Every finding on record at The Wartburg Home

Based on observation and interviews conducted during the recertification survey from 7/22/25 to 7/28/25, the facility did not ensure food was stored, prepared, and distributed in sanitary conditions in accordance with professional standards for food service safety. Specifically, there were unlabeled and undated food items in the kitchen, storeroom, and unit pantry, there was expired foods in the kitchen, storeroom, and unit pantry, there was a cell phone on the food prep area, dietary staff did not wear proper hair and beard restraints, there were boxes stored on the floor, there was personal staff item in kitchen food prep area and there were poor sanitary conditions in unit pantries. Findings include: The facility policy Food and Supply Storage, last revised 1/2025 included documentation that food past the use by date or expiration date should be discarded; opened packages should be covered, labeled and dated; and items should be stored at least 6' above the floor and 18' below sprinklers. The facility policy Uniform Dress Code, last revised 1/2025 included documentation that associates working with food are expected to wear the approved hair restraint when on duty regardless of length or presence of hair and to restrain all facial hair with a beard net. The facility policy Use and Storage of Food Brought to Residents from the Outside last revised 1/2025 included documentation that care is taken ensure food is handled properly for safe and sanitary storage and consumption. The facility policy Area and Equipment Cleaning last revised 1/2025 included documentation of assignment of daily cleaning responsibilities of each position workflow. During kitchen observation and interview conducted on 7/22/25 at 9:35 AM, the following items were observed: in the kitchen there was undated roasted garlic Caesar dressing, undated swiss cheese, sliced pork and deli ham with an expiration date of 7/21/25, undated parmesan cheese (block) with visible mold, container of liquid, labeled as salad, dated 7/6/25 with no expiration date (the Food Service Director stated the item was salad dressing) and an undated container of chopped garlic. In the freezer there was undated lasagna with no identifying label, and peach cobbler with an expiration date of 7/12/25. In dry storage there was Thick- it in an unsealed plastic bag, and raisins with a 7/12/25 expiration date. In the food prep area, there were approximately 10 slices of cooked bacon on a paper plate, wrapped in plastic, unlabeled/undated and unknown food in a 1/3 pan covered in plastic, unlabeled, and undated (the Food Service Director stated they were unable to identify the food). In the emergency food supply, there was 1 case of dry milk powder with a 3/6/23 expiration date, Hershey's Chocolate Syrup with a 7/2024 expiration date, and 16 five-gallon bottles of water with a 12/31/23 expiration date. On the floor there were four boxes with a delivery date of 6/3/25, a large bucket of dish detergent, and chemicals on the floor under the shelving. The Food Service Director stated the chemicals had been there since before 11/2024. There were 13 boxes stacked less than 6 from the ceiling. During an interview at this time, the Food Service Director stated a storeroom diet aide works twice a week to rotate stock, label, date, and dispose of expired items, and they should have removed expired food and water and moved boxes off the floor and away from the ceiling. During observation on 7/22/25 at 11:06 AM, a personal cell phone was observed on the prep counter. At that time, the Food Service Director stated they did not know who the cell phone belonged to and that it should not have been in the food prep area, Dietary [NAME] #5 and Dietary Aide #14 stated it was not their cell phone. Dietary [NAME] #5 was observed with a beard approximately half an inch long and not wearing a beard restraint. Dietary Aide #14 was observed not wearing a hair net. Both stated they had just arrived in the kitchen and did not put on them on yet. Dietary [NAME] #5 stated their beard wasn't long enough to require a hair restraint. During an observation of Unit 2 North pantry and interview on 7/24/2025 at 11:56 AM, there was a slice of toast on the floor between the refrigerator cabinet and the half wall and a 2x 2 puddle of water that had been walked through and tracked across the floor located in the middle of the pantry floor. Dietary Aide #7 stated the housekeeping department cleans the pantries. Further observation of the items in the refrigerator