Every finding on record at The Pines Healthcare & Rehab CTRS Machias Campus

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00359779, and #NY00363581) during an Extended Standard survey completed on 2/3/2025, the facility failed to protect residents from abuse by other residents for three (3) (Resident #17, #71, and #75) of 12 residents reviewed. Specifically, on 11/4/2024, Resident #68 struck Resident #71 in the face with their walker, resulting in a laceration across the bridge of Resident #71's nose, and skin tears to their right cheek and chin. Additionally, on 12/5/2024, 12/10/2024, and 12/11/2024, physical altercations occurred between Residents #17 and #75, who were roommates and remained roommates until after the third altercation on 12/11/2024. This resulted in actual harm to Resident #71. The findings are: The policy titled Abuse/Neglect - Reporting Process, last revised 12/15, documented it is the policy of the facility to treat all residents with kindness, dignity, and consideration. They ensure all residents are free from verbal, sexual, physical, and mental abuse. The policy titled Abuse Preventing and Reporting, last revised 9/23, documented an abusive act is defined as any act of commission or omission that causes potential or actual physical or emotional harm or injury to a resident. Physical abuse is defined as any act or omission which may cause or causes physical pain, harm or injury to the resident or where it is reasonable to believe that pain, harm or injury would result. Physical abuse may include, but is not limited to slapping, pinching, kicking, pushing or rough handling, and/or failure to intervene in a resident altercation that results in physical harm to a resident. 1. Resident #68 had diagnoses that included unspecified dementia with behavioral disturbance, restlessness, and agitation. The Minimum Data Set (a resident assessment tool) dated 10/9/2024 documented Resident #68 was severely cognitively impaired, was usually understood, and usually understands. The Kardex (a guide used by staff to provide care) dated 1/31/2025 documented Resident #68 was independent with ambulation on the unit, using a rolling walker. The facility could not provide a Kardex for the time of the abuse 11/4/2024. The comprehensive care plan dated 6/18/2021 documented Resident #68 had a history of physical and verbal aggression, intolerance of noise and of others entering their room, related to dementia. Staff were to assess and anticipate resident's needs, intervene before agitation escalates, guide away from source of distress, and allow to share feelings. On 2/2/2024 a Velcro stop sign was added across entry doorway as needed and the door to their room was to be closed. Resident #71 had diagnoses that included chronic obstructive pulmonary disorder (lung disease that blocks airflow and make it difficult to breath), unspecified dementia without behavioral disturbance, and depression. The Minimum Data Set, dated dated dated [DATE] documented Resident #71 was severely cognitively impaired, sometimes understands, was sometime understood, continuously had disorganized thinking and wandered occasionally. The Kardex dated 1/31/2025 documented Resident #71 was independent with wheelchair mobility on the unit. The facility could not provide a Kardex for the time of the abuse 11/4/2024. The comprehensive care plan identified as current, dated 6/12/2023, documented Resident #71 had impaired cognitive function related to dementia and to cue, reorient and supervise as needed. The comprehensive care plan documented Resident #71 had a communication problem related to a hearing deficit. Staff were to anticipate and meet needs and to be conscious of Resident #71's position when in groups, activities, and dining room to promote communication with others. The comprehensive care plan did not document that Resident #71 wandered into unsafe places or displayed behaviors directed towards others. Review of the resident-to-resident incident reports for Resident #71 and Resident #68 completed by Registered Nurse #1, and the facility's investigation report completed by the Director of Nursing dated 11/4/2024, revealed at 2:45 PM, Resident #71 was propelling their wheelchair down the hallway when they opened Resident #68's room door and started to enter. Resident #68 met Resident #71 in the doorway, lifted their walker to Resident #71's face, and began pushing them out of their room. Resident #71 began yelling, which alerted staff, who then immediately intervened and separated the two (2) residents. Resident #71 sustained a skin tear to their right cheek and chin and a laceration across the bridge of their nose with a moderate amount of bloody drainage. Bruising was also noted across their nose. Resident #71 was visibly upset and showed moderate signs of pain and discomfort. Tylenol was given, the wounds were cleansed, and steri-strips (thin, sticky bandages applied to skin to help cuts or wounds stay closed) were applied to their right cheek and nose, along with a dry clean dressing to their chin. X-rays were obtained and were negative for any fractures. Resident #68 became aggressive towards staff and was sent to the emergency room for evaluation. The reports documented Resident #68 had a history of aggression towards other residents and staff, had a private room for safety, and the door was kept shut. The resident-to-resident reports and the facility investigation report did not document the stop sign was in place across Resident #68's door at the time of the abuse on 11/4/2024. Interdisciplinary progress notes dated 11/4/2024 through 11/11/2024 documented staff monitored and treated Resident #71's facial injuries (bruising, swelling, laceration, scratches) and administered Tylenol as needed for visible signs of pain. The Medication Administration Record dated 11/1/2024 -11/30/2024 documented Resident #71 was administered Tylenol 500 milligrams nine (9) times for pain between 11/5/2024 and 11/10/2024 after they were struck in the face by Resident #68. Prior to 11/4/2024, Resident #71 had not been receiving pain medication. During observations on 1/27/2025 between 9:42 AM and 10:01 AM, both Residents #71 and #68 were in their rooms, directly across the hall from each other. Resident #68's door was closed and had a stop sign across their doorway. During an interview on 1/29/2025 at 11:44 AM, Licensed Practical Nurse #1 stated Resident #68 did not like people in their personal space and most incidents involving this resident on the unit involved other people entering their room. They stated that if someone got too close to Resident #68, they would become provoked and would attempt to hit the other person. Licensed Practical Nurse #1 stated they did not know if the stop sign was in place on Resident #68's door on 11/4/2024 at the time of the attack. Additionally, they stated Resident #71 had difficulty hearing, so other residents get frustrated when they tried to talk to them. During an interview on 1/29/2025 at 11:51 AM, Certified Nurse Aide #1 stated they were at the nurse's station on 11/4/2024 when they saw Resident #71 wheel down the hallway to Resident #68's room, open the door and enter. They then heard yelling and started to walk down the hallway when they saw Resident #68 push Resident #71 out of their room with their walker. Resident #68 had already closed the door and returned to their room when Certified Nurse Aide #1 arrived at the incident. They stated Resident #71 was bleeding from areas on their face that corresponded with where the walker had hit them. Certified Nurse Aide #1 stated they did not recall if the stop sign was across Resident #68's door on 11/4/2024. The unit had a lot of wanderers who would remove stop signs across doors, and staff did their best to redirect residents. During an observation on 1/30/2025 at 11:18 AM, Resident #68 was in their room, the door was closed and there was no stop sign across the entry way. Resident #71 was in their room across the hall watching television. During an interview on 1/30/2025 at 11:23 AM, Licensed Practical Nurse #1 stated Resident #71 had swelling, bruising to their face and showed signs of pain for days following the incident, requiring Tylenol to relieve the pain. Additionally, they stated they did not know why the stop sign was missing from Resident #68's doorway. They stated other residents frequently go around the unit and remove them, and staff have to look through rooms to find them. During an interview on 1/30/2025 at 11:30 AM, Social Worker #1 stated following the incident on 11/4/2024, Resident #71 was assessed, was holding their injuries and appeared to be in pain. Social Worker #1 stated Resident #68 was assessed and sent to the hospital for evaluation of their increased aggression, and upon their return was seen by the facility provider for their behaviors. Their mood fluctuates because of their dementia. They stated if Resident #68 was in a bad mood, they preferred to be alone and that was why they were care planned to have their door shut. Social Worker #1 stated they did not know if the stop sign was across Resident #68's door on 11/4/2024 at the time of the incident. During an interview on 1/30/2025 at 12:30 PM, Registered Nurse Head Nurse #2 stated there were stop signs across doorways on the memory care unit to deter residents from entering rooms that were not theirs, but residents removed them and hid them. Staff constantly had to check for stop signs and would replace them when they noticed they were missing. During an interview on 1/30/2025 at 1:10 PM, the Medical Director stated Resident #68 was evaluated following an incident that included them having aggressive, assaultive behaviors towards Resident #71. During a telephone interview on 1/30/2025 at 2:06 PM, Registered Nurse #1 stated on 11/4/2024 around 3:00 PM they were paged to the memory care unit. Staff stated they heard screaming and responded to find Resident #68 hitting Resident #71 in the face with their walker. Resident #68 picked the walker up and brought it down on Resident #71's face a couple times. The residents were separated. Resident #71 was assessed, neuro checks were initiated, and first aid was rendered to their facial injuries. Resident #71's Health Care Proxy was called, and they did not want them to be sent to the hospital. The Medical Director was updated and ordered an x-ray of Resident #71's nose and orbitals (eye socket). Registered Nurse #1 that Resident #68 was assessed and was aggressive towards staff, so they were sent to the hospital for an evaluation. Registered Nurse #1 stated that Resident #68 had worsening aggression, behaviors, and confusion in the weeks leading up to the incident. Registered Nurse #1 stated they had been concerned something bad was going to happen. They could just flip a switch. Resident #68 didn't like other people in their personal space and would push people towards the door with their walker if they entered their room. Registered Nurse #1 stated they arrived after the incident and did not know if the stop sign was in place prior to the incident. They stated they had brought their concerns to the Director of Nursing, Administration, and the Medical Director before 11/4/2024 because of Resident #68's history of aggression toward others. Resident #68 had recently been evaluated in the hospital for increased aggression because they were a safety issue to staff and other residents with no findings. Registered Nurse #1 stated Resident #71 was nonverbal, but after the 11/4/2024 incident you could see it on their face, they were worried when wheeling around the unit. During a telephone interview on 1/31/2025 at 8:32 AM, Resident #68's Health Care Proxy stated they were made aware of the incident on 11/4/2024. They were told there was a physical altercation between Resident #71 and another resident, resulting in a minor cut to Resident #71's cheek. They were not aware Resident #71 was hit in the face with a walker. Resident #71's Health Care Proxy stated that if Resident #71 was in their right mind they would have been very upset at the situation and would have been afraid of the person doing this to them. During a telephone interview on 2/3/2025 at 8:40 AM, Risk Management Investigator #1 stated they don't typically investigate resident-to-resident incidents. If it's a reportable incident with a major injury, they may work jointly on the investigation. Risk Management Investigator #1 stated they did not work on this case with the facility and would have expected to be notified. A resident striking another resident with a walker causing cuts and swelling to the face would be considered a major injury. During an interview on 2/3/2025 at 10:40 AM, the Director of Nursing stated they investigated the incident on 11/4/2024 involving Resident #68 and #71. Resident #68 had a history of aggressive behaviors directed towards others. The Director of Nursing stated that Resident #68 was aggressive about Resident #71 entering their room. During the interview, the Director of Nursing reviewed Resident #71's nursing progress notes and stated following the incident, Resident #71 displayed signs of discomfort, was visibly upset, and was medicated for pain. They stated Resident #68 caused harm to Resident #71 during the incident on 11/4/2024. During an interview on 2/3/2024 at 11:46 AM, the Administrator reviewed Resident #71's nursing progress notes and stated, It is safe to say Resident #71 was exhibiting signs of fear and pain following the incident on 11/4/2024 with Resident #68. 2. Resident #17 had diagnoses that included unspecified dementia with mood disturbance, depression, and anxiety. The Minimum Data Set, dated dated dated [DATE] documented Resident #17 was moderately cognitively impaired, was usually understood, and usually understands. The Kardex dated 12/6/2024 documented Resident #17 required an assist of one for ambulation with a rolling walker, was independent for wheelchair mobility on the unit, and required 15-minute checks. Facility could not provide a Kardex for the day of the altercation, 12/5/2024. The comprehensive care plan dated 9/30/2024 documented Resident #17 had impaired cognition and was dependent on staff for meeting emotional, intellectual, physical and social needs. The care plan documented on 10/23/2024, the resident physically grabbed and slapped another resident in the hallway. Approaches included to invite to scheduled activities and may need one-to-one visits. The care plan documented on 12/5/2024, the resident was hit by another resident due to going through their things; on 12/10/2024 the resident was slapped by another resident who thought resident had taken their walker. Approaches included to cue, reorient and supervise as needed. Additionally, the care plan documented Resident #17 was found crawling on the floor on 12/11/2024. The 15-minute checks were not documented on the comprehensive care plan. Resident #75 had diagnoses that included Alzheimer's disease, Bell's palsy (temporary paralysis or weakness of the facial muscles on one side of the face), and dementia without behavioral disturbance. The Minimum Data Set, dated dated dated [DATE] documented Resident #75 was severely cognitively impaired, sometimes understands, was sometimes understood, and had fluctuating disorganized thinking. The Kardex dated 12/6/2024 documented Resident #75 was independent with a rolling walker for ambulation on the unit. The Kardex documented on 12/6/2024, 15-minute checks were initiated. The facility could not provide the Kardex for the day of the altercation, 12/5/2024. The comprehensive care plan dated 6/21/2024 documented Resident #75 had a communication problem related to oral deformity, Bell's palsy, and hearing deficits. Resident #75 had impaired cognitive function related to dementia and could be possessive over other residents. On 9/13/2024, Resident #75 hit another resident. Staff were to anticipate the needs of the resident. Resident #75 wandered and had impaired safety awareness. The care plan documented on 12/5/2024, hit another resident for going through their things and the other resident hit back; on 12/10/2024, Resident #75 slapped another resident due to thinking they took their walker. Approaches included a Velcro stop sign across entry way and to cue, reorient and supervise as needed. Fifteen- minute checks were initiated on 12/5/2024 after the altercation but were not documented on the comprehensive care plan. Review of Resident #17's progress notes dated 12/2/2024 included Social Worker #1 documented a room change occurred on 12/2/2024. The nursing home facility investigative report, dated 12/5/2024 and completed by the Administrator, documented Resident #75 observed Resident #17 going through their belongings and slapped Resident #17 on the face. Resident #17 slapped Resident #75 back, also on the face. The incident was reported to Licensed Practical Nurse #1 by Resident #17, and while they were talking to Licensed Practical Nurse #1 about the incident, Resident #75 approached to tell their side of the story. Residents were new roommates, and both were able to ambulate independently. Resident #17 indicated they did not like their living arrangement. Both residents were placed on 15-minute checks to monitor their whereabouts and to avoid further altercations. The resident-to-resident incident report Resident to Resident Physical Contact for Resident #75 dated 12/10/2024, completed by Registered Nurse Head Nurse #4, documented Resident #75 came out to the dining room and accused Resident #17 of stealing their walker, attempted to take it back, and began hitting Resident #17 on their arms. The residents were separated; 15-minute checks were still in place at the time and continued. Review of Resident #17's nursing progress notes dated 12/10/2024 at 8:15 AM and 8:19 AM included Licensed Practical Nurse #1 documented they witnessed Resident #75 smack Resident #17 because they thought Resident #17 took their walker. They were separated and placed on opposite sides of the dining room. Resident #17 had a red mark on their left arm and was crying. One-to-one was provided to Resident #17 and 15-minute checks continued. The resident-to-resident incident report Resident to Resident Physical Contact for Resident #75 dated 12/11/2024, completed by the Assistant Director of Nursing, documented Certified Nurse Aide #10 saw Resident #75 walking towards their room and when they entered, heard Resident #17 say, It is my bathroom too. Certified Nurse Aide #10 heard a noise and went to check. They observed Resident #17 and Resident #75 crawling around on their bedroom floor. Resident #75 stated Resident #17 pulled them down. The incident report documented Resident #17 and #75, who were roommates, had been having difficulty getting along. To avoid further potential negative interaction, Resident #75 was moved to a private room on another unit. During an interview on 1/27/2025 at 9:51 AM, Resident #17 stated they tended to get upset when they were in group settings. Resident #17 stated they remembered slapping someone because they wouldn't leave them alone, so they had to push them away. Resident #17 appeared paranoid and anxious during the interview. During an interview on 1/29/2025 at 11:40 AM, Licensed Practical Nurse #1 stated Resident #17 and Resident #75 had been arguing for a couple days and had slapped each other. On 12/11/2024 Certified Nurse Aide #10 found them crawling on the floor in their bedroom after slapping each other. They stated Resident #17 seemed afraid of Resident #75. During an interview on 1/29/2025 at 10:29 AM, Certified Nurse Aide #1 stated Resident #17 and Resident #75 were not a good match for roommates because they each thought someone else was always stealing from them and could be very possessive over things. During a telephone interview on 1/30/2025 at 2:17 PM, Registered Nurse #1 stated the two residents became roommates because room changes needed to occur to accommodate male beds on the secure unit. Resident #75 also had room change in September because they had an altercation with their previous roommate. Resident #17 recently moved to the secure unit for safety related to their wandering. Registered Nurse #1 stated they were not surprised when the residents had issues after becoming roommates because they both had issues with other residents in the past. Registered Nurse #1 stated they brought up their concerns with them not being compatible roommates at their weekly interdisciplinary meetings with Administration, the Director or Nursing, therapy, dietician, unit managers, and staffing, but there was no other available bed on the secure unit. Resident #75 was eventually moved after the incident on 12/11/2024, and that had helped Resident #17 with their paranoia. A call was placed to Certified Nurse Aide #10 1/31/2025 at 12:23 PM without success. During an interview on 2/3/2025 at 10:29 AM, the Director of Nursing stated Resident #17 and Resident #75 were put on 15-minute checks following the incident on 12/5/2024 and remained roommates. There were no available beds on the secure unit, and they were attempting to keep both residents on the secure unit. They stated the incident that occurred on 12/10/2024 happened in the dining room, so it did not indicate a room change. The incident on 12/11/2024 was not witnessed, so they only had the residents' account. They eventually moved Resident #75 off the secure unit after the incident on 12/11/2024 to avoid further conflict. NYCRR 415.4(b)(1)(i)

