission Physician's Order Sheets or send orders electronically. The facility Policy on Medication Reordering, dated 6/2/21, documented when a medication is ordered, it should be sent over to the pharmacy via the Electronic Medical Record (EMR). The pharmacy would then fill the medication and deliver it to the facility. If a medication needs to be reordered for a resident, the nurse should reorder it through the EMR. If the medication was not available for administration, then the facility would contact the medical provider for orders until the medication could be obtained. The undated facility policy Medication Errors, noted to establish a procedure for monitoring and keeping a record of any errors which may be observed in the medication system in the facility, whether they occurred through the source of supply, or in the ordering of administration of medications. The Director of Nursing (DON) and/or Supervisory Personnel will instruct licensed nursing personnel to enter any problems or errors they notice in the medication system at the facility. Licensed personnel will further be instructed to take appropriate actions to have errors corrected and to enter that information in the Medication Incident/Error Report Form. Serious errors should be brought to the attention of the nursing supervisor and/or the attending Physician immediately. In the case of a medication error, the Physician and the Pharmacist must be notified immediately. 1.Resident #3 had diagnoses that included epilepsy (seizures), hypothyroidism (low thyroid hormone levels that may cause serious complications if not treated for an extended period), and dysphagia (difficulty swallowing). Active Physician orders dated 6/14/23 included but were not limited to Zonisamide 100 milligrams (mg) daily at bedtime for seizures and levothyroxine 125 micrograms (mcg) daily for hypothyroidism. Review of Resident #3's EMR revealed that the resident was sent to the hospital on 7/30/23 due to bowel complications and readmitted [DATE]. Resident #3 was sent back to the hospital again on 8/18/23 after being found unresponsive and had not returned to the facility at the time of the survey. The August 2023 Medication Administration Record (MAR) documented that from 8/3/23 - 8/17/23, Resident #3's Zonisamide was not documented as administered 9 out of 15 days and the levothyroxine was not documented as administered 6 consecutive days from 8/4/23-8/9/23. Review of nursing progress notes generated for medications not administered, dated 8/3/23 to 8/17/23 included that the Zonisamide and levothyroxine were not administered to Resident #3 due to the medication not being available or on order from the pharmacy. There was no documented evidence that the medical team had been notified of the missed doses. In a nursing progress note dated 8/18/23 Registered Nurse (RN) #1 documented that Resident #3 was found sitting in a chair, unresponsive to painful stimuli and with shallow breathing. 911 was called and Resident #3 was sent to the hospital for evaluation. On 8/19/23 RN #1 documented that a call to the hospital informed RN #1 that Resident #3 had been admitted to an intensive care unit with questionable seizure-like activity and pneumonia. During an interview on 9/12/23 at 1:50 PM, Physician #1 stated that they saw Resident #3 on 8/11/23 and nothing (out of the ordinary) was seen on physical exam. Physician #1 stated that they do not recall being notified that the resident had not received multiple doses of their anticonvulsant medication and that they would consider this a significant medication error. Physician #1 stated that not receiving the anticonvulsant nine out of 15 days could have led to a seizure. In an email correspondence on 9/12/23 at 3:57 PM, the Pharmacy's Quality Assurance staff member stated that Resident #3's Zonisamide and levothyroxine prescriptions were filled 6/14/23 with 30 and 14 tablets respectively. On 6/21/23, Resident #3 was made inactive in the pharmacy records (due to a hospital readmission). The pharmacy staff member stated that Resident #3 was readmitted to the facility (on 6/26/23) but the medications were not reordered until 8/8/23 when levothyroxine was reordered but not Zonisamide. During an interview on 9/13/23 at 1:35 PM, LPN #6 (who signed Resident #3 MARS as medications not available on several occasions) stated that during medication pass, if a medication is not available, they would call the pharmacy and notify the doctor/medical provider. LPN #6 stated they have found that if a medication is unavailable, it is often because the doctor/medical provider had not reordered it. LPN #6 recalled caring for Resident #3 but did not recall specifically the issues with medications that were not available. After review of the MARS, when asked what they did after documenting the medication was not available, LPN #6 stated that they assumed they had called the pharmacy but could not remember if they did and stated they had not documented calling Pharmacy. LPN #6 stated they were not thoroughly trained on the computer (i.e., reordering medications). 