included an undated peanut butter sandwich, and a resident's person lunch bag dated 7/11/25 containing an expired yogurt dated 7/11/25. Registered Nurse Assistant Unit Manager #4 stated items are dated by nursing staff on the date they are received and should be disposed of after three days by the dietary staff. During an interview with the Food Service Director on 7/24/2025 at 12:08 PM, they stated the dietary staff are responsible for sweeping the unit pantry floors and housekeeping staff are responsible for mopping the unit pantry floors. They stated it is the dietary staff responsibility to dispose of expired food items in the unit pantry refrigerators. During an interview on 7/24/2025 at 2:12 PM, the Interim Director of Environmental Services stated housekeeping staff are not responsible for providing cleaning of the unit pantries. They stated that dietary staff is responsible for cleaning all equipment, floors and refrigerators in the unit pantries. During an interview on 7/25/2025 at 12:28 PM, the Administrator stated the cleaning of unit pantries is the responsibility of the dietary staff which includes floors, refrigerators, microwaves, counters, and cabinets. There is a Duty Roster that is posted for each dietary staff to know their responsibilities. 10 NYCRR 415.14(h)

Based on observations and interviews during the recertification survey from 7/22/25 to 7/28/25, the facility did not ensure that essential kitchen equipment was maintained in safe operating condition. Specifically, dishwashers in all four-unit pantries were broken, Unit 1 South pantry food warmer, tall standing freezer, and steam table were broken, and the main kitchen dish machine did not reach proper temperature for sanitization in wash (150-165 degrees), rinse, or final rinse (180 degrees) modes. The findings are: During an observation of the Unit 1 South pantry on 7/24/25 at 12:48 PM, a puddle of water was observed by the right front leg of the food warmer and a towel was observed inside the bottom of the upper door frame. Dietary Aide #8 stated the food warmer was broken and leaking water. They also stated the steam table was not working and they were using the hot box to keep food warm, the tall freezer was broken, and the dishwasher was broken. They stated they had verbally told the supervisor about the broken equipment weeks ago, which was the procedure they used to inform the supervisor. There was no documented evidence of communication regarding repairs for the pantries on the units. There was no documented evidence of work orders related to the broken equipment in the pantries on the units. During an interview on 7/25/25 at 11:46 AM, the Food Service Director stated they were aware of the broken equipment on the units. They stated some equipment was broken before they were employed and they had decided not to send repair requests for those items. They stated the procedure for broken unit dishwashers was to send the dishes to the main dish machine in the kitchen for washing. The Food Service Director stated they were aware of a broken refrigerator on a unit but had decided not to repair because there was other refrigeration available. They stated the broken steamtable on Unit 1 South had been evaluated for repair by an outside company with proof of estimate on 6/12/25, but the Food Service Director stated they did not feel it was a priority to repair. During an interview on 7/25/25 at 12:28 PM, the Administrator stated they were not made aware of any broken equipment in the pantries until the evening of 7/23/25 when they were informed of the broken steamtable in the Unit 1 South pantry. They stated there are regular scheduled environmental rounds to identify equipment that would need repaired. They stated if repairs cannot be done onsite, an outside company should be consulted for a proposal. During an interview on 7/28/25 at 12:00 PM, Dietary Aide #11 confirmed the procedure for reporting broken equipment is to verbally report to dietary supervisor. During an observation of the main kitchen dish machine with the Food Service Director on 7/25/25 at 1:17 PM the wash cycle displayed temperature of 124 degrees, rinse cycle displayed E and final rinse cycle displayed temperature of 94 degrees. During that time, the Food Service Director stated they were unable to explain what the E on the rinse cycle was referring to, and why the temperatures were below 150-165 degrees for wash and 180 degrees for final rinse cycle. They stated they will contact the Director of Facilities for assessment and repair. During an interview on 7/28/25 at 8:59 AM, the Food Service Director stated the main kitchen dish machine is out of order due to a computer board malfunction as of 7/25/25 afternoon and the facility had been using paper products for dining all weekend. 10 NYCRR 415.5(e)(1)(2)