Based on interviews and record review conducted during a Complaint investigations (#NY00330289, #NY00359779, #NY00363581, #NY00341814, #NY00354482, #NY00331807, #NY00357719, #NY00363961) completed during an extended Standard survey on 2/3/25, the facility did not ensure that all alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to administrator of the facility and to other officials (including to the State Survey Agency) for 10 (#17, #30, #42, #47, #68, #71, #72, #75, #95 and #161) of 12 residents reviewed. Specifically, allegations of resident abuse (#47, #68, #71, #17, #75, #72, and #161) and injuries of unknown origin (# 95) were not reported within 2 hours to State Agency. Additionally, resident neglect (#30, #42 and #161) was not reported within 24 hours to the State Agency. This resulted in no actual harm with the potential to affect all residents that is substandard quality of care. The findings are: The policy and procedures titled Abuse/Neglect - Reporting Process dated 12/2015, documented it is the policy of the facility to comply with all State and Federal regulations with regards to abuse and neglect. The New York State Department of Health will be notified of any resident abuse or neglect, whether suspected or confirmed. The Nursing Supervisor will notify the Administrator and Nursing Director. The Administrator will notify the Social Worker. The Administrator and/or Nursing Director will take responsibility for notifying the State Health Department within five working days that abuse/neglect has occurred. a. Resident #47 had diagnoses including morbid obesity, depression, and heart failure. The Minimum Data Set (a resident assessment tool) dated 10/17/24 documented Resident #47 was cognitively intact. The nursing home facility investigation report submitted successfully to the State Agency competed by the Administrator documented that Resident #47 reported to Social Worker #1 that Certified Nurse Aide #9 had touched them inappropriately during incontinent care a couple days prior. The incident was documented to have occurred on 10/15/24 at 2:00 PM, staff was first made aware on 10/17/24 at 3:00 PM, the Administrator was first made aware on 10/17/24 at 3:00 PM and reported the allegation to the State Agency on 10/18/24 at 1:46 PM. During a telephone interview on 2/3/25 at 8:26 AM, Investigator #1 stated they were notified of Resident #47's allegation on 10/17/24. They considered this allegation to be one of sexual abuse and should have been reported to the State Agency within two hours. During an interview on 2/3/25 at 9:33 AM, the Director of Nursing stated being inappropriately touched was considered sexual abuse. They stated the facility investigative report documented the incident was submitted to the State Agency on 10/18/24 at 1:46 PM and it should have been reported sooner because it was a potential abuse allegation. b. Resident #68 had diagnoses including dementia with behavioral disturbance, restlessness, and agitation. The Minimum Data Set, dated dated dated [DATE] documented Resident #68 was severely cognitively impaired Resident #71 had diagnoses that included chronic obstructive pulmonary disorder (lung disease that blocks airflow and make it difficult to breath), dementia without behavioral disturbance, and depression. The Minimum Data Set, dated dated dated [DATE] documented Resident #71 was severely cognitively impaired. Review of the resident-to-resident incident reports for Resident #71 and Resident #68 completed by Registered Nurse #1, and the facility's investigation report completed by the Director of Nursing dated 11/4/2024, revealed at 2:45 PM Resident #71 was propelling their wheelchair down the hallway when they opened Resident #68's room door and started to enter. Resident #68 met Resident #71 in the doorway, lifted their walker to Resident #71's face, and began pushing them out of their room. Resident #71 began yelling, which alerted staff, who then immediately intervened and separated the two (2) residents. Resident #71 sustained a skin tear to their right cheek and chin and a laceration across the bridge of their nose with a moderate amount of bloody drainage. Bruising was also noted across their nose. Resident #71 was visibly upset and showed moderate signs of pain and discomfort. Tylenol was given, the wounds were cleansed, and steri-strips (thin, sticky bandages applied to skin to help cuts or wounds stay closed) were applied to their right cheek and nose, along with a dry clean dressing to their chin. X-rays were obtained and were negative for any fractures. Resident #68 became aggressive towards staff and was sent to the emergency room for evaluation. The reports documented Resident #68 had a history of aggression towards other residents and staff, had a private room for safety, and the door was kept shut. The resident-to-resident reports and the facility investigation report did not document the stop sign was in place across Resident #68's door at the time of the abuse on 11/4/2024. The nursing home facility investigation report was submitted successfully to the State Agency on 11/6/24 at 3:18 PM by the Director of Nursing. During an interview on 1/29/25 at 1:56 PM, the Director of Nursing stated the facility had 48 hours to submit a report so that is why this incident was reported and submitted on 11/6/24. c. Resident #95 had diagnoses of dementia, muscle weakness, and a fracture of right wrist. The Minimum Data Set, dated dated dated [DATE] documented Resident #95 was severely cognitively impaired. Review of a facility report titled, Incident-by-Incident Type, dated 12/20/23 at 12:21 PM submitted by the Director of Nursing documented Resident #95 had an injury of unknown source (acute fracture of fourth finger right hand) identified on 12/19/23 at 11:29 AM. The nursing home facility investigation report submitted successfully to the State Agency on Wednesday 12/20/2023 at 2:31 PM by the Director of Nursing for allegations of injury of unknown source (acute fracture of fourth finger right hand). The report documented the incident occurred was on Tuesday 12/19/23 at 11:29 AM. The Administrator was first made aware of the incident on Wednesday 12/20/23 at 12:13 PM. d. Resident #17 had diagnoses include including dementia with mood disturbance, depression, and anxiety. The Minimum Data Set, dated dated dated [DATE] documented Resident #17 was moderately cognitively impaired. Resident #75 had diagnoses that included Alzheimer's disease, Bell's Palsy (weakness in the muscles in one side of the face). The Minimum Data Set, dated dated dated [DATE] documented Resident #75 was severely cognitively impaired. The nursing home facility investigation report submitted successfully to the State Agency dated 12/5/24, completed by Administrator, documented Resident #75 observed Resident #17 going through their belongings and slapped Resident #17 on the face. Resident #17 slapped Resident #75 back, also on the face. The incident was reported to Licensed Practical Nurse #1 by Resident #17, and while they were talking to Licensed Practical Nurse #1 about the incident, Resident #75 approached to tell their side of the story. Residents are new roommates, and both are able to ambulate independently. Resident #17 indicated they did not like their living arrangement. Both residents were placed on 15-minute checks to monitor their whereabouts and avoid further altercations. During an interview on 2/3/25 at 10:29 AM, the Director of Nursing stated the incident between Resident #17 and Resident #75 occurred on 12/5/24 at 7:45 AM, they were made aware at 8:30 AM. They stated they reported the incident to the State Agency on 12/6/24 at 2:06 PM, over 48 hours from when the incident occurred. They stated the incident should have been reported within 24 hours. Review of resident-to-resident incident report Resident to Resident Physical Contact for Resident #75 dated 12/10/24, completed by Registered Nurse Head Nurse #4, documented Resident #75 came out to the dining room and accused Resident #17 of stealing their walker, attempted to take it and began hitting Resident #17 on their arms. Residents were separated, 15-minute checks were still in place at the time and continued. Review of resident-to-resident incident report for Resident #75 dated 12/11/24, completed by Assistant Director of Nursing, documented Certified Nurse Aide #10 saw Resident #75 walking towards their room and when they entered, heard Resident #17 say it is my bathroom too, heard a noise and went to check on it. They observed Resident #17 and Resident #75 crawling around on their bedroom floor. Resident #75 stated Resident #17 pulled them down. The incident report documented Resident #17 and #75 had been having difficulty getting along, and they were roommates. To avoid further potential negative interaction, Resident #75 was moved to a private room on another unit. Review of State Agency computerized reporting/tracking system data base on 2/3/25 revealed there were no further facility reported incidents involving Resident #17 and Resident #75. During an interview on 1/29/25 at 3:45 PM, the Director of Nursing stated the documents provided to survey team were the extent of what the facility had regarding the incidents on 12/10/24 and 12/11/24 between Resident's #75 and #17. e. Resident #72 had diagnoses including congestive heart failure, atrial fibrillation (an irregular contracting of the upper chambers that can cause the blood to pool) and peripheral vascular disease (poor circulation in the lower extremities.) The Minimum Data Set, dated dated dated [DATE] documented Resident #72 was cognitively intact The nursing home facility investigation report submitted successfully to the State Agency documented on 1/18/24 at 8:30 AM Resident #72 reported to Registered Nurse Supervisor #4 an incident of alleged verbal and mental abuse by a staff member that occurred on 1/8/24 at 11:00 PM. The report documented the Administrator submitted the report on 1/18/24 at 2:43 PM to the State Agency. f. Resident #42 had diagnoses including dementia, anxiety, and diabetes. The Minimum Data Set, dated dated dated [DATE] documented Resident #42 had severe cognitive impairment. The undated nursing home facility investigative report completed by the Director of Nursing documented that Resident #42 was found not to be wearing their shorts per their care plan and had three scratch marks to their left hip. The incident was documented to have occurred on 12/6/24 at 2:08 AM, staff were first made aware of the incident at 12/6/24 at 2:08 AM, the Administrator was first made aware on 12/6/24 at 2:31 AM. The incident was reported to the State Agency on 12/9/24 at 3:06 PM. During a telephone interview on 2/3/25 at 8:33 AM, Investigator #1 stated they were not responsible for notifying the State Agency but thought care plan violations needed to be reported within 24 hours. During an interview on 2/3/25 at 9:36 AM, the Director of Nursing stated on 12/6/24 staff did not follow a resident's care plan; there was an injury which made the incident reportable. They stated the facility investigative report documented administration was notified on 12/6/24 at 2:31 AM. The Director of Nursing stated this type of incident needed to be reported to the State Agency within 48 hours because it was a care plan violation. The Director of Nursing stated they used the 2016 Nursing Home Incident Reporting Manual to decide what was reported and when. g. Resident #30 had diagnoses including dementia, rheumatoid arthritis, and dermatitis. The Minimum Data Set, dated dated dated [DATE] documented Resident #30 was moderately cognitive impaired. The facility accident and incident investigation dated 9/13/24 at 10:00 AM documented that while Resident #30 was repositioning themselves in their wheelchair they hit their arm on the armrest and sustained a skin tear to the right forearm at. The facility accident and incident investigation documented that Resident #30 did not have on their protective arm sleeves. Review of the Risk Management Nursing Home Investigation dated 9/16/24 documented a skin tear occurred on 9/13/24 at 10:00 AM. The Director of Nursing was not made aware until they received a counseling slip for Certified Nurse Aide #5 on 9/16/24 in their mailbox. The Director of Nursing reported the injury related to the care plan violation to the State agency on 9/16/24. Review of the State Agency computerized reporting/tracking system data base report submitted on 9/16/24 at 3:00 PM, revealed Resident #30 sustained a skin tear on 9/13/24 at 10:00 AM due to not having their protective sleeves on per their plan of care. During a telephone interview on 1/31/25 at 1:29 PM, Investigator #2 stated they were notified on 9/16/24 by the Director of Nursing about the care plan violation. The incident occurred on 9/13/24 at 10:00 AM and was determined to be neglect. Investigator #2 does not advise the facility to report or not to report incidents and was the facility's responsibility. During an interview on 2/3/25 at 10:09 AM, the Director of Nursing stated care plan violations that did not involve serious bodily injury needed to be reported within forty-eight hours to the State Agency. This incident was not reported until 9/16/24. h. Resident #161 had diagnoses including anxiety, fractured right humorous (upper arm), and diabetes mellitus. The Minimum Data Set, dated dated dated [DATE] documented Resident #161 was cognitively intact. a. The accident and incident investigation dated 5/9/24 documented at 1:14 PM Resident #161 was sitting on the edge of their bed, bumped their left lateral forearm on the siderail which was in the up position and sustained a skin tear. Per the investigation it was revealed the side rail should have been down when care was not being provided. Certified Nurse Aide #12 left the siderail up after care which resulted in the injury. Review of the State Agency computerized reporting/tracking system data base revealed the incident was submitted to the Department of Health on 5/10/24 at 2:17 PM by the nursing home Administrator. The undated Nursing Home Facility Incident Report documented the incident was submitted to the Department of Health on 5/10/24 at 2:17 PM by the Administrator. The allegation type specified other, and the incident was the result of a care plan violation. The incident occurred on 5/9/24 at 1:14 PM and the Administrator was made aware on 5/9/24 at 8:00PM. The facility risk management team was notified to begin a formal investigation. The Risk Management Nursing Home Investigation with a received date of 5/9/24 documented that Resident #161 had sustained a skin tear after bumping their arm on the siderail which was in the raised position. The care plan reflected the siderail be in up position during care only. At the time of the injury no care was being provided and the skin tear was the result of the care plan violation. b. The undated Nursing Home Facility Incident Report documented the incident was submitted to the Department of Health on 7/1/24 at 9:44 PM by the Director of Nursing. The allegation type was listed as sexual abuse. The incident date was 7/1/24 and occurred at 2:30 AM. The staff were made aware of the allegation on 7/1/24 at 6:00 AM. The Administrator was made aware on 7/1/24 at 8:25 PM. The report concluded that Certified Nurse Aide #4 continued providing Resident #161 care despite Resident #161 refusal of incontinence care and unwanted touching. The risk management team was notified and would conduct a full investigation. Review of the State Agency computerized Complaint/Incident Investigation Report revealed an alleged allegation of sexual abuse occurred on 7/1/24 at 2:30 AM. Staff were made aware of the incident at 6:00 AM and the Administrator was notified on 7/1/24 at 9:44 PM and reported the incident to the State Agency at 9:45 PM. During a telephone interview on 1/31/25 at 1:23 PM, Investigator #1 stated the alleged sexual abuse allegation should have been reported by the facility to the State Agency within two hours. During an interview on 2/3/25 at 9:30 AM, the Director of Nursing stated they ruled the care plan violations as unintentional for both Resident #30 on 9/13/24 and #161 on 5/9/24, and thought they had forty-eight hours to report them to the State Agency. The Director of Nursing stated not following the care plan would be neglect. The sexual abuse allegation on 7/1/24 for Resident #161 should have been reported to the State Agency no later than 4:30 AM and was not. During an interview on 2/3/25 at 1:31 PM, the Administrator stated abuse was any allegation of mistreatment including sexual, financial, physical, verbal; anything that potentially could cause harm whether physical or psychosocial. The Administrator, Director of Nursing and Assistant Director of Nursing were responsible to initiate the initial report of abuse or neglect to the State Agency. They stated they were following guidance from 2015/2016 for reporting and were not aware of the current regulation and guidance. During an interview on 2/3/25 at 1:32 PM, the Administrator stated their reporting policy had not been updated since 2015 and it should have been to ensure they were compliance with current regulations. 10NYCRR 415.4 (b)(1)

Based on interview and record review conducted during an extended Standard survey completed on 2/3/2025, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body is responsible and accountable for the Quality Assurance and Performance Improvement program. Specifically, the administration did not ensure abuse and neglect reporting policies and procedures were updated and consistently implemented. This has the potential to affect all residents residing in the facility. The findings are: REFER TO: F 600 - Free from Abuse and Neglect F 607 - Develop/Implement Abuse/Neglect Polices F 609 - Reporting Alleged Violations Review of the policy and procedure titled Abuse/Neglect - Reporting Process dated 12/2015 documented at any time when a visitor or staff member witnesses or is made aware of possible resident abuse or neglect, the following procedure must be implements: The employee will report the incident to the Nursing Supervisor immediately and will initiate an Incident/Accident Report. The Nursing Supervisor will notify the Administrator and Nursing Director. The Administrator and/or Nursing Director will take responsibility for notifying the State Health Department within five working days that resident abuse/neglect has occurred. During an interview on 1/30/25 at 10:21 AM, the Director of Nursing stated the most recent Abuse/Neglect - Reporting Process policy and procedure was last revised in December 2015. During an interview on 2/3/25 at 9:36 AM, the Director of Nursing stated they rely on the Risk Management Team to do the investigation and rule out abuse or neglect when staff were involved. They stated policies were reviewed a couple time of month during a meeting that included the Director of Nursing, Administrator, Medical Records, Inservice Coordinator/Infection Preventionist and sometimes the Assistant Director of Nursing. Policies were reviewed and updated based on Quality Assurance projects. They stated they were unaware of the updated regulations for reporting allegations of suspected abuse/neglect and expected a big email or a Dear Administrator Letter would have been sent to the Administrator or themselves During an interview on 2/3/25 at 1:31 PM, the Administrator stated they would usually get updated on new and changes in regulations through letters posted in the secure online system that allows New York State health department, providers, and facilities to share health information and there were a lot of changes between 2020 and 2024. They believed the change in the regulation for reporting was in 2022 and they must have missed that specific letter. Their policy was last reviewed in 2015 and should have been updated by the Policy and Procedure Team. The Policy and Procedure Team were responsible for updating policies and procedures included the Administrator and Director of Nursing. They stated the policy should have been updated so the facility could stay within compliance of state guidelines. During an interview on 2/3/25 at 3:28 PM, County Legislature #1 stated they were part of the governing board that oversees the facility. They stated they believed the Administrator was updating their policies and procedures, as expected. County Legislature #1 stated it was expected all policies and procedure were reviewed and updated because they should be up to date with the current regulations. 10 NYCRR 415.26