2.Resident #5 diagnoses that included hypothyroidism (low thyroid hormone levels which can cause serious complications if untreated), bipolar disorder (a chronic mental health disease associated with often serious mood swings), and cellulitis (skin infection caused by bacteria). Physician orders included but were not limited to: a. Bactrim 800-100 mg twice daily for cellulitis of the left lower extremity for seven days, dated 8/4/23. b. Seroquel 125 mg every morning, dated 7/24/23 and 100 mg at bedtime for anxiety ordered 2/9/23 and another 50 mg was added at bedtime for bipolar disorder, dated 7/7/23. c. Levothyroxine 250 mcg daily for hypothyroidism, dated 7/22/23 and increased to 275 mcg on 8/17/23. Review of Resident #5's MAR dated 8/1/23-8/22/23 revealed that the Bactrim was not documented as administered as ordered on 2 of 14 days, the Seroquel on 13 of 23 days and the levothyroxine on 9 of 23 days. Review of nursing progress notes generated for medications not administered, dated 8/1/23 to 8/22/23 revealed that the Bactrim, levothyroxine, and Seroquel were not administered as ordered to Resident #5 due to the medication being unavailable or on order from the pharmacy. There was no documented evidence that the medical team had been notified of the missed doses. In an email correspondence on 9/12/23 at 3:57 PM, the Pharmacy's Quality Assurance staff member wrote that all the above medications were sent as ordered. 3.Resident #6 had diagnoses that included epilepsy and respiratory failure. Active physician orders dated 8/1/23-9/30/23 included valproate 750 mg three times a day for status epilepticus (type of seizure). Review of Resident #6's [DATE]/6/23 - 8/20/23, revealed valproate had not been documented as administered as ordered on 7 of 15 days with no reason given for five doses and two doses documented as not available. Review of Nursing Progress Notes dated 8/6/23 to 8/20/23 revealed no documented evidence that a medical provider had been notified that the medications were unable to be administered as ordered. In an email correspondence on 9/12/23 at 3:57 PM, the Pharmacy Quality Assurance staff member documented that valproate refills for Resident #6 had been sent to the facility as requested on 8/2/23 with a 10-day supply but that the reorder was not requested until 8/22/23. During an interview on 8/24/23 at 1:45 PM, LPN #5 stated if a medication was not available to be given, they should reorder it from the pharmacy, write a progress note and put a note in the communication book for the provider and notify their nurse manager. During an interview on 8/24/23 at 2:45 PM, RNM #1 (first floor RNM and RNM for Residents #3 and #5) stated if a nurse came across a medication that was unavailable, they should check the facility's Pyxis system (automated medication dispensing machine) if they have access to it (as they did not think all nurses did), send the refill order to the pharmacy via the EMR, call the pharmacy, and notify the nurse manager, Assistant Director of Nursing (ADON), or the DON. RNM #1 stated they have been having issues with medications not being available and that the nurses should be reordering refills timely. RNM #1 stated that if medications such as anticonvulsants are unavailable, staff should be getting a STAT (immediate) order from the medical team for the medication to be removed from the Pyxis (which has an emergency supply of specific medications) and call pharmacy. During an interview on 8/25/23 at 12:56 PM, DON #1 stated that medication refills are reordered through the EMR (by the nurses) and should be done when there is a three-to-four-day supply left. DON #1 stated if a medication was not available to be given, they should call the pharmacy, see if the medication was available in the Pyxis, and notify the nurse manager if unavailable. Additionally, DON #1 stated nurses should notify the medical provider, especially for life-sustaining medications such as antiseizure medications. DON #1 stated they were not aware of any issues with missed doses of Residents #3 and #5's anti-seizure medication due to not being available and that it would be considered a medication error. 