Based on observation, record review and interviews during the recertification survey from 7/22/25-7/28/25, the facility did not ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice for one of one resident (Resident #7) reviewed for respiratory care. Specifically, Resident #7 was receiving oxygen via nasal canula tubing which was observed in the resident's mouth instead of in the resident's nostrils.The findings are:The Policy and Procedure titled Respiratory Care last revised 6/25/2021, documented each resident's respiratory function shall be maintained and optimized to the fullest extent possible. Nurses and certified nurse aides were responsible to monitor nasal cannula, BIPAP, CPAP (or any other respiratory device) placement and condition each shift.Resident #7 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, heart failure, and non-Alzheimer's dementia. The 7/3/25 Physician's Orders documented continuous oxygen at 2 liters per minute via nasal canula.The 7/14/25 Minimum Data Set (resident assessment tool) documented Resident #7 had severely impaired cognition, was dependent on staff with all functional abilities and had shortness of breath when sitting, at rest, or lying flat. During observation on 7/23/25 at 9:43 AM and 12:31 PM Resident #7 was in their bed, awake, with the nasal canula prongs observed in the resident's mouth. During an interview on 7/25/25 at 1:17 PM, Certified Nurse Aide #2 stated they provided assistance to Resident #7 with all activities of daily living and stated Resident #7 required total care. Certified Nurse Aide #2 stated they should check for the correct placement of the nasal canula after all cares were provided. Certified Nurse Aide #2 stated they were responsible for monitoring placement of the nasal canula throughout their shift and should report concerns to the nurse. Certified Nurse Aide #2 stated they were not aware that the resident's nasal cannula had been in the resident's mouth. During an interview on 7/25/25 at 1:26 PM, Licensed Practical Nurse #3 stated they were responsible for Resident #7. Licensed Practical Nurse #3 stated they were responsible for monitoring the nasal canula and oxygen administration for all residents on their assignment to ensure oxygen was administered per the physician's orders. They stated they had not noticed the nasal canula had not been inserted into Resident #7's nostrils on 7/23/25. 10 NYCRR 415.12(k) (6)

Based on observation, record review and interviews conducted during the 7/22/25-7/28/25 recertification survey, the facility did not ensure that all medications were secured in a locked storage area. Specifically, Symbicort (budesonide-formoterol) aerosol inhaler was observed on Resident #35's room table, not under direct supervision of authorized staff. The findings are:The undated Policy and Procedure titled Storage of Medications documented only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. The undated Policy and Procedure (P&P) titled Self-Administration of Medications documented those residents deemed capable, and who desire to self-administer their medications, will be permitted to do so, after appropriate counseling and with the specific order of the resident's physician.Resident #35 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease, diabetes mellitus, and heart failure. The 7/15/25 Physician's Order documented Budesonide 0.25mg/2ml suspension for nebulization. Inhale 2 ml (0.25mg) by nebulizer 2 times per day.The Minimum Data Set (resident assessment tool) dated 7/20/25 documented the resident was cognitively intact.During observations on 7/22/25 at 12:24 PM and on 7/23/25 at 12:58 PM, Resident #35 was sitting in their room. Symbicort (Budesonide-formoterol) 80-4.5mcg/ACT Aerosol inhaler was observed on the resident's table. The resident stated the nurse brought them the Symbicort inhaler and stated they could self-administer the medication. The resident stated they did not remember the nurse's name. The resident stated they knew to self-administer the medication. The resident stated that every day, later in the day, the nurse came and picked up the medication. During an interview on 7/25/25 at 9:58 AM Licensed Practical Nurse #3 stated they did not know any residents on the second floor who would be capable and desired to self-administer their