Based on interview and record review conducted during an a Complaint investigation (#NY00330289, #NY00331807, #NY00341814, #NY00354482, #NY00357719, #NY00359779, #NY00363581, and #NY00363961) during the extended Standard survey completed on 2/3/25, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. In addition the facility did not ensure their abuse reporting policy and procedures were updated to include current regulations and guidance. Specifically, the facility did not ensure their policy for abuse reporting was current. This affected 10 (Residents #17, 30, 42, 47, 68, 71, 72, 75, 95, and #161) of 12 residents reviewed. Additionally, one (Employee #4, agency Licensed Practical Nurse) of seven employees that worked in the facility and were subject to the New York State Nurse Aide Registry Verification, was not reviewed through the New York State Nurse Aide Registry prior to their employment as required. This resulted in no actual harm with the potential for more than minimal harm with the likelihood to affect all residents and is substandard quality of care. The findings are: REFER TO: F 609 - Reporting of Alleged Violations Review of the policy and procedure titled Abuse/Neglect - Reporting Process dated 12/2015 documented at any time when a visitor or staff member witnesses or is made aware of possible resident abuse or neglect, the following procedure must be implements: The employee will report the incident to the Registered Nurse Nursing Supervisor immediately and will initiate an Incident/Accident Report. The Nursing Supervisor will notify the Administrator and Nursing Director. The Administrator and/or Nursing Director will take responsibility for notifying the State Health Department within five working days that resident abuse/neglect has occurred. Review of the policy and procedure titled Abuse Prevention and Reporting dated 9/2023 documented, all facility applicants will be screened by the hiring manager or their designee for abuse by checking the on-line New York Nurse Aide Registry Prometric.com and printing a copy of the report for submission with all new hire paperwork prior to the first day of employment. All non-licensed staff will be finger-printed per New York State Department of Health regulations via the Criminal History Check module of the New York State Health Commerce System (HCS). The policy did not include a timeline of when the New York State Department of Health was to be notified. 1. Review of the State Operational Manuals issued 11/22/2017 and 8/8/2024 documented to Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. During an interview on 1/30/25 at 10:21 AM, the Director of Nursing stated the most recent Abuse/Neglect - Reporting Process policy and procedure was last revised in December 2015. They stated the policies were reviewed at the facility. During an interview on 2/3/25 at 9:36 AM, the Director of Nursing stated they rely on the Risk Management Team to do the investigation and rule out abuse or neglect when staff were involved. They stated policies were reviewed a couple time of month during a meeting that included the Director of Nursing, Administrator, Medical Records, Inservice Coordinator/Infection Preventionist and sometimes the Assistant Director of Nursing. Policies were reviewed and updated based on Quality Assurance projects. They stated they were unaware of the updated regulations for reporting allegations of suspected abuse/neglect and expected a big email or a Dear Administrator Letter would have been sent to the Administrator or themselves. During an interview on 2/3/25 at 1:31 PM, the Administrator stated they would usually get updated on new and changes in regulations through letters posted in the secure online system that allows New York State health department, providers, and facilities to share health information and there were a lot of changes between 2020 and 2024. They believed the change in the regulation for reporting was in 2022 and they must have missed that specific letter. Their policy was last reviewed in 2015 and should have been updated by the Policy and Procedure Team. The Policy and Procedure Team were responsible for updating policies and procedures included the Administrator and Director of Nursing. They stated the policy should have been updated so the facility could stay within compliance of state guidelines. 2. Review of the employee file for Employee #4's (agency Licensed Practical Nurse) revealed the employee was hired on 12/15/24. Review of the timesheets provided by the facility revealed Employee #4 had worked in the facility on: - 12/15/24 from 1:30 PM to 10:45 PM. - 12/21/24 from 1:45 PM to 10:30 PM. - 12/22/24 from 2:00 PM to 10:30 PM. - 12/25/24 from 2:00 PM to 10:30 PM. - 12/28/24 from 2:00 PM to 10:30 PM. - 12/29/24 from 2:00 PM to 10:30 PM. - 1/1/25 from 2:00 PM to 10:30 PM. - 1/4/25 from 2:00 PM to 10:30 PM. - 1/5/25 from 2:00 PM to 10:30 PM. - 1/11/25 from 2:00 PM to 10:30 PM. - 1/12/25 from 2:00 PM to 10:30 PM. - 1/18/25 from 2:00 PM to 10:30 PM. - 1/19/25 from 2:00 PM to 10:30 PM. - 1/25/25 from 2:00 PM to 11:15 PM. During an interview on 1/29/24 at 2:20 PM, the Administrator (Authorized Person for Criminal History record Check) and the Infection Control/ In-Service Coordinator (Authorized Person for Criminal History record Check) stated employee #4 was hired to work at the facility as a Licensed Practical Nurse. The New York State Department of Health will be notified by the Nursing Director and/or Administrator when there is reasonable cause to believe that abuse has occurred. During an interview on 1/30/25 at 9:16 AM the Administrator stated the facility had no documentation that a New York State Nurse Aide Registry Verification report had been completed for Employee #4 prior to their employment at the facility. 10 NYCRR 415.4(b)

Based on observation, interviews, and record review conducted during a Complaint investigation (#NY00341814, #NY00354482, #NY00363961) during an extended Standard survey completed on 2/3/25, the facility did not ensure that all residents care plans were implemented as planned, consistent with resident's rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for three (Residents # 30, 42, & 161) of three resident's reviewed. Specifically, care plan interventions were not followed by staff. Issues included: protective sleeves (#30), and shorts (#42) were not provided as planned, and a side rail was left in the up position when care was not being provided (#161) all breaks in implementation resulted in minor injuries. The findings are: The policy and procedure titled Comprehensive Care Plans last revised 10/23 documented it is the responsibility off all staff that are providing hands on care to consult and follow the Comprehensive Care Plan and Kardex. All staff are trained upon orientation and annually that compliance with all directives on a resident's care plan/Kardex are expected to be followed at all times. 1. Resident #30 had diagnoses including dementia, rheumatoid arthritis, and dermatitis. The Minimum Data Set (a resident assessment tool) dated 7/29/24 documented Resident #30 was moderately cognitive impaired, was sometimes understood and sometimes understands. They required partial/moderate assistance with upper body dressing. The comprehensive care plan dated 7/23/24 documented Resident #30 had fragile skin and had the potential for impaired skin integrity. The planned interventions included one assist for dressing and bilateral arm (protective sleeves) while out of bed. The Kardex Report (a guide used by staff to provide care) with an as of date of 9/16/24 documented bilateral (both) arm (protective sleeves) on in the morning and off at bedtime. Review the facility accident and incident investigation dated 9/13/24 completed by Registered Nurse #4 documented at 10:00 AM, Resident #30 was not wearing the (protective sleeves) and sustained a skin tear to their right forearm while repositioning themselves in their wheelchair. Review of the nursing progress notes dated 9/13/24, Registered Nurse #4 documented at 10:29 AM Resident #30 rearranged themselves in their wheelchair, hit their right upper arm on the arm rest, and sustained a skin tear. Review of the Risk Management Nursing Home Investigation dated 9/16/24 documented Certified Nurse Aide #5 did not provide Resident #30's (protective sleeves) on 9/13/24. The care plan violation resulted in a skin tear to Resident #30's right upper arm. During an observation and interview on 1/28/25 at 9:50 AM, Resident #30 was wearing (protective sleeves) on both arms with long sleeves and stated the sleeves protected their skin so if they bumped into things, the skin protectors prevented their skin from splitting as their skin was frail. During an interview on 1/31/25 at 12:36 PM, Certified Nurse Aide #5 stated they were aware Resident #30's care plan reflected the (protective sleeves) to protect their skin from injury and checked the care plan prior to care for resident safety. They provided personal care on 9/13/24 for Resident #30. The (protective sleeves) were not in Resident #30's room, then got pulled to another unit during care and putting the (protective sleeves) on slipped my mind. During an interview on 2/3/25 at 12:19 PM, Registered Nurse #4 stated following the care plan prevented injuries to the residents. Certified Nurse Aide #5 should have informed the nurse the (protective sleeves) were missing. Having the (protective sleeves) on may have prevented the skin tear. All staff were responsible for following the care plan. 2. Resident #42 had diagnoses that included dementia, anxiety, and diabetes. The Minimum Data Set, dated dated dated [DATE] documented Resident #42 had severe cognitive impairments, was rarely understood and rarely understands. Resident #42 was dependent on staff assistance for dressing. The comprehensive care plan revised on 3/9/22 documented Resident #42 had an activity of daily living self-care deficit. Interventions included one staff assist for turning and repositioning, shorts on at all times and one staff assistance for lower body dressing. The Kardex Report dated 12/6/24 documented Resident #42 was to have shorts on at all times, under both bed mobility and dressing categories. Review of the self-inflicted injury report dated 12/6/24, Registered Nurse Supervisor #1 documented there were three scratches to the Resident #42's left hip. The scratches were cleansed, and shorts were applied to protect the resident's skin from self-inflicting wounds. Resident #42 had a long history of scratching themselves and was care planned to wear shorts in bed for prevention; the shorts were not placed on Resident #42 during the shift prior. Review of the Risk Management Nursing Home Investigation with a received date of 12/6/24 documented that on 12/6/24 Resident #42 was found to have three linear self-inflicted scratches on their left hip, and they were not wearing their shorts at that time. Investigator #1 documented an interview with Certified Nurse Aide #4 on 12/10/24. Certified Nurse Aide #4 gave a statement they were not familiar with Resident #42, were overwhelmed, and did not review the care plan prior to providing nightly care. They did not place shorts on Resident #42. Investigator #1 documented Certified Nurse Aide #4 did not follow the care plan. During an observation on 1/29/25 at 3:44 PM, Resident #42 was sitting up in their chair. They were holding onto the bottom of their shirt in one hand and their sweatpants with the other hand. While holding their clothes, they were moving their fingers and feeling their clothing. During an observation and interview on 1/30/25 at 9:10 AM, Certified Nurse Aide #8 provided incontinent care to Resident #42. They placed shorts back on Resident #42 after completion. They stated the care plan included that Resident #42 should always wear shorts and Resident #42 wears the shorts because they had a tendency of scratching themselves. During a telephone interview on 1/31/25 at 10:19 AM, Certified Nurse Aide #2 stated they were not familiar with Resident #42 but looked at the care plan that night (12/6/24) to see what type of assistance they needed. They noticed Resident #42 did not have their shorts on, but soon after both Licensed Practical Nurse #3 and Registered Nurse Supervisor #1 went to check on Resident #42. During a telephone interview on 1/31/25 at 1:24 PM, Registered Nurse Supervisor #1 stated they were supervising the night Resident #42 was found without their shorts on and scratch marks on their left hip (12/6/24). They stated Resident #42 had a history of scratching and digging at themselves and that was why they wore shorts at all times. When they arrived at the unit to assess Resident #42, they were digging at their left leg and that was where the scratch marks were. They were superficial marks, were cleansed, shorts were applied, and the administration were notified via electronic mail. During a telephone interview on 2/3/25 at 9:08 AM, Licensed Practical Nurse #3 stated Resident #42 was always moving their hands, grabbing, and scratching wherever they could reach. They stated on 12/6/24 they remembered going into the room with Registered Nurse Supervisor #1, Resident #42 did not have on their shorts like care planned and there were scratch marks on their left hip. They stated there was a break in the care plan at that point and the shift prior should have placed the shorts on Resident #42 for their safety. During a telephone interview on 2/3/25 at 9:16 AM, Certified Nurse Aide #3 stated they assisted Certified Nurse Aide #2 with their rounds, noticed Resident #42 did not have shorts on, had scratches to their hip, and then notified Licensed Practical Nurse #3 immediately after care. They stated the care plan showed that Resident #42 should have shorts on at all times and the shift prior must not have placed shorts on Resident #42. When they looked in Resident #42's drawer, there were plenty of shorts in the drawer. A telephone call and voicemail were left for Certified Nurse Aide #4 on 1/31/25 at 10:48 AM and on 2/3/25 at 8:19 AM with no return call. 3. Resident #161 had diagnoses including anxiety, fractured right humorous (upper arm), and diabetes mellitus. The Minimum Data dated 5/10/24 documented that Resident #161 was cognitively intact, was understood and understands. They required substantial/maximum assistance for bed mobility and bed rails were not used. The comprehensive care plan dated 5/3/24 documented Resident #161 had an activity of daily living self-deficit, and the left side rail may be left up during care. Resident #161 required assistance from two staff members for bed mobility. The comprehensive care plan further documented that Resident #161 had a skin tear on 5/9/24. The Kardex Report dated 5/9/24 documented Resident #161 required the assistance of two staff members for bed mobility and the side rails up during care. Review the facility accident and incident investigation dated 5/9/24 Registered Nurse #7 documented at 1:14 AM, Resident #161 was sitting on the edge of their bed and blood was on the floor and siderail. Resident #161 stated to Registered Nurse #7 they hit their arm on the siderail which was only to be raised during care. Resident #161 sustained a skin tear to the left lateral forearm. There were no measurements of the skin tear documented on the accident and incident investigation. Message left for Registered Nurse #7 on 1/31/25 at 9:04 AM with no returned response. Review of the risk management nursing home investigation dated 5/9/24 documented at 1:14 AM that a skin tear was discovered to Resident #161 left lateral forearm from bumping their arm on the siderail of their bed, which was in the raised position. Resident #161's care plan instructed that the side rails of the bed should only be up during care. At the time of the injury Resident #161 was not receiving care and therefore the siderails should have been down. During intermittent observations from 1/27/25 through 1/31/25 between the hours of 9:00 AM and 3:00 PM and on 2/3/25 between the hours of 9:00 AM and 2:00 PM there were no care plan violations noted related to the use of siderails. During an interview on 1/31/25 at 10:33 AM, Certified Nurse Aide #7 stated they didn't recall the incident on 5/9/24. Care plans were checked at the start of the shift to properly care for the residents. When the care plan specified for the siderails to be up during care they should have been up during care. Otherwise, the siderails should be down. It was a long time ago. During an interview on 1/31/25 at 12:19 PM, Licensed Practical Nurse #5 stated Certified Nurse Aide #7 should have reviewed the care plan and put the side rail down, then the skin tear could have been avoided. During an interview on 2/3/25 at 9:36 AM, the Director of Nursing stated their expectation was for all nursing staff including Certified Nurse Aides, Licensed Practical Nurses, and Registered Nurses to review the care plan prior to providing care and to follow the care plan. During an interview on 2/3/25 at 12:39 AM, Registered Nurse #3, former Inservice Coordinator stated following the care plan was covered in new employee orientation and reviewed annually with mandatory trainings. All staff were expected to review the resident care plan before touching a resident to ensure they provided the care they need to provide. During an interview on 2/3/25 at 1:00 PM, Registered Nurse #4 stated Resident #161 bumping their arm on the siderail was a care plan violation and Certified Nurse Aide #7 should have made sure the siderail was down upon leaving the room. During an interview on 2/3/25 at 1:32 PM, the Administrator stated not following the care plan could affect a resident wellbeing. 10 NYCRR 415.11 (c) (1)

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00341814) during an extended Standard survey completed on 2/3/25, the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (1) (Resident #161) of one (1) reviewed for dignity. Specifically, the certified nurse aide provided care despite the resident's refusal and resulted in Resident #161 feeling ashamed and humiliated. The finding is: The policy and procedure titled Resident Choice and Rights last revised 1/2023 documented it is the policy of this facility to provide and encourage resident choices in all aspects of their care and daily routines to maintain their dignity, individualism and customary routines. Your Rights as A Nursing Home Resident in New York State dated 2022 documented as a resident in this facility, you have rights guaranteed to you by state and federal laws. This facility is required to protect and promote your rights. Your rights strongly emphasize individual dignity and self-determination, promoting your independence and enhancing your quality of life. You have a right to be valued as an individual, to be treated with consideration, dignity and respect in full recognition of your self-worth. You have the right to accept or refuse care and treatment. Resident #161 had diagnoses including anxiety, fractured right humorous (upper arm), and diabetes. The Minimum Data Set (a resident assessment tool) dated 5/10/24 documented that Resident #161 was cognitively intact, was understood and understands. The comprehensive care plan dated 5/3/24 documented Resident #161 had bladder incontinence related to impaired mobility. The care plan included incontinence checks as needed. The Kardex Report (guide used by staff to provide care) dated 5/9/24 documented Resident #161 required the assistance of two staff members for toileting and did not reflect incontinence care. The Risk Management Investigation dated 7/1/24 documented at approximately 3:00 AM on 7/1/24, Certified Nurse Aide #4 touched Resident #161 in the genital area without announcing their presence. When Resident #161 told Certified Nurse Aide #4 to remove their hand, Certified Nurse Aide #4 continued touching Resident #161 and stated to Resident #161 they were checking their brief to ensure they were dry. Later that morning at approximately 5:30 AM, Certified Nurse Aide #4 provided personal hygiene care to Resident #161, despite Resident #161 wanting to complete their own care. While washing Resident #161's genital area, Certified Nurse Aide #4 told Resident #161 they were checking for disease. Resident #161 told Registered Nurse #6 they were sleeping and startled by Certified Nurse Aide #4's grabbing and tugging at their brief at 3:00 AM and told Certified Nurse Aide #4 to get their hand out of there. Certified Nurse Aide #4 continued to move their hand around on their private area. Later that same morning at approximately 5:30 AM, Certified Nurse Aide #4 assisted Resident #161 with morning care and stated Certified Nurse Aide #4 was insistent in trying to get Resident #161's clothing off. Resident #161 repeatedly told Certified Nurse Aide #4 that I do that myself, please stop, but Certified Nurse Aide #4 kept insisting. Certified Nurse Aide #4 then spread Resident #161's legs apart and told them that they were looking for disease and looked at Resident #161's peri area. Registered Nurse #6 reported Resident #161 was crying, was very embarrassed. Resident #161 required assistance for transferring but preferred to be independent for most things and will ring the bell when they required assistance to use the toilet. During an interview on 1/31/25 at 11:43 AM, Certified Nurse Aide #7 stated Licensed Practical Nurse # 5 requested they go and check on Resident #161 on the morning of 7/1/24. Resident #161 was sobbing and felt offended that Certified Nurse Aide #4 would treat them like that. It was Resident #161's right to refuse care. Certified Nurse Aide #7 stated the resident felt disrespected, ashamed and expressed that Certified Nurse Aide #4's treatment towards Resident #161 was undignified. During a telephone interview on 1/31/25 at 12:19 PM, Licensed Practical Nurse #5 stated providing care when they don't want the care was demeaning. Resident #161 had the right to refuse care. During a telephone interview on 1/31/25 at 1:57 PM, Registered Nurse #6 stated Certified Nurse Aide #4's actions on 7/1/24 were inappropriate and they should have stopped care on both occasions. During an interview on 2/3/25 at 8:52 AM, Social Worker #1 stated they would have expected that Certified Nurse Aide #4 to have stopped care right away, report to the nurse, and reapproach later. Certified Nurse Aide #4's violated Resident #161's choice not to have care and it was undignified. During an interview on 2/3/25 at 9:33 AM, the Director of Nursing stated placing your hands on someone inappropriately without talking to them even after they told you to stop was a dignity concern. Resident #161 felt reluctant to discuss the care they had received on the morning of 7/1/24. Certified Nurse Aide #4 violated Resident 161's rights to be treated with dignity and respect. During a telephone interview on 2/3/25 at 1:45 PM, Certified Nurse Aide #4 denied the allegations and stated they would not force care on a resident that didn't want it. Certified Nurse Aide #4 stated that would be disrespectful. 10NYCRR 415.3 (2)(f)(ii)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00323316) completed on 9/13/23, the facility did not implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for one (Resident #1) of three residents reviewed. Specifically, staff did not implement Resident #1's care plan intervention for the use of dycem (a nonslip, self-adhesive mat) in their recliner consistently across all shifts. The finding is: The policy and procedure (P&P) titled Assignments/Accountability revised 11/19, documented all staff will be held responsible for checking the residents Kardex (a guide for providing care)/care plan prior to providing care. 1. Resident #1 had diagnoses including cerebral infarction (stroke), cognitive impairment, and repeated falls. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/6/23 documented the resident was sometimes understood, sometimes understands, and had moderate cognitive impairment. The Comprehensive Care Plan (CCP) dated 6/6/22 documented Resident #1 was a high risk for falls related to deconditioning, gait/balance problems, vision/hearing problems, and a history of falls. The CCP documented an intervention for the use of dycem on the seat of the recliner. The Kardex dated 9/5/23 documented dycem on seat of recliner. The investigation report dated 9/2/23 at 11:08 AM, documented Registered Nurse (RN) #1 was called to the unit because Resident #1 was on the floor laying on their right side in front of the recliner. It further documented that Certified Nurse Aide (CNA) #1 was interviewed and was counseled on checking the care plan and making sure all safety devices were in place. The counseling form dated 9/2/23, documented Resident #1's recliner did not have dycem and Resident #1 slid out of the recliner. Additionally, it was documented CNA #1 did not check if dycem was in the recliner. During an observation and interview on 9/13/23 at 11:51 AM, Resident #1 was sitting in their wheelchair in their room. There was no visible bruising on Resident #1's exposed skin (face and hands). A brown reclining chair was observed in the corner of the room with a blue piece of dycem in the center of the seat. Resident #1 stated on the day of the fall, they remembered sitting down in their chair. Resident #1 stated they pushed a button, but the chair went the wrong way, and it kept going up. Resident #1 stated they could not remember if the dycem was in their chair or not, but they slid out of their chair like it was a slide. During a telephone interview on 9/13/23 at 3:38 PM, CNA #1 stated they were responsible for providing care to Resident #1 on the day Resident #1 fell . CNA #1 stated they transferred Resident #1 to the recliner after providing toileting. CNA #1 stated they assumed the dycem was in the recliner but did not check if it was there before transferring Resident #1 to the recliner. CNA #1 stated Resident #1 was care planned to have dycem in their recliner to keep them from slipping out of it. During an interview on 9/13/23 at 2:16 PM, RN #2 stated Resident #1 was found on the floor in front of their recliner and the fall was unwitnessed. RN #2 stated from reading the witness statements, CNA #1 did not check the care plan and did not make sure the dycem was in the recliner chair. RN #2 stated it was important to check the care plan and make sure everything was in place to prevent incidents such as falls like this from happening. During an interview on 9/13/23 at 2:31 PM, RN #1 stated they were supervising when they were called to the unit at the time of Resident #1's fall on 9/2/23. RN #1 stated Resident #1 was laying on the floor on their right side in front of their reclining chair. RN #1 stated the reclining chair was raised up. RN #1 stated after doing their assessment, they checked the care plan to see if everything was in place. RN #1 stated there was no dycem in the reclining chair or anywhere near it. RN #1 stated CNA #1 should have followed the care plan and checked for the dycem before transferring Resident #1 into the chair. RN #1 stated the care plan should have been followed for safety reasons. During an interview on 9/13/23 at 3:02 PM, the Director of Nursing (DON) stated it was expected that all staff checked the care plan before providing care. DON stated there was a break in the care plan when CNA #1 did not make sure the dycem was in the recliner before transferring Resident #1 into it. 10NYCRR 415.11 (c)(3)(ii)

