Every finding on record at The Villages of Orleans Health and Rehabilitation

Based on interviews and record review conducted during survey, the facility failed toensure that a resident's environment remains as free of accidents as possible and receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents. Specifically, on 05/03/2026, Certified Nurse Aide #1 failed to follow Resident #1's care plan to use two person assist for bed mobility, resulting in Resident #1 falling to the floor and sustaining a head injury. Resident #1 later had a change in their condition and required transfer to the emergency room for an evaluation where they were diagnosed with post-concussive syndrome (mild traumatic brain injury caused by impact to the head). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The facility completed corrective measures prior to the start of survey. Citation is issued as Past Non-Compliance.The findings include: The facility policy titled Interdisciplinary Care Plans dated October 2021, documented each resident of the facility shall have a written care plan. Certified nurse aides will have access to the Kardex (a guide used by staff to provide care) to ensure safety. The Kardex will be located electronically in kiosks to facilitate care by direct caregivers daily. Certified nurse aides and nurses will follow the care plan as written. Care givers were expected to review the Kardex for their assignment each shift. Resident #1 had diagnoses including multiple sclerosis (chronic neurological disorder), bilateral lower extremity below the knee amputations, and morbid obesity. The Minimum Data Set (a resident assessment tool) dated 03/05/2026 documented Resident #1 had moderate cognitive impairment and was dependent on staff for the ability to roll from lying on back to their left and right side. The Kardex dated 05/03/2026 documented that Resident #1 required the assistance of two staff members for bed mobility (overall rolling). The iQIES (Internet Quality Improvement and Evaluation System) five-day Nursing Home Investigative Report dated 05/11/2026 documented Resident #1 stated Certified Nurse Aide #1 was cleaning them up and rolled the resident to the right side of the bed. Certified Nurse Aide #1 turned around to get supplies and Resident #1 stated they kept going to the right and fell off the bed. There were no witnesses to the event and Certified Nurse Aide #1 admitted to the nursing supervisor and the Director of Nursing they did not use the assistance of two staff members while completing care. The Witnessed Fall Form dated 05/03/2026 documented that Resident #1 rolled off the bed and on to the floor during a positioning change. The form documented the fall was unwitnessed and Resident #1 had bruising to the forehead, bruising to left ear, and a left ear abrasion. The note dated 05/04/2026 at 12:34 PM by Licensed Practical Nurse #1, documented Resident #1 appeared more confused and complained of increased head pain which the resident described as throbbing pain towards the left back portion of the head and increased back pain. The Medical Director was updated, and a new order was received to send the resident to the emergency room for evaluation and treatment. The hospital After Visit Summary dated 05/04/2026 documented Resident #1 sustained a mild brain injury (post-concussion syndrome) after a fall. The resident returned to the facility after emergency room evaluation. The typewritten interview with Certified Nurse Aide #1, completed, signed and dated 05/06/2026 by the Director of Nursing, documented that Certified Nurse Aide #1 stated they provided care to Resident #1 by themselves and were unaware the resident required assistance of two staff members for bed mobility and they were very upset they had rolled the resident on to the floor. During a telephone interview on 08/17/2026 at 3:09 PM, Certified Nurse Aide #1 stated they were providing care to Resident #1 on 05/03/2026 when the resident rolled to another side and out of my control when I turned my back to get some supplies and fell out of the bed. Certified Nurse Aide #1 stated they did not check the Kardex prior to providing care to Resident #1 and they should have. During an interview on 08/20/2026 at 10:02 AM, the Director of Nursing stated staff were expected to review the residents' Kardex at the beginning of their shift when they get their assignment, and prior to providing care to any resident. The Director of Nursing stated on 05/03/2026, Certified Nurse Aide #1, turned around and left the resident on their side and the resident rolled out of bed, striking their head on an oxygen concentrator causing injury to the resident. During an interview on 08/20/2026 at 10:26 AM, Physical Therapist #1 stated Resident #1 required the assistance of two staff members for bed mobility because it was safer to have a two person assist due to the resident's size, it would be too much for staff to roll the resident and manage their tasks. Staff needed to have a second member of staff to stabilize the resident to prevent them from rolling out of bed. Physical Therapist #1 further stated that staff should check the Kardex daily prior to providing care. During an interview on 08/20/2026 at 10:47 AM, Nurse Practitioner #1 stated staff should read the care plan before providing care to residents. They stated on 05/03/2026, Certified Nurse Aide #1 did not use the assistance of two staff members per the care plan and Resident #1 fell out of bed and sustained an injury (concussion). During an interview on 08/20/2026 at 10:57 AM, the Administrator stated staff were expected to review and follow the care plan prior to providing resident care. During a telephone interview on 08/20/2026 at 12:39 PM, the Medical Director stated staff were expected to review and follow the care plan prior to providing resident care. They stated Resident #1 sustained a concussion (after the fall on 05/03/2026) with no long-term effects and returned to their baseline. 10 New York Code Rules Regulations (NYCRR) 415.12(h)(2)The following corrective actions were implemented by the facility to correct the non-compliance as of 05/28/2026. - Certified Nurse Aide (agency aide) #1 was suspended pending investigation and then was placed on the do not return to the facility list (terminated) on May 5, 2026. - Resident #1 was assessed and their care plan was reviewed with no changes. - Quality Assurance meeting was held 05/05/2026 and incident discussed. - Education was provided to all nursing staff on care plan compliance. - Orientation and Annual training were reviewed, and the care plan compliance policy was reviewed with no changes made. - An audit tool was developed to ensure care plan compliance with bed mobility (daily for one week, then weekly for one month, then monthly for three months. - Audits were reviewed by Administration and reported to the Quality Assurance Committee.

Based on interviews and record review conducted during survey, the facility failed to ensure that residents received treatment and care in accordance with professional standards, the comprehensive resident-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. Specifically, the facility failed to complete neuro checks (a focused neurological assessment used to monitor brain and nervous system function) and the facility failed to complete a timely registered nurse assessment after Resident #1 sustained an unwitnessed fall with a head injury. The findings include: The facility policy titled Resident-Accident-Incident Report dated 04/2017 documented to ensure residents receive the appropriate assessment and care, following an accident/incident the nurse will fill out the Accident and Incident report and report will include, but not limited to the following: Initiate 48 hour fall monitoring orders; If resident hit head or fall was unwitnessed add fall order with neuros (checks); Director of Nursing must be notified of any falls when there is no Registered Nurse in the building; Registered Nurse on duty must assess and write an assessment note; If no Registered Nurse on duty, the accident/incident will be reported to the next Registered Nurse on duty within 24 hours for them to assess the resident and a Registered Nurse progress note to be written. Resident #1 had diagnoses including multiple sclerosis (chronic neurological disorder), bilateral lower extremity below the knee amputations, and morbid obesity. The Minimum Data Set (a resident assessment tool) dated 03/05/2026, documented the resident had moderate cognitive impairment. The Witnessed Fall Form dated 05/03/2026 documented that Resident #1 rolled off the bed and on to the floor during a positioning change. The form documented the fall was unwitnessed and Resident #1 had bruising to the forehead, bruising to left ear, and a left ear abrasion. a. The Order Summary Report, active orders as of 05/03/2026 documented 72-hour status post fall monitoring every shift per facility protocol for three (3) days with the start date of 05/03/2026. Review of Resident #1's electronic medical record dated 05/03/2026 revealed there was no documented evidence neuro checks were initiated and completed. During a telephone interview on 08/19/2026 at 12:49 PM, Licensed Practical Nurse #2 stated they were the building Charge Nurse on 05/03/2026 when Resident #2 sustained a fall. They stated they could not recall specifics of the fall, but if the fall was unwitnessed or if there were indications the resident had struck their head, neuro checks would have been initiated and documented in the electronic medical record. During an interview on 08/20/2026 at 10:02 AM, the Director of Nursing stated they expected staff to initiate and complete neuro checks when a resident experiences an unwitnessed fall or if a resident hits their head during a fall. Additionally, they stated staff did not initiate neuro checks after Resident #1 had an unwitnessed fall and hit their head that caused bruising as documented in the report dated 05/03/2026. During an interview on 08/20/2026 at 10:57 AM, the Administrator stated the bruising documented on the 05/03/2026 accident and incident report could indicate that Resident #1 hit their head during the fall and that neuro checks should have been completed. During a telephone interview on 08/20/2026 at 12:39 PM, the Medical Director stated they would expect staff to initiate and complete neuro checks per the facility protocol for routine neuro checks after unwitnessed falls and/or a resident hit their head during a fall. b. Review of Resident #1's electronic medical record dated 05/03/2026 revealed there was no documented evidence that a registered nurse assessment was completed. Review of the 05/03/2026 3:00 PM - 11:00 pm Staffing Worksheet documented Licensed Practical Nurse #2 was the building Charge Nurse and Registered Nurse #1 was assigned on the Canal View unit. Review of Registered Nurse #1's 05/03/2026 timecard documented the nurse punched in on 05/03/2026 at 1:41 PM and punched out on 05/04/2026 at 6:18 AM. During a telephone interview on 08/19/2026 at 12:49 PM, Licensed Practical Nurse #2 stated they were the building Charge Nurse on 05/03/2026 when Resident #2 sustained a fall. They stated they could not recall specifics of the fall, but usually the registered nurse in the building would complete an assessment. During a telephone interview on 08/20/2026 at 9:18 AM, Registered Nurse #1 stated they worked the evening shift on 05/03/2026 but did not assess Resident #1 after the fall. During an interview on 08/20/2026 at 10:02 AM, the Director of Nursing stated a registered nurse assessment after a resident fall should be completed within 24 hours of a fall per facility policy. Additionally, they stated a registered nurse assessment was not completed on 05/03/2026 after Resident #1 fell despite a registered nurse being in the building at the time of the fall. During an interview on 08/20/2026 at 10:57 AM, the Administrator stated that registered nurse/provider assessments should be completed as soon as possible after a fall and if a registered nurse/provider were in the building the assessment should be completed immediately. New York State Code Rules and regulations 415.12

Based on observation, interview, and record review conducted during an Abbreviated survey (#2604865) the facility did not ensure each resident receives adequate supervision to prevent elopement for one (1) (Resident #1) of three (3) residents reviewed for elopement. Specifically, the facility discontinued Resident #1's wander guard on 08/20/2025, the facility did not implement additional care plan interventions after the removal of a wander guard (device that alarms if the resident leaves a designated area). The resident did not have a physicians order to go out on pass and left the faciity on [DATE] with a staff member, Housekeeper #1.The finding is:The policy titled Elopement/Missing Resident dated 07/2024 documented patients/residents identified at risk to elope will have an individualized interdisciplinary plan of care. Exit seeking behavior may include but not limited to history of elopement, opening doors to outside, making statements referencing leaving the facility, seeking to find someone/something outside the facility, and noncompliance with facility protocols.The policy titled Resident Out on Pass - Social Leave of Absence dated 09/2011, documented the resident must have an active resident may go out on pass with responsible party order from the provider. The responsible party will sign the resident out, indicating who they are taking out (which resident), the time they are leaving the facility, destination, and anticipated time of return along with a signature.Resident #1 had diagnoses including diabetes mellitus (high blood sugar levels), vascular dementia (type of dementia caused by reduced blood flow to the brain), and schizoaffective disorder bipolar type (mental health condition). The Minimum Data Set (a resident assessment tool) dated 07/10/2025 documented the resident was moderately cognitively impaired and required supervision or touching assistance with transfers and ambulation.The comprehensive care plan documented Resident #1 was an elopement risk/wanderer related to history of attempts to leave facility and had poor safety awareness which was documented as initiated on 03/03/2025. The comprehensive care plan had documented to verify placement of the wander guard bracelet under wheelchair every shift which was discontinued on 08/20/2025. There were no additional interventions initiated to the elopement risk/wanderer care plan 08/20/2025 through 08/28/2025.The Health Care Proxy - Decision-Making Capacity Determination, signed and dated 01/30/2025 by the medical provider, documented the resident lacked capacity to make their own medical decisions.The Wandering Risk evaluation dated 07/08/2025 documented the resident was at moderate risk of wandering.The Progress Note completed by Licensed Practical Nurse Unit Manager #1 signed and dated 08/20/2025 4:40 PM documented Resident #1 had removed the wander guard bracelet from their ankle twice and removed the bracelet from the wheelchair once. Resident #1 declined to have the wander guard bracelet applied to their person or chair stating they would remove it again. The note documented Resident #1 had not made any recent attempts or voiced wanting to leave the facility. The wander guard was removed from physician orders and care, and the resident remained an elopement risk. The progress note did not document any additional preventative interventions or increased monitoring.Review of the physician orders 08/01/2025 - 08/30/2025 did not include the order Resident #1 may go out on pass with responsible party.The facility Nursing Home Facility Incident Report dated 08/29/2025 documented on 08/29/205 at approximately 5:00 PM Resident #1 left the facility with Housekeeper #1. Housekeeper #1 drove the resident to the resident's hometown and arrived at the responsible party's house approximately 45 minutes away from the facility.During an observation on 11/13/2025 at 9:49 AM, Resident #1 was observed well kempt, self-propelling their wheelchair in a common area. The resident asked if the surveyor knew there a particular street was and if they could give them a ride there later.During telephone interview on 11/13/2025 at 10:25 AM, Resident #1's responsible party stated Resident #1 came to their home unexpectedly on 08/29/2025 at approximately 5:45 PM accompanied by a person unknown to the responsible party. The responsible party contacted an acquaintance that worked at the facility to come get Resident #1.During an interview on 11/13/2025 at 10:45 AM, Licensed Practical Nurse #2 stated they received a telephone call from Resident #1's responsible party on 08/29/2025 at approximately 6:00 PM. Licensed Practical Nurse #2 went to the responsible parties home and encouraged Resident #1 to return to the facility.During an interview on 11/13/2025 at 11:48 AM, the Director of Nursing stated Licensed Practical Nurse #2 called them on 08/29/2025 at approximately 6:15 PM- 6:30 PM to report Housekeeper #1 had driven Resident #1 to their responsible party's house. The Director of Nursing stated they immediately sent out a facility wide alert at 6:27 PM that Resident #1 had eloped from the facility. Additionally, they stated no care plan interventions were initiated when the wander guard bracelet was discontinued on 08/20/2525.During an interview on 11/14/25 at 8:05 AM, Licensed Practical Nurse #3 stated Resident #1 spoke daily of wanting to leave the facility to see the tall buildings, often stating they were leaving later in the week or being discharged . They stated the resident would have to be redirected. Licensed Practical Nurse #3 stated there was no increase monitoring of Resident #1's whereabouts after the wander guard was removed and prior to their elopement.During a telephone interview on 11/14/2025 at 8:57 AM, with interpreter #473966, Housekeeper #1 stated Resident #1 had requested a ride to their hometown and they picked Resident #1 up at the facility and transported the resident approximately 45 minutes away. Housekeeper #1 stated that Resident #1 had told them their daughter would give them money for gas. Housekeeper #1 stated they were unaware that they should not have taken Resident #1 out of the facility.During telephone interview on 11/17/2025 at 9:30 AM, the Medical Provider stated Resident #1 had variable mental status with poor judgement and at times could be manipulative. The Medical Provider stated facility staff should not be transporting residents unless trained to do so and must follow the procedures in place for signing residents out to ensure the facility knows if a resident leaves the facility.Based on observation, interview, and record review the facility implemented the following corrective actions as of 09/23/2025.Resident #1's care plan was reviewed on 08/29/2025. A wander guard was replaced, and every 15-minute checks were initiated.The facility reeducated all staff regarding elopement policy and not to take residents out on pass.All residents at risk for elopement were reevaluated. Then were reviewed daily for one week, weekly for a month, and monthly for three months.Facility policies regarding elopement/wandering residents and out on pass were reviewed.10 NYCRR 415.12(h)(2)

Based on observation, interview, and record review conducted during a Recertification survey completed 1/31/25, the facility did not provide a safe, clean, comfortable and homelike environment; and did not maintain comfortable temperatures levels between 71 degrees Fahrenheit to 81 degrees Fahrenheit for three (Orchard View, [NAME] View South, and [NAME] View North) of five resident units. Specifically, air temperatures were not maintained above 71 degrees Fahrenheit in resident common areas (Orchard View) and a resident shower room ([NAME] View South). Additionally, the [NAME] View North nurse's station structure/area that was visible and used by to residents had broken hinged doors, chipped laminate countertops, scratched and chipped paint; recliner chairs and straight back chairs that were in disrepair; and a 2-person sofa that was visibly soiled. The findings are: The policy titled Environmental Comfort and Safety dated 8/2024 documented the facility was committed to providing a homelike environment that promotes the well-being and comfort for all residents. For temperature control the ambient temperatures in resident rooms, dining rooms and common areas would be maintained within the range of 71-81 degrees Fahrenheit. The policy titled Homelike Environment dated 8/2024 documented the facility aimed to create a setting that feels welcoming and comfortable, that enhanced the quality of life for residents. Common areas would be decorated with furnishing that reflect a homelike atmosphere. 1. During an observation and interview on the Orchard View Unit on 1/27/25 at 9:56 AM, Resident #17 stated it was not warm enough in the facility. They were wearing a zip up hoodie sweatshirt, t-shirt, and pajama pants. On 1/27/25 temperatures obtained on the Orchard View unit using the surveyor's stem type thermometer included: -at 10:30 AM, 68.9 degrees Fahrenheit in the center of the common area -at 10:44 AM, 69.1 degrees Fahrenheit in the hallway outside room [ROOM NUMBER] and #27. Resident #10 was seated in the hallway and stated it was a little nippy in here today. -at 10:50 AM, 68.4 degrees Fahrenheit in room [ROOM NUMBER] there was one resident in room at this time. On 1/27/25 at 10:32 AM, Licensed Practical Nurse #10 was observed wearing their winter jacket on the unit. They stated it was very cold in the facility. They stated they started their shift at 6:00 AM and it's been cold since they arrived. On 1/28/25 temperatures obtained on the Orchard View unit included: -at 9:08 AM, 70.1 degrees Fahrenheit in the hallway outside rooms [ROOM NUMBERS]. A resident seated in that area stated it was cold. -at 9:11 AM, 69.6 degrees Fahrenheit in the center of the common area, Resident #110 stated it was cold. On 1/30/25 at 8:15 AM, the temperature in the Orchard View common area was 67.5 degrees Fahrenheit, there were four residents seated in this area. Resident #10 stated it was chilly. During an interview on 1/30/25 at 8:18 AM, Certified Nurse Aide #6 stated it was cold in the facility, they were wearing black winter scarf because their neck got cold. During an interview on 1/30/25 at 9:30 AM, Licensed Practical Nurse #11 stated it was always cold in the facility. They covered the residents with blankets, and they had just got the electric fireplaces, but they weren't helping. During an observation interview on 1/30/25 at 9:33 AM, Resident #84 was seated in a recliner chair in the common area. They stated it was cold in the facility, and even with their coat on it was cold. The resident was observed wearing a thick buttoned up plaid flannel shirt/jacket. There were 12 other residents seated in the common area. During an observation and interview on 1/30/25 at 9:50 AM, the Director of Maintenance #1 stated the temperatures should be between 71-81 degrees Fahrenheit per the regulation. At 9:52 AM, the Director of Maintenance #1 used the facility's infrared thermometer and aimed it at a spot on the wall between rooms [ROOM NUMBERS], it was 70.0 degrees Fahrenheit, then aimed it at the floor in the middle of the common area and it was 68.0 degrees Fahrenheit. They stated that resident rooms were easier to control than the common areas on the units because they had their own separate control. They stated the common area temperatures depended on if the unit doors were open or closed and that they went around and closed those doors every morning, but it was hard to keep them closed because staff and residents go in and out. If the doors were open, the temperatures would go down. During an interview on 1/31/25 at 10:07 AM, the Licensed Practical Nurse Unit Manager #2 stated they bundled up the residents when they got cold, there were a couple residents who were always cold. If they thought the unit was cold, they would call the Director of Maintenance #1 to let them know, they were not sure how the temperatures were controlled. During an interview on 1/31/25 at 11:41 AM, the Director of Nursing stated they were not sure what the air temperatures were supposed to be, if they noticed a resident was cold, they would call Director of Maintenance #1. They were not aware if there was anything wrong with the heat. They have noticed the villages dining room being cold recently and maintenance had addressed that, with different interventions with the windows. They make sure the shades were down, and windows were shut. During an interview on 1/31/25 at 2:56 PM, the Administrator stated some areas of the building get a little colder when its colder outside. They expected temperatures to be between 71 and 81 degrees Fahrenheit. 2. During an initial observation on [NAME] View South Resident Spa shower room on 1/27/25 at 10:43 AM, upon entering the shower room the air/and room temperature felt cold. During an interview on 1/27/25 at 11:11 AM, Resident #78 stated the [NAME] View South shower room has no heat, it was always cold in there. During an observation on 1/28/25 at 3:09 PM [NAME] View South shower room felt cold, and a cold draft was present. The surveyor's stem type thermometer was used to measure the air temperature of that area, and the temperature was 62.2 degrees Fahrenheit. During an observation on 1/29/25 at 9:42 AM, the [NAME] View South shower room felt cold. During an interview at the time of the observation Resident #78 approached the Surveyor and stated they hadn't taken a shower in a week and would like to, but it was too cold in the shower room. Resident #78 added the staff were aware of the shower room being too cold. During an interview on 1/29/25 at 9:46 AM, Certified Nurse Aide #11 stated Resident #78 had complained of the shower room being too cold. Certified Nurse Aide #11 stated residents sometimes refuse or decline their showers due to the cold temperature in the shower room. Certified Nurse Aide #11 stated maintenance was aware of the shower room being cold. Certified Nurse Aide #11 stated it was important that resident felt comfortable while taking a shower. During an interview and observation on 1/29/25 at 10:27 AM-10:36 AM, Licensed Practical Nurse Unit Manager #8, stated there tends to be complaints about the temperature of the shower room on [NAME] View South in the winter, when it's cold. Licensed Practical Nurse #8 stated they felt a cold draft upon opening the door to the shower room. They stated the shower room was not homelike, and felt cold. They stated the temperature of the shower room was not acceptable for residents to be showered in there at that time. Licensed Practical Nurse #8 stated maintenance had been notified and it was suggested to keep shower room door open to allow heat in. During an observation and interview on 1/29/25 at 10:41 AM, in the [NAME] View shower room the Director of Maintenance pointed the facility's infrared thermometer at outside wall of the shower stale, obtaining a temperature of 61 degrees Fahrenheit and 65 degrees Fahrenheit on an inside wall in the shower room. The Director of Maintenance stated the room probably needed to be resealed and they could not feel any source of heat coming into that room. The surveyor's stem type thermometer obtained an air temperature of 65.5 degrees Fahrenheit at that time. Additionally, they stated were notified a couple of days ago about the shower room temperature. During a follow up interview on 1/31/25 at 8:26 AM, the Director of Maintenance stated room temperatures should be between 71-81 degrees Fahrenheit, including the shower rooms. They stated it was state regulation to maintain these temperatures to provide a comfortable and homelike environment to the residents. During an interview on 1/31/25 at 2:56 PM, the Administrator stated some areas of the building get a little colder when its colder outside. They expected temperatures to be between 71 to 81 degrees Fahrenheit. 3. During intermittent observations from 1/27/25-1/30/25 between 8:25 AM and 3:10 PM, the [NAME] View North nurse's station was in the middle of a large common area were the unit hallways and the dining room branched from. The five walled station was highly visible from the hallways, dining room and entrance onto the unit. The outside walls of the station were observed to have a laminated covering that was broken away in random areas, including the corners, of the five walls with exposed particle board. The countertop and edges were observed to also have chipped/missing laminate in numerous areas. There was an observed wooden support that was crooked under the countertop. Two hinged doors were present to enter the five walled station. They were observed to have chipped laminate, and one door had an area of peeling black (duct) tape at the bottom. Two recliners were observed to be inside of the walled station. A gray recliner was observed in the area with the footrest ripped and stuffing exposed, along with a blue recliner that was ripped at the arm rest with stuffing exposed. The recliners were placed at the inner wall and the wall was observed to have chipped and scratched paint. During an observation on 1/27/25 at 9:54 AM, Resident #52 was observed sitting within the nursing station with their head on the countertop. During an observation on 1/27/25 at 3:46 PM, 1/29/25 at 1:23 PM, and 1/29/25 at 4:00 PM, Resident #8 was observed to be sitting in the blue leather recliner that was in disrepair within the nursing station walls. During an interview on 1/29/25 at 1:23 PM, Certified Nurse Aide #14 stated that the nurse's station and the recliner chairs were not visually presentable, not home like and could be more sanitary. Certified Nurse Aide #14 stated that the [NAME] View North unit was not kept up as the other units were. During an interview and observation on 1/30/25 at 8:33 AM, a two-person sofa was observed to have a small hole on the seat, food debris and two black stains prior to entrance of the television lounge. In the television lounge Resident #108 was observed to be sitting in a green straight back chair that was ripped on the arm rest with stuffing exposed. Resident #71 was observed to be sitting in a brown leather recliner that had scratches down the left side. At Resident #71's left side was noted to be a pink straight back chair was ripped on the seat with the cushion exposed. During the interview at the time of the observation, Resident #71 stated that the pink straight back chair needed some maintenance and if the seat didn't get fixed, someone was going to go through it. During an interview on 1/30/25 at 3:01 PM, Licensed Practical Nurse Unit Manager #8 stated the gray and blue recliners were taken to the dumpster on 1/29/25 because the Director of Social Work saw how awful they were. They stated that there was peeling and chipping laminate on the nurse's station that did not present as homelike. Licensed Practical Nurse #8 stated the nurse's station was visible to the residents and visitors and should have been cleaner because it looked dingy. During an interview on 1/30/25 at 3:05 PM, Certified Nurse Aide #16 stated the nursing station was clean but looked old and needed to be remodeled. They stated residents had the right to look at nice things. During an interview on 1/30/25 at 3:10 PM, Resident #52's spouse stated they did not like the looks of the [NAME] View North unit, it was not homelike, and it was dirty. They stated the unit did not have enough chairs for the visitors to sit in. During an interview on 1/31/25 at 8:29 AM, the Director of Social Work stated that the [NAME] View North nurse's station could be visualized by residents, visitors and staff. They stated that the nurse's station was part of the resident's home, that the station had scuff marks in paint, and it was not new looking. The Director of Social Work stated that they did order some new recliners for the unit because the old furniture was not homelike for residents and visitors to be sitting in chairs that had rips with stuffing coming out of them. During an interview and observation on 1/31/25 at 10:02 AM, the Director of Housekeeping and Laundry was brought to the [NAME] View North Unit. After visualization of the nurse's station, they stated it did not have a home like appearance. They stated the station had been there for [AGE] years and needed to be replaced. They visualized the love seat at the entrance to the television lounge and stated it was clean but had two black marker stains on it. The two ripped straight back chairs were no longer present in the television lounge. During an interview on 1/31/25 at 11:25 AM, the Director of Nursing stated the [NAME] View North nurse's station could be seen as soon as one enters closed doors of the unit. They stated they did not like the station, it did not have a homelike appearance, and the laminate doors and countertops were peeling. During an interview on 1/31/25 at 1:57 PM, the Administrator stated they felt the [NAME] View North Nursing Station structure was sound and they had not received any complaints about the appearance of the station. They stated a homelike environment was a constant process and they look at all areas of the facility. During an interview on 1/31/25 at 2:05 PM, the Director of Maintenance stated they would describe the [NAME] View North nurse's station as panels, saw dust and glue. They stated that it was structurally safe, felt it was home like, but it was difficult to replace broken Formica. 10 NYCRR 415.5(h)(2,4)