medications. The nurse stated the facility had a policy that residents were not allowed to keep their own medications in their rooms. If any residents admitted to the facility brought their own medications, the responsibility of the nurses was to ask the residents to give the medications to the nurse. The nurse would label and keep the medications in the medication cart. Licensed Practical Nurse #3 opened the medication cart and showed Resident #35's medications for respiratory care. The nurse opened the July 2025 Medication Administration Record for Resident #35 and showed the medications the resident was currently taking. At that time, the surveyor showed the nurse the picture of Resident #35's Symbicort inhalation aerosol medication that had been observed on 7/22/25 and 7/23/25. The nurse stated they had not seen that medication before in Resident #35's room. During an interview on 7/25/25 at 10:28 AM, the Director of Nursing stated that residents cannot keep any medications in their rooms. The Director of Nursing stated any resident who believed they were capable and desired to self-administer their medications would be permitted to do so after appropriate assessment/return demonstration, and a physician order was obtained. The Director of Nursing stated currently they did not know any resident in the facility who was allowed to self-administer their medications. They stated that it was the nurse's responsibility to inform residents and ask if they had any medications in their rooms. During an interview on 7/25/25 at 10:46 AM, Registered Nurse # 4 stated they were the admitting nurse for Resident #35. They stated residents cannot have any medications in their room. They stated that they were responsible for asking if the resident had their own medications. Registered Nurse stated they were not aware the resident had their own medications. During an interview on 7/25/25 at 3:28 PM, Certified Nurse Aide #2 stated they helped Resident #35 with personal care during the day. The Certified Nurse Aide stated they did not see any medications in Resident #35's room and was unaware that Resident #35 was taking any medications by themselves. NY CRR 415.18 (e) [1-4]

Based on record review, and interviews conducted during an abbreviated survey (NY00327590), the facility did not ensure prompt efforts were made to resolve a resident's grievance. Specifically, Resident #1's Family Representative (FR) complained to the facility on [DATE] regarding incontinence care and bathroom ambulation needs not being rendered. There was no evidence that a grievance form was initiated and completed in accordance with the facility policy and there was no documented evidence that the complaints were addressed. The findings are: A review of the facility's grievance policy, titled Grievance Policy, dated 8/16/2017 stated each resident has the right to voice grievance. Such grievances include those with respect to care and treatment which has been furnished, as well as that which has not been furnished, the behavior of staff, and other concerns regarding their Long-Term Care (LTC) facility stay. The voice grievance is not limited to formal, written but may include a resident's verbal complaint to a staff. The grievance official (identified as the administrator on interview) is responsible for overseeing the grievance process, leading any necessary investigation, tracking grievance through their conclusions, and notifying the resident/family of the outcome. The facility will provide information about procedures to file a grievance during admission, readmission, and the care planning process. Resident # 1 had diagnoses that included stroke, traumatic brain injury, primary generalized arthritis, osteoporosis. The Admission Minimum Data Set (MDS, an assessment tool) dated 10/24/2023 documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 12 denoting moderate cognitive impairment. No documented issues with mood; occasional incontinence of the bowel and bladder. Activities of Daily Living (ADL) needs partial assistance for mobility and toileting, and dependent care (the helper does all the work) for personal hygiene, bathing and dressing. Review of the facility nursing progress note dated 11/4/2023 by Staff #4(Licensed Practical Nurse) at 3:03 PM documented the Resident #1's Family Representative (FR) at approximately 1:10 p.m. confronted Staff #4 and asked if Resident #1 was showered and why the resident was being told by Staff #2 to urinate in their diaper. Staff #4 documented the FR referred to the staff members (Staff # 2 and