Based on observation, interview, and record review conducted during a Standard survey completed on [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with resident's wishes for one (Resident #33) of three residents reviewed for advanced directives. Specifically, the facility did not ensure all resident advanced directives identifiers were consistent with the resident's wishes. The finding is: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses that included delusional disorders, anxiety disorder and major depressive disorder. The Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident was cognitively intact. A facility policy and procedure titled Cardiopulmonary Resuscitation (CPR) dated ,d+[DATE] documented a blue bracelet/badge is worn by residents who desire CPR, and a white bracelet/badge is worn by residents who do not wish to be resuscitated (DNR). Residents not wishing to wear bracelets will wear the badges. Residents not wishing to wear either a bracelet or a name badge, or residents found unresponsive without a bracelet or badge will have their electronic medical orders in the EMR (electronic medical record) consulted for code status. The Nurse transcribing a physician's order which changes DNR status is responsible to change the wrist band. ID (identification) bracelet/badge will be checked for presence and accuracy every shift by Medication Nurse and documented on EMAR. (Blue = CPR, White - DNR). If a resident wears an ID badge to identify CPR status, care plan will reflect this choice. If a resident is not wearing ID badge while sleeping, the ID badge will be placed at the bedside. Staff will identify CPR status via EMR or Kardex in the resident's closet. During intermittent observations on [DATE] at 11:59 AM and 3:12 PM, [DATE] at 8:16 AM and 1:19 PM, [DATE] at 8:33 AM and 1:12 PM and [DATE] at 8:39 AM Resident #33 had a blue identification (ID bracelet) band on the right side of their wheelchair (w/c). The resident had no additional wrist bands/badges on. Resident #33's MOLST (Medical Orders with Life Sustaining Treatment) dated [DATE] documented the resident's responsible party completed the MOLST, requested a DNR order and a Do not intubate (DNI) order. The physician reviewed and signed the form on [DATE]. The Order Recap Report (physician orders) for Resident #33 dated [DATE] through [DATE] documented the order for was CPR discontinued on [DATE], and a new order for DNR/ DNI was written on the same day. The comprehensive care plan identified as current by the Director of Nursing (DON) documented, Resident #33 had a MOLST with a DNR/ DNI order dated [DATE]. Interventions included to honor resident wishes for DNR. Resident 33's Medication Administration Record (MAR) dated [DATE] through [DATE] documented to check for presence and accuracy of code status via ID bracelet/badge every shift-Blue = CPR, White = DNR. Nurses initialed the MAR, indicating the bracelet was verified for accuracy. During an interview on [DATE] at 8:27 AM, Certified Nursing Assistant (CNA) #2 stated the resident's arm band was on the w/c because some residents preferred not to have it on their wrist. The color of the arm band indicates the resident's code status, blue for full code or white for DNR. CNA #2 stated the resident was a full code, therefore CPR would be performed by the nurses. During an interview on [DATE] at 8:49 AM, Unit Clerk (UC) #1 stated to determine code stats the staff look at a resident's bracelet (arm band), which was located either on the resident's arm or on their w/c. A white arm band was an indication of a DNR order, and a blue band an indication of a full code order and CPR would be performed. During an interview on [DATE] at 8:40 AM, Licensed Practical Nurse (LPN) #4 stated advanced directives were listed on the MAR and color of bracelet (arm band) indicates their code status, white for DNR and blue for CPR. The arm band was either on the resident or on the resident's w/c. LPN #4 stated if they were notified a resident was unresponsive, they would look at the color of the bracelet, check their vital signs and if no pulse and/or respirations they would send a staff member to page a Code Blue and start CPR. LPN #4 stated the arm band should be accurate because it is checked every shift as indicated on the MAR by a nurse. During an interview on [DATE] at 8:50 AM, Head Nurse (HN) Registered Nurse (RN) #4 stated a resident's arm band should be accurate to their wishes of advanced directives. A white arm band indicates a DNR order, and blue arm band indicates a CPR order. HN RN #4 stated if a resident was found without vital signs, and they had a blue arm band on they would initiate CPR while another staff member looked at the medical record (MR) for the orders. HN RN #4 stated the accuracy of the arm bands color were to be checked every shift by a nurse. They would look at the current orders and compare the orders with the color of the arm band to ensure the accuracy of the code status. HN RN #4 stated they were ultimately responsible to ensure the advanced directives and arm band color was accurate. During an interview on [DATE] at 9:21 AM, LPN #5 stated they would initiate CPR based on the color of the arm band, because the arm band was to be checked for accuracy every shift by a nurse. Therefore, it should be accurate at all times. The nurse was look at the electronic medical record (EMR) orders and to ensure the color of the band was correct. White was for a DNR orders, and blue band was for full code, meaning to initiate CPR. During an interview on [DATE] at 9:28 AM, LPN #4 stated they check status of the arm band accuracy by comparing the orders in the ERM with the color of the arm band to ensure the code status is accurate. LPN #4 reviewed Resident #33's EMR and stated the resident has orders for a DNR. LPN #4 reviewed the MAR and stated accuracy was verified 17 times this month. During an observation and interview on [DATE] at 9:35 AM, LPN #4 stated Resident #33's arm band was on right side of the resident's w/c and the color of the band was blue. Therefore, the residents code status was identified as a full code and CPR would have been performed if needed. LPN #4 stated they should have noticed the arm band was the wrong color and they should have informed the Unit Clerk to provide the correct color arm band to maintain accuracy of their code status. During an interview and observation on [DATE] at 9:39 AM HN RN #4 stated Resident #33's MOLST was completed on [DATE] indicating their wishes for a DNR order. The Assistant Director of Nursing (ADON) should have had the arm band changed on [DATE] when the order was written. HN RN #4 observed Resident #33's arm band on the right side of the w/c and stated the color was blue indicating the resident was a full code and CPR would have been initiated. HN RN #4 stated the nurses should have caught that the band was wrong while checking for accuracy. During an interview on [DATE] at 9:50 AM, the ADON stated they had assumed the color arm band was changed on [DATE] when the MOLST was completed. The ADON also stated the arm band color should always be accurate because it is checked by the nurses every shift for accuracy of the color compared to the EMR orders. Therefore, they would have expected the resident's arm band to be white indicting DNR per their wishes. During an interview on [DATE] at 10:46 AM, the DON stated they would have expected the color of the arm band to be accurate to the resident's wishes because they have a process in place that the nurses are checking the accuracy of the arm band color with the EMR orders every shift and the process was ineffective since Resident #33 had the wrong color arm band on their w/c. The DON also stated they would expect the nurses to check the EMR orders prior to initiating CPR and stated they were concerned if nurses would initiate CPR based on the color of the arm band as their interviews stated. 10 NYCRR 415.3(f)(2)(iii)

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00288007) during the Standard survey completed on 1/27/2023, the facility did not ensure that all alleged violations of abuse, neglect, or mistreatment are thoroughly investigated for one (Resident #26) of two resident reviewed. Specifically, the facility did not complete an investigation into an injury (left hand swelling with bruising middle finger) of unknown origin. The finding is: The facility policy and procedure titled, Abuse Prevention and Reporting dated 10/21 documented an abusive act is defined as any act of commission or omission that causes potential or actual physical or emotional harm or injury to a resident. The Director of Nursing or his/her designee will notify the attending physician immediately if the resident requires medical attention. A comprehensive incident report will be completed immediately by the Registered Nurse (RN) Supervisor which will include the names of all witnesses, a description of the event, the extent of the resident's injury and / or indication of apprehension. The facility policy and procedure titled, Accident and Incident (A/I) Reports- Resident dated 1/19 documented that an Accident was any event resulting in serious bodily harm, such as a fracture, a laceration which requires closure, a second- or third-degree burn, or an injury requiring admission to a hospital. An incident was defined as any happening which is not consistent with the routine operation of the facility or the routine care of a resident. The procedure documented an accident/incident report is to be completed within the Electronic Medical Record (EMR). Details must contain the direct, accurate details of the occurrence, the nurse's description, the resident's description (if able) and the description of the action taken. Document the injury observed at the time of the incident, predisposing factors that may have contributed to the incident. Upon notification of the A/I and for the following 2 shifts, the Supervisor or Head Nurse will examine the resident, interview the staff who may have witnessed or have knowledge of how an incident may have occurred, and record the appropriate information in the Notes section of the incident report. During the next three consecutive shifts, the supervisor will compete a follow-up of the incident by examining the resident and documenting a progress note in the Incident Report. The Interdisciplinary team will review each incident at morning report for completeness, appropriateness of interventions and to determine if further interventions is necessary. 1. Resident #26 was admitted with diagnoses which included Alzheimer's Disease, peripheral vascular disease (PVD -a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and diabetes type 2. The Minimum Data Set (MDS - a resident assessment tool) dated 9/17/21 documented Resident #26 was severely cognitively impaired and required extensive assistance with dressing and bed mobility. The Comprehensive Care Plan (CCP) identified as current by the Director of Nursing (DON) documented Resident #26 had limited physical mobility related to contractures of both shoulders, both elbows, both wrists, both hips, both knees and both ankles initiated on 2/20/17 and revised on 4/1/22. Interventions included to provide gentle range of motion (ROM) as tolerated with daily care, passive range of motion (PROM) both upper extremities (UE) with AM (morning) care; PROM left wrist/fingers with PM (afternoon) care, left comfy splint with finger separator on at all times, off for hygiene and ROM as tolerated; initiated on 2/20/18 and revised 9/28/22. Review of Occupational Therapy Notes dated 12/7/21 through 2/3/22 revealed the following: -Dated 12/7/21 documented, Reason for referral: It is reported during clinical grand rounds that resident will benefit from Occupational Therapy services for left ROM and wrist application to reduce risk of contracture and skin breakdown. Goal: AROM (active range of motion) Left Wrist Flexion to 0 degrees in order to tolerate left hand brace use for reduced risk of contractures and skin breakdown. -Dated 12/8/21 documented, Pain assessment, resident grimaces during left 3rd finger PROM, does not limit resident's functional activities. -Dated 12/13/21 Occupational Therapist (OT) #1 documented, left 3rd finger noted with edema and nursing staff notified and this writer requested use of ice. Unit nurse and family member (daughter) asked therapist about left finger edema stating that resident has significant pain. Resident, family member, and nurse aware of resident's left digit edema and complaints of discomfort when touched. -Dated 12/15/21 documented, resident found to be with facial expression of pain but unable to report discomfort or pain and does not answer yes or no when asked. Communication between nursing staff and therapist regarding skin integrity of resident's left index and middle finger. -Dated 12/17/21 documented, left middle finger remains slightly swollen with index finger pressing into middle. -Dated 12/20/21 document, Resident left 3rd finger with decreased discomfort and remains slightly swollen. -Dated 12/21/21 documented, left middle finger with decreased edema to little or none. -Dated 12/23/21 documented, left-hand ROM, no complaints of pain in left hand. Review of Progress Notes dated 11/22/21 through 10/24/22 revealed the following: -Dated 11/22/21 through 12/12/21 revealed no evidence of left-hand swelling. -Dated 12/13/21 at 1:28 PM Licensed Practical Nurse (LPN) #2 documented; resident seen by Occupational Therapy (OT) this morning. Left hand noted to be swollen, complaints of tender to touch, routine Tylenol as ordered. -Dated 12/13/21 at 5:37 PM Registered Nurse (RN) #2 documented; family asked to speak to supervisor as they were concerned about resident's left hand. Left middle finger bruised and swollen and straight, tender to touch. When asked if their hand hurt the resident nodded yes. Family states the left hand has been contracted and wanted to know who extended the hand. Writer referred them to Head Nurse (HN) and OT for further information. Medical Doctor (MD) notified per family request and Ultram 50 milligrams (mg) by mouth every 6 hours as needed for severe pain for 24 hours. X-ray results pending at this time. -Dated 12/13/21 at 7:34 PM Registered Nurse (RN) #2 documented; resident's left-hand x-ray came back no acute bone abnormalities. MD and daughter notified of results. Ice applied to area and Ultram given with positive effect. -Dated 12/14/21 at 3:52 AM LPN #3 documented left hand 3rd and 4th digits swollen with signs and symptoms of tenderness to the touch, facial grimacing when placing left hand on a washcloth, routine Tylenol given. -Progress notes reviewed 12/5/21 through 1/1/22 documented left hand remained swollen on December 15, 16, 17, 18, 19, 20, and 21 of 2021. Review of Provider Visit - MD V3 form documented by the Medical Director (MD) #1 revealed the following: -Dated 12/14/21 documented the resident was noted to have some pain and swelling without erythema (redness) in the fingers on the left hand. Resident has been working with OT for the last two days to relieve contractures, which appear to be mostly straightened at this point in time. Fingers of left hand are tender to palpation or minimal movement. Plain film (x-ray) of the left hand, three views, no acute bony abnormalities with mild to moderate degenerative joint disease and osteopenia. Impressions: Musculoskeletal pain of the fingers of the left hand. Continue around the clock Tylenol and Ultram for several days until the area of inflammation settles down. -Dated 12/24/21 documented the resident was noted to have swelling of the left hand. No history of trauma, interval x-rays were negative, and the selling has since resolved. On 1/23/23 at 9:58 AM observation of Resident #26's left hand revealed index finger contracted, and 3rd finger left hand was straight. There were no signs of discomfort, redness, bruising or discolorations. During an interview on 1/23/23 at 9:58 AM, a family member stated they do not believe the facility thoroughly investigated the injury when their mother was noted to have a swollen 3rd finger with a bruise. They stated they were aware the facility completed a hand x-ray which determined it was negative for fracture, and believed the facility tried to blame a certified nursing assistant (CNA) but believes the injury occurred during ROM possibly during therapy and doesn't believe the facility investigated the injury. During an interview on 1/26/23 at 1:31 PM, CNA #1 stated, they recalled Resident #26 had a bruise to their left-hand 3rd finger and reported it but doesn't recall who they reported it too. CNA #1 also stated they recall the swelling had increased throughout that week when the bruise was noted. CNA #1 stated they recall the therapist speaking to them to try to determine reason for the swelling and bruise but doesn't recall writing a statement or nursing department personnel investigating the reason for the injury. During an interview on 1/26/23 at 1:01 PM, RN #3 stated they were familiar with Resident #26 and recall the resident had an injury of unknown origin of their left hand. RN #3 stated an A/I should have been completed by RN #2 because they were the Nursing Supervisor. An investigation should have been completed to determine the reason for the injury and to rule out abuse. During an interview on 1/26/23 at 1:53 PM, RN # 2 stated they recall Resident #26 having a bruise and swollen finger on the left hand, evaluating the resident and documented their assessment in the progress notes and referred the incident to the Head Nurse. RN # 2 stated they believed there was an A/I completed, but if there wasn't then there should have been an A/I and investigation completed to determine the cause of the unknown injury and rule out abuse. During an interview on 1/27/23 at 10:17 AM, OT #1 stated they recall Resident #26 having a swollen left hand and immediately informed a nurse and the daughter. OT #1 stated they recall the resident's left hand 3rd finger was contracted one day and then the next day it wasn't and believed something must have happened. OT #1 stated with PROM there may be a slow improvement (decrease in contracture) but not to the extent that was noted with the finger straightened. Therefore, they believed an incident may have occurred which caused the swelling and change in the contracture. OT #1 stated they believed an investigation should have been completed to determine the reason for the bruise and swelling of the left hand. During an interview on 1/27/23 at 10:52 AM, the DON stated the facility doesn't have an A/I or investigation related to the unknown injury of Resident #26 left hand middle finger that was noted 12/13/21. Upon further review of the medical record the DON stated because the resident had a bruise and sudden swelling of the left-hand a thorough investigation should have been completed to determine the cause of the injury of unknown origin. 10 NYCRR 415.4 (b)(3)