Based on observations, interviews, and record review conducted during a Complaint (Complaint #NY00349205, #NY00338010) investigation during the Standard survey completed on 1/31/25, the facility did not ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for six (Orchard View lounge area, Canal View lounge area, [NAME] View South lounge area, Main Lobby , Villages Dining Room, Garden View lounge area) of seven resident areas and three (Resident #s 11, 115 and 320) of five residents reviewed for accidents. Specifically, the facility did not identify as potential accident hazards electric fireplaces with hot surfaces that were in resident accessible areas (Villages Dining Room, Canal View lounge area, Garden View lounge area, Orchard View lounge area, [NAME] View South lounge area, and the main lobby). Additionally, a cognitively impaired resident with exit seeking behaviors eloped from the facility undetected (Resident #115); safety devices (bilateral foot pedals and calf protector/foot board) were not place as planned (Resident #11) and Resident #320 was transferred by a staff member and an untrained family member. The findings are: 1. Observation during the initial building tour on 1/27/25 from 9:30 AM until 11:30 AM revealed the facility had seven wall-mounted electric fireplaces. They were in the Villages Dining Room (two), Canal View lounge area, Garden View lounge area, Orchard Unit lounge area, [NAME] View South lounge area, and the main lobby. The six electric fireplaces located on resident units were Brand A and the one in the main lobby was Brand B. At the time of the initial building tour, all electric fireplaces were producing heat, except for the electric fireplace in the main lobby. During the initial building tour on 1/27/25 at 10:45 AM, the Director of Maintenance stated the electric fireplace in the main lobby was set to a thermostat, and it automatically produced heat when the temperature in the room dipped below the thermostat's setpoint. During observations and interviews of the electric fireplaces for (6) six resident areas revealed the following: Orchard View lounge: 1/30/25 at 10:25 AM revealed Resident #115 was sleeping in a wheelchair within inches of where heat emanated from the bottom the electric fireplace that was mounted on the wall. The electric fireplace was producing heat at this time, which came from the bottom center of the unit. The bottom of the unit was at Resident #115's shoulder level, had no shielding from the metal, and was very hot to the touch. At the time of the observation, Certified Occupational Therapy Assistant #1 stated to the Surveyor who was touching the electric fireplace, It's hot, it'll burn you. Certified Occupational Therapy Assistant #1 stated the electric fireplaces were installed throughout the facility about one month ago and they were usually producing heat. They stated they had periodically noticed that Resident #115 tended to wheel themselves up to the electric fireplace. Certified Occupational Therapy Assistant #1 stated the electric fireplaces were concerning because some residents had dementia and loss of sensation for hot surfaces. During an interview on 1/30/25 at 10:30 AM, Certified Nurse Aide #1, stated Resident #115 often wheeled themselves up to the fireplace. They stated they did not receive safety training from the facility when the electric fireplaces were installed. -1/30/25 at 12:07 PM, the electric fireplace in the Orchard View lounge was on and blowing warm air. A sticker on the front of the electric fireplace said, warning surface can get hot when the heater is on. The surface along the bottom center of the fireplace was hot to the touch, the surveyor had to pull their hand away after a few seconds. The temperature was measured of that area, and it ranged from 157.8 degrees Fahrenheit to 167.5 degrees Fahrenheit. During an interview on 1/30/25 at 12:13 PM, Licensed Practical Nurse #11 stated the electric fireplaces were always on and were told they were on the max setting. They never saw any residents touching it, but there were a couple residents who liked to sit by it for warmth. They were never told to keep the residents away from them. They were grateful they put the fireplaces in because it was cold in here. During an interview on 1/30/25 at 12:19 PM, Certified Nurse Aide #6 stated the electric fireplaces were always on. They stated they have touched it to see how much heat it put out, but didn't think it was hot enough to burn a person. They were never told to keep residents away from it. Canal View lounge: 1/20/2025 at 12:02 PM there was an electric fireplace mounted on the wall in the common area (lounge) under the TV. There were no residents near the electric fireplace at the time of the observation. The area at the bottom was producing heat, felt warm and measured 156 degrees Fahrenheit. During an interview on 1/30/25 at 12:17 PM, Certified Nurse Aide #3 stated a resident had asked them to turn up the heat and they were checking the fireplace to see how warm it was. Certified Nurse Aide #3 stated they felt heat at the bottom and was unsure how the electric fireplace worked. They stated they did not receive safety training from the facility when the electric fireplaces were installed. [NAME] View South lounge: 1/27/25 at 1:29 PM and 1/29/25 at 12:39 PM, the wall mounted electric fireplace was observed with warning label stating surface can get hot when heater was on. The electric fireplace was producing heat at this time, which came from the bottom center of the unit. At those times, the surveyor touched the metal area of the electric fireplace, emitting hot air with their fingers and immediately pulled back their hand as the surface was too hot to touch. On 1/30/25 at 12:03 PM, wall mounted electric fireplace was powered on and no heat was emitting from the unit at this time. Director of Maintenance stated this electric fireplace had a thermostat, and if the room was warm enough the electric fireplace would not run. Main Lobby: 1/30/25 at 12:04 PM, there was an electric fireplace was recessed into a wall. The electric fireplace had metal vents on top of a display of artificial blue fire flame lights and it was blowing out very hot air. The surveyor's digital thermometer was placed across the vents blowing out the hot air and it measured 230 degrees Fahrenheit. The vent grates were touched by the surveyor and immediately needed to be pulled away. During an interview on 1/30/25 at 12:09 PM, Certified Nurse Aide #10 stated they have not received any training or in-service on the use of the electric fireplaces and would contact maintenance if they had any concerns or questions. During an interview and observation on 1/30/25 at 12:15 PM, Certified Nurse Aide #10 stated they did not know how long the electric fireplace had been in the Main Lobby and did not know how it worked. At 12:19 PM Certified Nurse Aide #10 went into the lobby and placed their hand about three inches from where the air was blowing out. Certified Nurse Aide #10 stated the air was hot, and it was hot enough to burn someone especially if they touched it. During an interview on 1/30/25 at 12:16 PM, Licensed Practical Nurse #8, Unit Manager stated they have no responsibility with the functionality of the electric fireplaces on [NAME] View South and the Main Lobby. They stated they have seen the Director of Maintenance check them first thing in the morning during their rounds. Licensed Practical Nurse #8 stated they have never observed any residents on [NAME] View touching the electric fireplace and no concerns have been brought to their attention about the electric fireplaces being too hot. During an observation and interview on 1/30/25 at 12:26 PM-12:31 PM in the Main Lobby, the Administrator placed their hand on front of metal grate, of the electric fireplace emitting heat and stated they wouldn't want to keep their hand on it. They stated their natural response was to pull their hand away from the metal grate as it was too warm. The surveyor's thermometer was placed on the metal surface across the vent emitting hot air and it measured 240-245 degrees Fahrenheit. The temperature was verified by the Administrator. The Administrator stated anybody could touch the electric fireplace and they wouldn't recommend anyone holding their hand on the metal grate. The Administrator stated the Main Lobby was a highly unoccupied resident area. Villages Dining Room dining room: 1/30/25 at 12:05 PM, the wall mounted electric fireplace by the Servery revealed the bottom center metal grate surface temperature felt warm and ranged between 142 degrees Fahrenheit (F) to 163.3 degrees Fahrenheit. During an interview on 1/30/25 at 12:09 PM, Certified Nurse Aid #3 stated the Maintenance Director was responsible to turn on the electric fireplaces and adjust the temperatures. They stated they had not received any education on how far the residents needed to be kept away from the electric fireplaces. During an interview on 1/30/25 at 12:13 PM, Registered Nurse #2 the nursing staff did not have access to the electric fireplace remote. Registered Nurse #2 stated that they did receive verbal education by the Director of Nursing on the electric fireplaces to keep residents at a safe distance away but could not state specifically how far they had been instructed to keep the residents away from them. During an interview on 1/30/25 at 12:23 PM, Certified Nurse Aide #15 stated they were briefly educated on the electric fireplace and were told not to place residents too close to the electric fireplaces. They stated that the electric fireplace was hot underneath. Observation with the Director of Maintenance in the Villages Dining Room on 1/30/25 at 12:00 PM the Director of Maintenance pointed the facility's infrared thermometer into the electric fireplace from the bottom center and it read 100 degrees Fahrenheit. The Surveyor's stem type thermometer was set on the metal surface on the bottom center and measured 142.6 degrees Fahrenheit. At this time, the Director of Maintenance placed their hand on the bottom center of the unit, kept it there for greater than five seconds. The Director of Maintenance stated they felt there were no safety risks related to the electric fireplaces, as they had not seen any resident touch the units in a way that could burn them. The Director of Maintenance stated the two electric fireplaces located in the Villages Dining Room were set to on and produced heat constantly. They stated the electric heaters in the resident units and main lobby were set to a thermostat, which was set to 82 degrees Fahrenheit. The Director of Maintenance stated when the electric fireplaces were first installed in December 2024, they performed daily checks on them. The checks were now performed monthly. They stated their checks were performed by pointing the facility's infrared thermometer upward into the unit through the bottom center, where the heat came from. Additionally, on 1/31/25 at 10:10 AM, the Director of Maintenance stated the building's electric and hydronic heating systems were fully functional. It was their idea to purchase and install the electric fireplaces, and they did it for resident enjoyment. The most recent log titled Wall Heaters, dated 1/23/25, documented the seven electric fireplaces were operational and their temperatures ranged from 150 to 165 degrees Fahrenheit. During an interview on 1/31/25 at 2:39 PM, the Administrator stated the electric fireplaces had a safety UL (Underwriter's Laboratory) rating. They stated they knew there was a maximum temperature according to regulations, but were unable to specify the maximum temperature, and stated they liked the electric fireplaces because they were homelike. Garden View: 1/30/25 at 12:06 PM the electric fireplace was mounted on the wall approximately 3 feet from the floor. The electric fireplace was very hot to the touch on the bottom, and the surface temperature the metal vent and measured 175.8 degrees Fahrenheit. During an interview on 1/30/25 at 12:08 PM, Licensed Practical Nurse #6 stated they had observed residents approach the fireplace to warm themselves, but no one had attempted to touch it. Licensed Practical Nurse #6 stated the fireplace had a hot surface and could potentially burn someone if they touched it. During an interview on 1/30/25 at 12:10 PM, Certified Nurse Aide #12 stated the electric fireplace felt very hot to them and some of these residents don't know they shouldn't touch it. The policy and procedure titled Electric Heaters, issued 12/2024, documented only electric heaters that meet fire safety standards and are UL (Underwriter's Laboratory) listed or have equivalent safety certification can be used. Electric heaters should be used under supervision, especially in areas accessible to residents, to prevent accidents or misuse. Regular inspections and maintenance of electric heaters will ensure they are in good working condition and do not pose any safety hazards. Compliance with local and state regulations regarding the use of electric heaters will be ensured, including any restrictions or guidelines specific to healthcare settings. The Maintenance Supervisor is responsible for ensuring compliance with all safety standards. The user manual for Brand A electric fireplace documented this heater is hot when in use, to avoid burns, do not let bare skin touch hot surfaces. Keep combustible materials such as furniture, pillows, and clothes at least three feet from front, sides, and rear of the heater. Extreme caution is necessary when any heater is used by or near children or invalids, and whenever the heater is left operating and unattended. The user manual also documented to turn the heater fan on, press the heat button. Press and hold the heat button for five seconds to cycle through heat settings, which ranged from 62 to 82 degrees Fahrenheit. The user manual for Brand B electric fireplace documented always keep clothing, papers, and other combustibles at least three feet away from the front of this heater, and away from the bottom, sides, and rear of this heater. This heater is for residential use only, not for commercial use. Never leave this heater unattended. This heater is hot when in use. Avoid injury, do not touch hot surfaces or attempt to move this heater while it is hot. The user manual also documented the flame effect must be on for the heater to function, press the heat button once for low heat (750 [NAME]) and press heat button again for high heat (1500 [NAME]). Temperature can be set from 62 to 82 degrees Fahrenheit. 2. Resident #115 had diagnoses including nontraumatic intracerebral hemorrhage (brain-bleed), legal blindness, and heart failure. The Minimum Data Set (resident assessment tool) dated 7/15/24, documented Resident #115 was severely cognitively impaired, was understood and usually understands. There was no wandering behaviors documented. Review of Census data revealed Resident #115 was moved from another unit of the facility to their current room on the Orchard unit on 7/18/24. The comprehensive care plan initiated 5/3/24 documented Resident #115 had limited physical mobility related to weakness with a revision on 7/10/24 to allow for ambulation with a rolling walker with 1 assist by a Certified Nurse Aide for distance as tolerated. Locomotion, initiated 5/3/24 and revised 5/7/24, was to be with a standard wheelchair. Resident #115's comprehensive care plan initiated 5/23/24 documented they had impaired cognitive functioning or impaired thought process and the interventions to be addressed by Certified Nurse Aides were that they needed to be cued, reoriented and supervised as needed. Wandering Risk Assessments completed for Resident #115 documented for 7/15/24 that Resident #115 ambulated with 1 Assist and the assessment did not have a way to reflect that Resident #115 was capable of self-propelling in their manual wheelchair. The 7/15/24 assessment did not indicate a history of wandering and scored as a low risk for wandering. A progress note dated 7/15/24 documented that Resident #115 was encountered twice self-propelling through the double doors and down the hallway away from the villages asking staff am I going the right way?. Resident redirected both times back to unit. Nursing made aware. A progress note dated 7/22/24 documented Resident #115 was encountered going through the double doors with another resident stating they were going outdoors. Both residents were educated that they needed a staff member with them to be outside and were re-directed to their unit. A progress note dated 7/23/24 completed by Licensed Practical Nurse #3 documented that Resident #115 was missing at 7:20 PM and a search was started on the unit, then notified the supervisor and alerted all staff of the missing resident. A progress note dated 7/23/24 documented that Licensed Practical Nurse #12 found Resident #115 in the facility parking lot sitting in their wheelchair and brought Resident #115 back into the building and to their unit at 7:45 PM. Resident #115 was assessed by a Registered Nurse, was calm and cooperative with no distress or injuries noted. A progress note dated 7/23/24 documented that a wander alert device was applied to Resident #115's left ankle. Review of further Wandering Risk Assessments revealed the next assessment was completed on 7/24/24, the day following the elopement. The 7/24/24 assessment noted a room change as a recent experience. That room change took place on 7/18/24, prior to the elopement. The 7/24/24 assessment again noted Resident #115 as ambulating with 1 assist and did not reflect that Resident #115 was capable of self-propelling in their manual wheelchair independently. Resident #115 scored as moderate risk for wandering. During multiple observations on 1/30/25, Resident #115 was observed self-propelling in their wheelchair independently by using their feet to propel the manual wheelchair around the unit and their safety alert device was in place. During an interview on 1/31/25 at 10:59 AM, Licensed Practical Nurse/Unit Manager #2 stated Resident #115's Wandering Risk Assessment was updated after the two encounters in the hallway on 7/15/24 and should have been updated again on 7/22/24. After the 7/22/24 documented encounter, Resident #115's case should have been discussed by the Interdisciplinary team and supervision should have been increased. During an interview on 1/31/25 at 10:34 AM, Occupational Therapist #1 stated they were the staff person who encountered Resident #115 on 7/22/24 in the hallway going through the double doors from the villages side of the building with another resident and they stated they did report this encounter to nursing staff, at the time of redirecting the two residents to their unit. They did not recall who specifically they reported to. During an interview on 1/30/25 at 10:32 AM, Certified Nurse Aide #6 stated they were one of two staff who were on break in their cars in the parking lot and observed Resident #115 self-propelling in their wheelchair around the end of A-wing and into the parking lot on 7/23/24 at about 7:40 PM. They stated Resident #115 told them they had gotten out through the courtyard glass door and then through the fence gate. Certified Nurse Aide #6 stated they believed that the fence gate was not locked, and that gate usually was locked. During an interview on 1/30/25 at 10:53 AM, Licensed Practical Nurse #3 stated they noticed that Resident #115 was missing from the unit on 7/23/24 at about 7:20 PM. They reported this to the Registered Nurse Supervisor on shift and a search of the facility commenced. Licensed Practical Nurse #3 stated they were going down the main hall from the main lobby area toward the front door of the facility, when Licensed Practical Nurse #12 was bringing Resident #115 through the front doors. Licensed Practical Nurse #3 stated Resident #115 was very tickled by their experience and stated they had exited through the door and then the fence to get to the parking lot. They stated Resident #115 told them they were told if the door was unlocked, they could go outside. Licensed Practical Nurse #3 stated they believed Resident #115 had just recently moved to the Orchard unit from the Garden unit, at the time of the elopement. They also stated they were not aware of any other times Resident #115 had attempted to leave the unit and that Resident #115 was not wearing a wander alert device at the time. During an interview on 1/30/25 at 9:12 AM, Director of Nursing #1 stated they investigated this elopement and concluded Resident #115 used the glass door in the main lobby area to exit to the garden and from there the fence gate. They stated the glass door was usually unlocked until about 8 PM daily. They stated the fence gate was unlocked because the grass had been mowed and the pad lock had not been re-locked. They stated Licensed Practical Nurse #12 had noticed Resident #115 in the parking lot and observed them self-propelling around the corner of A-wing, the service wing of the facility. During an interview on 1/31/25 at 12:02 PM, the Administrator stated that supervision levels for Resident #115 should have been increased on 7/15/24 after the resident was encountered self-propelling through the double doors to the hallway from the villages section of the facility. After reading the progress note for 7/22/25 regarding Resident #115 being encountered with another resident exiting the villages through the double doors, the Administrator stated a wander alert device should have been placed at that time for Resident #115's safety. The Administrator stated the other resident was one who was allowed to use the garden area independently. The policy and procedure titled Elopement/Missing Resident revised 7/2024 documented the facility would provide a safe and secure environment for all residents and any resident identified as a risk for elopement will be reassessed monthly, upon admission/readmission, 7 days from admission/readmission, change in level of care, and/or environment. The Wander Risk Assessment will be completed to determine the resident's risk for elopement. Exit seeking behavior may include but was not limited to opening doors to the outside, making statements referencing leaving the facility, seeking to find someone/something outside of the facility. The policy and procedure titled Wanderguard Alarm Procedure revised 4/2017 documented that to ensure the safety of wandering residents at risk of elopement, the facility had a Wanderguard System installed on all exiting doors to the outside. 3. Resident #11 had diagnoses of dementia, cerebral infarction (a type of stroke), and aphasia (absence or difficulty with speech). The Minimum Data Set, dated dated dated [DATE] documented Resident #11 was rarely understood, rarely understands and had severe cognitive impairment. The Minimum Data Set documented that Resident #11 required partial/moderate (helper does less than half the effort) assistance with transfers and ambulation and was dependent (helper does all of the effort) with wheelchair mobility. The comprehensive care plan with last revised on 1/16/25 documented Resident #11 had limited physical mobility related to weakness, utilized a manual wheelchair and required bilateral elevating footrests and a calf protector/footboard was to be in place. Review of the Kardex (a guide used by staff to provide care) dated 1/31/25 documented Resident #11 had a manual wheelchair with bilateral elevating footrests and calf protector/footboard. The Physical Therapy Treatment Encounter Notes from 7/18/24 through 7/23/24 documented Resident #11 had difficulty keeping their bilateral feet on elevating footrests which would increase the risk for skin integrity issues. The note also documented that when Resident #11 did not have footrests on their wheelchair their feet would not rest fully on the floor and would be at risk for bumping their feet into the wheelchair caster wheels. Nursing recommendations had been updated to include a calf protector/footboard when Resident #11 was to be in the wheelchair. Education had been provided to a certified nurse aide (unidentified) regarding the need to have bilateral elevating footrests and calf protector/ footboard in place. Observations made on 1/27/25 at 12:22 PM and 1/30/25 at 8:40 AM revealed that Resident #11 was sitting in their wheelchair and did not have bilateral foot pedals and calf protector/foot board in place as care planned. Observations made on 1/28/25 at 8:57 AM, Resident #11 was sitting in their wheelchair and did not have the calf protector/footboard in place as care planned. The resident's right foot was off the foot pedal and in between the foot pedals touching the floor. Continued observations on 1/29/25 at 10:58 AM, and 1/29/25 at 4:29 PM revealed that Resident #11 was sitting in their wheelchair and did not have the calf protector/footboard in place as care planned. Observation on 1/30/25 at 9:45 AM, Resident #11 was observed to be sitting in their wheelchair by the nurse's station and did not have bilateral foot pedals and calf protector/footboard in place. Certified Nurse Aide #14 reposition Resident #11 in wheelchair and transport Resident #11 to dining room (approximately 50 feet) with no foot pedals in place and was sliding forward in wheelchair. Resident #11 held their feet up extended outward approximately an inch off the floor during transport. During an interview on 1/30/25 at 9:52 AM, Certified Nurse Aide #14 stated that Resident #11 would frequently slide down in their wheelchair and that was why they had just repositioned them. Certified Nurse Aide #14 stated that Resident #11 did not have foot pedals or a calf board on and was unsure if they should have them in place. They stated Resident #11 was not on their assignment. During an interview on 1/30/25 at 10:00 AM, Certified Nurse Aide #20 stated they were assigned to Resident #11 and had provided care to them. Certified Nurse Aide #20 stated they had not checked Resident #11's care plan prior to providing care and did not see foot pedals or a calf protector/foot board in the resident's room. Certified Nurse Aide #20 stated they had not previously seen Resident #11 utilize foot pedals. Certified Nurse Aide #20 reviewed the transfer and ambulation section of Resident #11's care plan on the computer and stated they had not seen that Resident #11 was to have foot pedals or a calf protector/ footboard. During an interview on 1/30/25 at 10:26 AM, Licensed Practical Nurse #3 stated the residents care needs and safety devices would be documented on the care plan and Kardex (a guide used by staff to provide care). Both the nurses and certified nurse aides were responsible to ensure the care plan was followed. Licensed Practical Nurse #3 was observed to pull up Resident #11's Kardex on the computer and stated that Resident #11 was care planned to have bilateral foot pedals on their wheelchair and a calf protector/footboard was to be in place. They stated they were unaware that Resident #11 did not have both the foot pedals and calf protector/footboard on as care planned and it was important to prevent injury. During an interview on 1/30/25 at 10:39 AM, Licensed Practical Nurse Unit Manager #8 stated the cart nurses were responsible to make sure the certified nurse aides followed the care plan and all positioning devices were in place. The Licensed Practical Nurse Unit Manager #8 stated Resident #11 was to have bilateral foot pedals on due to edema. Resident #11 did not self-propel themselves and did not have the strength to hold up their legs while being transported and could be injured without the foot pedals. Licensed Practical Nurse Unit Manager #8 stated they were unaware that Resident #11 was care planned to have a calf protector/footboard. During an interview on 1/30/25 at 2:39 PM, the Director of Rehabilitation stated Resident #11's calf protector and footboard was added to their care plan in July 2024. They stated Resident #11 was having difficulty keeping their feet on their foot pedals and their feet were not touching the floor without the pedals. The Director of Rehabilitation stated the calf protector, and footboard was issued to prevent foot or leg injuries. They would expect nursing staff to follow the recommendations made for Resident #11 and that Resident #11 would be at risk for injury without having foot pedals or the calf protector/ footboard in place. During an interview on 1/31/25 at 12:40 PM, the Director of Nursing stated they expected the certified nurse aides to read the Kardex prior to providing resident care and ensure all safety devices including foot pedals and calf boards were in place as this would be important to prevent falls and injuries. 4. Resident #320 had diagnoses that included a fracture of the left femur, dementia and atrial fibrillation (an irregular heart rate that causes poor blood flow). The Minimum Data Set (a resident assessment tool) dated 3/7/24 documented Resident #320 had severe cognitive impairment, usually understands and was usually understood. The comprehensive care plan dated 3/29/24, documented Resident #320 had self-performance deficit related to limited mobility. Interventions included that Resident #320 may require a two-person approach due to combativeness. The care plan did not indicate that family could assist with transfers. The Kardex (guide used by staff to provide care) dated 4/1/24, documented that Resident #320 was dependent for wheelchair mobility; a maximal assist of one assist for toileting, bathing, dressing and hygiene; and a moderate assist of one for bed mobility and transfers. The Kardex documented that Resident #320 may require a two-person approach due to combativeness. The Kardex did not indicate that family could assist with transfers. Review of the facility's undated Investigation Summary signed by the Director of Nursing, documented on 4/4/24 they were notified by a supervisor that Resident #320 has sustained a femur fracture to their left leg and the resident was sent to the emergency department. The summary documented that on 4/2/24 that the Director of Nursing was called to assess an area of bruising to Resident #320's left upper thigh and then again on 4/3/24. It was documented that on 4/3/24 there was swelling noted to Resident #320's left leg from the hip to knee with complaints of pain. X-rays from the pelvis to the foot were then ordered. Certified Nurse Aide #14 statement within the facilities investigation dated 4/5/24 at 8:30 AM, documented that Resident #320's family requested for the resident to be toileted, and the family member assisted with the transfer. Certified Nurse Aide #14 documented Resident #320 complained of pain but could not located it. They documented they left the resident in bed with their family member. Review of the Progress notes dated 4/5/24 at 12:14 PM, the Director of Nursing documented that they spoke with Resident #320's family member and asked them if they had a history of transferring the resident. The Director of Nursing documented the family replied yes, and they had not been trained/cleared by therapy for activities of daily living care. They documented that staff had told the family numerous occasions that they were to ask for help from the staff and the family member replied they sometimes did not want to wait. During an interview on 1/29/25 at 1:26 PM, Certified Nurse Aide #14 stated that Resident #320 was a maximal assist of two for transfers. They stated the resident was easy to transfer but at times would not let go of the handrail in the bathroom. They stated they did transfer Resident #320 with the assist of their family member to the toilet, off the toilet and then into bed. Certified Nurse Aide #14 stated during the transfer on to the toilet Resident #320 complained of pain to their hip. They stated the transfer went well and that the family was comfortab [TRUNCATED]