Staff #4) by an offensive name. FR informed Staff #4 that they do not want Staff #2 to care for their mother again. Staff # 4 documented the incident and referred the incident to Staff #7 (Director of Nursing (DON) and nurse manager. During an interview conducted with Staff #5(Social Worker) on 01/10/2024 at 1:45 pm, Staff #5 stated there was no grievance or complaint filed for Resident #1 despite the FR verbalizing concern about toileting and incontinent care which was also mentioned during the care plan meeting on 11/07/2023. The FR complaint was not documented in the care plan notes. Staff #5 stated the grievance complaint procedure is posted in the facility, and the FR was also a Social Worker. During an interview conducted with the Administrator on 1/10/2024 at 4:09 pm, the administrator stated verbal complaints should be written down or emailed. If Staff #5 received a complaint and informed Staff #7(Director of Nursing), they should have completed a grievance form or Staff # 7 should have asked Staff #5 to complete one. Once the form is completed, the complaint will be investigated by the Staff #5 and administration. During an interview conducted with the Staff #7(Director of Nursing) on 01/16/1024 at 10:55 am, Staff #7 stated they did not file a grievance because the problem was addressed immediately and did not need a grievance because there was no harm. During an interview with the FR on 01/16/2024 at 1:37 p.m., FR stated no one told them about the grievance process, and they were not aware of the grievance information posted. Staff #7 told them the concerns would be addressed with reeducation; no other information was provided to them. 10NYCRR 415.3(d)(1)(ii)

Based on record reviews and interviews during the recertification and abbreviated surveys (NY00306039) 6/13/23 to 6/20/23, the facility did not ensure that residents or resident's representatives were notified in writing of the facility Bed Hold Policy for 4 of 5 residents reviewed for hospitalization . Specifically, Residents #257, #103, #74, and #97. were transferred to the hospital and the facility did not provide evidence that a written notice of the facility Bed Hold Policy was given to the residents or representatives. Findings include: The facility Policy and Procedure, titled Bed Hold and Return to Facility, revised 6/1/19, documented the facility would provide written information about the bed hold duration and payment amount before transfer to the hospital or therapeutic leave. 1. Resident #257 was readmitted to the facility with diagnoses including left femur fracture, fall, and post procedural pain. The 4/15/22 Significant Change Minimum Data Set (MDS, an assessment tool) documented the resident had severe cognitive impairment. The Hospital Transfer sheet dated 10/13/22 documented the resident was transferred to the hospital on 10/12/22. 2. Resident #103 was readmitted [DATE] to the facility with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and dementia. The 4/16/23 MDS 5-day assessment documented the resident had severe cognitive impairment. The 4/17/23 nursing progress note documented Resident # 106 was hospitalized on [DATE]. 3. Resident #74 was admitted with diagnoses including dysphagia, hypertension and peptic ulcer disease. The 5/8/23 MDS documented severely impaired cognition. The 4/27/23 physician note documented Resident # 74 was discharged to the hospital for evaluation of cough and fever. During an interview with Administrator on 6/15/23 at 3:30 PM, the Administrator stated that Notice of Bed Hold Policy for R #257, #106, #74 and #97 was not being given to residents or resident representative at the time of transfer/discharge to the hospital. During an interview with Admissions Director on 06/16/23 at 9:45 AM, the Admissions Director stated they do not give the notice of bed hold policy, they use to, but stopped when the requirement to hold a bed stopped. If they are private pay they will call and ask family if they want to pay for the bed. If they are Medicaid they will hold the beds without asking for payment. 415.3 (h) (4) (i) (a) 41666 44673