Based on observation, interview, and record review during the Standard survey started on 1/23/23 and completed on 1/27/23, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility did not develop policy and procedures regarding medical marijuana use. This involved Resident #58. The finding is: 1.Resident # 58 was admitted to the facility with diagnoses which included dorsalgia (back pain), polyneuropathy (a disease process involving a number of nerves), and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 12/22/22 documented Resident #58 was cognitively intact, had frequent pain, received scheduled pain medications, prn (as needed) medications, and non-medication interventions. During an interview on 1/23/23 at 1:17 PM, Resident #58 stated they had seen a pain management specialist who recommended medical marijuana use due to chronic pain. The resident stated they had used the medical marijuana for over a year and that their facility physician knew they used it. The resident stated that after their most recent appointment with their pain management physician (last week) facility staff informed them they could not have it anymore. The resident stated they didn't understand why this was happening now, when they had been using medical marijuana for a while. The comprehensive care plan dated 2/22/22 documented Resident #58 had chronic back pain, neuropathy, and migraines. Interventions included to administer analgesic (pain medications) as ordered, evaluate the effectiveness of pain interventions. The CCP did not include the use of medical marijuana. Review of Resident #58's medical record revealed a document titled Official New York State Medical Cannabis Patient Certification dated 7/18/22 with an expiration date of 7/18/23. Review of Resident #58's outside consult visit dated 7/18/22, revealed the visit was for pain management and treatment included to start medical marijuana. Review of the Consultation Form dated 1/19/23, revealed the resident was to continue taking medical marijuana for management of chronic pain. Review of the Provider Visit dated 7/22/22 at 2:37 PM, written by the Medical Director (MD) #1 revealed Resident #58 had been seen recently by a consultant who had suggested medical cannabis; however, the provider did not have a license to prescribe it and the facility did not have a license to dispense it. This was discussed with the patient and alternate possible solutions were suggested. The patient was directed to address further questions with the Administrator. Review of the social work (SW) Progress Note dated 1/20/23 at 2:00 PM, written by SW #1, revealed they spoke with Resident #58 regarding marijuana use in the facility related to a neurological assessment that dictated to use the substance to control chronic pain. The resident was told they could not store any items containing marijuana in their room or within the facility due to the physician not being able to prescribe it and the facility not having a license. The SW explained that the resident's family could bring in the substance for them to take while they were there, but they could not leave substances in the facility. The resident shared that they understood the facility's policy and requested more information to better understand why they couldn't keep the substances in their room. Review of the nursing Progress Note dated 1/20/23 at 2:00 PM, written by Registered Nurse (RN) #1 documented the resident was notified the facility could not dispense, prescribe, or allow the resident to store marijuana products in their room. The resident was also told they could not vape in the facility and that family would be allowed to bring in one product for immediate oral consumption after notifying the nurse so the resident could be monitored for side effects per administration. The resident reported having edible gummies in bedside stand and denied that their family could come in to remove them to take them home, agreed to allow staff to dispose of them. They were removed by staff and immediately flushed down the toilet, witnessed by the SW and ADON (Assistant Director of Nursing). During an interview on 1/26/23 at 9:40 AM, the Licensed Practical Nurse (LPN) #1 stated Resident #58 was able to self-administer eye drops and an inhaler and had an order to keep them at their bedside. During an interview on 1/26/23 at 12:17 PM, ADON stated Resident #58 had a recommendation for medical marijuana, but the facility didn't have a license to do that. The ADON stated they couldn't order or supply it and couldn't dispense it. The ADON stated the resident would be able to get it in the community if a doctor ordered it for them. The ADON stated the Administrator said they would look into this. During an interview on 1/26/23 at 2:15 PM, the MD #1 stated medical marijuana was all new territory for us and hadn't had the chance to verify everything that needed to be in place for a resident to use it. The MD stated their understanding was they needed a special license to prescribe medical marijuana and they told the resident that. The MD stated they also told the resident the nursing home didn't have a license to dispense and suggested to meet with Administration and family to work it out. The MD stated they don't have a policy for medical marijuana or a policy about if a family brings it in. The MD stated they discussed with the resident the regulatory issues and until they figured it out, family could get it for them, but to let staff know if they took any, so if the resident got lethargic, they would know why, and needed a safe place to store. The MD stated there was no medical reason why the resident couldn't have the medical marijuana and it was all a bureaucratic/regulatory issue at this point. The MD stated they hadn't looked into the process for obtaining medical marijuana for a resident of a nursing home. During an interview on 1/27/23 at 8:53 AM, the SW #1 stated Resident #58's most recent consult was brought up in morning report last week. They Administrator directed them to talk to the resident about it. They were told that if the resident's daughter was going to bring in gummies, the resident could have them as long as the staff knew about it but couldn't have them here because there was no safe way to store and distribute it. The SW stated they were in the process of looking into the regulations about it and they wanted to be able to provide it safely, because its legal in New York state and family would have to bring it in. The SW stated they were still developing a plan and they were not aware of the prior consult from July that recommended medical marijuana. During a telephone interview on 1/27/23 at 10:09 AM, RN #1 stated Resident #58 had a recent consult and they recommended to continue medical marijuana. The RN #1 stated their facility didn't have a license to dispense or store it. The RN #1 stated they talked to the resident with SW #1 present and the resident disclosed that they had some in their room and disposed of it with the resident's permission. RN #1 stated they didn't know if the facility had a policy, so they went right to administration with their questions and the Administrator directed what to do. RN #1 stated they asked the resident if they had been taking it and the resident said they took 1-2 per week and didn't know if any staff knew about it. During an interview on 1/27/23 at 11:03 AM, the Director of Nursing (DON) stated the facility had no policy for use of medical marijuana. The DON stated the July consultation was discussed with the MD, who was not and still is not qualified to write medical marijuana orders. The DON stated they did not contact the Department of Health (DOH) or the Bureau of Narcotic Enforcement (BNE) for any guidance. The DON stated they didn't know about the cannabis website. During an interview on 1/27/23 at 11:20 AM, the Administrator stated they recalled hearing about Resident #58's consult in July and didn't feel the facility was certified to jump into a medical marijuana program. The Administrator stated they did start reaching out to get more information but it kind of fell off their radar until the next consult came up last week. The Administrator stated they didn't know what the guidance was, and they didn't contact DOH or BNE. The Administrator stated they could have come up with a policy back when it was all over the media that medical marijuana was legal, but they didn't at the time think about looking into it for their facility. 10 NYCRR 400.2

Based on interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 3/3/21, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not ensure three of three employees (Certified Nurse Aide (CNA) #1, Licensed Practical Nurse (LPN) #s1, 2) reviewed were screened for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. The finding is: The NYS Department of Health (DOH) DAL (Dear Administrator Letter) NH-20-07, Required COVID-19 Testing for all Nursing Home and Adult Care Facility Personnel, dated 5/11/20, documented: This Directive supplements the prior (DOH) Advisory concerning hospital discharges to nursing homes (NHs), as well as the DAL sent on April 29, 2020. The directive documented: With respect to COVID-19, state and federal rules and regulations require that NHs adhere to appropriate safety measures including, but not limited to: . Requiring all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. The Centers for Disease Control and Prevention (CDC) guidance, Preparing for COVID-19 in Nursing Homes, updated 11/20/20 documented: Screen all HCP (health care personnel) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. The facility policy and procedure (P&P) titled COVID-19 revised 3/2021 documented All staff are screened for the following health related items upon entry into the building: Known contact with someone with a known COVID-19 infection; Fever at or above 100.0; Travel to known COVID-19 hotspots; Cough/shortness of breath. The policy did not include screening staff every 12 hours while on duty. 1. During an interview on 3/3/21 at 8:55 AM, the Administrator stated the facility census was 106 residents. This included three COVID-19 positive residents on the second floor. a) Review of CNA #1's Employee Timecard Report from 2/13/21 through 3/3/21 included the following: - 2/13/21: 11:57 PM to 2:33 PM. (totaling 14.5 hours) - 2/24/21: 11:58 PM to 2:30 PM. (totaling 14.5 hours) During an interview on 3/3/21 at 9:48 AM, CNA #1 stated she has worked overtime and double shifts. She stated employees get screened when they enter the building at the start of their shift and do not get re-screened or have a temperature re-taken when working a double shift (two 8-hour shifts, totaling 16 hours). CNA #1 stated she was not aware they needed to be re-screened every 12 hours while on duty. Review of the facility Daily Temperatures form dated 2/13/21 and 2/24/21 documented one screening for CNA #1 on each date. There was no documentation that CNA #1 was screened every 12 hours while on duty. b) Review of LPN #1's Employee Timecard Report for 2/15/21 through 3/3/21 included the following: - 2/20/21: 6:00 AM to 10:00 PM. (totaling 16 hours) During an interview on 3/3/21 at 9:33 AM, LPN #1 stated she has worked overtime and double shifts. She stated she does not get re-screened or have a temperature re-taken when working a double shift. LPN #1 stated she was not aware they needed to be re-screened every 12 hours while on duty. Review of the facility Daily Temperatures form dated 2/20/21 documented one screening for LPN #1 on 2/20/21. There was no documentation that LPN #1 was screened every 12 hours while on duty. c) Review of LPN #2's Employee Timecard Report from 2/13/21 through 3/2/21 included the following: - 2/22/21: 10:00 PM to 11:37 AM. (totaling 13.5 hours) - 2/27/21: 9:56 PM to 2:32 PM. (totaling 16.5 hours) During an interview on 3/3/21 at 1:07 PM, LPN #2 stated he has worked overtime and double shifts. He stated employees get screened when they enter the building at the start of their shift and do not get re-screened or have temperature retaken when working a double shift. LPN #2 stated he was not aware they needed to be rescreened every 12 hours while on duty. Review of the facility Daily Temperatures dated 2/22/21 and 2/27/21 documented one screening for LPN #2 on each date. There was no documentation that LPN #2 was screened every 12 hours while on duty. During an interview on 3/3/21 at 12:05 PM, the Administrator stated employees get screened when they enter the building at the start of their shift. The Administrator stated she was not aware staff needed to be rescreened every 12 hours while on duty. During a telephone interview on 3/3/21 at 12:37 PM, the Register Nurse (RN) Infection Preventionist (IP) stated employees get screened when they enter the building at the start of their shift and if an employee works over their shift or a double shift, they do not get re-screened or have temperature retaken every 12 hours. The RN IP stated she was not aware staff needed to be rescreened every 12 hours while on duty. During an interview on 3/3/21 at 12:52 PM, the RN Director of Nurses (DON) stated employees get screened when they enter building at the start of their shift. The RN DON stated she was not aware staff needed to be rescreened every 12 hours while on duty. 415.19(a)(1) 400.2

Based on interview and record review completed during the Standard survey completed on 1/15/2020, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one for one (Resident #9) of three residents reviewed for pressure ulcers. Specifically, the lack of weekly pressure ulcer assessments to include measurements. In addition, the lack of care plan development for the pressure ulcer on the left foot 3rd toe. The finding is: The facility policy and procedure titled Pressure Ulcer/Wound management and Treatment revised 7/2018 documented a Registered Nurse (RN) will accurately assess and reassess all wounds/pressure ulcers on a weekly basis/at least every seven days. Abide by the National Pressure Ulcer Advisory panel (NPUAP) publications, Pressure Ulcer Prevention and Treatment Clinical practice Guideline on staging pressure ulcers and measurement on wounds/pressure ulcers. Care plans will reflect treatment per physicians order in the approach/ interventions section of the comprehensive care plan (CCP). The RN assessment will be documented at least every 7 days via picture and Skin/ Wound assessment in the Electronic Medical Record (EMR) and will have ongoing monitoring via the treatment record. Take a picture of the wound with approved facility iPod (portable media player and multi-purpose pocket computer). Measurement of length/width is completed on the iPod, depth of wound is measured manually by the nurse and entered into the iPod in the corresponding area. 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 10/8/19 documented the resident was cognitively intact and has one unhealed Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis) and one unstageable pressure ulcer (ulcer covered with slough or eschar). Review of the comprehensive care plan (CCP) with initiated date of 3/31/18 revealed the resident has actual skin impairment. The CCP documents a left heel pressure ulcer present on admission, and a right heel unstageable pressure area dated 9/20/19. Interventions included: assess/record/monitor wound healing of bilateral heels; measure length, width and depth where possible; assess and document status of wound perimeter, wound bed and healing progress. There was no documented evidence the left foot 3rd toe pressure ulcer is identified, care planned and has interventions in place. Review of the Physician order [REDACTED]. A & D to left heel every day and evening for dry skin, pressure area, with an order date of 9/7/19. Santyl ointment 250 Unit/ Gram (GM) ([MEDICATION NAME]) (a sterile enzymatic [MEDICATION NAME] ointment). Apply to right heel wound topically every day shift for ulcer, cover with 4 x 4 gauze, cover with heel Allevyn (a foam dressing) and wrap with Kling dressing (a gauze roll that gently sticks to itself, highly absorbent and conforms and moves with bodies motions), with an order date of 12/7/19. Review of the Treatment Administration Record (TAR) dated 1/1/20 through 1/31/20 revealed to apply small amount of A & D (vitamin A and vitamin D ointment) to tip of 3rd digit on left foot, cover with a band-aid every day and evening shift for pressure area, with a start date of 12/1/19. A & D to left heel every day and evening for dry skin, pressure area, with a start date of 9/7/19. Santyl ointment to right heel wound topically every day shift for ulcer, cover with 4 x 4 gauze, Allevyn and Kling with a start date of 12/8/19. Review of the Skin and Wound Evaluations dated (MONTH) 1, 2019 through (MONTH) 15, 2020 revealed the resident had a deep tissue injury (DTI) (persistent non-blanching deep red, maroon or purple discoloration) on the left foot 3rd digit, with no documented evidence the wound was measured weekly. The Wound Measurements length and width was blank on the following dates: (MONTH) 1st, 3rd, 10th, 17th, 24th, 31st, 2019 and (MONTH) 7th and 14th, 2020. Review of the Skin and Wound Evaluations dated (MONTH) 7, 2019 through (MONTH) 15, 2020 revealed the resident had a stage 2 pressure ulcer on the left heel, with no documented evidence the wound was measured weekly. The Wound Measurements length and width was blank on the following dates: (MONTH) 7th, 14th, 21st, 28th; (MONTH) 4th, 11th, 18th, 25th; (MONTH) 9th, 16th, 30th; (MONTH) 7th, 13th, 27th; (MONTH) 3rd, 10th, 17th, 24th; (MONTH) 1st, 8th, 22nd, 29th; (MONTH) 12th, 19th, 26th; (MONTH) 3rd, 10th, 17th, 24th, 31st 2019; and (MONTH) 7th and 14th 2020. Review of the Skin and Wound Evaluations dated (MONTH) 1, 2019 through (MONTH) 15, 2020 revealed the resident had an unstageable pressure ulcer on the right heel, with no documented evidence the wound was measured weekly. The Wound Measurements length and width was blank on the following dates: (MONTH) 1st, 8th; (MONTH) 12th, 19th, 26th; (MONTH) 3rd, 10th and 31st 2019. During an interview on 1/15/20 at 11:28 AM, Licensed Practical Nurse (LPN) #1 stated skin rounds are usually completed every Tuesday by the Registered Nurse (RN) and the RN was to complete the Skin and Wound Evaluations including measurements of the wounds weekly. LPN #1 searched the computer and stated there were no measurements documented of the left heel, right heel and left 3rd toe in the computer on the identified dates listed above. During an interview on 1/15/20 at 12:00 PM, the Director of Nursing (DON) stated there should be measurements in the computer for each pressure ulcer area identified weekly. The measurements are generated from the pictures taken by the I-pod and the measurements should have been transferred to the Skin and Wound Evaluation Template in the computer system. The DON stated the Head Nurse (HN) was responsible to ensure the measurements are in the assessment documentation and in the absence of the Head Nurse the Nursing Supervisor was responsible. The DON stated the pressure ulcers identified on the right heel, left heel and left foot 3rd toe do not have weekly measurements (as identified above) on the Skin and Wound Evaluations or in the computer system next to the picture. The DON stated she was uncertain if this is a computer I-pod system error or user error, but each area should have weekly measurements and the Head Nurse should be reviewing the measurements weekly to assess and compare the measurements week to week. The DON stated the left foot 3rd toe pressure ulcer was identified as a DTI on 12/1/19 and there were no measurements in the medical record from the date initiated to present (1/15/20). During an interview on 1/15/20 at 1:10 PM, the DON stated there should have been a care plan initiated for the left foot 3rd toe pressure ulcer. During an interview on 1/15/20 at 1:43 PM, the HN RN #1 stated weekly assessments are completed via use of the I-pod but had inadvertently not completed the steps to transfer the measurements to the Skin and Wound Evaluation template. RN #1 stated she looks at the pictures to determine if the wound is improving or not. During an interview on 1/15/20 at 2:05 PM, the DON stated the I-pod doesn't have the capability to measure the depth of wounds, therefore the nurse should be manually measuring the depth of the wounds and the HN should have ensured the measurements were in the medical record weekly. 415.12(c)(2)