Based on interview and record review conducted during a Complaint investigation (#NY00357991) during a Standard survey completed on 1/31/25, the facility did not ensure that a resident has the right to refuse treatment for one (1) (Resident #69) of five (5) residents reviewed for immunizations. Specifically, Resident #69's Representative did not give consent for a COVID-19 vaccine, and the resident received it. The finding is: The policy and procedure titled COVID-19 Vaccination for Residents, with a revised date of 12/2024 documented to obtain a verbal and/or written consent and/or declination from recipient or qualified representative and note in the immunization tab of the medical record prior to administration of the COVID-19 vaccination. The policy documented the administering nurse would verify consent prior to administering the vaccine. The policy and procedure titled Resident [NAME] of Rights, with a revised date of 8/2023 documented those resident rights included the right to consent to or refused treatment. Resident #69 had diagnoses that included dementia, schizoaffective disorder and diabetes. The Minimum Data Set (a resident assessment tool) dated 11/14/24 documented Resident #69 had severe cognitive impairment, was sometimes understood and sometimes understands. The comprehensive care plan dated 3/1/24 documented Resident #69 had advance directives, documented the resident had a Power of Attorney and a Health Care Proxy. The undated Vaccine Consent Form documented that Resident #69's Representative verbally declined the COVID-19 vaccination. The Immunization Report dated 1/26/25 documented that Resident #69 was administered the COVID-19 vaccination on 9/13/24 by Registered Nurse #4. The New York State Immunization Information System website information provided by the facility documented that Resident #69 received the COVID-19 vaccination on 9/13/24. The progress notes documented the following: -10/21/24 at 12:09 PM, the Director of Nursing documented that Resident #69 was assessed due to the COVID-19 vaccine given on 9/13/24. -10/21/24 at 12:46 PM, the Assistant Director of Nursing documented that per Resident #69's representative, the resident was not to receive any further vaccinations. Review of the Physician Visit notes dated on: - 10/23/24 at 6:26 AM, the Medical Director documented that Resident #69 was seen for an acute visit due Resident #69 receiving the COVID-19 vaccination and family had directed the facility not to have it. During an interview on 1/30/25 at 3:01 PM, Licensed Practical Nurse Unit Manager #8 stated that Resident #69's representative did not want the resident to receive the COVID -19 booster, there was miscommunication and Resident #69 received the booster in September 2024. A telephone interview was attempted with the former Assistant Director of Nursing/Infection Preventionist on 1/30/25 at 4:28 PM. During a telephone interview on 1/30/25 at 4:39 PM, Resident #69's Representative stated they received a few telephone calls from the facility that vaccines were coming around. They stated they were unsure who called them but they had declined the COVID-19 booster for Resident #69. They stated they also told Licensed Practical Nurse Unit Manager #8. Resident #69's Representative stated they were notified by Resident #69's Power of Attorney that during a visit with the resident, the resident told the Power of Attorney they received two shots that day. Resident #69's Power of Attorney questioned the nursing staff, and they replied that Resident #69 received the influenza and COVID-19 vaccination. Resident #69's representative stated that they advocate for Resident #69, as the resident could not advocate for themselves and by Resident #69 receiving the COVID-19 booster, their wishes were not honored. During a telephone interview on 1/30/25 at 5:00 PM, Registered Nurse #4 stated they would receive a list from the Assistant Director of Nursing for every resident and the vaccination they were to receive. Registered Nurse #4 stated that Resident #69's name was on the list, and they gave them the COVID-19 booster and influenza vaccination. They stated the Assistant Director of Nursing did not provide them with the actual acceptance/declination forms to review. If the form indicated decline, then the resident should have not been given the vaccination. They stated they do not know what Resident #69 vaccination acceptance/declination form indicated because it was not in front of them. Registered Nurse #4 stated the error appeared to be a communication error and they did not receive any education after the situation. They stated that if a resident does not want a vaccination, they had the right to refuse. During an interview on 1/30/25 at 5:14 PM, the Assistant Director of Nursing stated that when they assumed the role of Assistant Director of Nursing the former Assistant Director of Nursing/ Infection Preventionist gave them a stack of vaccination consent/declination forms for the residents. They stated they created a spread sheet and mistakenly added Resident #69 to the list to administer the COVID-19 booster. The Assistant Director of Nursing stated that Registered Nurse #4 did not have the consent sheets with them upon administration of vaccinations but just the list which residents and which vaccination they were to give. They stated that Registered Nurse #4 gave Resident #69 the COVID-19 booster due to the error and they did not mean for a resident to get a medication they did not want. After review of the Vaccine Consent Form for Resident #69, they stated that the form was not dated but it should have been. The Assistant Director of Nursing stated the Resident #69 rights, choices and wishes were unintentionally not honored by receiving a the COVID-19 vaccination. During an interview on 1/31/25 at 11:30 AM, the Director of Nursing stated the Assistant Director of Nursing oversaw the resident immunization efforts and Registered Nurse #4 would administer them. They stated the Assistant Director of Nursing inappropriately transcribed that Resident #69 was to have the COVID-19 booster on a list they made for Registered Nurse #4 to administer vaccinations. They stated since Resident #69 received the COVID-19 booster when their representative had declined the booster, it went against the resident wishes. During a telephone interview on 1/31/25 at 12:30 PM, the Nurse Practitioner stated that Resident #69 could not make their own decisions, their family declined the COVID-19 booster and the resident should not have received it. During an interview on 1/31/25 at 1:57 PM, the Administrator stated if a resident or their resident representative had declined to have a vaccination then the resident should not get the vaccination if the documentation was in place. The Administrator stated that it goes against a resident's choice. 10 NYCRR 415.3(f)(1)(ii)

Based on observation, interview, and record review conducted during a Standard survey completed on 1/31/2025, the facility did not ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms, used for the least amount of time and document ongoing re-evaluation of the need for restraints for one (Resident #370) of three residents reviewed for physical restraints. Specifically, Resident #370 had no assessment/evaluation for the initiation of the use of a position change alarm. Additionally, there was no documented evidence to address the reason that warranted the use of the device. The finding is: The policy and procedure titled Personal Alarms dated 10/2023 documented to establish guidance for the appropriate use of personal alarms to ensure resident safety while maintaining dignity and autonomy. The procedure documented to conduct a comprehensive assessment of each resident to determine the need for the personal alarm based on their individual risk factors and needs. Document the rational for using the personal alarm and any alternative interventions considered. The State Operational Manual issued 11/2024 defines position change alarms as an alerting device intended to monitor a resident's movements and emits an audible signal when a resident moved in certain ways. Additionally, a position alarm may limit a resident's movement when the resident was afraid to move to avoid setting off the alarm. Resident #370 had diagnoses including depression, dementia and compression fractures of the spine. The Minimum Date set (resident assessment tool) dated 1/23/2025 documented they were severely cognitively impaired and was sometimes understood and sometimes understands. Resident #370 required extensive assist of one person for ambulation and transfers, a bed/chair alarm was used daily and wandering behaviors were documented during the assessment period. The comprehensive care plan with an initiation date of 1/18/2025 and a revision date of 1/30/2025 documented Resident #370 had an actual fall related to adjustment to a new environment, confusion and unsteady gait. The care plan documented a goal that included restraints used to prevent resident's falls will be minimized or eliminated. Interventions included the use of an electric chair alarm and staff were to ensure the device was in place and functioning every shift. The Kardex (a guide used by staff to provide care) dated 1/30/2025 documented under Safety, the resident uses an electric chair alarm ensure the device is in place and functioning every shift. Review of the Order Recap Report dated 1/18/2025 documented check function of chair alarm every shift for safety. Review of the interdisciplinary progress notes dated 1/13/2025-1/30/2025 revealed there was no documented evidence that Resident #370 was assessed for the use and rational for the personal chair alarm. During an observation on 1/27/2025 at 2:11 PM Resident #370 was observed in the common area in front of the television the resident leaned forward in the wheelchair on several occasions activating the personal alarm. The resident would sit back in the wheelchair each time the alarm activated. During an observation on 1/29/2025 at 9:12 AM Resident #370 was observed in the main dining room in their wheelchair with a personal alarm on the seat of the wheelchair and the alarm box hanging from the back of the wheelchair, no unsafe movements were observed. During an observation on 1/29/2025 at 12:04 PM Resident #370 was observed in the main dining room in their wheelchair with the personal alarm on the seat of the wheelchair and the alarm box hanging from the back of the wheelchair. During these observations Resident #370 did not exhibit any attempts to self-transfer from the wheelchair. During an interview on 1/31/25 at 12:30 PM, Certified Nurse Aide #2 stated Resident #370 used and alarm because they would get up and try to walk without their walker and they were very unsteady on their feet. Resident #370 had a fall at home but could not recall if the resident had a fall in the facility. Certified Nurse Aide #2 could not recall any other interventions in place to prevent falls besides keeping them in the common area when out of bed, and using the chair alarm. During an interview on 1/31/2025 at 12:41 PM, Licensed Practical Nurse #1 stated Resident #370 had only been at the facility for a couple weeks. Licensed Practical Nurse #1 stated the resident wore an alarm because they believed the facility was afraid, the resident could fall, and the resident would get up on their own. Licensed Practical Nurse #1 was unsure if the resident fell when in the facility, or if any other fall prevention interventions were in place. They were unsure if there should be an assessment completed. During an interview on 1/31/2025 at 12:46 PM, Assistant Director of Nursing #1 stated the supervisors were responsible to determine if an alarm was needed based on the resident's fall assessment. Assessments should be done on admission, quarterly and as needed. The Assistant Director of Nursing #1 also stated they did not believe chair alarms were restraints as they don't restrict the resident. During an interview on 1/31/2025 at 1:17 PM, Director of Nursing #1 stated Resident #370 had a personal alarm because they had history of falls. Less restrictive devices that could be used were placing the resident in the common area, activity programs and recliner chairs. Director of Nursing #1 was unsure if other interventions were tried or not prior to placing the personal alarm and it would depend on the cause of the fall. They check with the staff to see how the resident is doing with the alarm but does not document those conversations. Director of Nursing #1 also stated it would be a good idea to document and or complete an assessment for the use of alarms. 10 NYCRR 415.4(a)(2)(3)

Based on interview and record review conducted during a Standard Survey completed 1/31/25, the facility did not ensure that all alleged violations including abuse were reported immediately, but not later than two hours after the allegation was made to the State Survey Agency for one (Resident #70) of seven residents reviewed. Specifically, the Director of Nursing was notified of an allegation of resident sexual abuse, and it was not reported to the New York State Department of Health as required. The finding is: The policy and procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised 10/19 documented the facility prohibits abuse. Abuse: Shall mean, inappropriate physical contact with a resident. Inappropriate physical contact includes but is not limited to sexual molestation. When to report: In response to allegations of abuse the facility must: Ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse to officials in accordance with State law through established procedures. 1. Resident #70 had diagnoses that included congestive heart failure, type 2 diabetes mellitus, and unspecified schizophrenia (mental disorder). The Minimum Data Set (a resident assessment tool) dated 10/6/24 documented Resident #70 was cognitively intact was understood and understands, and did not display any behaviors. The comprehensive care plan initiated 12/5/2024 documented Resident #70 had a behavior problem related to confabulations and accusatory statements against staff. Interventions included: administer medications as ordered, anticipate and meet the resident's needs, assist to develop more appropriate methods of coping and interacting, encourage to express feelings appropriately, if reasonable discuss behaviors, explain/reinforce why behavior is inappropriate and/or unacceptable, use female caregivers as able and two staff approach. During an interview on 1/27/25 at 12:52 PM, Resident #70 stated they had been sexually abused while at the facility. They stated a black male lifted their shirt, took their hands and rubbed Resident #70's breasts up and down. Resident #70 stated they were stunned when this happened. They felt ashamed, embarrassed and didn't talk about it at first. Resident #70 stated once they said something about it in therapy, everyone knew about, and staff asked them about it. Physical Therapy Treatment Encounter Note dated 12/5/2024 electronically signed by Physical Therapy Assistant #1 documented they notified Director of Rehab and Social Worker that Resident #70 reported a male certified nurse aide (not recently) was inappropriately touching their breasts. They documented Resident #70 was reporting anxiety/fear over this issue and discussing this issue. Physical Therapy Assistant #1 documented that Resident #70 was incontinent of urine that morning and had asked Resident #70 why they hadn't asked the male aide to assist them. They documented that Resident #70 stated I don't want a man to help me. Immediately after that conversation with Resident #70, Resident #70 told Physical Therapy Assistant #1 about the incident. Review of soft file provided by the Director of Nursing during standard survey completed 1/31/25 revealed there was no evidence the abuse allegation was reported to the New York State Department of Health. During an interview on 1/27/25 at 1:35 PM, the Director of Nursing stated when they talked to Resident #70 about the abuse allegation, there were no facts to support the allegation at that time and no further investigation was completed. During an interview on 1/31/25 at 8:31 AM, the Assistant Director of Nursing stated the Director of Nursing was responsible for reporting allegations of abuse to the Department of Health. The Assistant Director of Nursing stated they knew there were timeframes for reporting abuse to the Department of Health but wasn't aware of them and would have to speak to the Director of Nursing. During an interview on 1/31/25 at 9:34 AM, Licensed Practical Nurse #8 Unit Manager, stated all abuse allegations need to be reported to the Director of Nursing, and Administrator. They stated the police, medical provider, family may need to be notified and there was a two-hour time limit to report abuse to the Department of Health. During an interview on 1/31/25 at 11:25 AM, Licensed Practical Nurse #5, Supervisor, stated any abuse allegation made by a resident need to be reported to a supervisor, the Assistant Director of Nursing and/or the Director of Nursing. They stated the Director of Nursing was responsible to report allegations of abuse to the Department of Health, depending on the allegation within two hours or twenty-four hours. During an interview on 1/31/25 at 1:07 PM, the Director of Nursing stated Licensed Practical Nurse #8, Unit Manager notified them on 12/5/24 at unknown time of Resident #70's allegation of abuse. The Director of Nursing stated they did not report Resident #70's abuse allegation to the Department of Health. They felt that after speaking with Resident #70 they didn't have evidence to support their allegation. The Director of Nursing stated they notified the Administrator of the allegation the same day on 12/5/24. Additionally, the Director of Nursing stated, should have gone with my gut and reported. During an interview on 1/31/25 at 3:07 PM, the Administer stated they were made aware of Resident #70's allegation by Director of Nursing. The Administer stated typically any abuse, neglect, mistreatment was to be reported within two hours. 10 NYCRR 415.4(b)(2)