10 NYCRR 415.12(m)(2)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (complaint #NY00320053, #NY00321305, and #NY00322131) it was determined that for three (first, second, and third floors) of three resident use floors the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, the telephone and fax systems were not functional or not functioning properly. The findings are: During an interview on 8/23/23 at 8:48 AM Certified Nursing Assistant CNA #1 stated that they do not have phones up here (third floor) and if they need help, they have to take the stairs to get help. CNA#1 stated that they had an emergency a little over a month ago and had to run downstairs to get the nurse. During an interview on 8/23/23 at 9:12 AM Director of Nursing (DON) #1 and the Assistant Director of Nursing (ADON) #1 stated that the FAX machine is not working and that the phones went out when there was a bad rainstorm, and they are now into month two with no phone system. The ADON also stated that they have given their business cards to residents to use their cell phones to call them for help, but not all residents have cell phones. During an interview on 8/23/23 at 9:15 AM Licensed Practical Nurse (LPN) #2 stated that the phones do not work on the floor and if there is an emergency, they have to use their personal cell phone or run downstairs. During an interview on 8/23/23 at 9:16 AM the Director of Medical Records/Unit Secretary (DMR) stated that the phones were out for two months. The DMR also stated that their phone and FAX in their office was still not working. The DMR stated that the copier/FAX machine on the first floor does not send or receive Faxes, and that when the phone system was down, they had to use their personal cell phones to schedule appointments. During an interview on 8/23/23 at 9:22 AM LPN #1 stated that the overhead page system is connected to the phones, so nothing works. During an interview on 8/23/23 at 9:57 AM Registered Nurse Manager (RNM) #1 stated that there has been some work on the nurse call system since Monday, but prior to that there were no call lights, no phones, and no working fax machine for over a month. RNM #1 also stated that they use the fax machine for receiving lab results and since it has not been working the results are mailed causing a delay in care. During an observation on 8/24/23 at 9:18 AM the handset for the telephone at the first-floor nurse station was picked up by the surveyor and no dial tone was heard. When the speaker button was depressed on the base of the phone a dial tone was only heard over the speaker. During an observation on 8/24/23 at 9:30 AM the second-floor nurse station telephone was unlit and inoperable. During an interview at this time LPNM #1 stated that they leave their office, next to the nurse station, unlocked so that the phone in that room can be used. During an observation on 9/7/23 at 9:11 AM the telephone at the second-floor nurse station had no dial tone. When the surveyor attempted to make an outgoing call from the phone in the nurse manager office, a message stated, 'I'm sorry, we cannot connect your call at this time.' During an interview on 9/7/23 at 10:05 AM LPN #7 (at the first-floor nurse station) stated that you must use the speaker to make or receive telephone calls at this desk phone. If there is a call of a personal nature, they take the caller's phone number and call back either with their own personal phone or the supervisor's phone for privacy. During an interview on 9/7/23 at 11:30 AM the Regional Director of Maintenance stated that they were working on getting the phones fixed. During a phone interview on 9/11/23 at 1:50 PM Physician #1 stated that they were aware of the issues with the phones and fax machine not working at the facility and that it has been going on for long time, weeks, persistent prior to 7/23/23 and since they returned from vacation on 8/4/23. Physician #1 also stated that facility leadership staff were aware of the issues at the time with the phones, fax, and internet. During a phone interview on 9/11/23 at 4:07 PM and again on 9/13/23 at 2:17 PM and 2:41 PM the Care Coordinator (CC) for a mobile X-ray company serving the facility stated that they tried to fax an X-ray to the facility for Resident #3 on five