Based on interview and record review during the Standard survey completed on 1/15/20, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility did not provide documentation that verified one (Food Service Helper) of five employees that worked in the facility, during the last four months, and were subject to the New York State Nurse Aide Registry, had been screened through the New York State Nurse Aide Registry prior to their employment. The finding is: A review of the facility's policy for Abuse Prevention, revised 9/2016, revealed: All applicants, regardless of department, will be screened through the on-line New York State Nurse Aid Registry for record of abuse prior to hire. A New Hire form will be completed by the department head at the time of hire indicating via the checklist that this task has been completed. Observations on 1/13/20 between 8:15 AM and 11:09 AM revealed the Juniper Unit was a 32 -bed unit and 32 residents were residing on the unit. Further observation on the unit revealed the servery was located in the middle of the dining room. The servery was open to the dining room, and tables and chairs were on either side of the servery. During an interview on 1/14/20 at 11:09 AM the Administrator stated, Employee #4 was a Food Service Helper that worked on the Juniper Unit and the facility had check lists that showed screening had been done for new employees. The Administrator further the stated the Key Board Specialist 2 conducted the nurse aide registry checks for new employees, the Nutritional Program Director would not conduct nurse aide registry checks for new employees, and the facility did not have documentation that the employee had been screened through the New York State Nurse Aide Registry prior to their employment. During an interview on 1/14/20 at 11:08 AM the Key Board Specialist 2 stated she did not have documentation that Employee #4 had been screened through the New York State Nurse Aide Registry prior to their employment, she conducted nurse aid registry checks on all of the new employees, and she must have forgotten to conduct a nurse aid registry check for the Employee #4. Key Board Specialist 2 further stated she did not have a check list that showed certain tasks (including the New York State Nurse Aide Registry screening) had been completed for the employee and she did the nurse aid registry checks for new hires by memory. During an interview on 1/14/20 at 11:28 AM the Nutritional Program Director stated, Employee #4 was a Food Service Helper and the employee only worked on the Juniper Unit plating food and washing dishes in the servery. The Nutritional Program Director further stated she did not conduct nurse aide registry checks for employees. Review of facility staff employee files, for compliance with the New York State Nurse Aide Registry regulations on 1/14/20, revealed: Employee #4 (Food Service Helper) started working at the facility on 11/10/19 and the file contained no documentation that the employee had been screened through the New York State Nurse Aide Registry prior to their employment. On 1/14/2020, a review of a Time and Attendance Daily Hours Report for Employee #4 revealed: Employee #4 worked at the facility for 10 days, between 11/10/19 and 1/12/20. On 1/14/202, a review of the job description of a Food Service Helper revised 6/19/14 revealed: This is routine manual work performed under immediate supervision in connection with preparation of and serving food in a cafeteria and cleaning of kitchen equipment, silver, and dishes. Does related work as required. Typical work activities: sets tables, serves food from steam tables in cafeteria-type dining hall, clears tables of dirty dishes, cleans tables, chairs, serving tables, and other equipment. 415.4(b)(1)(ii)(a)(b)

Based on interview and record review conducted during the Standard survey completed 12/11/18, the facility did not ensure that each resident receives adequate supervision to prevent accidents and that the resident's environment remains as free from accident hazards as is possible. Four (Residents #9, 33, 41, and 217) of eight residents reviewed for accidents had issues that involved lack of supervision for residents that had resident to resident physical contact and did not have decision-making capacity. In addition, there was lack of timely physician and resident's family or responsible party notification of the incidents. The findings are: Facility policy and procedure (P&P) entitled Resident Accident and Incident Reports (A&I) dated 4/2018 documented each resident receives adequate supervision and assistive devices to prevent accidents, the facility will complete a comprehensive assessment of all potential risk areas to determine resident vulnerability and plan accordingly. In addition, the facility will identify environmental hazards and individual resident risk of an accident involving the need for supervision and /or; evaluate/ analyze the hazards and risks and or implement interventions to reduce resident risk/ and or monitor effectiveness of the interventions and modify those interventions as necessary. Facility P&P entitled Notification of Change in Resident Condition dated 3/2015 documented licensed nursing personnel, as warranted, will notify the attending physician and family member/ responsible party of a change in a resident's condition. In addition; a family member or responsible party will be notified of any significant change in a resident's condition including significant changes in medications, treatment plans, illness and/ or injury. 1. Resident #33 was initially admitted to the facility on [DATE], readmitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS - a resident assessment tool) dated 9/22/18 documented the resident was severely cognitively impaired and sometimes understood. Section E entitled Behavior documented the resident has physical and verbal behavioral symptoms and wanders daily. Comprehensive Care Plan (CCP) documented a problem initiated on 4/19/17; Resident has history of displaying an obsession with other residents on her unit. She has become very possessive and upset when staff must separate and/ or provide to the other resident. Because of her dementia she does not have the capacity to consent to sexual relations. The following was documented: - 7/5/17 Recently hospitalized for [REDACTED]. Since she returned her behavior has improved. - 9/1/17 Male resident that resident was obsessed with was moved to a different unit today, observe resident for emotional distress and encourage her to participate in activities. - 10/5/17 Continues to fixate on other residents, it changes day to day. Staff to redirect as needed. - 11/17/17 Continues to fixate or obsess over another female resident. Often noted with inappropriate touching or attempting to kiss her. Staff intervened and resident moved to another unit. Approaches included do not allow resident to inappropriately touch other residents, push other resident in w/c (wheelchair) or attempt to stand other residents; intervene if resident displays inappropriate sexual behaviors towards other residents; Monitor for acute emotional distress and provide 1:1 (one to one) as needed; Provide redirection, validation approach as needed and explore options that resident might respond to i.e. a call to her friend, family intervention, reproaching resident, reminding resident what is allowable in the facility; Social Worker (SW) intervention as needed; and motion alarm in doorway of room at hours of sleep. Goal(s) documented the resident will be compliant with staff when they redirect her to another area; resident will not display acute emotional distress; resident will not display inappropriate sexual behaviors towards any other residents. Kardex Report (used by staff to provide care) dated 12/7/18 documented do not allow resident to inappropriately touch other residents, push other resident in w/c, or attempt to stand other residents; and needs frequent reminders about inappropriate behaviors. Progress Notes dated 7/19/17 through 12/7/18 documented the following: -7/28/17, 8/1/17, 8/2/17, 8/6/17, 8/8/17, 8/9/17, 8/11/17, 8/12/17, 8/13/17, 8/14/17, 8/15/17, 8/17/17, 8/19/17 and 8/25/17; resident with Resident #217 kissing and holding hands. -8/18/17 resident with Resident #217 on the couch kissing him [MEDICATION NAME]. -8/23/17, 8/25/17 Resident #217 sitting with resident for long periods, open mouth kissing. -8/23/17 at 9:30 PM Resident #217 found in resident's bed and she became combative striking staff. -8/27/17 resident sitting with, an unidentified, male resident occasionally kissing. -8/30/17 resident kissed Resident #217. -9/1/17 resident kissing and sitting on Resident #217's lap. -6/4/18 resident kissing an unidentified resident in dining room. -8/11/18 resident with Resident #9 intimately kissing and then again later with Resident #41. -11/20/18 resident kissing Resident #38 in the hallway. -11/21/18 Resident #41 complained of resident kissing her. -12/6/18 resident sitting on couch with another female (Resident #9) and was kissing her on the face and lips. There was no documentation the family and Physician or Psychiatrist had been notified of the resident to resident physical contacts. Provider Visit-MD notes dated 7/21/17 through 10/16/18 documented on 7/21/17 and 8/22/17 the resident had been stable per nursing. There was no documentation the Physician had been notified of the resident to resident physical contact incidents. Provider Visit-MD notes dated 8/24/17 documented the resident was seen for follow-up after a physical altercation. The situation evolved as follows; another resident, who is profoundly demented, but appears to have a romantic attachment to this resident, which is mutual, was in her bed last night. Nursing staff was attempting to extract the other resident and when the female resident entered the room, she began assaulting the staff. In the process of assaulting the staff, she struck her hand against the wall and has complaints of pain and swelling in the first two fingers of her left hand. She has mobility and can move them. There was nothing exquisitely tender. She has recollection of the events surrounding. Assessment & Plans; Alzheimer's dementia with aggressive behaviors. Referral to Psychiatrist. Consideration for [MEDICATION NAME] (mood stabilizer medication) versus atypical antipsychotics to [MEDICATION NAME] impulsivity. Risk benefit analysis; neither resident has capacity, therefore, neither resident could give consent for what appears to be a somewhat mutual relationship. This is the second or third episode of situations where one or another resident in this duo has become assaultive at attempts to separate or impose any sort of order. Utilize [MEDICATION NAME] at bedtime pending evaluation by the Psychiatrist. Provider Visit - MD notes dated 9/22/17, 11/14/17, 1/9/18, 3/6/18, 5/1/18, 8/21/18, and 10/16/18 documented the resident has been stable per nursing staff. There was no documentation the Physician had been notified of the resident to resident physical contact incidents. Psychiatrist Visits dated 9/19/17 thorough 9/14/18 documented the following: -9/19/17 Reportedly the resident was having a situation with another male resident and she was very aggressive if anyone tried to separate them. Now, the male resident is moved to a different unit and things have been better now. She still does get overly affectionate with any other resident and it is difficult to redirect her. -12/12/17 Staff reports that she is much improved, but they are having hard time giving her medications and she refuses probably once a day, misses some dosages and staff deny any new behaviors. The Plan; resident has been doing better, continue her on current medications. -3/13/18 Resident is doing better and is much improved, they deny any complaint or concern today, she can sleep through the night, and she has been compliant with her medications without any side effects. The Plan; resident has been doing better, continue the current medications. -6/12/18 Resident is doing pretty good, she had one incident where she kissed a male resident on the mouth and staff reports it happened only once. The Plan; resident is doing well and will continue the current medications. -9/14/18 Reported resident has been doing well except she refuses to take her medications sometimes, they deny any behavioral issues. The Plan; resident is doing well, will continue her on current medications. There was no documentation the Psychiatrist was notified the resident had kissed Residents #9 and 41 on 8/11/18. Unit Evergreen A&I Reports dated 7/19/17 through 12/7/18 had no A&I's completed for the resident kissing Residents #33, 9, 41 and 217 per the above Progress Notes. During an interview on 12/7/18 at 11:30 AM, Certified Nursing Assistant (CNA) #1 revealed when she sees someone kissing she will try to redirect or go to the nurse to see if the residents can be together. During an interview on 12/7/18 at 11:34 AM, CNA #2 revealed she does not stop the residents from holding hands however, she will separate them if they are too close or kissing. She will report those behaviors to the nurse. During an interview on 12/7/18 at 11:37 AM, CNA #3 revealed holding hands is okay. Kissing is inappropriate and is discouraged and is reported to the nurse. Resident #33 gets overly affectionate with other residents and has no gender preference, who-ever may be around so today it may be a different person from yesterday. She had been on every 15-minute checks in the past but now is on frequent checks. The nurses will put the resident on 15-minute checks when the nurse believes it is necessary. During an interview on 12/7/18 at 11:48 AM, Licensed Practical Nurse (LPN) #1 revealed the residents are separated if they are cuddling, hugging or kissing, Resident #33 has a history of kissing residents without their permission and they keep an eye on her. She had been on frequent monitoring checks in the past for her sexual behaviors, but is not on frequent checks now. Only the Nursing Supervisor or Nurse Manager can initiate frequent checks. She documents the behavior and informs her Nursing Supervisor and /or Nurse Manager however, she does not contact the Physician or the family. During an interview on 12/7/18 at 12:00 PM, Registered Nurse (RN) #1 Supervisor revealed she is familiar with Resident #33's behaviors of holding hands, kissing other residents and no one on this resident's unit has capacity to make decisions now. Holding hands, a kiss on the cheek or lips is okay if the other resident is okay with it. If the other resident being kissed displayed an action, such as pushing the resident away indicating the resident is not receptive; then the SW would be notified, staff would intervene to separate the residents and an A&I would be completed and the family of the residents would be notified. If the residents do not display kissing is unwanted then an A&I would not be completed and no notifications are needed. During an interview on 12/7/18 at 12:15 PM, the SW revealed she is familiar with Resident #33 and described the resident as being hypersexual and becomes sexually fixated on one person or another. Holding hands is okay but kissing should be reported to the multidisciplinary team and a SW referral is completed. An A&I is not completed unless it was unwanted touching or kissing. She had been on every 15-minute checks in the past, but is not now. The SW revealed she does not know how to stop the resident's behaviors or protect the other residents from being kissed by Resident #33. She had not had conversations with Residents #9, 41 or 217's family each time the resident was kissed by Resident #33. Regarding Resident #217, sometimes he minded, but neither resident had capacity to understand. He was eventually moved to another unit per the daughter's request in (MONTH) (YEAR). During an interview on 12/7/18 at 1:08 PM, the Director of Nursing revealed there is no cut and dry answer if the dementia resident can consent to being kissed; it is judged by the resident's actions, such as; if a resident pushes a resident away then those affections are unwanted and the staff would intervene. She was familiar with Resident #33 and described her as being sexual. If residents are sexually affection such as holding hands or kissing in a public place it is not horribly inappropriate unless a resident is showing it is unwanted affection, then an A&I is completed, the family and Physician are notified and residents are maintained separated or moved to another unit. It is not possible to provide Resident #33 with a constant 1:1 and we do not know how to protect the other residents from being kissed until the other resident displays the action to be unwanted. During an interview on 12/7/18 at 1:26 PM, the Administrator revealed she is familiar with Resident #33 and that residents have rights to sexuality with others and consent is not just verbal but also by action such as affirmative active participation. If the resident is not crying, grimacing, pulling/ pushing away it is considered giving consent. If hand holding, kissing looks to be distressful to the other resident then it would be stopped and the Nursing Supervisor would be notified. An A&I would be completed including notification to the family and Physician and the residents would be maintained separated or moved to another unit. She was unaware Resident #33 [MEDICATION NAME] or intimately kissed another resident or that Resident #41 complained of being kissed and stated an A&I should have been completed. The staff are unable to anticipate unwanted contact therefore monitor for unwanted sexual contact is the intervention. 1:1 for a prolonged period of time is not feasible in this setting and we're doing the best we can. During an interview on 12/11/18 at 10:53 AM, the Medical Director revealed he is familiar with and updated regularly about Resident #33 being affectionate to both men and woman. He had not been updated on any concerns of unwanted contact voiced from Resident #41. He stated that nursing had measures in place for evaluations, assessments and family notification. During an interview on 12/11/18 at 11:06 AM, the RN Nurse Manager revealed an A&I is completed only when a resident expresses unwanted contact such as pushing the other resident away or verbally expressing kissing was unwanted. The family and Physician are notified when an A&I are completed. Resident #41 should have had an A&I completed and the family and Physician notified if she complained about being kissed. The staff try to keep the residents away from each other, but they do not know how to prevent Resident #33 from approaching other residents, because they are all on the unit together and the staff are unable to keep them separated. During an interview on 12/11/18 at 11:25 AM, the Psychiatrist revealed kissing is not appropriate for anyone who cannot consent, the staff need to separate the residents, if it is not one particular person then continued observation is needed to protect the others. He was not updated about Resident #33's continued behaviors; the last update was approximately three weeks ago about a decline in the resident's appetite. The Psychiatrist stated he should have been notified; the resident may not be on the correct dosage and the behavior should be prevented to protect the other residents. 2. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] documented the resident is rarely/ never understood and decision-making is severely impaired. CCP documented a problem initiated on 8/17/17 the resident has impaired cognitive function/ dementia or impaired thought processes related to Alzheimer's, dementia with poor long and short-term memory, disorientation to person, place and time, impaired reasoning, coping and decision-making skills with a history of [MEDICAL CONDITION] with brain surgery. There were no Approaches related to affectionate interaction i.e. being kissed by another resident. Progress Notes dated 8/11/18 through 8/31/18 had no documentation the resident had been intimately kissed by Resident #33 on 8/11/18 as noted in Resident #33's medical record and no evidence of family or Physician notification. Progress Notes dated 11/20/18 through 12/10/18 had no documentation the resident had been kissed on the face and lips by Resident #33 on 12/6/18 as noted in Resident #33's medical record and no evidence of family or physician notification. Provider Visit-MD note dated 10/16/18 had no documentation the Physician or family had been notified the resident had been kissed on the face and lips by Resident #33 on 8/11/18. SW Progress Notes dated 10/17/17 through 12/10/18 had no documentation the Physician or family had been notified the resident had been kissed on the face and lips by Resident #33 on 8/11/18 and 12/6/18. 24-hour shift report dated 12/6/18 had no documentation the Physician or family had been notified the resident had been kissed on the face and lips by Resident #33. Refer to interviews under Resident #33. 3. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] documented the resident is severely cognitively impaired. CCP documented a problem initiated on 6/29/18 the resident has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, dementia, difficulty making decisions, impaired decision-making and short-term memory loss. There were no Approaches related to affectionate interaction i.e. being kissed by another resident. Progress Notes dated 8/11/18 through 9/11/18 had no documentation the resident had been kissed by Resident #33 on 8/11/18 as documented in Resident #33's medical record and no evidence of family or Physician notification. Progress Notes dated 11/16/18 through 12/10/18 had no documentation resident voiced a complaint about being kissed as documented in Resident #33's medical record. In addition, there is no evidence of a follow-up by an RN or SW and no evidence of family or Physician notification. A&I Reports dated 12/1/18 through 12/11/18 had no A&I completed that the resident complained of being kissed by Resident #33. Provider Visit-MD note dated 11/13/18 had no documentation the Physician was notified of the resident's complaint of being kissed by Resident #33. Refer to interviews under Resident #33. 4. Resident #217 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] documented the resident is severely cognitively impaired. CCP documented a problem initiated on 1/5/17, the resident has impaired cognitive function/ dementia or impaired thought processes related to Alzheimer's dementia, impaired decision-making and long-term memory loss. In addition, a problem initiated on 4/19/17, the resident has history of close relationship with a female resident on the unit, staff had to intervene due to their incapacity for consent, safety concerns and worsening aggressive behaviors with interventions to keep health care agent aware of resident's status, staff to intervene if any sexual behavior beyond holding hands is displayed. Progress Notes dated 8/1/17 through 9/15/17 had no documentation that the staff separated and/or prevented the resident and Resident #33 from kissing, or sitting on the resident's lap on the following dates: 8/1/17, 8/2/17, 8/6/17, 8/8/17, 8/9/17, 8/11/17, 8/12/17, 8/13/17, 8/14/17, 8/15/17, 8/17/17, 8/18/17, 8/19/17, 8/25/17, 8/30/17, 9/1/17 and being found in Resident #33's bed on 8/23/17 as documented in Resident #33's medical record. In addition, there was no documentation the Physician or family had been notified of the incidents. Progress Note dated 8/31/18 documented the resident's daughter was upset and believed her father had not been kept safe from the other resident, and requested a unit change. Progress Note dated 9/1/18 documented the resident was moved to another unit. Refer to interviews under Resident #33. 415.12(h)(1)(2)