Based on interview and record review conducted during a Complaint Investigation (#NY00338010) conducted during the Standard survey completed on 1/31/25, the facility did not ensure that all alleged allegations of abuse, neglect, or mistreatment were thoroughly investigated for two (Resident #70 and #320) of seven residents reviewed. Specifically, there was a lack of evidence thorough investigations were completed into an allegation of sexual abuse (#70) and a femur fracture of unknown origin (#320). The findings are: The policy and procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, with a revised date of 10/19, documented both state and federal regulations require the facility to investigate incidents and complaints generated from residents and/or visitors. Documentation is required with respect to accidents and incidents that must be recorded. The policy documented with respect to allegations of abuse, mistreatment, and neglect, facilities must document that the allegations are thoroughly investigated, including any incident that is not consistent with routine operation of the facility or routine care of the resident, such as bruise, or any injury of unknown origin. The supervisor who has been informed of the allegation was to complete the initial investigation report and forward a copy to the Administrator. That notification is in addition to immediate notification to the Director of Nursing. The policy and procedure titled Resident Accident-Incident Report, with a revised date of 4/17, documented to obtain employee statements that would be needed to investigate the accident/incident. For an investigation of injuries of unknown origin, the charge nurse on duty at time of accident/incident occurs, will initiate accident incident investigation form. The policy documented that beginning with the shift the accident/incident occurred, charge nurse will get statements from the caregivers on that shift. The nurse will go back two more shifts within the 24-hour period prior to the accident incident, date the investigation form and list caregivers for the other two shifts and pass investigation on to the next shift for the other caregiver's statements. 1. Resident #70 had diagnoses that included congestive heart failure, type 2 diabetes mellitus, and unspecified schizophrenia (mental disorder). The Minimum Data Set (a resident assessment tool) dated 10/6/24 documented Resident #70 was cognitively intact was understood and understands, and did not display any behaviors. The comprehensive care plan revised 10/11/2024 documented that Resident #70 used antidepressant medication related to depression and schizophrenia. Interventions initiated 10/1/2024 included to administer antidepressant as ordered, and monitor/document/report adverse reactions to antidepressant therapy. The care plan prior to the abuse allegation on 12/5/24 did not document the resident had behaviors director towards others or a history of making accusatory or false statements. Review of progress notes dated 10/31/24 through 12/12/2024 revealed there was no evidence that Resident #70 displayed behaviors or that an allegation of abuse was made, reported and or investigated. Review of Physical Therapy Treatment Encounter Note dated 12/5/2024, electronically signed by Physical Therapy Assistant #1 documented they notified the Director of Rehab and Social Worker that Resident #70 reported a male certified nurse aide (not recently) was inappropriately touching their breasts. They documented Resident #70 was reporting anxiety/fear over this issue and discussing this issue. Physical Therapy Assistant #1 documented that Resident #70 was incontinent of urine that morning and had asked Resident #70 why they hadn't asked the male aide to assist them. They documented that Resident #70 stated I don't want a man to help me. Immediately after that conversation with Resident #70, Resident #70 told Physical Therapy Assistant #1 about the incident. Review of soft investigation file provided by the Director of Nursing contained a Daily Census of 12/4/2024 of [NAME] South, total residents on unit 12 printed 12/5/24 at 12:31 PM. Handwritten notes present on Daily Census documented: assessed-no injuries (redness, discoloration, open areas), no complaints offered pain/discomfort, no signs/symptoms of fear, anxiety or stress, unable to give details on touching; Interviewed 12/5/24, no issues with any male staff member; Upset when told Monday they weren't ready to discharge due to safety. The file contained a copy of Resident #70's face sheet, brief interview for mental status evaluation, copy of updated care plan, a mini-mental state examination effective 10/1/24 with score of 27 out of 30 and an undated list of residents who require a two staff approach. The file did not contain interviews, and/or statements with staff and other residents. There was no investigation summary completed ruling out the abuse. During an interview on 1/27/25 at 12:52 PM, Resident #70 stated they had been sexually abused while at the facility. They stated they had only been at the facility for a short time when the abuse happened. They stated a black male lifted their shirt, took their hands and rubbed Resident #70's breasts up and down. Resident #70 stated it happened around bedtime, they couldn't remember their face, did not know the person's name and had not seen them since. Resident #70 stated they were stunned when this happened. They stated took happened at bedtime a short time after they were admitted to the facility, 12 weeks or more ago. They didn't talk about it at first and once they said something about it in therapy, everyone knew about, and staff followed up with them. During an interview on 1/29/25 at 11:06 AM, Certified Nurse Aide #11 stated approximately a month ago while taking care of Resident #70, Resident #70 stated to them they were assaulted by a guy on overnights. Certified Nurse Aide #11 stated that Resident #70 demonstrated with their hand a rubbing motion over their chest and down their side. Certified Nurse Aide #11 stated they reported the allegation immediately to Licensed Practical Nurse Unit Manager #8. Certified Nurse Aide #11 stated Licensed Practical Nurse Unit Manager #8 told them they were already aware of the allegation. Certified Nurse Aide #11 stated after reporting allegation, nothing further was discussed with them about the allegation. Additionally, Certified Nurse Aide #11 stated they would consider Resident #70's allegation, sexual abuse. During an interview on 1/31/25 at 8:40 AM, Social Work Director #1 stated they recall hearing about an abuse allegation made by Resident #70. They believed the Director of Nursing had mentioned it during morning meeting or in passing. Social Work Director #1 stated that Resident #70 demonstrated and stated to them that a male lifted their shirt and rubbed their chest. The Social Work Director #1 stated Resident #70 didn't display any emotions on how they felt about it, and they were not asked to write a statement about this. During an interview on 1/31/25 at 9:34 AM, Licensed Practical Nurse Unit Manager #8, stated they were not working the day Resident #70 made the sexual abuse allegation. Licensed Practical Nurse Unit Manager #8 stated they were notified by the Director of Nursing of Resident #70's allegation. They stated when they asked Resident #70 about the allegation, Resident #70 stated a man came into their room and touched their breasts in an inappropriate manner. They stated Resident #70 stated they never wanted that man to touch them again. Licensed Practical Nurse Unit Manager #8 stated they did not document on Resident #70's allegation because the Director of Nursing had stated they had started a soft file on the allegation. Licensed Practical Nurse Unit Manager #8 stated there were men that work in the facility and there were male residents that wander. During an interview on 1/31/25 at 12:09 PM, Physical Therapy Assistant #1 stated on 12/5/24 Resident #70 stated a male certified nurse aide, not recently, had touched their breasts inappropriately and that Resident #70 did not know the certified nurse aide name. Physical Therapy Assistant #1 stated Resident #70 stated they hadn't seen this aide in a while but reported being fearful and anxious over seeing them again. Physical Therapy Assistant #1 stated they notified the Director of Therapy, the Social Worker and the Director of Nursing of Resident #70's abuse allegation. The Physical Therapy Assistant #1 stated they did not remember if they were asked to write a statement. During an interview on 1/31/25 at 1:07 PM, Director of Nursing stated they were thought they were notified of Resident #70's abuse allegation on 12/5/24 by Licensed Practical Nurse Unit Manager #8. They stated they did not recall at what time they were notified. The Director of Nursing stated they completed a skin assessment on Resident #70 and assessed the other residents on the unit. The Director of Nursing stated that Resident #70 stated someone had touched their breasts. The Director of Nursing stated they did not feel it was sexual in nature. Resident #70 was upset over being told they weren't leaving the facility. The Director of Nursing stated they reviewed a whole week back of schedules and there were no male caregivers on Resident # 70's unit. The Director of Nursing stated they did not notify the medical provider or emergency contact, and can't give any excuse for that, I usually do. They stated Resident #70 did have capacity. The Director of Nursing stated they did not write down any verbal conversations or get statements from any staff and should have. Additionally, they stated they notified the Administrator the same day, 12/5/24 of the allegation. During a telephone interview on 1/31/25 at 2:29 PM, Medical Doctor #1 stated they expected to be notified of abuse allegations and did not recall being informed of Resident #70's sexual abuse allegation. They stated an investigation should be done to make sure the resident's needs, and safety were being maintained. During an interview on 1/31/25 at 3:07 PM, the Administrator stated the Director of Nursing made them aware of the abuse allegation made by Resident #70. They stated there was nothing collaborating Resident #70's allegation. The Administrator stated they would expect the Director of Nursing to start an investigation, obtain statements from residents, staff, assess the residents involved and document their findings, position on the abuse allegation. 2. Resident #320 had diagnoses that included a fracture of the left femur, dementia and atrial fibrillation (an irregular heart rate that causes poor blood flow). The Minimum Data Set, dated dated dated [DATE] documented Resident #320 had severe cognitive impairment, usually understands and was usually understood. The comprehensive care plan dated 3/29/24, documented Resident #320 had self-performance deficit related to limited mobility. Interventions included that Resident #320 may require a two-person approach due to combativeness. The care plan documented that Resident #320 was high risk for falls related to confusion and vision/hearing problems. Interventions included to anticipate needs, place call light within reach, lock bilateral wheelchair breaks, offer toileting every two hours and fall mats on both sides of the bed. The Kardex (guide used by staff to provide care) dated 4/1/24, documented Resident #320 was dependent for wheelchair mobility; a maximal assist of one assist for toileting, bathing, dressing and hygiene; and a moderate assist of one for bed mobility and transfers. The Kardex documented that Resident #320 may require a two-person approach due to combativeness. Review of the facility's undated Investigation Summary signed by the Director of Nursing, documented on 4/4/24 they were notified by a supervisor that Resident #320 has sustained a femur fracture to their left leg and the resident was sent to the emergency department. The summary documented that on 4/2/24 that the Director of Nursing was called to assess an area of bruising to Resident #320's left upper thigh and then again on 4/3/24. It was documented that there was swelling noted to Resident #320's left leg from the hip to knee with complaints of pain. X-rays from the pelvis to the foot were then ordered. The investigation documented there were three licensed practical nurse witnesses and six certified nurse aide witnesses. Facility Employee Statement forms were included in the facility's investigation folder from all three licensed practical nurse and six certified nurse aides that were listed in the Investigation Summary. After review of all the Employee Statement forms the following inconsistency was noted: -Licensed Practical Nurse #14 statement dated 4/7/24 at 7:00 AM, documented on 4/1/24 Resident #320 was noted with a yellow bruise the size of a hand from the knee to thigh and was reported to the house supervisor. Review of the facility's Staffing Worksheet from 3/30/24-4/1/24 revealed there was no documented evidence all staff working on the unit were interviewed. There were two additional nurses and five additional certified nurse aides that worked from when the bruise was documented as originally noted on 4/1/24. During an interview on 1/31/25 at 10:56 AM, the Director of Nursing stated on 4/2/24 staff alerted them to an area of discoloration to Resident #320 left inner thigh. They stated they assessed Resident #320 and noted the resident had older yellow tinge discoloration, at that time there was no pain or change in range of motion to the residents left leg. The Director of Nursing stated on 4/3/24 the staff alerted them again to assess Resident #320. They stated Resident #320 had more bruising, swelling and pain to their left leg. Resident #320 was ordered an x-ray, was found to have a left femur fracture. The Director of Nursing stated they started the investigation and interviewed staff members that could have had contact with the resident 48 hours back from 4/4/24. The Director of Nursing stated they had no further Employee Statements to present and had completed some telephone interviews some staff. They stated they did not document the telephone interviews but should have. The Director of Nursing stated they did read the employee statements at the time of investigation. The Director of Nursing was given Licensed Practical Nurse #14 statement dated 4/7/24 at 7:00 AM to review. The Director of Nursing stated it probably would have been a good idea to interview all staff that could have had interactions with Resident #320 48 hours prior to 4/1/24 because that is when the bruise was first noted and therefore, they did not complete a thorough investigation. During an interview on 1/31/25 at 1:57 PM, the Administrator stated their expectation for an investigation when a resident was noted to have a fracture of unknown origin was for one (an investigation) to be conducted. They stated they would have expected all staff that could have taken care of the resident to be interviewed, and the investigator would typically go back 48 hours from when an injury was noted. The Administrator stated staff statements should be detailed and include the date time and if something unusual was noted. They stated they would expect telephone interview to be documented and saved by the investigator. 10NYCRR 415.4(b)(3)

Based on observation, interview, and record review conducted during a Standard Survey completed on 1/31/25, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs for two (2) (Garden View and [NAME] View North) of three (3) medication rooms observed. Specifically, in both medication rooms, controlled drugs were stored in a locked metal box, inside a locked small refrigerator that was not permanently affixed to the wall or countertop. Additionally, the Garden View medication refrigerator housed a locked metal box, containing emergency narcotics, that was not permanently affixed to the refrigerator. This involved Residents #6, 8, 40, and 82. The findings are: The policy and procedure titled Controlled Medication Storage and Count, dated 1/2023, documented a controlled substance requiring refrigeration will be kept double locked in the med room refrigerator within the metal locked box. During an interview and observation of the Garden View medication room on 1/30/25 at 8:41 AM, a locked medication refrigerator was sitting on the counter, it was not secured to the counter or the wall. Licensed Practical Nurse #6 stated the keys to the medication refrigerator were kept by the Nursing Supervisor. Each medication nurse carried the keys to their unit narcotic box, but the medication refrigerator contained medications from all the Villages (Garden View, Orchard, Canal). Licensed Practical Nurse #6 stated the medication refrigerator had never been permanently affixed to the counter or wall. During an interview and observation of the Garden View medication room on 1/30/25 at 2:41 PM, Licensed Practical Nurse #5 (covering Supervisor), opened the locked medication refrigerator. The refrigerator contained 2 locked metal boxes. One locked box was permanently affixed to the shelf, and the second locked box was not permanently affixed. Licensed Practical Nurse #5 stated they did not have a key to the second metal box, because it was for emergency use only. The key to that box was locked inside the automated medication dispensing system and required pharmacy approval for access. They stated the refrigerator had never been permanently affixed and they did not know that it should be. The affixed metal box was opened by Licensed Practical Nurse #5 and contained: -one unopened, 10 milliliter vial of Lorazepam (a controlled substance and anti-anxiety/anti-seizure medication) and one unopened 30 milliliter bottle of Lorazepam for Resident #40 -three unopened, 1 milliliter vials of Lorazepam for Resident #6 -four unopened, 2.5 milliliter vials of Lorazepam for Resident #82 During an interview on 1/30/25 at 3:00 PM, Licensed Practical Nurse #2 stated the medications inside the second locked metal box were for emergency use. The key was only accessible by calling the pharmacy, getting an access code, and having two staff members type their credentials into the automated dispensing system. They stated the pharmacy monitored the contents of the emergency box. Licensed Practical Nurse #2 stated, not having the metal box secured to the inside of the refrigerator and by the refrigerator not being permanently affixed, made it a higher risk for diversion. During an interview and observation of the [NAME] View North medication room on 1/31/25 at 8:37 AM, the locked medication refrigerator contained: for Resident #8, one 10 milliliter vial of Lorazepam. The vial was located inside an unlocked stainless-steel box affixed to a shelf inside the refrigerator which was sitting on top of a foot-stool on the floor and was not permanently affixed. Licensed Practical Nurse #7 stated the refrigerator was not affixed to anything and was sitting on a stool. Licensed Practical Nurse #7 attempted to lock the stainless-steel box inside the refrigerator but could not and said the key wasn't working. They stated they counted the Lorazepam that morning and the key wasn't working then either. They were not sure how long the key didn't work. During an interview on 1/31/25 at 8:47 AM, Licensed Practical Nurse Unit Manager #8 stated they were the medication nurse on the [NAME] View North unit on Monday (1/27/25) and the key to the stainless-steel lock box worked, they just had to work with it and wiggle it. They stated the lock box in the refrigerator should have been locked when there was a controlled medication inside. They weren't sure how long the refrigerator had not been permanently affixed and they would call the pharmacy to fix the lock. During an interview on 1/31/25 at 10:58 AM, Pharmacy Manager #1 stated they expected the facility to keep their controlled drugs secured in a double locked container. They stated they did not know the refrigerator was not permanently affixed to the counter or that the emergency narcotics box was not affixed to refrigerator. They stated that pharmacy staff monitor and count the contents of the emergency box weekly, and they had not had any diversion. Pharmacy Manager #1 stated the box contained Lorazepam for emergency use. They stated, not having the box secured to the inside of the refrigerator and by the refrigerator not being permanently affixed, made it a higher risk for diversion. During an interview on 1/31/25 at 12:59 PM, the Director of Nursing stated they were aware that the medication room refrigerators were not permanently affixed and contained controlled drugs. The Director of Nursing stated they have had their pharmacy come in every six months and this was never an identified issue. If they were not permanently affixed, it could be a risk for diversions. 10NYCCRR 415.18 (e)(2)