occasions beginning on 7/27/23 (date of the X-ray results) and the faxes failed. The CC stated that they followed up by emailing ADON #1 this information on four occasions, including on 7/27/23 and 7/30/23, but did not know if the facility received the emails. The CC later stated that the facility was still having difficulties with their phones, even as of today (9/11/23), that they called twice and emailed the administrator (assistant) to give them information from a resident's exam but could not get through to anyone. The CC said that when they called on 7/27/23 to confirm that the results for Resident #3 were received, they could not get through to anyone and the phone on never rang, rather, an error message came on stating 'the facility could not be reached at this time. The Acting Administrator was not available for interview. 10 NYCRR: 415.29, 415.29(b), 415.29(c)

Based on observations and interviews conducted during the Recertification Survey, it was determined that for one of one kitchen and one (third floor) of three nourishment rooms, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The issues involved an open ceiling tile above the tray line with exposed ready to eat food, improper hotholding of Time Temperature Control foods, thermometers that were not calibrated, mouse droppings on food items in the dry storage area, in the ceilings, and on the hood of the kitchen stove, and broken floor tiles in the dish room. This is evidenced by the following: 1. During the initial tour of the kitchen on 5/29/18 at 9:00 a.m. and follow-up visits that same day, the following issues were identified: a. At 9:00 a.m., the handwashing sink was not dispensing hot water because the foot pedal was broken. When interviewed at that time, the Director of Food Service (DFS) said she would call maintenance to fix the sink. b. At 9:15 a.m., the meat slicer had white residue stuck in the blade. When interviewed at that time, the DFS said that it was pieces of cloth from cleaning it, and then directed the dietary aide to get a cloth and wipe the meat slicer. c. At 3:35 p.m., there were multiple openings in the suspended ceiling tiles throughout the basement main kitchen. There was an approximately 4-inch x 8-inch opening with bowed ceiling tiles from water damage. When interviewed at that time, the Director of Maintenance said there was a leak from an overflowing sink in the first floor clean utility room. Further observations revealed hundreds of small brown mouse droppings on top of the stainless steel hood directly above the tilt skillet, plate warmer, and a cart of hamburger buns. d. At 3:42 p.m., there were multiple small brown mouse droppings on the floor in the basement dietary dry food storage room. Droppings were also observed on unopened boxes of food and on the tiles above the suspended ceiling. The ceiling grid was damaged and sagging from a prior water leak and was not tightfitting. The sagging tiles were located directly above boxes of food items on shelves including, but not limited to cereals. In addition, there was a brown liquid and dead bugs in the light fixtures in the dry storage room. 2. During observations on 5/30/18 at 11:45 a.m., there was an open tile in the main kitchen above the tray line where staff were assembling food for the lunch meal. At that time, the surveyor stopped the tray line, asked that the tile be replaced, and the exposed food be discarded. The DFS said the ceiling had been opened since the previous week because the electrician was working on fixing the steam table. 3. During an observation on 6/4/18 at 2:00 p.m., the ice water bath to check the accuracy of thermometers revealed that the digital thermometer was not calibrated. When interviewed at that time, the DFS said she checks the thermometer every morning and has had to calibrate it only three times. The temperature registered at 37 degrees (*) Fahrenheit (F). The DFS said she was unable to find the directions to recalibrate her Ecolab thermometer. She said she did not know what was wrong with the thermometer, and she was going to get a new thermometer out of supplies. Review of the Temperature Log documentation revealed that the thermometer had been recorded each day at 32 *F for the past five months. 4. In an observation on 6/5/18 at 10:35 a.m., there were pools of grayish colored water on the floor in the kitchen dishroom, and there were many cracked, broken, missing, and pitted floor tiles. 