Based on interview and record review conducted during a Standard Survey completed on 12/11/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not conduct or complete a Legionella risk assessment, to identify where Legionella and other opportunistic pathogens could grow and spread in the facility's potable water system, and the facility did not have a water management plan in place to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building's potable water system. This affected the entire building including four (Juniper, Cedar, Cypress, Evergreen) of four resident units. The finding is: 1. During an interview on 12/5/18 at 1:30 PM, the Superintendent of Maintenance and Grounds stated the facility had no documentation a Legionella risk assessment had been conducted for the building's water systems and a Legionella water management program was not in place for the building's potable water supply. The facility policy and procedure (P&P) entitled, Pneumonia - Legionella Disease Surveillance and Testing contained information on how to diagnose the bacterial disease called [DIAGNOSES REDACTED] however, it did not contain information on how to manage the facility's water system to control Legionella bacteria. During an interview on 12/11/18 at 1:05 PM, the Administrator stated the facility does not have a completed risk assessment or water management plan in place. These documents are currently in the process of being created and the facility's Legionella policy covers the human infection, but not the environmental controls. The Centers for Medicare & Medicaid Services Survey and Certification Letter S & C 17-30 subject: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17 revised 6/9/17 with an effective date of Immediately: documented Healthcare Facilities must conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. Healthcare Facilities must have water management P&P's to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water systems. 415.19(a)(1)

Based on interview and record review conducted during the Standard survey completed on 7/18/17, the facility did not ensure that all alleged violations involving abuse, mistreatment or neglect were immediately reported to the administrator, and were thoroughly investigated. One (Resident #43) of six residents reviewed for abuse and neglect had issues. Specifically, the facility did not thorougly investigate bruising of unknown origin found on a resident with dementia. The finding is: 1. Resident #43 was admitted to the facility on [DATE] and has a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 6/26/17 revealed the resident is severely cognitively impaired. Review of an untiltled facility incident report dated 6/6/17 revealed a Certified Nurse Aide (CNA) noted an ecchymotic area (purplish patch caused by blood under the skin) on the underside of the residnet's left second toe. The report documents the most like cause is from being transferred without shoes on and hitting her foot on the pedal of the wheelchair. Area lines up with the foot pedal. Reveiw of a nursing Health Status Note dated 6/6/17 written by a Licensed Practical Nurse revealed the ecchymotic area measured two centimeters by one centimeter (cm). Review of an untitled facility incident report dated 6/11/17 revealed, staff noted a discolored area on the resident's upper left lateral thigh, meausring 16 cm x 8 cm with light purple ecchymosis. The incident report documented the staff was canvassed for possible causes of discoloration. Only probable correlation voiced by staff was that they noted resident was not sitting with proper alignment in wheelchair which may have caused pressure on her thigh area. A therapy referral was sent for wheelchair positioning. There is no documented evidence of any further Registered Nurse assessment. During an interview on 7/18/17 at 9:00 AM, Registered Nurse (RN #1) Head Nurse who prepared the report dated 6/11/17 stated when an injury of unknown origin is found, an assessment is made and staff is questioned if anything happened to the resident. RN #1 stated she questions staff caring for the resident on that shift and the other shifts are questioned as a follow up. RN #1 stated she could not remember if she did a further assessment on the resident's thigh on 6/11/17. She reported staff interviews are not documented but taken verbally. Review of an untitled facility incident report dated dated 6/12/17 revealed the resident had a red/purple area on the right elbow measuring 1 cm x 1.8 cm, and had no swelling. The incident report documented the resident sits in the wheelchair with arms on armrests and puts them down inside the wheelchair most likely cause due to an area was previously found on left elbow. There is no evidence that staff were interviewed for possible causes for the ecchymosis. Review of a hospital Department of Imaging Services report dated 6/19/17 revealed the resident had a CT scan (computerized axial tomography) of the abdomen and pelvis as follow up to bilateral renal calculus. The report documented the following impressions that included; a subacute (refers to the pain following the fracture of a bone) comminuted fracture (a break or splinter of the bone into more than two fragments) of the left femoral neck (hip). A superimposed infectious process cannot be excluded. During an interview on 7/17/17 at 2:00 PM, the Director of Nursing (DON) stated the incident reports do not include staff statements because many times the staff have nothing to contribute, if there are no witnesses. The DON stated she was trying to investigate the fracture through interviews with the hospital before the resident's admission to the facility. The resident was in the hospital for over a month and she believed the resident may have fallen while there. The DON stated the hospital had not returned any of her calls. The DON stated she did not believe the bruising of the foot or the thigh was associated with the fractured femur and did not have any further investigation related to either incident dated 6/6/17 and 6/11/17. Review of the policy and procedure entitled Accidents and Incident Reports with a revised dated of 5/17 revealed upon notification of the Accident/ Incident the Supervisor or Head Nurse will examine the resident, interview staff who may have witnessed or have knowledge of how an incident may have occurred, and record the appropriate information in the Notes section of the incident report. During the next three consecutive shifts, the supervisor will complete a follow-up of the incident by examining the resident and documenting a progress note in the Incident Report. The Interdisciplinary Team will review each incident at a morning report for completeness and appropriateness of interventions. 415.4(b)(3)

Based on observation, interview, and record review conducted during a Standard survey completed on 7/18/17, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Two (Resident #32 and #92) of five residents reviewed for unnecessary medications had issues involving the lack of an attempt of a gradual dose reduction (GDR) of an antipsychotic medication; the lack of evidence of behavioral concerns and supporting documentation to support the continued use of the antipsychotic medication. The findings are: 1. Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 6/9/17 revealed the resident is usually understood and understands. The resident has severely impaired cognitive skills. Section N- Medications documented the resident received antipsychotic medication during the assessment time frame. Review of an Order Summary Report dated 7/17/17 revealed Quetiapine [MEDICATION NAME] ([MEDICATION NAME]- an antipsychotic drug) 25 mg (milligrams) T (tablet), give 1.5 tablet orally at bedtime for Mood disorder 37.5 mg dose. Review of the Medication Administration Record [REDACTED] Review of the Physician's visits/ progress notes from 7/1/16 through 6/2/17 reveal no documented GDR attempts or documented evidence the GDR would be clinically contraindicated. Review of the monthly Consultant Pharmacists Medication Regimen Reviews (MRR) dated from July 2016 through June 2017 revealed no recommendations for possible GDR of the [MEDICATION NAME]. Review of the Multidisciplinary Care Conferences dated 1/31/17, 5/10/17 and 6/20/17 revealed there were no recommendations for a possible GDR of the [MEDICATION NAME]. Review of Social Services Progress notes from July 2016 through July 2017 revealed there were no recommendations or notations for a possible GDR of the [MEDICATION NAME]. Review of Initial/ Quarterly Behavioral & Psychoactive Medication Assessments dated 8/26/16 and 11/11/16 reveal no GDR of the [MEDICATION NAME] was attempted. Review of the current Comprehensive Care Plan printed on 7/17/17 revealed there was no care plan developed to address the use of an antipsychotic medication. During an interview on 7/18/17 at 9:36 AM, the Registered Nurse (RN#1) Head Nurse stated, We meet during the quarterly care plan meetings and discuss the medications the resident is on. I cannot say we document what we discuss every time. I know there is a problem with the system for the antipsychotic medications and monitoring them for GDR's. When the Pharmacist makes a recommendation, it is placed in the doctor's folder to sign. I found though if I am not here when the doctor signs the order; sometimes I do not see what he has ordered and it gets filed. During an interview on 7/18/17 at 10:04 AM, the Social Worker stated, We do not meet specifically for [MEDICAL CONDITION] medication reviews. We review all the residents' medications at their quarterly/ annual care plan meetings. The team may discuss and then recommend a GDR for medications. This recommendation is then taken to the physician to make the final decision. The Pharmacist comes in monthly and will also make recommendations for a GDR. He will send the recommendations directly to the physician to sign if they agree or disagree. I do not get a copy of this. Review of a policy and procedure entitled Antipsychotic Drugs/ Gradual Dose Reduction dated 10/07 revealed it shall be the policy of the facility to provide accurate documentation of any resident on an antipsychotic medication and to comply with State and Federal regulations. Residents who use antipsychotics receive GDR on two separate quarters during the first year and annually thereafter and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Review of an undated policy and procedure entitled Behavior Problems/ Psychoactive Medication Assessments revealed the purpose is to assure that all resident's drug regimens are free of unnecessary drugs and to assure that the resident on psychoactive medications, receives gradual dose reductions and/or programs in an effort to discontinue these drugs, if appropriate. 2. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident rarely or never understands and rarely or never is understood. The resident has severely impaired cognitive skills. There were no documented episodes of physical or verbal behaviors. The resident did display other behavioral symptoms that were not directed towards others. Those behavioral symptoms did not put the resident at significant risk for physical illness or injury; did not interfere with the resident's care; and did not interfere with the resident's participation in activities or social interactions. Review of the MDS revealed that the resident's behavior did not impact others. The medication section documented the resident received antipsychotic medications during the assessment time frame. During an observation of toileting on 7/14/17 at 10:09 AM, the Certified Nurse Aide (CNA #2) transferred the resident with a sit to stand lift from the wheelchair to the toilet. The resident was unable to extend her arms and continuously hold the stabilizing bars at shoulder level. The resident was observed to cry out as her arms were extended and the lift rose the resident to a standing position. CNA #2 offered reassurance to the resident and slowly lifted the resident to standing. The resident appeared to calm with the CNA's reassurances and once fully lifted. The resident was brought into the bathroom and the resident's pants and disposable brief was removed. The CNA provided incontinence care to the resident due to fecal incontinence. The resident began to cry out after being suspended in a standing position for at least five minutes while the CNA cleaned the resident. Review of an Order Summary Report of active orders as of 7/17/17 revealed orders for Quetiapine 25 mg, one tablet by mouth in the afternoon for agitation and [MEDICATION NAME] (antianxiety medication) 0.5 mg one tablet three times a day (TID) for severe agitation. Review of Physician order [REDACTED]. Review of physician progress notes [REDACTED]. - On 3/10/17 the physician documented, Alzheimer's dementia with agitated and combative behaviors. Mood, affect and behavior appear to be adequately controlled on [MEDICATION NAME] 25 mg at 1700 hours and [MEDICATION NAME] 0.5 mg tid. Given our focus is on comfort and dignity, graduated dosage reductions are relatively contraindicated. - On 5/5/17 the physician documented, Alzheimer's dementia with agitated and combative behaviors. Review of the medical record revealed the Consultant Pharmacist Medication Regime Review Recommendation (MRR) dated 4/13/17 that stated, Resident has been receiving a psychopharmacological medication Quetiapine 25 mg QD (every day) for several months. I suggest a gradual dose reduction (GDR) be attempted or document why the clinical rationale for any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. The physician documented he disagreed with the recommendations without any rationale documented. Review of the Multidisciplinary Care Conference dated 5/16/17 revealed the resident was taking [MEDICATION NAME] and [MEDICATION NAME]. The Nursing Summary did not identify any behavioral concerns. The Social Work Summary documented, Advanced dementia. Disoriented to person, place and time. Poor long and short term memory. Impaired ability to stay on task, comprehend others. The Recreation Summary documented, Dementia/cognitive impairment, anxious/agitated with hands on care. The Physician Summary documented, Medically stable, no medication changes. Review of Progress Notes from 4/1/17 to 7/17/17 revealed the following: - From 4/1/17 to 4/30/17 nursing staff documented 11 episodes of the resident yelling out, swatting at staff, restlessness, anxious or resistive with care. - From 5/1/17 to 5/31/17 nursing staff documented two episodes of occasionally yelling out during medication or hands on care. - On 5/19/17 at 3:21 PM, the Social Worker documented, She (Resident #32) is not normally abusive or aggressive however when she receives HOC (hands on care) she can be resistive due to her confusion and pain/joint issues. Staff provide routine pain meds and a calm, slow approach and re-approach prn (as needed). - From 6/1/17 to 6/30/17, there are no documented episodes of adverse resident behavior. - From 7/1/17 to 7/17/17, nursing staff documented one time that the resident is resistive to care. Yells out with AM (morning care) and toileting despite gentle approach. Resident settles down once task is completed. During an interview on 7/14/17 at approximately 11:00 AM, Registered Nurse (RN #1) Head Nurse (HN) stated that nursing staff will document any resident behaviors in the progress notes. The HN stated that there are no behavioral tracking logs. The HN further stated that the facility did not have a BMAR (Behavior Modification Assessment Record) Committee but utilized the Multidisciplinary Care Conference to review the use of the resident [MEDICAL CONDITION] medications. During an interview on 7/17/17 at 2:31 PM, the Director of Social Work (DSW) stated that it was a team effort to review the use of [MEDICAL CONDITION] medications. The DSW stated that each resident is reviewed quarterly. And further stated a resident would be reviewed sooner if a resident appears overly sedated, having a reaction, or having some type of problem related to the use of the medication. The DSW stated the Resident #32 has had a recent decline in her status and is not as active and mobile as she had been. The DSW stated the resident will cry out with care and does have joint discomfort that is being treated with routine and as needed pain medications. During an interview on 7/18/17 at 8:06 AM, the Director of Nursing (DON) stated that resident's behavior concerns are documented by staff in the progress notes. The DON further stated that resident behaviors are discussed and tracked in morning report. The DON further stated that the Consultant Pharmacist will review progress notes for resident taking [MEDICAL CONDITION] medications. The Head Nurse (HN) will verbally review the Consultant Pharmacist Medication Regime Review Recommendations with the physician. During an interview on 7/18/17 at 9:14 AM, the HN (RN #10) stated she does not remember speaking with physician regarding the Consultant Pharmacist Medication Regime Review Recommendation dated 4/13/17 for a GDR of [MEDICATION NAME] for Resident #32. Review of a policy and procedure entitled Antipsychotic Drugs/ Gradual Dose Reduction dated 10/07 revealed it shall be the policy of the facility to provide accurate documentation of any resident on an antipsychotic medication. Residents who use antipsychotics receive GDR on two separate quarters during the first year and annually thereafter and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Further review of the policy revealed Head Nurses will completed an initial Behavior Problem/Psychoactive Medication Assessment on admission for every resident on [MEDICAL CONDITION] medication. The Head Nurse will complete a Behavior Problem/Psychoactive Medication Quarterly Assessment for every resident on [MEDICAL CONDITION] medication. The Behavior Problems/Psychoactive Medication Assessment will be reviewed by the Multidisciplinary Team quarterly with each care plan review. 415.12(l)(1)