Based on observation, interview, and record review conducted during a Standard survey completed 1/31/25, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues with foods being unlabeled or outdated in the refrigerators; stained, worn ceiling tiles, lack of [NAME] #2 wearing a beard guard in food preparation areas. Additionally, during the puree observation texture modified bread mix was not prepared and used in accordance with the manufacturer's directions. The findings are: The policy and procedure titled Food Storage Refrigerator and Freezer dated 8/2017 documented to ensure foods are stored properly to minimize spoilage and contamination and ensure taste and quality of food. All food items must be labeled and dated. The policy and procedure titled Cleaning of Food Storage Areas documented to ensure maintenance and cleanliness to storage areas. All kitchen areas shall be kept clean and free litter and rubbish. All counters, shelves and equipment shall be kept clean and maintained in good repair. The facility policy and procedure titled Hair Coverings dated 3/2017 documented it is the policy of the facility to prevent hair from contaminating food or beverage. Food code recommends that food handles wear beard nets or other hair restraints when appropriate. However, the rule is not specific about the length or the beard that requires a net. It is the responsibility of the management staff in the food service department to monitor and enforce the policy. During an observation on 1/27/2025 at 9:32 AM of the main kitchen revealed the following: -reach in refrigerator ajacent to the stove had an open undated packages of sliced corn beef and turkey. -walk-in cooler had a tray of five (5) premade sandwiches in clear plastic baggies dated 1/24/25 and four (4) prepared 4-ounce cups of canned fruit dated 4-ounce cups of canned fruit dated 1/24/25. -3-tier metal cart across from the dish machine had approximately 29 plastic coffee mugs stored ready for use that were right side up uncovered, the cart had a large amount of brown liquid on the second and third tier. -ceiling tiles had brown and yellow discolored spots and stains throughout the kitchen, being more prevalent over the dish machine. -floor beneath the coffee station across from the tray line was soiled with large area of dried brown liquid. During an interview at the time of the observation 1/27/2025 at 9:32 AM the Food Service Director #1 stated all open foods should be dated and labeled if they are not, they should be discarded. The floor under the coffee station should be cleaned. The coffee mugs should be stored upside down or a tray covering them. The nourishments in the walk-in refrigerator should be discarded because they were three days old. During an observation on 1/29/2025 at 11:35 AM, [NAME] #2 had a surgical mask on with approximately 1/2 inch long facial hair that was exposed under their chin and both cheeks [NAME] #2 was on tray line and in and out of kitchen area with food service and preparation occurring. During the pureed food observation and interview on 1/30/25 at 10:33 AM with [NAME] #1 stated there were approximately 32 residents requiring a pureed diet texture and they would be pureeing hot dogs. [NAME] #1 added 6 to 8 cooked hot dogs to the food processer added a small amount of water and blended till smooth and repeated the same process twice, pouring the pureed hot dogs into a square metal pan. A discussion took place during the observation with [NAME] #1 and the Food Service Director #1. [NAME] #1 was instructed by the Food Service Director to use bread or the Texture Modified Bread Mix to substitute the hot dog bun. [NAME] #1 obtained a box of Texture Modified Bread Mix from under the prep station and placed an eight-ounce disposable cup in the contents of the box. [NAME] #1 added 6-8 cooked hot dogs to the food processer added a small amount of water and processed the hot dogs for approximately 30 seconds. [NAME] #1 then proceeded to take the eight-ounce cup and filled the cup approximately half full with the modified bread mixture without reviewing the manufactures preparation directions and added it to the pureed hot dogs in the food processer, blended the mixture and hotdogs together and added it to the square metal pan of hot dogs previously processed. [NAME] completed the same process three times adding the pureed hotdogs and bread mixture to the same metal pan. Review of the Texture Modified Bread Mix manufactures mixing directions documented the following for 18 slices of bread: -combined in a bowl 2 cups of bread mix 2/3 cup vegetable oil and stir with a fork till breadcrumbs are well coated. - add three cups of hot water -mix well with a fork or whisk, pour mixture into a nonstick pan sprayed with nonstick cooking spray, cover with plastic wrap and let stand at room temperature for at least 30 minutes. -slice and serve There was no recipe available for the preparation of hotdogs with buns puree. During an interview on 1/30/25 at 10:56 AM, [NAME] #1 stated they have used the Texture Modified Bread Mix in the past but not the way the Food Service Director #1 told them too. They would normally mix the bread mixture with water and serve it separately. They were unsure what the manufactures directions called for. [NAME] #1 after tasting a sample of the pureed hot dogs stated, it tastes like a hot dog. The Surveyor tasted the hot dog/bun puree, and it was gritty. During an interview on 1/30/25 at 10:57 AM, Dietary Aide #1 after trying a sample of the pureed hot dogs stated they did not like it, said it looked gross, tasted it made a face and walked away. During an observation on 1/30/25 at 2:57 PM [NAME] #2 was observed in the food preparation area across from the stove, prepping sandwiches. Their beard guard was around their neck below their chin. During an interview on 1/30/25 at 3:03 PM, [NAME] #2 stated they should be wearing a beard guard when in the kitchen or they would wear a surgical mask. They were unsure if a surgical mask would be considered a beard guard and would have to check with the Food Service Director. [NAME] #2 was observed during the interview to have their beard guard covering only their chin area leaving their mustache and cheek areas exposed and this was in a food prep area. During an interview on 1/31/25 at 11:12 AM the Food Service Director #1 stated staff who have facial hair should wear a beard guard, at all times when in the kitchen. They stated beard guards were available and were unsure if a surgical mask was an acceptable substitute. Food Service Director #1 stated they have used the Textured Modified Bread Mix in the past but was unsure what the directions called for when preparing the product and would have to clarify how it should be used. They were also unsure what could be done about the kitchen ceiling tiles. During an interview on 1/31/25 at 11:59 AM, the Registered Dietitian stated the directions should be followed in preparing the Texture Modified Bread Mix and it should not be added from the box directly into food. All open food should be labeled and dated, if not then it should be thrown away. The Registered Dietitian stated staff who have facial hair should always wear a beard guard when they were in the kitchen. 10 NYCRR 415.14(h)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/31/25 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infection for two (Resident #42 and Resident #89) of five residents reviewed for Enhanced Barrier Precautions. Specifically, Enhanced Barrier Precautions were not initiated for Resident #42 who had a sacral pressure ulcer and staff did not wear appropriate personal protective equipment (PPE) during pressure ulcer care. Additionally, staff did not wear appropriate personal protective equipment (PPE) while they emptied a urinary catheter bag (a urine collection bag) for Resident #89 who had an indwelling foley catheter (tube inserted into the bladder to drain urine) and was on Enhanced Barrier Precautions. The findings are: The policy and procedure titled Enhanced Barrier Precautions dated 12/2024 documented that Enhanced Barrier Precautions (EBP) were an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involved gown and glove use during high-contact resident care activities. High contact resident activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, urinary catheter care and wound care: any opening requiring a dressing. Enhanced Barrier Precautions should be used for the duration of a resident's stay in the facility or until the resolution of the wound of discontinuation of the indwelling medical device that placed them at higher risk. 1. Resident #42 had diagnoses that included sacral pressure ulcer stage 3 (area above the tail bone with full thickness tissue loss, with no bone, tendon or muscle exposed), spinal stenosis (narrowing of one or more areas in your spine), and acute kidney failure. The Minimum Data Set (an assessment tool) dated 1/13/25 documented Resident #42 was cognitively intact and had one stage 3 pressure ulcer that was not present upon admission. The comprehensive care plan revised on 1/31/25, documented Resident #42 had a sacral pressure ulcer related to immobility and urinary incontinence. Interventions included to administer treatments as ordered and to follow policies and protocols for the prevention/treatment of skin breakdown. The comprehensive care plan documented that Enhanced Barrier Precautions were resolved on 12/12/24 and had not been re-implemented on until 1/31/25. Review of the facility's Enhanced Barrier Precaution line list provided by the Assistant Director of Nursing and dated 1/29/25 revealed that Resident #42 was not on Enhanced Barrier Precautions. Review of Resident #42's medication administration record from 1/1/25 to 1/31/25 revealed that there was no physician order in place for Enhanced Barrier Precautions until 1/31/25. Additionally, the medication administration record documented that Resident #42 had been treated with antibiotics for a sacral wound infection from 1/7/25 to 1/17/25. Review of Resident #42 physician orders which included all active, completed and discontinued orders revealed that Enhanced Barrier Precautions for Resident #42 had been discontinued on 12/27/24 and had not been re-ordered until 1/31/25. Review of skin and wound note dated 1/15/25, the Wound Consultant documented that Resident #42 had a stage 3 sacral pressure ulcer. The wound status was documented as stable, peri wound was macerated, with a moderate amount of serous drainage (clear/yellow drainage) was noted. During intermittent observations on 1/27/25 at 11:05 AM, 1/28/25 at 9:12 AM, 1/29/25 at 9:00 AM and 1/30/25 at 8:48 AM, Resident #42 was sitting in wheelchair in their room. There was no Enhanced Barrier Precaution signage posted on Resident #42's door, and there was no personal protective equipment located outside or inside of Resident #42's room. One closed lid garbage can was noted in Resident #42's room and labeled isolation trash only. During an observation and interview on 1/20/25 at 8:48 AM, Licensed Practical Nurse #4 completed wound care to Resident #42's sacral wound. Resident #42 was able to stand up while Licensed Practical Nurse #4 completed their wound care. The pressure ulcer was noted to have yellow/brown drainage. Licensed Practical Nurse #4 stated the pressure ulcer was a stage 3 and had tunneling present (opening underneath the surface of the skin). Licensed Practical Nurse #4 described the pressure ulcer as being opened with small amount of brown drainage. They cleansed the wound with Dakins (antiseptic for wound care) solution, applied collagen powder (promotes new tissue formation), calcium alginate (absorbent fibrous material used for wound management) and covered the pressure ulcer with a dressing. Licensed Practical Nurse #4 utilized gloves for personal protective equipment and did not wear a gown during the observation. Licensed Practical Nurse #4 stated that Resident #42 was not on Enhanced Barrier Precautions, they stated that they believed if the wound was cultured and came back clear Enhanced Barrier Precautions would not be needed. They stated the Assistant Director of Nursing determined who was placed on enhanced barrier precautions. During an interview on 1/31/25 at 9:04 AM, Licensed Practical Nurse Unit Manager #8 stated any resident with a draining wound would be placed on Enhanced Barrier Precautions. They stated that Enhanced Barrier Precautions would be important to protect staff and residents from the spread of infections. Licensed Practical Nurse Unit Manager #8 stated that Resident #42 was not on Enhanced Barrier Precautions because their wound did not have drainage. During an interview on 1/31/25 at 10:45 AM, the Assistant Director of Nursing stated they would review and update the list of residents on Enhanced Barrier Precautions during morning report and conduct audits on the precaution signage, caddy, care plan and orders for Enhanced Barrier Precautions. The Assistant Director of Nursing stated any resident who had open wounds would be placed on Enhanced Barrier Precautions. They stated that if the wound was granulated and had scant to no drainage, they would remove the resident from Enhanced Barrier Precautions. The Assistant Director of Nursing stated that Resident #42 had been removed from Enhanced Barrier Precautions, their wound had improved and had no drainage. They stated that if Resident #42's wound started to drain again that they would be at risk for infection and should be placed back on Enhanced Barrier Precautions. The Assistant Director of Nursing stated that they were not aware Resident #42's wound had drainage. During an interview on 1/31/25 at 12:46 PM, the Director of Nursing/Infection Preventionist stated they reviewed the resident list of Enhanced Barrier Precautions daily at morning report. They stated that they would expect that any resident with an open draining wound would be placed on Enhanced Barrier Precautions. They stated it was important to protect the residents and prevent the spread of infection from staff to resident. The Director of Nursing /Infection Preventionist stated that Resident #42 had an open wound, they would be at risk for infection and should have been on Enhanced Barrier Precautions. 2. Resident #89 had diagnoses that included a history of urinary tract infections and low back pain. The Minimum Data Set, dated dated dated [DATE] documented Resident #89 was cognitively intact and had a foley catheter. The comprehensive care plan dated 12/12/24 documented Resident #89 was on Enhanced Barrier Precautions for use of an indwelling catheter and that a gown and gloves were to be worn for high contact resident care related to their foley catheter. Resident #89's current Kardex (guide used by staff to provide care) documented to maintain Enhanced Barrier Precautions - use of gown and gloves - during high-contact resident care activities related to their foley catheter. During an observation on 1/27/25 at 1:21 PM, Licensed Practical Nurse #4 entered Resident #89's room to empty Resident #89's foley catheter bag of urine. Resident #89 had an order for Enhanced Barrier Precautions, which was posted at the door of their room along with a supply cart with personal protective equipment. Licensed Practical Nurse #4 stated this was going to be quick and told the surveyor they could remain in the room. Licensed Practical Nurse #4 was wearing gloves only, proceeded to empty the urine collection bag at the resident's bedside into a urinal, measured the urine, and then emptied the urinal into the toilet in the resident's room. Licensed Practical Nurse #4 did not wear an isolation gown while caring for the resident's foley. Review of the Enhanced Barrier Precautions sign on Resident #89's door documented gloves and gown were required for high contact resident care activities for device care or use of a urinary catheter. During an interview on 1/29/25 at 8:59 AM, Licensed Practical Nurse #4 stated they should have worn a gown along with the gloves when they emptied Resident #89's foley urine bag on 1/27/25. The reason for the gown was to protect residents from anything the nurse may carry and to protect the nurse and other residents from any possible source of infection the urine may carry. During an interview on 1/29/25 at 8:49 AM, Assistant Director of Nursing stated the personal protective equipment they expected staff to wear when a resident is on Enhanced Barrier Precautions was a gown and gloves, to empty a foley urine bag. This was important, in case there was any splashing and to protect the staff person and residents from contracting any possible infection. During an interview on 1/29/25 at 9:05 AM, Director of Nursing/ Infection Preventionist stated the personal protective equipment they expected a staff to wear when emptying a foley urine bag was a gown and gloves. This was important because urine could be a source of infection, and they would not want the staff person to carry any possible infection from one resident to another. 10NYCRR415.19 (a) (2)

Based on record review and interview conducted during the Standard survey completed on 1/31/25, the facility did not ensure Certified Nurse Aide performance reviews were completed once every 12 months per year for three (Certified Nurse Aides #7, #8, #9) of five reviewed. Specifically, there was no evidence Certified Nurse Aide #7, #8, and #9 who had worked for the facility more than 12 months had performance reviews completed at least once every 12 months. Additionally, the facility did not have a process/system in place to conduct annual performance evaluations for certified nurse aides. The finding is: Review of Certified Nurse Aide #7 employee file revealed they were hired on 11/24/17 and there was no evidence that an annual performance review had been completed. Review of Certified Nurse Aide #8 employee file revealed they were hired on 7/19/23 and there was no evidence that an annual performance review had been completed. Review of Certified Nurse Aide #9 employee file revealed they were hired on 11/6/20 and there was no evidence that an annual performance review had been completed. During an interview on 1/31/25 at 12:26 PM, the Director of Nursing stated the facility did not conduct any annual performance reviews for Certified Nurse Aides and that there was no process in place to track when performance reviews needed to be completed. They stated a new union contract was being negotiated and would try to have annual reviews added to the contract. The Director of Nursing stated it was a priority to establish a process to conduct annual performance and competency reviews for the Certified Nurse Aides, they stated it was important to ensure residents were receiving the best care. During a telephone interview on 1/31/25 at 2:00 PM, Certified Nurse Aide #8 stated they had worked at the facility full time for almost 2.5 years. They stated they never had a performance review or evaluation completed. During an interview on 1/31/25 at 2:05 PM, the Administrator stated there was no current process in place for annual performance reviews and that historically performance evaluations had not been completed by the facility. The Administrator stated it would be important to evaluate certified nurse aides to ensure they were competent with skills. The facility was unable to provide a policy and procedure for employee annual performance evaluations. 10NYCRR 415.26 (d)(7)

Based on observation and interviews conducted during the Standard survey completed on 1/31/25, the facility did not ensure the nursing staff information was posted on a daily basis and contained the required information. Specifically, the facility did not post daily the current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent place readily accessible to residents and visitors for 4 of 5 days reviewed. The undated policy and procedure titled BIPA Staff Posting documented the nursing supervisor or designee will post the facilities staffing at the beginning of their shift. The 3:00 PM -11:00 PM and 11:00 AM -7:00 AM nursing supervisor/designee will update this information for their shift. The number and categories of nursing staff, as well as the total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care and include the facility name, current date and resident census. Posting information must be displayed in a clear and readable format and be posted in a prominent place readily accessible to residents and visitors. The finding is: During observations made on 1/27/25 at 10:44 AM and 1/27/25 at 11:58 AM, the Daily Staffing was posted on the bulletin board located down the front entrance hallway and was dated 1/24/25. Continued observation on 1/27/25 at 12:43 PM revealed the Daily Staffing form posted was dated 1/27/25 and had included the current census number of 117 and total number and actual hours worked for direct care staff. During an observation on 1/28/25 at 10:10 AM, the Daily Staffing was posted on the bulletin board located down the front entrance hallway was dated 1/27/25. Continued observation on 1/28/25 at 4:15 PM revealed there was no Daily Staffing form posted on the bulletin board. Intermittent observations made on 1/29/25 at 8:53 AM, 1/29/25 at 1:38 PM, 1/30/25 at 7:19 AM, 1/30/25 at 11:12 AM, 1/30/25 at 4:15 PM, and 1/31/25 at 8:32 AM revealed there was no posting of the Daily Staffing form on the bulletin board down the front entrance hallway or at the front reception desk. During an interview on 1/31/25 at 11:45 AM, Human Resource Manager #1 stated that they were responsible to complete and post the Daily Staffing form. They stated the daily staffing was posted on the bulletin board outside their office located in the front entrance hallway and they would adjust the staffing form throughout the day to reflect the actual staff in the building. Human Resource Manager #1 stated the Nursing Supervisor was responsible to complete, update and post the Daily Staff form on the weekends. Human Resource Manager #1 stated that they had completed the Daily Staffing forms from 1/27/25 - 1/31/25. They posted the 1/27/25 form in the afternoon but did not have a chance to get the forms posted the rest of the week and should have. They stated it was important to have the Daily Staffing form posted so that families would know how many staff members were providing care to the residents. During an interview on 1/31/25 at 12:32 PM, the Director of Nursing stated Human Resource Manager #1 was responsible to complete and post the Daily Staffing form. They stated they would complete and post the Daily Staffing in the absence of Human Resource Manager #1 and that the Nursing Supervisor would complete the form on the weekend. The Director of Nursing stated the Daily Staffing form was to be posted on the bulletin board in the front entrance hallway, so that it would be accessible to visitors, families and residents. They stated would expect the Daily staffing form to be completed and posted. It was important for visitors and families to know the actual staffing of the building. The Director of Nursing stated they were unaware that the Daily Staffing form had not been posted from 1/28/25 - 1/31/25. 10NYCRR 415.13

Based on observation, interview, and record review conducted during a Partial Extended Abbreviated survey (Complaint #NY00331042) started on 1/10/24 and completed on 1/12/24, the facility failed to ensure that residents were free from significant medication errors for one (Resident #1) of three residents reviewed. Specifically, on 1/4/24 Licensed Practical Nurse #1 dispensed Resident #2's 5:00 PM medications and directed Licensed Practical Nurse #2 to administer the medications to Resident #2. Licensed Practical Nurse #2 did not verify the medications and dosages. Neither Nurse verified the resident, and Licensed Practical Nurse #2 erroneously administered Resident #2's medications to Resident #1. Subsequently, Resident #1 had a change in condition, became confused and had incoherent speech. Resident #1 was transferred to the hospital on 1/4/24 at 8:15 PM via ambulance and admitted . Additionally, on 1/10/24 two (Orchard Unit, Canal Unit) of five units medication carts were observed to have multiple paper medication cups with medications in the top drawer. Some of the medication cups were labeled with resident's names, and some were unlabeled. Licensed Practical Nurses #3 and #4 were unable to identify the medications. This resulted in actual harm to Resident #1's health and safety with the likelihood to affect all residents in the facility that receive medications from staff that is immediate jeopardy and substandard quality of care. The findings are: The policy and procedure titled Medication Administration dated 7/2021 documented the individual administering the medication must check the label three times (3) to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The individual administering medications must verify the resident's identity before giving the resident his/her medications. 1. Resident #1 had diagnoses of metabolic encephalopathy (neurological disorder), dysphagia (difficulty swallowing), hypertension (high blood pressure), and traumatic brain injury. The Minimum Data Set, dated dated dated [DATE] documented the resident was moderately cognitively impaired. The comprehensive care plan initiated 10/21/21 documented Resident #1 had impaired cognitive function. Interventions included for staff to administer medications as ordered. Resident #2 had diagnoses of epilepsy (seizure disorder), paranoid schizophrenia (mental disease), and hypertension. The Minimum Data Set, dated dated dated [DATE] documented the resident was moderately cognitively impaired. The nurses' note dated 1/4/24 at 5:42 PM by Licensed Practical Nurse Supervisor #5 documented Resident #1 received another resident's 5:00 PM medications. The medical doctor was updated, and new orders were received to monitor the resident's vital signs every four hours for 24 hours and monitor for sedation. The nurses' note dated 1/4/24 at 7:09 PM written by Licensed Practical Nurse Supervisor #6 documented the medications that were administered in error to Resident #1 included but were not limited to: Clozapine (antipsychotic medication) 200 milligrams, Melatonin (sleep aide) 3 milligrams, Simvastatin (cholesterol lowering medication) 40 milligrams, Trazadone (antidepressant) 25 milligrams, Amantadine (medication used to reduce uncontrolled movements) 150 milligrams, Keppra (anticonvulsant) 1000 milligrams, Depakote (anticonvulsant) 500 milligrams, Diltiazem (cardiac medication to treat high blood pressure, chest pain) 45 milligrams. The nurses' note dated 1/4/24 at 7:13 PM by Licensed Practical Nurse Supervisor #6 documented Resident #1 was exhibiting altered mental status, incoherent speech. The medical doctor was notified with a new order to send to emergency department. A hospital medicine admission note dated 1/5/24 completed by a hospital provider documented Resident #1 was admitted to the hospital on 1/4/24 with diagnoses that included acute (severe and sudden onset) toxic encephalopathy (delirium, confusion, disturbance of normal brain function) secondary to accidental drug overdose, hypotension (low blood pressure) most likely from polypharmacy (concurrent use of multiple medications), and acute kidney injury (abrupt reduction in kidney function). During a telephone interview on 1/10/24 at 9:57 AM, Licensed Practical Nurse #2 stated they worked on 1/4/24 and were shadowing Licensed Practical Nurse #1. Licensed Practical Nurse #2 stated Licensed Practical Nurse #1 was preparing the medications using the electronic medication administration record in their presence, and they were administering the medications to the residents. Licensed Practical Nurse #2 stated Licensed Practical Nurse #1 prepared Resident #2's medications and indicated Resident #2 in a common area. Licensed Practical Nurse #2 stated they mistakenly administered Resident #2's medications to Resident #1. Licensed Practical Nurse #2 stated they did not confirm the identity of the resident prior to administering the medications. I should not administer medications that I did not prepare myself. There could be wrong medications or even missed medications. During an interview on 1/10/24 at 11:14 AM, Licensed Practical Nurse #1 stated on 1/4/24 Licensed Practical Nurse #2 was shadowing them. Licensed Practical Nurse #1 stated they dispensed Resident #2's medications in the presence of Licensed Practical Nurse #2 and instructed Licensed Practical Nurse #2 to administer the medications to Resident #2. Licensed Practical Nurse #1 stated they did not accompany or observe Licensed Practical Nurse #2 administer the medications. I should have given them. Licensed Practical Nurse #1 stated they realized Resident #1 had been administered Resident #2's medications and immediately notified the Nursing Supervisor (Licensed Practical Nurse #5). During an interview on 1/10/24 at 10:51 AM, the Director of Nursing stated they do not have an orientation for agency Licensed Practical Nurses. They shadow a facility nurse to get the lay of the land. The Director of Nursing stated it was the responsibility of the nurses to follow the 5 resident rights when passing medications and to do three verification checks. It is a professional standard of nursing practice. The Director of Nursing stated the medications that Resident #1 received erroneously would be considered significant and a harm to the resident. During an interview on 1/10/24 at 11:05 AM, the Administrator stated they expected the nurse that dispensed the medications to administer the medications to the correct resident. During a telephone interview on 1/10/24 at 11:32 AM, the Consultant Pharmacist stated it was the responsibility of the nurses to ensure the correct resident was administered the correct medications; and if a nurse was shadowing another nurse, both nurses should be present during the dispensing and administration of the medications. The Pharmacy Consultant stated they would consider the medications administered to Resident #1 to be significant medications and a significant medication error. During a telephone interview on 1/10/24 at 11:53 AM, the Medical Doctor stated they considered the medications administered to Resident #1 a significant medication error. 2. During a medication observation on 1/10/24 at 9:15 AM on the Orchard Unit, Licensed Practical Nurse #3 had seven residents' (Residents #4, 5, 6, 7, 8, 9, and 10) medications pre-poured into paper medication cups located in the top drawer. Some of the paper medication cups were labeled with resident names, and some were not. Licensed Practical Nurse #3 was unable to identify the medications that were in each cup. In addition, to the pre- poured resident medications there was an unlabeled plastic medication cup with nine white round tablets that Licensed Practical Nurse #3 identified as Tylenol 500 milligrams each. During an interview on 1/10/24 at 9:15 AM, Licensed Practical Nurse #3 stated they were not supposed to pre-pour resident medications because it increased the risk of medication errors. During a medication observation on 1/10/24 at 9:31 AM on the Canal Unit, Licensed Practical Nurse #4 had nine paper medication cups with medications in the top drawer of the medication cart and they were labeled with resident's names (Residents #11, 12, 13, 14, 15, 16, 17, 18, and 19). Licensed Practical Nurse #4 stated those nine cups were second attempts to administer medications. Licensed Practical Nurse #4 stated they were unable to identify the medications without looking at the EMAR (electronic medication record). In addition, there were 12 empty paper medication cups labeled with resident's names on top of the medication cart. During an interview on 1/10/24 at 10:51 AM, the Director of Nursing stated it was unacceptable for nurses to pre-pour medications and it was not allowed. During a telephone interview on 1/10/24 at 11:32 AM, the Consultant Pharmacist stated it was unacceptable for nurses to pre-pour medications because it increased the risk of medication errors. During a telephone interview on 1/10/24 at 11:53 AM, the Medical Doctor stated medications must be labeled; if medications were pre-poured, they were no longer labeled which increased the opportunity for medication errors. 10 NYCRR 415.12(m)(2)