5. During an observation on 6/5/18 at 1:55 p.m., there were five approximately 8-inch deep stainless-steel pots that were covered and unlabeled sitting on a table in the kitchen. The vessels were reported by the Food Service Director and cook to contain pureed pizza, gravy, and minestrone soup. The temperature of the soup was 116.6 *F. When interviewed at that time, the cook said the items were taken off the steam table about 10 to 15 minutes ago, and they were going to get cooled down in the walk-in cooler. The facility, Sanitation Policy, dated (MONTH) (YEAR), included to keep all kitchens, kitchen area and dining areas clean, free from litter and rubbish, and protected from rodents, roaches, flies and other insects. (10 NYCRR: 415.14(h), Subpart 14-1.30, 14-1.31(a), 14-1.40(a), 14-1.95, 14-110(d), 14-1.160)

Based on observations, staff interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 115) completed on 9/14/11, it was determined that for one of four residents reviewed for care issues, the facility failed to ensure that a resident (Resident #1) was free from physical abuse. Specifically, two separate attempts were made on 9/5/11 (Labor Day Holiday) by two different Licensed Practical Nurses (LPN) to straight catheterize (cath) Resident #1 to obtain a urine sample. There was no physician's order to straight cath the resident. During the first attempt, two Certified Nursing Assistants (CNA) and LPN #1 forcibly restrained the resident. During the second attempt, three CNAs and LPN #2 forcibly restrained the resident. The resident sustained [REDACTED]. All residents continued to be at risk for potential abuse as the facility failed to take immediate action, allowing all involved staff members to remain working through 9/14/11. This resulted in IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY AND SUBSTANDARD QUALITY OF CARE and was actual harm for Resident #1. This is evidenced by the following: The facility's policy entitled, "Prevention, Investigation, and Reporting of Resident Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property," dated May 2007, described physical abuse as inappropriate physical contact with a resident, which harms or is likely to harm the resident. On Page 1 of this policy, one of the facility's examples for identification of a victim of abuse includes "parallel injuries such as bilateral bruises on the upper arm, which suggests resident was held too tightly." Resident #1, a [AGE] year-old female, has [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment, dated 5/31/11, revealed that the resident's cognitive skills for daily decision making are severely impaired. Review of a dietary note, dated 8/23/11, revealed that the resident weighed 117 pounds. Review of the physician's order, dated 9/2/11, revealed that an order was written to obtain a urinalysis, culture, and sensitivity. There were no instructions written for how to obtain the urine sample. Review of an Incident/Accident Report, dated 9/6/11, revealed that at 10:36 a.m., staff reported that the resident was bruised on the right side of her face, on the right shoulder, and upper extremity. Review of physician progress notes [REDACTED]. was discolored and [MEDICAL CONDITION]. On 9/8/11, the NP documented that the "shoulder was very forward . . . Right clavicle was angled . . . x-ray shows mid third clavicle fracture." According to a timeline presented by the Director of Nursing (DON) on 9/13/11 at 2:50 p.m., the Registered Nurse Supervisor reported Resident #1's right face and shoulder bruises on 9/7/11. The DON initiated the investigation that day. This timeline included an x-ray, dated 9/8/11, which revealed a [MEDICAL CONDITION] third portion of the right clavicle with overriding of fracture fragments. On 9/9/11, the facility interviewed staff that were on duty and involved in the incident of 9/5/11. The facility documented that the resident was restrained during a straight cath procedure. The facility failed to take action to remove alleged perpetrators from direct care of residents until after surveyor intervention on 9/14/11. Review of daily staffing sheets, dated 9/8/11 through 9/14/11, revealed that CNA #1, CNA #2, CNA #3, LPN #1, and LPN #2 all worked one or more days during this time period providing direct care to residents. Interviews conducted on 9/13/11 are as follows: a. At 10:30 a.m., CNA #1 stated that on 9/5/11, she was asked to assist with Resident #1's straight catheterization. CNA #1 reported that she held the resident's left leg down while the resident was wiggling on her