Based on interview and record review conducted during the Standard survey completed on 7/18/17, the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the compressive assessment. Three (Residents #32, 92 and 107) of twenty-nine residents reviewed for care plan development lacked a plan to address the use of antipsychotic medications. In addition, Resident #32 lacked care plan development for limitations of care. Review of the facility policy and procedure entitled Comprehensive Care Plans, dated 2/2016 revealed it is the policy of the facility to develop and maintain a Comprehensive Care Plan for each resident that includes measurable objectives and time frames to meet their medical, nursing, mental and psychosocial needs as identified in the comprehensive Minimum Data Set (MDS) assessment. The procedure revealed Social Service/ Nursing are the responsible disciplines for initiating the problem statement in the behavioral triggered area. Nursing is the responsible discipline for initiating the problem statement in the [MEDICAL CONDITION] drug use area. All disciplines will contribute to approaches as necessary. The findings are: 1. Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 6/9/17 revealed the resident is usually understood and understands. The resident has severely impaired cognitive skills. Review of Section N- Medications, documented the resident received antipsychotic medication for the past seven days. Review of an Order Summary Report dated 7/17/17 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of undated Comprehensive Care Plan identified as current (printed on 7/17/17) revealed there was no documental plan for the use of an antipsychotic medication. During an interview on 7/18/17 at 9:36 AM, the Registered Nurse (RN#1) Head Nurse stated, We meet during the quarterly care plan meetings and discuss the medications the resident is on. I cannot say we document what we discuss every time. I know there is a problem with the system for the antipsychotic medications and monitoring them for GDR's (grandual dose reduction). When the Pharmacist makes a recommendation, it is placed in the doctor's folder to sign. I found though if I am not here when the doctor signs the order; sometimes I do not see what he has ordered and it gets filed. Care plan development for the use of antipsychotic medications are usually done by nursing, social work, or together. If the resident is on an antipsychotic medication they should have a care plan for it use. I am not sure why she doesn't, we must have missed it. During an interview on 7/18/17 at 10:04 AM, the Social Worker stated, We do not meet specifically for [MEDICAL CONDITION] medication reviews. We review all the residents' medications at their quarterly/ annual care plan meetings. The team may discuss and then recommend a GDR for medications. This recommendation is then taken to the physician to make the final decision. The Pharmacist comes in monthly and will also make recommendations for a GDR. He will send the recommendations directly to the physician to sign if they agree or disagree. I do not get a copy of this. Residents should be care planned for the use of an antipsychotic medication. I am currently going through the care plans to make sure they are all updated with the antipsychotic medications, and will add Resident #92 to the list. I think the charge nurse should be initiating the [MEDICAL CONDITION] medications on the care plans because they know when the medication is ordered. I do review the care plans as I will get notified when they have a care plan for an antipsychotic medication. 2. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident rarely or never understands and rarely or never is understood. The resident has severely impaired cognitive skills. The medication section documented the resident received antipsychotic medications on seven of seven days of the look back period. a) Review of an Order Summary Report of active orders as of 7/17/17 revealed orders for Quetiapine ([MEDICATION NAME]) 25 mg, one tablet by mouth in the afternoon for agitation. Review of two Multidisciplinary Care Conferences, dated 2/9/17 and 5/16/17, revealed the resident was taking [MEDICATION NAME] (Quetiapine) at the time of each care conference. Review of an undated electronic Comprehensive Care Plan identified as current revealed no documented evidence that a care plan was developed to address the use of an antipsychotic medication. During an interview on 7/17/17 at 2:31 PM, the Director of Social Worker (DSW) stated that all residents on antipsychotic medication should have care plan for the use of the medication. The DSW stated that it was the responsibility of the multidisciplinary team to ensure that care plans are developed and that team would include the Head Nurse and the Director of Social Work. During an interview on 7/18/17 at 8:06 AM, the Director of Nursing (DON) stated that there should be a care plan developed for resident behaviors and the use of antipsychotic medications. b) Review of an Order Summary Report of active orders as of 7/17/17 revealed orders for Limitation of Treatment Guidelines- no hospitalization s, consultations with specialists, blood draws, artificial nutrition/tube feedings, [MEDICAL TREATMENT], IV (intravenous- in the vein) meds or hydration, weights. Further review of the medical record revealed the Activation of Health Care Proxy form, signed by the physician on 11/11/14 and the Guideline for Limitation of Treatment' form last reviewed with the Health Care Proxy (HCP) on 10/7/15 listing no hospitalization s, no consultations with any specialist, no finger sticks (glucose monitoring), no [MEDICAL TREATMENT], no routine vital signs, no weights, no IV hydration, no IV meds, and on 5/26/16 no blood draws was changed to okay for blood work today, consult with HCP on as needed basis. Review of a physician progress notes [REDACTED]. We will discontinue [MEDICATION NAME] (antihypertensive medication) and let her family know. It presents a risk but no significant benefit. Review of the Multidisciplinary Care Conference, dated 5/16/17, revealed in the section labeled Physician Summary, Problems and Therapy the statement global decline, anticipated due to natural disease process. Review of the electronic Admission Record information dated 7/17/17, revealed the Advance Directive section documented DNR (do not resuscitate- allow natural death); do not hospitalized . The Limitation of Treatment Guidelines listed on the Order Summary Report, dated 7/17/17 were not included. Review of an electronic Comprehensive Care Plan identified as current revealed no documented evidence that a care plan was developed to address the resident's Advance Directives and limitation of treatment. During an interview on 7/18/17 at 8:00 AM, the DON stated that a care plan for limitation of treatment should be completed if there are extensive treatment limitations. During an interview on 7/18/17 at 10:55 AM, Licensed Practical Nurse (LPN #2) Medication Nurse stated she was not sure where the resident's Limitation of Treatments are listed within the electronic medical record (EMR). LPN #2 stated that the EMR was new in the last six months and she was not sure where everything is in the computer. During an interview on 7/18/17 at 10:57 AM, RN #1 Head Nurse (HN) stated that she does not usually care plan for limitation of care unless the resident is on comfort care or end of life. The RN HN further stated that each resident has different limitations of care that will change and it was be difficult to care plan that information. The RN HN further stated that the Limitation of Care should be included in the Advanced Directive section on the Admission Record form. Review of the facility policy and procedure entitled Limitations of Treatment, revised 2/2014 revealed in the procedure that the completed Guidelines for Limitation of Treatment will be place in the advanced directives section of the resident's medical record. Further review of the policy revealed, the Head Nurse /RN Supervisor and/ or Social Worker will review the Guidelines for Limitations of Treatment with the resident and/or Designated Representative quarterly or with a significant change initiated care plan review. 3. Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident rarely or never understands and rarely or never is understood. The resident has severely impaired cognitive skills. The medication section listed the resident received antipsychotic medications on seven of seven days of the look back period. Review of an Order Summary Report of active orders as of 7/17/17 revealed orders for Quetiapine ([MEDICATION NAME]) 50 mg, three tablets orally three times a day for anxiety. Review of an undated electronic Comprehensive Care Plan identified as current revealed no documented evidence that a care plan was developed to address the use of an antipsychotic medication. During an interview on 7/17/17 at 2:31 PM, the Director of Social Worker (DSW) stated that all residents on antipsychotic medication should have care plan for the use of the medication. The DSW stated that it was the responsibility of the multidisciplinary team to ensure that care plans are developed and that team would include the Head Nurse and the Director of Social Work. During an interview on 7/18/17 at 8:06 AM, the Director of Nursing (DON) stated there should be a care plan developed for resident behaviors and the use of antipsychotic medications. 415.11 (c)(1)

Based on interview and record review conducted during the Standard survey completed on 5/4/16, the facility did not revise the comprehensive care plan (CCP) after each assessment. One (Resident #41) of three residents reviewed for dental/oral care plans had an issue involving the lack of revision of the care plan to include dental recommendations to brush the resident's teeth three times a day. The finding is: 1. Resident #41 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/24/16 revealed the resident is moderately impaired for decision making and dependent on staff for personal hygiene. Review of a Dental Orders and Progress Note dated 12/9/15 revealed the resident was seen for an annual dental exam. The Progress Note documented that the patient's lower teeth were severely decayed and unrestorable. Patient needs his teeth brushed three times a day. Review of the current Comprehensive Care Plan (CCP) valid through 6/2016 revealed the resident has a few of his own teeth in poor condition, denies complaints, and has upper dentures. CCP approaches include obtaining a dental consult annually and as needed (PRN). The CCP documented that the resident has upper dentures and natural lower teeth with an approach to give oral care every AM (morning) and HS (bedtime) with staff assist. Review of the current Minicare Plan printed 4/11/16 revealed staff are to assist the resident with oral care every AM and every HS. Interview with a Certified Nurse Aide (CNA #2) on 5/3/16 at 7:15 AM revealed she generally takes care of the resident on the day shift. The CNA stated she does oral care with the resident once a day and then it gets done at bedtime. Interview with CNA #3 on 5/3/16 at 2:05 PM revealed he cares for the resident on the afternoon shift. CNA #3 stated he completes oral care for the resident one time during his shift. Interview with the Registered Nurse (RN #1) Head Nurse on 5/3/16 at 2:00 PM revealed she wasn't aware there were recommendations to brush the resident's teeth three times a day. 415.11(c)(2)(iii)

Based on observation, interview, and record review conducted during the Standard survey completed on 5/4/16, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Two (Juniper, Cypress Units) of four resident units observed for sanitary conditions had issues involving porous material used to wrap toilet piping and flush mechanisms in resident bathrooms and the porous surfaces in resident bathrooms being cleaned with disinfectant designed for non-porous surfaces. The findings are: 1. Observations of the Cypress Unit on 4/28/16 and 5/2/1, between the hours of 9:00 AM and 3:00 PM, revealed the following: - Resident room #145 - There was black foam padding attached with black tape on the toilet flush mechanism in the shared bathroom. - Resident room #163 - Black foam padding, was attached with black tape, on the back piping of the toilet in the shared bathroom. Observation of the shared bathroom in resident room #163 on 5/2/16 at 2:15 PM revealed the black foam padding was removed. The resident residing in the room stated The maintenance man came in and removed it and didn't tell me why. Observations on 5/2/16, between the hours of 7:00 AM and 3:00 PM, revealed the following: - Resident room #147, bathroom on the Cypress Unit - There was a large cut out egg crate foam attached to the toilet piping, with gray duct tape. - Resident room #256, bathroom on the Juniper Unit - There was black foam padding on the toilet piping wrapped with black tape. The base of the piping where the toilet met the pipes contained a whitish film on the pipes. Interview with Maintenance Worker #1 on 5/2/16 at approximately 2:53 PM revealed that the foam was the foam pipe insulation that is used on pipes. The Maintenance Worker also stated that he was unsure where the foam pipe insulation came from. Interview with Housekeeper #1 on the Cypress Unit on 5/3/16 at approximately 12:00 PM revealed that the housekeeper sprays disinfectant on the foam padding and wipes it off. The toilets are cleaned daily and if the foam padding is too soiled she would just have maintenance put a new one on. Interview with the Senior Maintenance Mechanic on 5/3/16 at approximately 12:00 PM revealed that he has been with the facility for four months and he threw away all of the extra black foam padding because he thought it was not being used properly. The Senior Maintenance mechanic stated he was unsure how long the padding had been attached to the toilets and stated I was not aware of the toilets having black foam padding. I assume it was there for the residents protection so they would not bump their backs when they sit down. Review of the manufacturer's literature for the disinfectant cleaner from 2016 revealed that the disinfectant cleaner is recommended for cleaning and disinfecting walls, floors and other hard non-porous environmental surfaces. Interview with the Inservice/ Infection Control Nurse on 5/3/16 at approximately 10:43 AM revealed that when cleaning porous surfaces with a cleaner designed for non-porous surfaces, staff need to either remove the foam or find another cleaner that can clean porous surfaces of bacterial contamination. There could be bacteria in it (the foam) and I don't know how they would keep it clean. Review of a facility policy and procedure entitled Infection Control and Environmental Services dated May 2010 revealed staff are to Use all cleaning products as directed by the manufacturer's recommendation. 415.5(h)(2)

Based on record review and staff interview, the facility did not provide each resident the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Two (Residents #6, 73) of 23 residents reviewed for quality of care had issues involving the lack of monitoring of therapeutic blood levels for a resident receiving anticoagulant therapy (blood thinning medication used to prevent the formation of blood clots) (Resident #73) and the lack of a Registered Nurse (RN) assessment and ongoing monitoring of a resident following unresponsive episodes (Resident #6). This resulted in actual harm that was not immediate jeopardy for Resident #73. There was no actual harm with potential for more than minimal harm that was not immediate jeopardy for Resident #6. The findings are: 1. Resident #73 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident had modified cognitive impairment for daily decision making and received anticoagulant medications. Review of a Resident Progress Note dated 7/20/12 revealed the resident was admitted to the facility on [DATE] from another nursing home. Review of a physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of undated, unsigned Discharge Instructions, from the previous nursing home, revealed directions for [MEDICATION NAME] 2 milligrams (mg) every day and to obtain a PT/INR on 7/23/12. Review of the entire medical record, including all documentation sent from the previous nursing home, revealed no documented evidence of a Discharge Summary from the Physician. Review of Admission physician's orders [REDACTED]. Review of an Admission history and physical examination see medical orders". Review of the Comprehensive Care Plan dated 8/2/12 revealed the resident was identified with a potential for altered lab (laboratory) values and altered bleeding related to the use of [MEDICATION NAME]. Additional review of the CCP revealed no documented evidence of a plan to monitor therapeutic blood values. Review of Medication Administration Records (MARs) dated 7/18/12 to 7/31/12 and 8/1/12 to 8/4/12 revealed the resident received [MEDICATION NAME] 2 mg daily. Review of a laboratory report dated 7/20/12 revealed the resident had a PT of 29.9 and an INR of 2.8. Review of Resident Progress Notes, 24 Hour Nursing Reports and physician's orders [REDACTED]. Review of a Resident Progress Note, written by a licensed practical nurse (LPN), dated 8/4/12 at 6:50 AM revealed the resident complained of neck pain and there were several ecchymotic areas (purplish patches caused by blood under the skin) on both of the resident's upper extremities. The LPN documented that the left upper extremity had three ecchymotic areas measuring 6 centimeters (cm) x 5 cm, 1 cm x 1 cm, 15 cm x 1 cm and the right upper arm had three areas measuring 12.5 cm x 11 cm, 1.5 cm x 2 cm, and 1.5 cm x 1.3 cm. Review of a Physician's Telephone Order dated 8/4/12 at 7:15 AM revealed an order to send the resident to the hospital for evaluation of neck pain/ distention and headache per the family's request. Review of a Resident Progress Note dated 8/4/12 at 8:00 AM revealed the resident was sent to the hospital on [DATE]. Review of a hospital History and Physical dated 8/4/12 revealed the resident was admitted with [MEDICATION NAME] toxicity and had an INR level greater than 10 and a PT of 144. The Physician documented that the resident received Vitamin K (a medication used to slow the bleeding time) intramuscularly in the emergency room . Review of a hospital Discharge Summary dated 8/6/12 revealed the resident was transfused with two units of fresh frozen plasma (the liquid portion of human blood that contains clotting factors) during the hospital stay. Interview with the Cedar Unit LPN Nurse Manager on 10/31/12 at 10:00 AM revealed that the facility did not have a written policy for monitoring anticoagulant therapy at the time that Resident #73 was sent to the hospital for [MEDICATION NAME] toxicity. During the interview, the LPN Nurse Manager stated there were no additional PT/INR laboratory reports available for Resident #73. During an interview on 10/31/12 at 10:40 AM, the resident's Physician stated when a resident is admitted on [MEDICATION NAME], the plan for monitoring would depend on the information received at the time of admission. The Physician stated his expectation would be after the PT/INR results were obtained, if the INR was below 2 or above 3, he would expect to be notified. If the range is in normal range, it would be addressed at the next physician visit. The Physician explained that Resident #73's PT/INR monitoring would have depended on the resident's history from where the resident was admitted from and the discharging Physician from the transferring facility should have forwarded a Discharge Summary. Interview with the Director of Nursing (DON) on 10/31/12 at 11:00 AM revealed there was no facility wide system for monitoring anticoagulants prior to 8/7/12. The DON explained that two different anticoagulant flow sheets were piloted in the facility after 8/7/12 and a decision to use one flow sheet was made in 10/12. The DON also stated that she sent a memo to each Nurse Manager on 8/7/12 directing them to obtain an order for [REDACTED]. 2. Resident #6 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed that the resident has moderately impaired cognition. Review of a Comprehensive Annual Examination Note, written by the Nurse Practitioner (NP), dated 6/19/12 revealed that Resident #6's [MEDICAL CONDITION] with absence spells were stable and that the resident was followed by neurology. Review of physician's orders [REDACTED]. Review of a Resident Progress Note, written by a Licensed Practical Nurse (LPN #1), dated 6/27/12 at 6:30 AM revealed that a certified nurse aide (CNA) reported that the resident was unresponsive and that the CNA put the resident back to bed. The LPN documented that the resident became responsive and the resident had a temperature of 97.9 degrees (normal 98.6), a pulse of 81 (average 80), a respiratory rate of 20 (normal 12 to 20), and a blood pressure of 195/90 (high). Review of subsequent Resident Progress Notes and 24 Hour Nursing Reports dated 6/27/12 and 6/28/12 revealed no documented evidence that the resident was assessed by a Registered Nurse (RN) after the unresponsive episode on 6/27/12 or that the resident's condition was monitored over the next 24 hours. Review of a Resident Progress Note, written by LPN #2, dated 7/17/12 for the 7:00 AM to 3:00 PM shift revealed at 1:00 PM the resident was not responding verbally to staff, was staring straight ahead and was returned to bed. At 2:00 PM, the LPN documented that the resident was responding "per usual". A corresponding entry for the Day shift on the 24 Hour Nursing Report dated 7/17/12 revealed documentation that the resident's blood pressure was 157/79 (high), pulse was 76 and respirations were 20. A Resident Progress Note, written by LPN #2, dated 7/17/12 for the 3:00 PM to 11:00 PM shift documented "no unresponsive periods this shift". Further review of Resident Progress Notes and 24 Hour Nursing Reports dated 7/17/12 and 7/18/12 revealed no documented evidence that the resident was assessed by a Registered Nurse (RN) or that the resident's condition was monitored following the unresponsive episode on 7/17/12. Review of a Resident Progress Note, written by LPN #4, dated 8/2/12 for the 3:00 PM to 11:00 PM shift revealed that the resident had a [MEDICAL CONDITION] episode, including unresponsiveness and blowing respirations that lasted 2 minutes and the resident "came to" on her own. Further review of Resident Progress Notes dated 8/2/12 and 8/3/12 and the 24 Hour Nursing Report dated 8/2/12 revealed no documented evidence that vital signs (blood pressure, pulse, respiratory rate, temperature) were obtained or that the resident was assessed by an RN and monitored after the unresponsive episode. Review of a Resident Progress Note, written by LPN #4, dated 8/7/12 for the 3:00 PM to 11:00 PM shift revealed Resident #6 had [MEDICAL CONDITION] activity that lasted more than 2 minutes and the resident was drooling with a vacant stare and not responding. Review of subsequent Resident Progress Notes and 24 Hour Nursing Reports for 8/7/12 and 8/8/12 revealed no documented evidence that the resident's vital signs were obtained or that the resident was assessed by an RN and monitored after the unresponsive episode. During an interview on 10/30/12 at 11:23 AM, LPN #5 stated that she knows when the resident has a [MEDICAL CONDITION] because "she stares blankly and her head goes down". The LPN stated that when the resident has a [MEDICAL CONDITION], she puts the resident in bed; takes the resident's blood pressure, pulse, respiration and temperature; notifies the RN Supervisor; and documents the information on the 24 Hour Nursing Report. When interviewed on 10/30/12 at 11:30 AM, the RN Nurse Manager stated that if the resident has a [MEDICAL CONDITION], the LPN should take vital signs, report to the RN and monitor the resident for the next 24 hours. The RN Nurse Manager confirmed that this was not done. During an interview on 11/1/12 at 9:45 AM, the Director of Nursing (DON) stated that she expects that when a resident has a [MEDICAL CONDITION], the resident is put to bed for safety, vitals are taken, the resident is assessed by an RN and put on the 24 Hour Nursing Report for monitoring. 415.12