Based on interview and record review conducted during a Partial Extended Abbreviated survey (Complaint #NY00331388) completed on [DATE], the facility did not ensure that required documentation was sent to the receiving provider in a hospital transfer for one (Resident #1) of three residents reviewed. Specifically, on [DATE] Resident #1 was transferred to the hospital emergently, after a significant medication error. Licensed Practical Nurse #6 did not provide the hospital provider with the correct Medical Orders for Life-Sustaining Treatment (advanced directives) form which resulted in a delay of treatment for Resident #1. The finding is: Resident #1 had diagnoses of metabolic encephalopathy (neurological disorder), dysphagia (difficulty swallowing), hypertension (high blood pressure), and traumatic brain injury. The Minimum Data Set, dated dated dated [DATE] documented the resident was moderately cognitively impaired, and no advance directives were documented. The comprehensive care plan with a revised date of [DATE], documented Resident #1 did not have advance directives and included a goal that resident's choice of advance directives would be honored. Interventions documented the resident as a full code. The nurses note dated [DATE] at 7:13 PM by Licensed Practical Nurse Supervisor #6 documented Resident #1 was exhibiting altered mental status, incoherent speech. The medical doctor was notified with a new order to send to emergency department. During an interview on [DATE] at 9:54 AM, Licensed Practical Nurse #6 stated Resident #1 experienced a change in condition (altered mental status, incoherent speech) on [DATE] at approximately 7:00 PM, the Medical Doctor was notified with a new order to send the resident to emergency department. Licensed Practical Nurse #6 stated they made copies of Resident #1's information from the electronic medical record, including the Medical Orders for Life-Sustaining Treatment form. Licensed Practical Nurse #6 stated there was a voided Medical Orders for Life-Sustaining Treatment scan dated [DATE] they scrolled past and sent a copy of a Medical Orders for Life-Sustaining Treatment form, dated, and reviewed by the Nurse Practitioner [DATE]. They further stated they were trained go to the Misc. (miscellaneous) tab of the electronic medical record to copy the most recent Medical Orders for Life-Sustaining Treatment. Review of the Medical Orders for Life-Sustaining Treatment form that was originally sent to the hospital on [DATE] revealed the form was dated and last reviewed by the Nurse Practitioner on [DATE]. The form documented Do Not Resuscitate, Do Not Resuscitate, Comfort Measures Only, Do Not Intubate, No IV fluids. Review of the Hospital ED (emergency department) to Hosp (hospital) Admission note dated [DATE] documented the resident arrived at the emergency department [DATE] at 9:09 PM. The resident was sent to the emergency department after accidentally receiving another resident's medications. The Medical Orders for Life-Sustaining Treatment documents Do Not Resuscitate, Do Not Intubate, No IV fluids, do not send to hospital, and Comfort Measures Only. The resident was lethargic and unable to give any history. At 2:30 AM on [DATE], the resident continued to be hypotensive with a systolic blood pressure in the 70's and heart rate in the 50's. Nursing home staff was notified that the resident would be sent back to the nursing home in light of the comfort care status, and they can be monitored at the nursing home. Approximately 20 minutes later the facility Nursing Supervisor contacted the hospital stating the wrong Medical Orders for Life-Sustaining Treatment was inadvertently sent with the resident. At 3:30 AM on [DATE] the hospital received a fax (facsimile) of Medical Orders for Life-Sustaining Treatment, signed by the resident indicating full code. Review of the second Medical Orders for Life-Sustaining Treatment provided to the hospital revealed the form was signed and dated [DATE] by Resident #1 and Medical Doctor documented attempt cardiopulmonary resuscitation and no limitations on medical interventions. During an interview on [DATE] at 10:12 AM, the hospital Associate Chief Nursing Officer stated Resident #1 arrived at the hospital emergency roiagnom on [DATE] at 9:09 PM with a Medical Orders for Life Sustaining Treatment form signed by the resident on [DATE] and reviewed by the Nurse Practitioner [DATE]. The advanced directive documented: Do Not Resuscitate, Comfort Measures Only, Do Not Intubate, and No IV (intravenous) fluids. The hospital contacted the facility on [DATE] at 2:30 AM to notify the facility that Resident #1 would be returning to the facility secondary to a declining medical condition (arousable to sternal rub, firm rub on the chest to test responsiveness, and confusion) and the limitations of care documented (no laboratory values were to be obtained, no IV fluids administered). Licensed Practical Nurse #6 contacted the hospital approximately 20 minutes later stating the incorrect Medical Orders for Life-Sustaining Treatment form was sent with Resident #1 and the current form documented there was no limitations on medical interventions and to attempt cardiopulmonary resuscitation (CPR). The hospital received the correct Medical Orders for Life-Sustaining Treatment form dated [DATE] at 3:30 AM and began medical treatment. During an interview on [DATE] at 10:41 AM, the Director of Nursing stated the facility does not have a current policy and procedure regarding transferring residents to the hospital. During an interview on [DATE] at 1:24 PM, the Medical Doctor stated they were unaware the incorrect Medical Orders for Life-Sustaining Treatment form was sent to the hospital with Resident #1 and the current form should be scanned into the electronic medical record in chronological order. During an interview on [DATE] at 7:58 AM Licensed Practical Nurse Supervisor #5 stated when sending a resident to hospital they were trained go to the Misc. (miscellaneous) tab of the electronic medical record to copy the most recent Medical Orders for Life-Sustaining Treatment. During an interview on [DATE] at 10:21 AM, the Director of Nursing stated staff were to make a copy of the original Medical Orders for Life-Sustaining Treatment form, found in the supervisor's office Medical Orders for Life-Sustaining Treatment book to send with the resident when transferring the hospital. During an interview on [DATE] at 10:34 AM, the Administrator stated staff were expected to copy the original Medical Orders for Life-Sustaining Treatment form, found in a binder in the supervisor's office, to send with the resident when transferring to the hospital. 10 NYCRR 415.3(h)(1)(iv)(d)-

Based on interview and record review conducted during an Abbreviated survey (Complaint # NY00325970) completed on 10/18/23, the facility did not ensure that all alleged violations including abuse 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, to the administrator of the facility and to appropriate officials (including the State Survey Agency) for one (Resident #1) of four residents reviewed. Specifically, facility staff did not report alleged physical and verbal abuse of a resident to the Director of Nursing (DON) or the Administrator which resulted in the alleged abuse not getting reported to the appropriate officials including the New York State (NYS) Department of Health (DOH) as required. This finding is: The policy and procedure (P&P) titled Signs and Symptoms of Abuse/Neglect Policy dated 10/26/16 documented the facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms to their supervisor or the DON. 1. Resident #1 was admitted to the facility with diagnoses including dementia, seizure disorder and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 8/12/23 documented Resident #1 had moderate cognitive impairments, was usually understood, and usually understands. The comprehensive care plan (CCP) with revision date of 12/16/22 documented Resident #1 demonstrated the potential for physical and verbally aggressive behaviors towards staff and residents. The CCP also documented the resident was incontinent of bowel and bladder related to seizure disorder and confusion. During an interview on 10/17/2023 at 10:13 AM, Certified Nurse Aide (CNA) #1 stated, last Thursday on 10/12/23 Resident #1 was agitated, wandering the unit, and refused to use their walker. CNA #1 stated they were walking with the resident until they calmed down because they didn't want the resident to get hurt or hurt someone else. Resident #1's pants were wet, and they needed to be changed. The nurse (LPN #1) came up to the resident, started pointing in the resident's face, told the resident they needed to go to their room to get changed, and grabbed the resident by the shirt. CNA #1 stated they reported the incident yesterday (10/16) to Lead CNA #1. During an interview on 10/17/2023 at 12:22 PM, Lead CNA #1 stated CNA #1 reported to them yesterday (10/16/23) that last week LPN #1 grabbed Resident #1's shirt and got into the resident's face. Lead CNA #1 stated that they told CNA #1 they needed to report the incident right away, not to wait, and to go and report the incident to the Social Worker (SW). The aide (CNA#1) stated to them that they would go to the SW. Lead CNA #1 stated they did not report the incident to the supervisor or to the DON and thought the SW would take care of it. During an interview on 10/17/2023 12:34 PM, the Social Worker Assistant stated they were unaware of any abuse allegations involving Resident #1 and that no staff members reported any allegations of abuse to them. During an interview on 10/18/2023 at 9:57 AM, the Administrator stated an investigation was started yesterday (10/17) and the alleged abuse was reported to the NYSDOH when they became aware of the allegation. During an interview on 10/18/2023 at 12:37 PM, the DON stated that staff know better, and they know when to report an abuse concern. The DON stated LPN #1 denied the allegation and they were not sure why Lead CNA #1 did not report the incident to them or the Administrator. The DON stated an investigation had been started (10/17) and they were not sure at the time of the interivew if any other staff witnessed the incident. The DON stated, that if staff felt uncomfortable to report a supervisor, they know they can come to me or report to the hotline. The incident should have been reported within 2 hours. 10NYCRR 415.4 (b)(1)

Based on interview and record review conducted during an Abbreviated survey completed on 8/10/23 the facility did not develop, implement and maintain an effective compliance and ethics program. Specifically, at a minimum the facility did not establish written compliance and ethics standards, policies, and procedures to follow that are reasonable capable of reducing the prospect of criminal, civil, and administrative violations under the Act. and promote quality of care, which include, but are not limited to, the designation of an appropriate compliance and ethics program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution; and disciplinary standards that set out the consequences for committing violations for the operating organization's entire staff/ individuals providing services under a contractual arrangement; and volunteers, consistent with the volunteers' expected roles. Additionally, the facility did not take steps to effectively communicate the standards, policies, and procedures in the compliance and ethics program to the organizations entire staff. Review of a New York State DAL (Dear Administrator Letter), dated May 28, 2010, titled Family Health Care Decision Act FHCDA, revealed that nursing homes are required to complete the following activities by June 1, 2010, to be compliant with the FHCDA, which includes developing general policies and procedures to comply with the provisions of the FHCDA, and provide for the governance of the Ethics Review Committee (ERC) functions, composition, and procedure. The ERC must include a minimum of five members; at least three must be health or social service practitioners, including one RN and one physician. At least one member must be a person without any governance, employment, or contractual relationship with the nursing home. Additionally, the residents' council must be given the opportunity to appoint two members. These individuals may not be either a resident of the facility or a resident's family member. The finding is: During an interview on 8/8/23 at 12:42 PM, Social Worker (SW) #1 stated they did not know if the facility had a compliance and ERC policy and procedure. Additionally, SW #1 stated they have not met with a committee to discuss appointing health care surrogates. During an interview on 8/9/23 at 11:53 AM, the Director of Nursing (DON) stated they were unable to locate a compliance and ethics review committee policy and procedure. The DON stated that they did not believe the facility had a compliance and ERC Program. During an interview on 8/9/23 at 12:32 PM, the Medical Director (#1) stated they did not know if the facility had a compliance and ERC policy and procedure. The MD stated they had ethics meetings in the past and the committee members include themselves, SW #1, Administrator, and the DON. During an interview on 8/10/23 at 9:45 AM, the Corporate Administrator/ acting Administrator stated they did not have access to the facility's P&P's and did not know if the facility had a compliance and ERC policy and procedure. The Corporate Administrator (acting Administrator) stated the Administrator who was on vacation, was unable to be reached so they were unable to verify if the facility had a compliance and ERC program with written policies and procedures that meet the requirements. 10 NYCRR 415.26 (b)(2)

Based on interview and record review conducted during an Abbreviated survey completed on 8/10/23, the facility did not ensure that each resident has the right to refuse treatment, participate in experimental research, and to formulate an advanced directive for three (Resident #1, #2, and #3) of four residents reviewed. The facility did not implement advanced directives following applicable state laws. Specifically, the facility Social Worker (SW #1) was appointed as Residents #1 and #2 Health Care Proxy (HCP) agent after the resident was admitted to the facility and the facility did not attempt to establish a guardianship for to make health care decisions for Resident #3. The policy and procedure (P&P) titled Health Care Proxy revised 1/1/2006 documented that upon admission, if necessary, a health care proxy shall be identified, and the appropriate paperwork shall be filed. Resident's and Responsible parties will be informed/educated about health care proxy law at the time of admission. They will be supplied with appropriate forms and given opportunity to appoint an agent. The P&P titled Medical Order for Life Sustaining Treatment (MOLST) revised 11/2021 documented, If a resident lacks capacity and does not have a health care proxy then a surrogate must be selected. A document titled Health Care Proxy Appointing Your Health Care Agent in New York State dated 8/22, form 1430 provided by the Corporate Administrator documented that you may choose any adult ([AGE] years of age or older), including a family member or close friend, to be your agent. If you select a doctor as your agent, he or she will have to choose between acting as your agent or as your attending doctor because a doctor cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. Ask staff at the facility to explain those restrictions. A guidebook titled The Health Care Proxy Law A Guidebook for Health Care Professionals dated January 1991 documented that an operator, administrator or employee of a general hospital, nursing home, mental hygiene facility or hospice may not serve as agent for any person who is a patient at the facility, unless the patient is related to the person they wish to appoint, or the patient created the proxy before being admitted to, or applying for admission to the facility. Physicians are the only exception to this rule. A patient can appoint his or her physician as agent, but the physician cannot serve as both the agent and the attending physician of a patient after the agent's decision-making authority begins. Any physician who has been appointed as a patient's agent cannot determine the patient's capacity to make health care decisions. The findings are: 1. Resident #1 had diagnoses that included dementia with moderate psychotic disturbance, anxiety disorder, and major depressive disorder (MDD). The Minimum Data Set (MDS-a resident assessment tool) dated 8/7/23 documented Resident #1 was severely cognitively impaired. The Admission Record (resident demographics) documented SW #1 as Resident #1's first Emergency Contact #1 Health Care Agent, Relationship - Case Worker. Resident #1 MOLST (Medical Orders for Life- Sustaining Treatment) form, dated 2/12/21 completed as a verbal consent by Resident #1 and signed by Medical Director (MD) #1, documented the following orders: Do Not Resuscitate (DNR, allow natural death), Do Not Intubate (DNI, do not place a tube down the resident's throat or connect to a breathing machine), limited medical interventions (receive medication by mouth or through a vein, heart monitoring and all other necessary treatment based on MOLST orders), do not send to hospital unless pain or severe symptoms cannot be otherwise controlled, no feeding tube, a trial of IV (intravenous) fluids, and determine use or limitations of antibiotics when infection occurs. The MDS dated [DATE] documented Resident #1 was moderately cognitively impaired. Resident #1's Health Care Proxy dated 5/30/22 documented Resident #1 appointed Social Worker (SW) #1 as their health care agent and was the Proxy was witnessed by the Activities Department Director (#1) and the Receptionist (#1). Review of Health Care Proxy - Decision - Making Capacity Determination form dated 7/12/22 signed by MD (#1) and co-signed on 7/18/22 by Nurse Practitioner (NP) #1 documented Resident #1 does not have capacity to make own personal health care decisions. Resident #1's MOLST form dated 11/1/22 signed by SW #1 and MD #1, documented the following orders: DNR, DNI, do not send to hospital, determine use or limitations of antibiotics. In addition, the MOLST was updated to include comfort measures only (medical care and treatment provided with the primary goal of relieving pain, other symptoms and reducing suffering) and no IV fluids. Review of Progress Notes (Interdisciplinary (IDT)) dated 4/1/22 through 8/9/23 revealed there was no documented evidence that a discussion occurred with Resident #1 to appoint SW #1 as their HCP agent and as to the changes made to MOLST dated 11/1/22. Review of Progress Note dated 8/1/23 MD #1 documented that Resident #1 was without really any social supports and SW #1 was established as resident's healthcare proxy. During an interview on 8/8/23 at 12:15 PM, Licensed Practical Nurse (LPN) #1 Unit Manager (UM) stated that SW #1 was appointed as Resident #1's HCP agent, and they were not related. Resident #1 was admitted to the facility prior to SW #1 being appointed as their HCP agent. LPN UM #1 stated they believed the MD #1 wanted a HCP agent appointed for the resident to make health care decisions. During an interview on 8/8/23 at 12:42 PM, SW #1 stated they recall the MD #1 saying that they had multiple discussions with Resident #1 concerning appointing someone as their HCP agent. SW #1 stated they had a conversation with Resident #1 and the resident was comfortable with them being their HCP agent. So, they (SW#1) were appointed as the HCP agent May 2022 per the resident's request. SW #1 stated the MD #1 was informed agreed that SW #1 had a good rapport with Resident #1 and should be their HCP agent. SW #1 stated the Administrator and Director of Nursing (DON) were aware they were appointed as Resident #1's HCP agent. During an interview on 8/9/23 at 12:32 PM, MD #1 stated they believed Resident #1 had enough understanding to determine who they wanted to appoint as their HCP agent and believed there was no conflict for SW #1 to be appointed as the agent for Resident #1. MD #1 stated they had informed the Administrator and the DON that SW #1 was appointed as Resident #1's HCP agent. The MD stated SW #1 was not related to Resident #1 and was admitted to the facility before SW #1 was appointed as their HCP agent. The MD stated they do not know the regulatory guidelines for appointing a HCP agent. 2. Resident #2 had diagnoses that included disorder of psychological development, anxiety disorder, and MDD. The MDS dated [DATE] documented Resident #2 was moderately cognitively impaired. The Admission Record documented SW #1 as Emergency Contact #1 Health Care Agent, Relationship - Case Worker. The MDS dated [DATE] documented Resident #1 was cognitively intact. Resident #2's Health Care Proxy dated 8/1/22 documented Resident #2 appointed SW #1 as their health care agent and the document was witnessed by the Activities Department Director (#1) and the Receptionist (#1). The Progress Notes (IDT) dated 7/1/22 through 8/9/23 revealed there was no documented evidence that a discussion occurred with Resident #2 to appoint SW #1 as their HCP agent. During an interview on 8/9/23 at 11:23 AM, Activities Department Director #1 stated that SW #1 asked them to witness a discussion with Residents #1 and #2 regarding appointing a HCP agent. The Activities Director stated Residents #1 and #2 were already residents at the facility and recalled Residents #1 and #2 were educated and expressed they wanted SW #1 to be their HCP agent. The Activities Director stated SW #1 was not a relative to Resident #1 and #2 and did not know if SW #1 was court appointed as their guardian. During an interview on 8/9/23 at 11:31 AM, Receptionist #1 stated that SW #1 asked them to witness a discussion with Residents #1 and #2 regarding appointing an HCP agent. The Receptionist stated Residents #1 and #2 were already residents at the facility and recalled Residents #1 and #2 were educated and expressed they wanted SW #1 to be their HCP agent. Receptionist stated SW #1 was not a relative to Resident #1 and #2 and did not know if SW #1 was court appointed as a guardian. During an interview on 8/8/23 at 12:42 PM, SW #1 stated they were Resident #2's HCP agent and acted as the resident's social worker. SW #1 stated Resident #2's HCP agent had passed away and the resident had no family left, therefore Resident #2 appointed them as their HCP agent. During an interview on 8/9/23 at 11:35 AM, SW #1 stated they were not related to Resident #2, was not appointed as a guardian by the courts and the resident was admitted to the facility before they were appointed as their HCP agent. SW #1 stated they did not know the NYS Health Care Proxy rules that applied to health care workers for residents in a long-term care. SW #1 stated the Administrator and DON were aware they were appointed as HCP agent. During an interview on 8/9/23 at 11:53 AM, the DON stated they do not know the facility's process of appointing a HCP agent and/or the New York State guidelines for appointing a HCP agent. The DON stated they were aware SW #1 was the HCP agent for both residents (#1, #2) and believed this was acceptable. During an interview on 8/9/23 at 12:32 PM, MD #1 stated they were not aware SW #1 was appointed as HCP agent for Resident #2 and believed if the resident appointed SW #1, they could be Resident #2's HCP agent and acting social worker. 3. Resident #3 had diagnoses that include Alzheimer's Disease, schizoaffective disorder bipolar type, and chronic obstructive pulmonary disease. The MDS dated [DATE] documented the resident was severely cognitively impaired. The Admission Record documented SW #1 as the Emergency Contact #1, Care Conference Person, Relationship - Case Worker and Community Registered Nurse (RN) #1 as Emergency Contact #2, Relationship - Case Worker. Review of the Health Care Proxy - Decision - Making Capacity Determination form dated 5/25/22 signed by MD #1 and co-signed on 5/27/22 by NP #1 documented Resident #3 does not have capacity to make own personal health care decisions. Review of SW Progress Notes 5/24/22 through 8/9/23 revealed a note dated 5/24/23 that documented Resident #3 was admitted to the facility, does not have a MOLST and will be a full code. Review of Medical Record 5/24/22 through 8/9/23 there was no documented evidence there was a MOLST form, a health care proxy form, and no documented evidence a guardianship process had been initiated. During an interview on 8/9/23 at 10:48 AM, RN #1 Community Mental Health Nurse stated they were aware they were listed as contact person for Resident #3's only for the purpose that they may receive health information to assist with managing Resident #3's care. RN #1 stated they were unable to make any health care decisions because it was a conflict of interest. RN #1 stated Resident #3 was not able to make any health care decisions, was admitted over a year ago and the facility should have ensured a guardian was appointed to make their health care decisions. During an interview on 8/9/23 at 10:54 AM, SW #1 stated Resident #3 was admitted without a MOLST, HCP or surrogate therefore the resident was a full code. SW #1 stated they had appointed themselves as the emergency contact #1 because there was no one they knew of to contact for medical changes. SW #1 stated they did not make any health care decision for Resident #3. SW #1 stated they had not informed the Administrator, and the DON Resident #3 did not have a guardian, surrogate, friend, or family member to make any health care decision because they forgot. SW #1 stated they should have followed up and ensured Resident #3 had a surrogate/ guardian appointed by the courts to act on their behalf for health care decisions. During an interview on 8/9/23 at 12:11 PM, the DON stated they were not aware SW #1 was Resident #1's emergency contact and believed contact the second contact the residents HCP agent. The DON stated they did not know contact #2 (RN #1) was the community mental health nurse for Resident #3. The DON stated if Resident #3 did not have any family, friends, or surrogate then the facility should have initiated the guardianship process to have the court appoint a guardian to make health care decisions. In addition, the DON stated they would have expected SW #1 to have informed the Administrator and the Administrator ensure a guardian was appointed. During an interview on 8/9/23 at 12:32 PM, MD #1 stated they were not aware Resident #3 did not have an HCP agent, or an appointed surrogate and they should have. The MD stated SW #1 should not be Resident #3's emergency contact and would have expected SW #1 to have informed them, the Administrator, and the DON to ensure Resident #3 was appointed a guardian through the courts to ensure someone was responsible to make the resident's health care decisions. During an interview on 8/10/23 at 9:45 AM, the Corporate Administrator/ Acting Administrator stated they were aware SW #1 was the HCP agent for Resident's #1 and #2. They stated that SW #1 was not related to either resident, and that SW #1 continued act as both resident's (#1, #2) social worker. Both residents were admitted before SW #1 was appointed as their HCP agent. The Corporate Administrator stated they followed the New York State Department of Health 1430 HCP form instructions and did not believe there was a conflict of interest or that there were additional restrictions for employees of long-term care health facilities. The Corporate Administrator stated they were not aware SW #1 was listed as Resident #3's emergency contact and that the resident did not have a HCP agent. The Corporate Administrator stated Resident #3 should have a guardian appointed for health care decisions and does not know if the Administrator was aware. 415.3 (e)(2)(iii)