right side. CNA #2, CNA #3, LPN #1, and LPN #2 also assisted. The resident screamed, "No, no, no, no." CNA #1 said she knows that staff is not allowed to restrain a resident. She did not think they had done anything wrong while the resident was being straight catheterized. b. At 10:55 a.m., CNA #2 stated that on 9/5/11, she and four other staff members assisted with a straight catheterization. CNA #2 stated that she held the resident's right leg down under her knee while the resident squirmed quite a bit. LPN #1 attempted to insert the catheter unsuccessfully. LPN #2 entered the room and said, "Lets get this over with," and proceeded to insert the catheter with success. CNA #2 reported that once the catheter was in, the resident calmed down. c. At 3:50 p.m., the Nurse Practitioner (NP) stated that on 9/2/11, she ordered a urine test for culture and sensitivity to antibiotics. She did not order a straight catherization to collect this sample. The NP reported that residents should not be restrained to perform a straight catheterization. Interviews conducted on 9/14/11 are as follows: a. At 9:30 a.m., LPN #1 stated that on 9/5/11, she was told she needed to get a urine sample for urinalysis from the resident. LPN #1 reported that during the first attempt to get the urine sample, CNA #3 held the resident's left hand, CNA #2 held the resident's right leg and hand, and LPN #1 held the resident's left leg. LPN #1 said she could not get the catheter in because the resident kept moving and reported to LPN #2 that she could not get a urine sample. LPN #2 brought them all back to the room to try again. LPN #1 said she grabbed the resident's left leg, CNA #3 had the left hand, CNA #1 had the right leg, and CNA #2 had the right hand. LPN #1 reported that the resident said, "Ow, ow, it hurts!" while LPN #2 inserted the catheter. When asked at this time if you need a physician's order to do a straight cath, LPN #1 said she never knew it had to say straight cath in the order to be able to get the urine sample by straight cath. b. At 11:00 a.m., the Medical Director/Resident's physician stated that when a physician orders a urinalysis, culture, and sensitivity test, the urine sample should be a clean catch. Nursing would have to ask for an order to do a straight cath. It needs to be written down. The Medical Director also stated that the videos of the resident prior to the injuries revealed no fall or bumping, and, up to this point, he thought it was a spontaneous fracture. He reported that he was not told that four staff members held the resident down for a straight cath procedure and that this would explain the resident's injuries. c. At 12:05 p.m., CNA #3 stated that on 9/5/11, a nurse asked for help because the resident was very combative. CNA #3 said she was at the head of the bed holding the resident's hands. LPN #1 held the left leg, and CNA #2 held the right leg, as the resident was very combative, yelling, screaming and kicking. CNA #3 reported that when LPN #1 was not able to get a sample, LPN #2 was successful with a different catheter. d. At 2:30 p.m., the Acting Administrator reported that she learned of the resident's bruises on 9/7/11, and did not realize until 9/9/11, that four staff members held the resident down during a straight catheterization. e. At 3:15 p.m., LPN #2 stated that before she attempted to straight cath the resident, she observed that the resident's vagina was very irritated. LPN #2 said that she did not know how long LPN #1 attempted, but she got right in. f. At 3:30 p.m., LPN #1 stated that her first attempt to straight catheterize the resident took 5 minutes, and the second attempt took 10 minutes. (10 NYCRR 415.4(b)(1)(i))

Based on observations, staff interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 115) completed on 9/14/11, it was determined that for one of four residents reviewed for care issues, the facility failed to thoroughly investigate and report an injury of unknown origin to the New York State Department of Health Complaint Hotline in a timely manner to ensure that a resident remained safe and that services were delivered in accordance with physician orders. The facility failed to recognize and act upon a physically abusive incident, to prevent the possibility of further abuse/neglect posing a serious risk to resident safety. Specifically, two different Licensed Practical Nurses (LPN) made two different attempts on 9/5/11 (Labor Day Holiday) to straight catheterize (cath) Resident #1 to obtain a urine sample. There was no physician's order to straight cath the resident. During the first attempt, two Certified Nursing Assistants (CNA) and LPN #1 forcibly restrained the resident. During the second attempt, three CNAs and LPN #2 forcibly restrained the resident. The resident sustained [REDACTED]. All residents continued to be at risk for potential abuse, as the facility failed to take immediate action, allowing all involved staff members to remain working through 9/14/11. This resulted in IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY AND SUBSTANDARD QUALITY OF CARE, and is evidenced by the following: The facility's policy entitled, "Prevention, Investigation, and Reporting of Resident Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property," dated May 2007, described physical abuse as inappropriate physical contact with a resident, which harms or is likely to harm the resident. On Page 1 of this policy, one of the facility's examples for identification of a victim of abuse includes "parallel injuries such as bilateral bruises on the upper arm, which suggests resident was held too tightly." On Page 2, under Reporting, the policy includes, "on holidays, the direct Supervisor will report the alleged abuse to the Nursing Supervisor who will immediately commence a full investigation. The Nursing Supervisor will immediately call the designated Administrator on call . . . to ensure an investigation takes place and the resident is protected." On Page 3, the Director of Nursing is charged with removing the alleged perpetrator/perpetrators from the residential unit until further notice and informing the resident that this has taken place. Resident #1 is 73-years old with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment, dated 5/31/11, revealed that the resident's cognitive skills for daily decision making are severely impaired. Review of a dietary note, dated 8/23/11, revealed that the resident weighed 117 pounds. Review of the physician's order, dated 9/2/11, revealed that an order was written to obtain a urinalysis, culture, and sensitivity. There were no instructions written for how to obtain a urine sample. Review of an Incident/Accident Report, dated 9/6/11, revealed that at 10:36 a.m., staff reported that the resident was bruised on the right side of her face, on the right shoulder, and upper extremity. Review of physician progress notes [REDACTED]. was discolored and [MEDICAL CONDITION]. On 9/8/11, the NP documented that the, "shoulder was very forward . . . Right clavicle was angled . . . x-ray shows mid third clavicle fracture." According to a timeline presented by the Director of Nursing (DON) on 9/13/11 at 2:50 p.m., the Registered Nurse Supervisor reported to her that she was informed that Resident #1 had right face and shoulder bruises on 9/7/11. The DON initiated the investigation that day. This timeline included an x-ray, dated 9/8/11, which revealed a [MEDICAL CONDITION] third portion of the right clavicle with overriding of fracture fragments. On 9/9/11, the facility interviewed staff that were on duty and involved in the incident of 9/5/11. The facility documented that the resident was restrained during the straight cath procedure. The facility failed to take action to remove alleged perpetrators from direct care of residents until after surveyor intervention on 9/14/11. Review of the daily staffing sheets revealed that all five employees involved in restraining the resident worked one or more days from 9/8/11 through 9/14/11 in direct care of residents. Interviews conducted on 9/13/11 are as follows: a. At 10:30 a.m., CNA #1 stated that on 9/5/11, she was asked to assist with Resident #1's straight cath. CNA #1 reported that she held the resident's left leg down while the resident was wiggling on her right side. CNA #2, CNA #3, LPN #1, and LPN #2 also assisted. The resident screamed, "No, no, no, no." CNA #1 said she knows that staff is not allowed to restrain a resident. She did not think they had done anything wrong while the resident was being straight catheterized. CNA #1 stated that she was not asked to write a statement until 9/13/11 and continued to work after the incident. b. At 10:55 a.m., CNA #2 stated that on 9/5/11, she and four other staff members assisted with a straight cath. CNA #2 stated that she held the resident's right leg down under her knee while the resident squirmed quite a bit. LPN #1 attempted to insert the catheter unsuccessfully. LPN #2 entered the room and said, "Let's get this