Based on interview and record review conducted during a Standard survey completed 7/21/23, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, one of one facility reviewed for sufficient staffing did not have a full-time (working 35 or more hours a week) qualified Director of Food and Nutrition services. The finding is: Refer to F 802, F 803, and F 812 for related information. The undated policy titled Role of the Dining Services Director documented the Dining Services Director effectively manages the Dietary Department to assure that the food service is safe, appetizing, and nutritious. Qualifications include enrollment and/or completion of an approved educational program. Responsibilities include supervises the food preparation and service for resident meals according to established menus and standardized recipes, insures food is prepared by methods that conserve nutritive value, is palatable and attractive to residents and of a quality that is acceptable to residents, insures that sanitation and safety standards are maintained above levels that are acceptable according to State and Federal regulations, and insures residents receive the proper food items to meet dietary needs and that food is served at the appropriate temperature for safety and palatability. Review of the Time Cards from 4/9/23 through 6/17/23 revealed the Dietary Consultant did not work full-time. 6/18/23 through 7/15/23 revealed they did not work at all at the facility. Review of the Time Cards from 5/14/23 through 5/20/23 revealed the Dietary Supervisor did not work full-time and between 5/21/23 through 7/15/23 did work full-time. During an interview on 7/17/23 at 9:20 AM the Dietary Supervisor introduced themselves as the Food Service Director/ Supervisor. They stated they were new and recently started the position in May 2023. Further interview on 7/20/23 at 10:45 AM they stated again that they were the Food Service Director and was trained for one month by the Dietary Consultant at which time they took over the dietary department. They stated they had no food service background prior to this job or food service education and that they used to be a Certified Nurse Aide (CNA) in a nursing home. They stated they were not a certified dietary manager or food service manager. During an interview on 7/17/23 at 11:00 AM, the Dietary Consultant stated they were no longer the Food Service Director as they have retired and only come in 2-3 days a week to help when they were short. They stated they had not even been there or worked for the past 3 weeks and that the Dietary Supervisor was now the Food Service Director. On 7/18/23 at 8:54 AM they stated once again they were retired and only comes in as a consultant when they are needed. They stated they have not been at the facility for 3 weeks and was asked to come in because the State was here. On 7/20/23 at 10:45 AM they stated technically the Dietary Supervisor was the Food Service Director and that they had trained them for a month at which time the Dietary Supervisor told them they felt comfortable doing the job. The Dietary Consultant stated, they are retired and have not worked for the past 3 weeks and that they only agreed with the Administrator to come in and help on occasion. During an interview on 7/20/23 at 2:58 PM, the Human Resource Director stated the Dietary Supervisor was the Food Service Director and had not been here that long since the end of April/ May. They stated the Dietary Consultant was retired but was still on the books and will come in on occasion to help. They stated the Dietary Consultant was no longer the Food Service Director. During an interview on 7/20/23 at 3:36 PM, the Registered Dietitian (RD) stated they only work part time 3 days a week. They stated the Dietary Supervisor has been the Food Service Director for a couple of months with one month being trained by the Dietary Consultant. During an interview on 7/21/23 at 9:15 AM, the Administrator stated that they were aware of the regulations regarding the qualifications for the Food Service Director. They stated the Dietary Consultant was the Food Service Director and the Dietary Supervisor was still in training for that position. They stated they had No such arrangement with the Dietary Consultant that they are retired and only comes in on an as needed basis. They stated, Nothing has changed with their operational status or on the books. They further stated the Dietary Supervisor was qualified for the position because they had worked as a CNA in a long-term care facility and had management experience. When asked if it was food service management experience they stated No. 10NYCRR 415.14(a)(1)

Based on observation, interview, and record review conducted during the COVID-19 Infection Control Focus Survey (Complaint #NY 514) completed on 5/9/20, it was determined that 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, facility staff (Certified Nurse Aides (CNA) and Licensed Practical Nurses (LPN)) entered and exited the room of a resident diagnosed with [REDACTED]. The same staff then entered the rooms of residents without COVID-19, passed breakfast trays, assisted with the residents' meal and provided hands on care without wearing PPE and completing proper hand hygiene. Staff on COVID-19 Units, COVID-19 rooms, and COVID-19 presumed rooms were not wearing proper PPE. PPE was not readily accessible to staff. Additionally, resident's under investigation for COVID-19 were not placed on droplet precautions per the facility process. This was a pattern of no actual harm that is immediate jeopardy to resident health and safety. The findings are: Review of the facilities policy and and procedure titled COVID-19 dated 3/12/20 documented the facility would: -Take every precaution to identify signs and symptoms of COVID-19 disease and implement infection control strategies to avoid possible spread of the disease. -Ensure employees clean their hands according to CDC guidelines including before and after contact with residents, after contact with contaminated surfaces and after removing PPE. -Identify dedicated employees to care for COVID-19 residents and provide infection control training. -Provide the right supplies to ensure easy and correct use of PPE, post signs on the door or wall outside the resident rooms to clearly describe what type of precautions are needed and required PPE. -Make PPE including facemask, eye protection, gowns and gloves available immediately outside of the resident's room. -In the event we suspect a resident is infected with COVID-19, staff will utilize N95 mask and eye protection and keep the resident isolated. a.) During an observation on 5/9/20 at 8:07 AM on the Garden View Unit (Rooms #1 to #15) nine of eighteen Residents' had plus (+) signs posted at the door. A stocked linen cart was uncovered, and most of the doors to the resident rooms were open. During an interview on 5/9/20 at 8:10 AM, LPN #2 stated the plus (+) sign posted at the doors indicated the resident was on precautions due to testing positive for COVID-19. During an observation on 5/9/20 at 8:12 am on the Orchard View (Rooms #16 to #28 ) Unit designated as a COVID-19 Unit revealed CNA #5 was not wearing a face shield or goggles while going in and out of resident's rooms diagnosed with [REDACTED]. During observations on 5/9/20 at 8:14 AM LPN #2 delivered a breakfast tray to an actively coughing resident diagnosed with [REDACTED]. LPN #2 was not wearing gloves and did not complete hand hygiene. LPN #2 then entered a non COVID-19 room while wearing the same uniform and face mask to provide hands on assistance to the resident. LPN #2 assisted the COVID-19 negative resident out of bed, stood behind the resident reaching around the residents' torso and hand over hand ambulated the resident to the bathroom with a wheeled walker. During observations on 5/9/20 at 8:15 AM CNA #3 delivered a breakfast tray to a resident diagnosed with [REDACTED]. CNA #3 exited the room did not remove their gloves or perform hand hygiene and searched a condiment caddy and drawers for sugar. While wearing the same gloves, CNA #3 then delivered a breakfast tray to a COVID-19 negative resident's room, assisted the resident to a seated position, and provided meal set up. While wearing the same gloves and without performing hand hygiene, CNA #3 exited the COVID negative room removed linens from an uncovered linen cart. He assisted another COVID-19 negative resident with feeding, touching their utensils while sitting within six feet of resident and with his face mask below the chin. During interviews on 5/9/20 at 8:25 AM and 8:54 AM, CNA #3 stated there was no PPE available, gloves should be changed between residents and hand hygiene should be performed prior to exiting a resident room and face masks should cover the mouth and nose. During an interview on 5/9/20 at 8:28 AM, LPN #2 stated PPE including a N95 (a particulate filtering face mask), gown, gloves, and face shield should be donned (put on) when entering a COVID-19 positive room, doffed (removed) when exiting the COVID-19 positive room, and proper hand hygiene completed. If we have the PPE, then I wear it but most of the time there is no PPE available on the unit. I checked the precaution bins on all three units and the bins are empty. We can't do our jobs the right way if we don't have the supplies. During observations of the precaution bins ([MEDICATION NAME]) at the entrance of Orchard View, Canal View, and Garden View units on 5/9/20 at 8:39 AM revealed there was no available PPE in the precaution bins. During an interview on 5/9/20 at 8:39 AM, the building supervisor RN (Registered Nurse) #1 stated the PPE was stored in a room that only the Director of Nursing (DON) and Assistant Director of Nursing (ADON) have the keys to. Additionally, RN #1 stated there wasn't enough PPE readily accessible to get us through the shift and she was unable to find the extra supplies in the ADON's office. b.) During observations on Autumn view (South) designated as a COVID-19 Unit on 5/9/20 at 8:36 AM, revealed there were three residents in the common areas ambulating, sitting in the hall and sitting in the small lounge area, others were in their rooms. CNA #1 was observed circulating amongst the unit, redirecting and assisting the residents with hands on care that were in the common area and in their resident rooms. CNA #1 was dressed in navy blue scrub pants and a bright pink sweatshirt. CNA #1 was wearing an N95 mask, she did not have on a gown or a face shield. During an interview on 5/9/20 at 8:45 AM, CNA #1 stated Autumn view (South) was a designated COVID-19 Unit. She was responsible for 10 residents (9 of which had a [DIAGNOSES REDACTED].#1 stated she gets confused as to when she should wear a gown and face shield. She thought she should always wear a gown and a face shield when on the COVID-19 unit but gets over heated when she wears them. CNA #1's face shield was sitting on the nurses' desk. During an interview on 5/9/20 at 8:49 AM, LPN #1 stated he was responsible for the front COVID-19 Unit (Autumn View South) and the back unit (Autumn View North) a non COVID-19 unit). LPN #1 stated there was one resident on the COVID-19 designated unit (South) that did not have COVID-19 but the resident did not come out of their room and was pretty much independent. LPN #1 further stated that four residents on the non COVID-19 unit (North) were now symptomatic with fevers and lethargy. When asked how he moves from unit to unit without cross contaminating he stated he does not do hands on care with the residents as he directs the CNA's to provide the hands on care, but he was responsible to pass the medications and complete treatments. LPN #1 stated CNA #1 should be wearing a gown and face shield along with her N95 while working on the COVID-19 unit. When asked why the two of them were not wearing gowns on the COVID-19 unit, LPN #1 stated often there weren't any. During an observation on 5/9/20 at 10:30 AM in the presence of the Director of Nursing (DON) the PPE storage room had: 1,000 surgical masks, 88,500 gloves, 600 powder free gloves, 480 N95 face masks, 1,950 gowns, 308 face shields, 19 pairs of goggles, 1,900 surgical masks, and 100 pairs of booties. Additional supplies included 24 containers of bleach wipes, 18 containers of sanitizing wipes plus 5 packages (80 count), 22 gallons of hand sanitizer, 20- 8 oz refillable bottles of hand sanitizer, 50- 3 oz refillable bottles hand sanitizer. The DON stated that only she and the Assistant Director of Nursing (ADON) had keys to this storage room. The extra PPE for staff when the DON and the ADON were not in the building was kept in the ADON's office. During an observation on 5/9/20 at 10:36 AM, the ADON's office had an 18 inch x 12 inch x 9 inch deep cardboard box with two N95 masks, three to four gowns, a box of gloves and four to five surgical masks. c.) Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 5/1/20 documented Resident #1 was severely cognitively impaired. Review of the comprehensive care plan (CCP) dated 4/7/20 revealed Resident #1 was a risk for COVID-19, the goal documented the resident would remain asymptomatic. Interventions included to monitor the resident's status. During an interview at 8:49 AM, LPN #1 stated there were four residents on the non COVID-19 unit (North) with fevers and lethargy. During an observation on 5/9/20 at 8:50 AM (Autumn View North) revealed residents were ambulating and co-mingling in the dining areas and hallways. Residents were not wearing face masks and there were no signs posted at any of the resident rooms to alert staff that residents were on precautions. Continued observations of the unit revealed a physical therapy assistant (PTA) was assisting Resident #1 (who was identified by LPN #1 as having symptoms of COVID-19) with morning care. The PTA was observed wearing goggles, a N95 mask, a resident gown over her clothing and having bare arms. After providing directed personal care, removing the gown and completing self hand and arm hygiene, the PTA walked Resident #1 out of their room and sat them down in a chair in the hallway without a mask. During interviews on 5/9/20 at 8:54 AM, CNA #2 and CNA #4 stated they have never worked Autumn View North before today. The nurse gave them report as to who was to get up out of bed. The CNA's were not aware of any residents that had COVID-19 on the unit or if there were any residents showing symptoms. Additionally, there were no signs posted at the doors alerting them to anyone on precautions and there was no available PPE on the unit. During an interview on 5/9/20 at 9:10 AM, PTA #1 stated that she was wearing a resident gown over her clothing as a precautionary measure, because she knew yesterday Resident #1 had a fever and that she scrubbed her arms down after providing morning care. During an interview on 5/9/20 at 10:49 AM, the Director of Nursing (DON) stated staff should absolutely be wearing a gown, gloves, N 95 mask and a face shield on the COVID-19 designated units and in suspected COVID-19 rooms. There should be signage posted at the doors alerting staff for any resident on precautions for COVID-19 or showing symptoms, and there should be available PPE on the units. Additionally, the PPE should be doffed when exiting the room of a resident diagnosed with [REDACTED]. There is a risk of transmission if this does not happen. The facility does practice extended use for gowns, face shields and N95 mask on the COVID-19 designated units. During an interview on 5/9/20 at 2:27 PM CNA #2 stated she had not received any training at the facility regarding their infection control policies/procedures or COVID -19. During an interview 5/9/20 at 3:00 PM, the DON stated, Resident #1 developed symptoms yesterday and was swabbed again today. Residents that are symptomatic on Autumn View North should have signs on their doors alerting staff the need to wear the appropriate PPE. That should have been done last evening when the residents became symptomatic and was not aware that had not happened. PPE should have been made available. Additionally, the DON stated that she did not educate agency staff and was not sure if anyone educated them on the facilities infection control policies, Standard/droplet precautions and COVID-19. A lot of agency staff have been relocated here. During an interview on 5/9/20 at 3:20 PM, the Regional Administrator stated he expected the Agency staff and facility staff to have been educated on the facilities infection control policies, standard/droplet precautions and COVID-19. Agency staff and facility staff should don the appropriate PPE prior to going into a COVID-19 positive room and/or a designated COVID-19 unit per those policies. Staff should doff the PPE when exiting the room of a resident diagnosed with [REDACTED]. During a telephone interview on on 5/9/20 at 3:50 PM, the facilities Medical Director was aware of the multiple people at the facility [DIAGNOSES REDACTED]. He expected the facility staff and Agency staff to wear the appropriate PPE, and follow the facilities policies regarding COVID-19 and infection control practices. He was not aware the Agency staff was not educated, and they should have been. If employees are not following the proper measures for infection control, there is a risk for transmission and spread. 415.19 (b)(1)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 119) completed on [DATE], the facility did not immediately consult with the resident's Physician when there was a significant change in the resident's condition and a need to alter treatment significantly for two (Residents #1, 2) of three residents reviewed for physician notification. Specifically, nursing staff did not consult with the physician when Resident #1 experienced abdominal distention with multiple episodes of vomiting, rectal bleeding, weakness, and abnormal vital signs. Subsequently, the resident expired prior to being transported to the hospital. Additionally, the Physician was not notified when Resident #2 developed skin concerns. This resulted in actual harm that is not immediate jeopardy for Resident #1. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident was moderately cognitively impaired. A facility policy entitled Change in Condition: When to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant dated 2014 revealed that any symptom, sign or apparent discomfort that is acute or sudden in onset, a marked change (more severe), or unrelieved by measures already prescribed, there should be immediate notification. This includes but not limited to; abdominal distention with vomiting (emesis), vomiting two or more times in 12 hours; and abrupt onset of general weakness with other acute symptoms. The undated comprehensive care plan documented the resident was non- ambulatory, had required the assist of two staff members for transfer, and was incontinent of urine. There was no care plan developed for bowel elimination or the use of antiplatelet medications (reduce the ability of platelets to stick together and inhibit the formation of blood clots). The physician's orders [REDACTED]. - Aspirin 81 mgs (milligrams) one tablet daily by mouth for [MEDICAL CONDITION]. - [MEDICATION NAME] (an antiplatelet medication) 75 mgs one tablet daily by mouth for coronary artery disease. - Milk of Magnesia (used to treat occasional constipation) 30 mls (milliliters) as needed at bedtime if there was no bowel movement for three days. - [MEDICATION NAME] suppository (used to treat occasional constipation) 10 mgs as needed if there was no bowel movement from the Milk of Magnesia; insert 1 suppository rectally the same day. - Saline enema (injection of fluid into the lower bowel by way of the rectum, used to relieve constipation) as needed if there was no bowel movement from the [MEDICATION NAME] suppository. - [MEDICATION NAME] 100 mgs give one capsule by mouth daily as needed for a laxative. - Humalog Insulin inject subcutaneously (beneath the skin) before meals and at bedtime per sliding scale (progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges). The Complex Alert Documentation Report regarding bowel movements dated [DATE] to [DATE] documented the resident had bowel movements on [DATE], [DATE], and [DATE]. The Medication Administration Record [REDACTED]. The nursing Progress Notes dated [DATE] documented the following: - 2:23 AM - The Licensed Practical Nurse (LPN #1) documented at the start of the shift the resident had multiple episodes of emesis that contained undigested food. The resident's abdomen was firm and distended with positive bowel sounds in all four quadrants. An as needed [MEDICATION NAME] suppository was given for constipation. There was a scant amount of rectal bleeding after the administration of the suppository. The following vital signs were documented: blood pressure (B/P),[DATE] (normal is ,[DATE]), pulse (P) 91 (normal is 60 to 100 beats per minute), respirations (R) 16 (normal is 12 to 20 breaths per minute) and were unlabored. The resident's temperature (T) was 97.6 Fahrenheit (F) (normal is 97XXX,[DATE].5 °F). - 3:50 AM - LPN #1 documented that the resident yelled out help me. The writer went to the resident's room and the resident had requested to go to the bathroom. The resident was weak and unable to sit up on the toilet without assistance from staff. The resident's vomiting had subsided. - 4:10 AM - LPN #1 documented the following vital signs: B/P ,[DATE], (TPR) 98.4 - 54 -16, SPO2 (amount of oxygen in the blood) 96% (percent) (normal is between 95 and 100 percent) on room air. Additionally, the resident had a blood glucose of 298 (normal is 70 to 110). The resident continued with a scant amount of rectal bleeding. The Supervisor (RN #1) was made aware. - 4:24 AM - Registered Nurse (RN #1) documented she was in the bathroom with the resident and the resident was unable to have a bowel movement. The resident was having trouble staying awake and was put back to bed. The resident had vomited twice in the past hour, her belly was soft and did not complain of pain when her belly was palpated. - 5:37 AM - LPN #1 documented the resident's abdomen remained distended, but was less firm. The resident was passing gas and had positive bowel sounds in all four quadrants. A scant amount of rectal bleeding continued and the Supervisor was made aware (RN #1). - 7:55 AM - RN #1 documented she went in to see the resident after being alerted by the aide that the resident seemed to be having trouble breathing. The resident was sitting in a wheelchair and was held up by two staff members. The resident's color was drained from her face and she was not responding to voice or pain stimuli. The resident's vital signs were: BP ,[DATE], P 92, PO2 74 %. - 7:59 AM - RN #1 documented the resident's abdomen was distended and bowel sounds were absent in three quadrants and were very diminished in the lower left quadrant. The resident's color had returned to her face but her breathing was labored. - 8:49 AM - RN #1 documented that she had spoken with the Physician and was advised to send the resident to the hospital for an evaluation. 911 was called. The resident was unresponsive, had a B/P of ,[DATE] and had left on a stretcher at 8:45 AM. - 12:09 PM - LPN #3 documented the ambulance arrived at facility at 8:30 AM to transport the resident. The resident's blood pressure had continued to drop and the resident's breathing became labored with periods of apnea (suspension of external breathing). Staff received a phone call from a member of the ambulance team the resident expired in the ambulance prior to leaving the parking lot. An ambulance report entitled Prehospital Care Report dated [DATE] documented the 911 call was received at 8:24 AM. The ambulance was dispatched at 8:25 AM, arrived on the scene at 8:30 AM and had resident contact at 8:31 AM. The narrative note documented the resident was found in bed having agonal respirations (gasping respiration). The resident was moved to the ambulance. The resident stopped breathing and artificial respirations had begun. Due to the resident's DNR/DNI (Do not Resuscitate (No cardiopulmonary resuscitation (CPR)/ Do Not Intubate (no breathing tubes to be placed) status, the resident was not intubated. The resident's heart stopped at 8:42 AM. The 24-Hour Report dated [DATE] on the 10:00 PM to 6:00 AM shift (the shift started on [DATE] at 10:00 PM and goes through [DATE]) documented the resident's abdominal was firm, distended with positive bowel signs in four quadrants. The resident had multiple episodes of emesis with undigested food particles. An as needed [MEDICATION NAME] was given, there was a scant amount of rectal bleeding. Results from the suppository were pending. There were no other notations for this resident on the previous shifts. During an interview on [DATE] at 11:50 AM, the Physician did not know the resident was having these issues during the night on [DATE] stating, this is news to me. The staff should have called her earlier if the resident was having emesis that contained undigested food or had vomited more than once on a shift. The physician's expectation was that staff call her if any resident was having any kind of acute symptoms. Additionally, if the staff could not get a hold of her for whatever reason, the staff should then call the Medical Director or whatever doctor was on call. The Physician further stated that she received a call at approximately 8:20 AM on [DATE] concerning the resident's condition. During an interview on [DATE] at 6:15 AM, LPN #1 stated when she came on duty on [DATE] (10:00 PM to 6:00 AM shift) she did not see any documentation the resident had a bowel movement, so she gave the resident a [MEDICATION NAME] suppository. At approximately 12:00 PM midnight the resident had emesis, she helped the aides clean her up and change her bedding. She stated that she informed RN #1 on several occasions that morning whenever the resident vomited or the resident's vital signs were taken. The last time she saw the resident was at approximately 5:45 AM with LPN #2. The resident's abdomen was not as distended as it was at the beginning of the shift and the resident was passing gas. She believed that LPN's were not to call the physician but RN's do if a resident had a change in condition. She believed RN #1 was going to call the physician about the resident and she left for the day at 6:00 AM. During an interview on [DATE] at 6:44 AM, RN #1 stated she was not aware of a second set of vitals that were taken on [DATE] at approximately 4:00 AM. She assessed the resident at that time but did not document her findings. The resident's abdomen was distended but the resident did not have pain or tenderness. She would have called the physician earlier if she had known about the second set of vitals or the resident had undigested food in her emesis. The resident was vomiting at the nurse's station and it was only liquid at approximately 11:00 PM on [DATE]. She had paged the physician at 7:30 AM on [DATE] and did not get a response. LPN #2 had paged the Physician at approximately 7:40 AM. The Physician called back around 8:00 AM and gave the order to send the resident to the hospital. During an interview on [DATE] at 7:09 AM, LPN #2 stated she saw the resident at approximately 6:30 AM on [DATE]. She performed a digital exam and the resident had stool in her rectum. The resident's abdomen was soft and she had bowel sounds. She gave the resident an enema at 6:40 AM because the resident did not have any results from the suppository. Around 7:00 AM, RN #1 said, the resident's blood pressure was low and to call the Physician. LPN #2 paged the Physician around 7:00 AM. LPN #3 then came in and took over for the night shift. LPN #2 did not document any of her notes because by the time she was ready to document the resident's medical record had been inactivated and she no longer had access to the record. During an interview on [DATE] at 8:07 AM, LPN #3 stated that she arrived at work approximately 8:10 AM. RN #1 was sitting at the nurse's station. She went to see the resident in her room and the resident was a grayish color and was barely breathing. She called 911 at approximately 8:30 AM. She asked RN #1 what happened, and RN #1 stated to her, silly me, I should have assessed her (the resident) earlier. After the ambulance crew left at approximately 9:30 AM, she called the Director of Nursing and told her what happened. During an interview on [DATE] at 8:20 AM, Certified Nurse Aide (CNA #2) stated she came on duty at 6:00 AM on [DATE] and the resident was yelling. She went to check on the resident and the resident wanted to go to the bathroom. She tried to the get the resident to sit up but the resident just flopped back onto the bed. She reported this to LPN #1 and was told the resident's vitals were fine. CNA #2 told the other nurse (LPN #2), and LPN #2 said she gave the resident an enema. The resident kept yelling out between 6:00 AM and 8:00 AM on that morning but the resident did have a habit of doing that. CNA #2 and CNA #3 went to check on the resident at 7:20 AM and that the resident's breathing was shallow. CNA #2 went to get the agency nurse who was on duty that morning. The agency nurse took the resident's vitals and that the resident left on an ambulance. During an interview on [DATE] at 8:30 AM, CNA #3 stated she had worked the 2:00 PM shift to 10:00 PM shift on [DATE]. She helped put the resident to bed at approximately 10:00 PM. The resident was her usual self, yelling at people or kicking staff. When she left for the night the resident was fine. When she came on [DATE] at 6:00 AM, CNA #2 asked her for her help in getting the resident out of bed and believed it was between 7:00 AM and 7:30 AM. When she saw the resident, the resident was super pale and her cheeks were drooping. This was not normal for this resident. She went and got LPN #2. The nurse told her the resident was trying to have a bowel movement and to put the resident back in to bed. During an interview on [DATE] at 12:30 PM, the Director of Nursing (DON) stated she expected her RN's to do assessments on a resident with acute symptoms and to call the physician right away if the resident was having acute symptoms. If the LPN or the RN felt uncomfortable calling a Physician for whatever reason, she was always available and they could call her. The RN should not make a judgement call and that it should be up to the Physician. During an interview on [DATE] at 2:40 PM, CNA #4 stated she worked a double shift from 3:00 PM on [DATE] to 6:00 AM on [DATE]. The resident was in bed sleeping at 10:00 PM on [DATE]. At approximately 11:30 PM, the resident had vomited all over herself and her bedding. She told LPN #1 what happened, they cleaned up the resident and did a complete bed change. At approximately 2:00 AM the resident was calling out to go to the bathroom, she got her to the bathroom but the resident couldn't sit up by herself. She informed RN #1 about the resident being very weak while sitting on the toilet. At 4:00 AM, the resident had again thrown up a little, she cleaned her up and notified LPN #1. LPN #1 asked her to take the resident to the toilet. She and the other aide did not feel comfortable taking her because the resident was so weak. CNA #4 told RN #1 about the resident being weak. During an interview on [DATE] at 2:55 PM, CNA #5 stated at 10:00 PM on [DATE] the resident was in her bed. At about 12:00 midnight the resident had thrown up. CNA #5 and CNA #4 cleaned up the resident and changed the resident's bed. She let LPN #1 know about the resident vomiting. LPN #1 wanted the resident to go to the bathroom at around 2:00 AM. The resident was weak and couldn't sit up while on the toilet. She told RN #1 about the resident at approximately 2:00 AM but could not say if the RN went to see her. At 4:00 AM, the resident was pale like a sheet of paper. She voiced her concerns about the resident to RN #1 and that RN #1 needed to go and see her. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] documented the resident was mildly cognitively impaired. Review of a policy and procedure entitled Wound Documentation dated ,[DATE] revealed the RN is to assess the wound and obtain an order from the physician to treat the wound. The comprehensive care plan dated [DATE] documented the resident required the assistance of two people for toileting and personal hygiene. The resident was to be toileted every two to three hours. A Nursing Progress Note dated [DATE] documented the resident had an excoriation of the genital area. The Nursing supervisor was notified and Calasoothe (a moisture barrier ointment that helps heal irritated skin) was applied. review of the resident's medical record revealed [REDACTED]. A Nursing Progress Note dated [DATE] documented there were red, open areas noted to the resident's genital area and a new order was obtained for Calosoothe to be applied every shift and as needed. physician's orders [REDACTED]. During an interview on [DATE] at 12:30 PM, Registered Nurse (RN #2) stated that Calosoothe needed to have a physician's orders [REDACTED]. During an interview on [DATE] at 12:45 PM, Certified Nurse Aide (CNA #3) stated the resident had the skin condition for approximately three weeks and they had only been applying the Calosoothe for a week and a half. During an interview on [DATE] at 6:45 AM, RN #1 stated she was aware of the excoriated area on the resident's genitals on [DATE]. She did not notify the physician about the area and did not obtain an order to apply the Calosoothe. During an interview on [DATE] at 12:00 PM, the Director of Nursing (DON) stated she expected her staff to report the skin issues to the Physician. 415.3(e)(2)(ii)(b)