over with," and proceeded to insert the catheter with success. CNA #2 reported that once the catheter was in, the resident calmed down. CNA #2 stated that she was asked to write a statement on 9/12/11 and continued to work after the incident. c. At 2:50 p.m., LPN #2 stated that on 9/5/11, LPN #1 told her that she could not obtain the urine sample because the resident was fidgeting and moving around. LPN #2 stated that with CNAs #1, #2, and #3, and LPN #1 holding the resident's legs and arms, she was able to obtain the urine sample. LPN #2 stated that during the procedure, the resident was fidgeting, moving around, fighting, and did not want to be touched. d. At 3:50 p.m., the Nurse Practitioner (NP) stated that on 9/2/11, she ordered a urine test for culture and sensitivity to antibiotics. She did not order a straight cath to collect this sample. The NP reported that residents should not be restrained to perform a straight cath. Interviews conducted on 9/14/11 are as follows: a. At 9:30 a.m., LPN #1 stated that on 9/5/11 she was told she needed to get a urine sample for urinalysis from the resident. LPN #1 reported that during the first attempt to get the urine sample CNA #3 held the resident's left hand, CNA #2 held the resident's right leg and hand, and LPN #1 held the resident's left leg. LPN #1 said she could not get the catheter in because the resident kept moving and reported to LPN #2 that she could not get a urine sample. LPN #2 brought them all back to the room to try again. LPN #1 said she grabbed the resident's left leg, CNA #3 had the left hand, CNA #1 had the right leg, and CNA #2 had the right hand. LPN #1 reported that the resident said, "Ow, ow, it hurts!" while LPN #2 inserted the catheter. When asked at this time if you need a physician's order to do a straight cath, LPN #1 said she never knew it had to say straight cath in the order to be able to get the urine sample by straight cath because the resident was incontinent. LPN #1 stated she was told she was suspended at this time, effective when she arrived for work on 9/14/11, did work prior to this date, and was not asked to write a statement about the incident. b. At 11:00 a.m., the Medical Director/Resident's physician stated that when a physician orders a urinalysis, culture, and sensitivity test, the urine sample should be a clean catch. Nursing would have to ask for an order to do a straight cath. It needs to be written down. The Medical Director also stated that the videos of the resident prior to the injuries revealed no fall or bumping, and, up to this point, he thought it was a spontaneous fracture. The Medical Director reported that he was not told that four staff members held the resident down for a straight cath and that this would explain the injuries. c. In a telephone interview at 12:05 p.m., CNA #3 stated that on 9/5/11 a nurse asked for help because the resident was very combative. CNA #3 said she was at the head of the bed holding the resident's hands. LPN #1 held the left leg, and CNA #2 held the right leg, as the resident was very combative, yelling, screaming, and kicking. CNA #3 reported that when LPN #1 was not able to get a urine sample, LPN #2 was successful with a different catheter. CNA #3 stated that when a resident is combative, she is supposed to stop and leave and go back later, but she is "not a nurse." CNA #3 stated she was asked to write a statement on 9/12/11. d. At 2:30 p.m. in a joint interview with the Acting Administrator, newly hired Adminstrator, and the DON, all reported that they learned about the resident's bruises and fractured clavicle on 9/7/11. When asked why an x-ray was ordered on [DATE], they stated that the resident's bruising was intense and the resident's cheek was swollen. They reported that they did not realize until 9/9/11 that four staff members held the resident down during a straight cath. When staff members involved in restraining the resident were asked to write statements, LPN #1, LPN #2, and CNA #1 refused to write statements. e. At 3:15 p.m., LPN #2 stated that before she attempted to straight cath the resident, she observed that the resident's vagina was very irritated. She did not know how long LPN #1 had attempted to insert the catheter. LPN #2 stated that she has never been asked to write a statement about this incident. f. At 3:30 p.m., LPN #1 stated that her first attempt to straight cath the resident took five minutes, and the second attempt made by LPN #2 took ten minutes. (10 NYCRR 415.4(b)(1)(ii))