Based on observation, interview and record review conducted during a complaint investigation (complaint #NY 751) during the Standard survey completed on [DATE], the facility did not provide 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 for two (Resident #21, 140) of eighteen residents reviewed for quality of care. Specifically, Resident #140 had incomplete neurological examinations, lack of timely notification of changes in the resident's condition, and lack of timely transport to the hospital after a fall with a head injury. The resident was not assessed by a qualified licensed professional staff member (registered nurse/ physician) prior to moving the resident, who was found on her back on the floor, and had sustained a head injury. This resulted in actual harm that is not immediate jeopardy for Resident #140. In addition, Resident #21's wishes for Comfort Care (conservative, supportive measures to prevent the spread of infection) were not honored in accordance with her care plan and pain medication was not administered according to physician's orders [REDACTED]. The findings are: 1. Resident #140 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated [DATE] revealed the resident had severe cognitive impairment with long and short term memory problems, was rarely understood and rarely understands. Review of a Fall Assessment Tool revealed an assessment performed on [DATE] indicated that Resident #140 was identified at high risk for falls. Review of the Long Term Resident Plan of Care in effect on ,[DATE] revealed the resident was identified with the potential for falls with Alzheimer's dementia as a contributing factor. The Plan of Care documented that the resident ambulates independently with an approach to utilize a Wanderguard (device to detect wandering) bracelet. Review of a nursing Progress Note, written by a licensed practical nurse (LPN #1), dated [DATE] at 9:00 PM revealed the resident was found on the floor in the dining room laying flat on her back and had a purple (not raised) bruise on the back of her head. The LPN documented that the LPN Supervisor assessed the resident and a Head Injury Report and the 48 Hour Fall Protocol was initiated. The LPN also documented that the physician was notified via fax about the fall and the resident's responsible party was notified. LPN #1 documented that the resident's range of motion (ROM) was within normal limits (WNL) and vital signs, including temperature, pulse, respirations and blood pressure were normal. Review of Fax Report to the Physician dated [DATE] at 9:12 PM revealed the "Problem" communicated to the physician was "resident found on floor, laying flat on back. Purple bruise on back of head (not raised). Head Injury Report and 48 Fall Monitor initiated. Additional review of the Fax Report revealed orders were faxed back to the facility on [DATE] at 10:17 AM. The PA replied in response to the fall with a head injury "Neuro checks every four hours. If complaints contact office." Review of an unsigned Head Injury Report dated [DATE] revealed that the resident's vital signs, including blood pressure, pulse, and respiratory rate were checked at four untimed intervals with no documentation of the resident's pupil reaction to light due to "ref" (resident refused). The fourth untimed entry documented that the resident complained of discomfort when the back of her head was touched and that she had a large amount of emesis (vomiting). Interview with LPN #1 on [DATE] at 3:15 PM revealed that assessments began after the resident fell and the emesis occurred at approximately 9:50 PM. The LPN stated she did not notify a registered nurse (RN) or the physician of the resident's emesis. Additional review of the Head Injury Report revealed at 11:15 PM on [DATE], the resident's "pupils were slow to react to light" and a "bruise remains back of head". Review of the Head Injury Report, nursing Progress Notes and the 24 Hour Nursing Unit Report dated [DATE] revealed no documented evidence that an RN or Physician was notified that the resident's pupils were slow to react. Additional review of the Head Injury Report revealed the following: - On [DATE] at 12:15 AM, the resident had a blood pressure of ,[DATE] (high blood pressure), pulse of 74 (average 80) and a respiratory rate of 18 (normal 12 to 20). The resident's pupils were "slow to react to light" and unsigned "Remarks" documented that the resident's pulse oximetry (measurement of oxygen in the blood) was "75" (normal 90 to 100 percent) on room air and oxygen was applied at 3 liters per minute (LPM) via nasal cannula (plastic tubing to deliver oxygen through the nose). The "Remarks" section documented that the resident had a moderate amount of watery yellow emesis. - At 1:15 AM, the resident had a blood pressure of ,[DATE], pupils were slow to react to light and "upper extremities (were) flaccid". - At 2:15 AM, the resident had a blood pressure of ,[DATE], pulse of 76, respirations of 20 and pupils were slow to react to light. Review of a Progress Note, written on the back of a SBAR (situation/ background/ assessment request) form by LPN #2, dated [DATE] at 2:20 AM revealed a call was placed to the Physician at 12:30 AM to update him regarding the resident's condition and at 2:20 AM, the Nurse Practitioner returned the call. Additional review of a SBAR nursing Progress Note, written by LPN #2, dated [DATE] at 2:20 AM revealed the resident fell at 8:15 PM during the 2:00 PM to 10:00 PM shift. The LPN documented that the resident was placed on the Head Injury Protocol and the 2:00 PM to 10:00 PM Nurse communicated that the resident had emesis. LPN #2 documented that the resident had moderate amount of watery yellow emesis at 12:15 AM, with a blood pressure of ,[DATE], a pulse of 80, respirations of 22 and the pulse oximetry of 77% on room air. Oxygen was applied at 3 LPM via nasal cannula and the pulse oximetry level increased to ,[DATE]%. The Supervisor checked the resident's lungs, rales (crackly lung sounds) were noted on the left, the resident's upper extremities were flaccid and a call was placed to the physician to update him on the resident's condition at 12:30 AM. There was no documented evidence that the Physician and/or Nurse Practitioner (NP) called back until 2:20 AM, when the NP called with new orders to transfer the resident to the hospital. Review of nursing Progress Notes, 24 Hour Nursing Unit Reports, and the Head Injury Report dated [DATE] to [DATE] revealed no documented evidence that additional attempts were made to contact the physician from 12:30 PM to 2:20 AM. Review of an ambulance "Run" sheet dated [DATE] revealed emergency medical personnel arrived at 3:02 AM and the resident was found in bed unresponsive and in "obvious respiratory distress." The Run Sheet documented that the resident had audible rales in both lungs. Review of the Emergency Department Triage form dated [DATE] at 3:30 AM revealed the resident was transferred directly to CT (CAT Scan - computerized topography - specialized x-ray exam) and the resident's pupils were fixed (unreactive to light). Review of the Emergency Physician Record dated [DATE] revealed the resident expired at 4:23 AM with a skull fracture and bilateral subarachnoid hemorrhages (bleeding in the brain). Interview with the 2:00 PM to 10:00 PM shift LPN (LPN #1) on the Dementia Unit on [DATE] at 3:15 PM revealed she was notified of the resident's fall in the dining room by the CNA. The LPN stated that the resident was capable of self ambulation and she was found on the floor with a red area on the back of her head. The LPN called for the LPN Supervisor, who checked the resident's ROM, and both nurses checked the resident's vital signs. LPN #1 stated she did not check the resident's pupil reaction to light because the resident had a habit of closing her eyes when she wanted to ignore you. After the LPN Supervisor assessed the resident, the LPNs transferred the resident to a wheelchair and transported her to her room, where she was toileted and then ambulated to bed. The LPN stated that residents who fall cannot be moved until they are assessed by the Nursing Supervisor and the LPN Nursing Supervisor made the decision to transfer Resident #140 off the floor on [DATE]. After the resident was in bed, LPN #1 stated she started the Head Injury Protocol. The LPN stated that the resident vomited at around 9:50 PM and she informed the LPN Supervisor who told her to inform the next shift. The LPN said when the resident vomited, the physician had already been notified and she did not relay this information to the Physician or anyone other than the LPN Supervisor and the 10:00 PM to 6:00 AM LPN on duty. The LPN recalled that the resident's vital signs were "okay". The LPN stated she did not call an RN because it is their practice to call the supervisor on duty. Interview with the LPN Supervisor on [DATE] at approximately 6:00 AM revealed she worked from 6:00 PM on [DATE] to 6:00 AM on [DATE] as the Supervisor for the building and also as the Medication Nurse for the "Villages" (three Resident Care Units). The LPN Supervisor stated she didn't see anything wrong with the resident after she fell , other than her head bruise which did not have an open area, lacerations or hematoma (collection of blood under the skin). The LPN Supervisor stated she gathered information, she didn't see anything unusual and she directed LPN #1 to continue to monitor the resident. The LPN Supervisor stated that she was told the resident did not hit her head. The LPN Supervisor stated that she started the 48 hour Fall Protocol because the resident fell and she instructed the nurse on the unit to call the doctor because "she was on the medication cart for the Villages." The LPN Supervisor explained that it wasn't until the LPN called her, "perhaps sometime before midnight," that she learned that Resident #140 had emesis. The LPN Supervisor stated she never looked at the Head Injury Report documentation; and she received all of her information verbally from the LPN's on duty. Sometime after midnight she went over to the resident's unit because of some "change," the physician was called, and she could not recall any further specific details. The LPN Supervisor recalled that they put oxygen on the resident and she listened to the resident's lungs. The LPN Supervisor stated the physician was called and she believes they called back within 15 minutes. When asked about the lack of initially checking the residents pupil reaction, the LPN Supervisor stated if the resident refused that would be "okay." When questioned about the sluggish pupil response, the LPN Supervisor stated she didn't know the resident's baseline and it could be normal. The LPN Supervisor stated she did not call the RN on duty because it is their practice to call the medical provider on call. During an interview on [DATE] at approximately 6:15 AM, LPN #2 who worked from 10:00 PM on [DATE] to 6:00 AM on [DATE], stated that when she came into work, LPN #1 told her that Resident #140 fell and hit her head and the Head Injury Report was initiated. LPN #2 stated that the 2:00 PM to 10:00 PM shift LPN informed her the resident had emesis and that the physician and responsible party was notified. The LPN stated the resident's vital signs were all stable and initially she did not check the resident's pupil response to light. The LPN stated she became concerned because the resident had another episode of emesis. LPN #2 stated that she called the LPN Supervisor who told her to put oxygen on the resident and her pulse oximetry level improved, her vitals were okay and her pupils were sluggish but responsive. During the interview, the LPN read her Progress Report and stated that the call was placed to the physician's answering service at 12:30 AM due the resident's change in condition at 12:15 AM, however the Nurse Practitioner called back after 2:00 AM. She recalled that Nurse Practitioner asked if the resident aspirated and ultimately decided to send the resident to the hospital. The LPN stated she did not call the RN because it is their practice to call the Supervisor on duty. During an interview on [DATE] at 9:00 AM, the Medical Director (the Resident's Physician) stated he could not recall how or when he was notified about the resident's fall with injury, he just knows he was notified about the event. The Medical Director did not recall having any conversation with the DON about the event. The Medical Director stated that a resident with a head injury usually receives physician orders [REDACTED]. The Medical Director stated that vomiting, low oxygen levels and sluggish pupil response are all clinically significant changes which would warrant timely physician notification for a resident with a recent/new head injury. Interview with the DON on [DATE] at approximately 10:51 AM revealed she was not notified about Resident #140's fall until [DATE] in morning report. The DON stated that she is on-call Monday through Friday every week unless she is on vacation, and she shares call every other week-end with the RN Assistant DON (ADON). The DON stated that neither she or the ADON was informed about the resident's fall until morning report on [DATE]. When questioned about the resident's low oxygen level and the delivery of oxygen, the DON stated it is part of emergency care and an order can be obtained afterward if needed. The DON stated when she performed her investigation, she reviewed the documentation; however, she did not interview the LPN's involved with the resident's care. Interview with the RN ADON on [DATE] at approximately 11:10 AM revealed she recalled speaking to the nurses and telling them that anytime something like this happens, the RN on call should be notified. 2. Resident #21 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment, usually understands and is sometimes understood. The MDS documented that the resident is totally dependent on staff for dressing, and requires extensive staff assistance for bed mobility, transfer, ambulation in room, toilet use, and personal hygiene. The MDS also documented that the resident receives scheduled to be administered daily and as-needed pain medication. Review of the Long Term Resident Plan of Care initiated on [DATE] identified the following problems: - Comfort Care initiated [DATE] with planned approaches to encourage the resident to talk openly of death, emotional & spiritual support, calm, tranquil environment, allow resident to stay in bed per their request, if reasonable, liberalized diet as much as possible, discontinue weight monitoring, evaluate for pain and offer medications as needed. - Pain/discomfort with contributing factors related to DJD, pubic fracture, status [REDACTED]. Review of the physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation on [DATE] at approximately 7:40 AM revealed two certified nurse aides(CNAs #1, 2) provided morning care for the resident. CNA #1 began washing the resident's face and the resident requested that the care be "put off until tomorrow." The CNA replied "I wish I could" and continued to wash the resident's under arms and torso. The resident stated "ah, ahhh just leave me alone for a little bit" and the CNA was observed to continue to wash the resident's upper torso. The resident stated "please let it go today" and the CNA instructed her to roll over. While she was performing that task, the resident said "let it go, can I just stay in bed?" While the CNA was washing her back the resident continued to moan "ah, ah, ah, ah, ah, ah, ah, ah, ah, ah, ahhhh, ah, ah, ahh, ahh, ha, ahh." The CNA then stated that the resident was "doing better today than usual, usually she's kicking up a storm." The resident was positioned on her back while CNA #1 performed pericare and the resident was incontinent of a moderate amount of brown stool. When the resident was turned on her side to provide fecal incontinence care, she moaned and when the care was over, said "can I have a little extra sleep?" The CNA then dressed the resident in a shirt and the resident stated "oh, oh, oh oh my God, ah, ah, ah, let me sleep the rest of the day away." The CNAs were observed to roll the resident from side to side to put her pants on and the resident moaned continually. Once morning care was done, the resident stopped moaning. The CNAs then sat the resident on the side of the bed in order to transfer the resident to a wheelchair with the resident continually moaning. The CNAs performed a stand, pivot transfer with the use of a gait belt and the resident continued to moan until the transfer was done. After transferring the resident, CNA #1 stated that the family wants the resident out of bed for breakfast. During the observation of care, the CNA did not attempt to notify a nurse of the resident's discomfort. Review of the MAR indicated [REDACTED]. Additional review of the ,[DATE] MAR indicated [REDACTED]. The 11:00 PM doses were circled indicating they were not administered/ however there was no documentation on the MAR indicated [REDACTED] During an observation on [DATE] at 7:00 AM, CNA #1 provided morning care to Resident #21. During hands on care, the resident moaned when the CNA positioned and dressed the resident. The resident did not verbalize a refusal of care. After CNAs #1 and #3 transferred the resident from the bed to the wheelchair with a gait belt, the resident gave out a loud groan and stated "why do you keep doing this to me?" The resident was unstable on her feet and the two CNA's after instructing the resident to take a step without success, half lifted and pivoted the resident into the wheelchair. The resident then stated "it's a hard thing for me to bear." Interview with an LPN Medication Nurse on [DATE] at 7:15 AM revealed she worked on [DATE]. Review of the MAR indicated [REDACTED]. The LPN stated occasionally the night nurse does not wake the resident up to give her pain medication. On [DATE], the resident got her scheduled [MEDICATION NAME] at 7:00 AM The LPN stated the CNA did not report anything "out of the ordinary" regarding the resident on [DATE] and stated she is one to holler out and refuse care a lot and the CNA's are told to reproach her. When questioned if the resident should stay in bed if that is her wish, the LPN replied that the daughter wants her out of bed and yesterday she reviewed the resident's medications with the daughter and the RN Unit Manager. The family stated at home they had previously used "a couple of extra strength Tylenol" to control the resident's DJD pain/discomfort. Interview with CNA #1 on [DATE] at approximately 6:40 AM revealed she provides resident care in accordance with decisions made by nursing and the family and that is why she got Resident #21 out of bed on [DATE]. The CNA stated that she does not know when the resident gets her pain medication and she has not asked the nurse about this prior to providing morning care. Interview with the RN Unit Manager on [DATE] at approximately 6:45 AM revealed that Resident #21 has pain all over due to DJD. The RN stated that the resident has scheduled pain medication and as needed pain medication. The RN stated that the resident is particularly stiff in the morning when she wakes up. The RN Unit Manager stated it is not okay for a nurse to not administer scheduled pain medication because a resident is sleeping, and the resident should be woken up to administer it. The RN recalled that the resident's family told her last week about the Tylenol she received at home; however, she had not acted on the information because she believed the resident's current pain regimen was effective. A Review of the MAR indicated [REDACTED]. 415.12