Based on record reviews and interviews conducted during a recertification survey 6/13/2023-6/20/2023, the facility did not ensure that the certified nurse aides (CNA) were provided the required 12 hours of training and annual in-service on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 8 out of 10 CNAs (CNA #1, 2, 3, 4, 5, 6, 7, and 8), reviewed for Nurse Aide training, were provided 12 hours of mandatory training. The findings are: Review of the facility CNA annual in-service training records revealed: - CNA #1 and #4 lacked 11 of the 12 hours of mandatory training. - CNA #2, #7 and #8 lacked 10 of the 12 hours of mandatory training. - CNA #3 and #5 lacked 12 hours of mandatory training including resident abuse prevention and dementia care management. - CNA #6 lacked 10.5 hours of mandatory training. During an interview on 6/20/2023 at 2:15PM, the Nurse Educator stated they were new in their role and could not find the old nurse educator documentation. During an interview on 6/20/2023 at 2:00 PM, the Director of Nursing (DON) stated they were new and were working on in-servicing the staff and updating the records. During an interview on 6/20/2023 at 2:10 PM the Administrator stated they knew they were not compliant with the CNA mandatory training. 415.26

Based on interview and record review during a recertification survey conducted 6/13/23-6/20/23, the facility did not ensure that baseline care plans were initiated for 2 of 5 residents reviewed for unnecessary medications. Specifically, Residents #46 and 17 were prescribed anticoagulation medications by the physician, and there were no care plans initiated within 48 hours of admission. The findings are: The Policy and Procedure titled Baseline Care Plan Policy revised 11/28/2017 documented the facility will develop and implement a baseline care plan within 48 hours of admission which provides instructions for care of the resident, increases resident safety, and safeguards against adverse effects. 1. Resident #46 was admitted on [DATE] with diagnoses including orthopedic aftercare, lung cancer and acute embolism/deep vein thrombosis in the lower extremity, The 6/3/23 Admission Minimum Data Set (MDS, a resident assessment tool) documented the resident received anticoagulant medication for the past 7 days. The 5/27/23 physician's order documented Enoxaparin (a blood thinner) 30 milligrams (mg)/0.3 millileter (ml) by subcutaneous syringe every 12 hours for acute embolism and deep vein thromosis of the distal lower extremity. There was no documented evidence in the 5/27/23 baseline care plan to address the risk of bleeding and/or use of anticoagulants. During an interview on 6/20/2023 at 12:45 PM Registered Nurse Unit Manager (RNUM) #2 stated there was no such care plan documented. RNUM #2 stated the registered nurse who completed the resident's admission assessment was responsible for addressing all minimum health care information to properly care for the immediate needs of the residents. RNUM #2 stated a care plan should have been initiated to address the resident's risk of bleeding on the prescribed anticoagulant medication. 2. Resident #17 was admitted to facility on 2/16/23 with diagnoses including hip fracture, hypertension, and diabetes. TheQuarterly Minimum Data Set (MDS) dated [DATE] documented the resident received anticoagulant medication for the past 7 days. The admission physician's order dated 2/16/23 documented Eliquis (a blood thinner) 5 mg, give 1 tablet by oral route 2 times a day, for hypertension. There was no documented evidence in the undated baseline care plan to address the use of anticoagulants. During an interview on 6/20/23 at 12:24 PM Registered Nurse Unit Manager (RNUM) #2 stated the registered nurse supervisors are responsible for auditing the charts to ensure care plans are completed. RNUM #2 stated they did not know why the baseline care plan did not include the use of anticoagulants. During an interview on 6/20/2023 at 1:15 PM, the Director of Nursing (DON) stated that baseline care plans should be completed on or shortly after admission either by the admissions nurse or by the registered nurse on the next shift. The DON stated that care plans should be created within 48 hours with all minimum health care information to properly care for the immediate needs of the residents, including risk of bleeding for residents on blood thinners. 415.11 (c) 45478

Based on record review and interview during a recertification survey conducted 6/13/23-6/20/23, the facility did not ensure that 1 of 3 residents (#17), reviewed for pressure ulcer, was provided the appropriate care to prevent the development of a pressure ulcer. Specifically, there were no physician ordered skin checks/monitoring for Resident # 17 with a left knee immobilizer and the resident developed a pressure ulcer. The findings are: The policy and procedure titled Pressure Ulcer Prevention revised 12/29/22 documented it is the policy that all residents shall be provided with consistent, comprehensive, interdisciplinary care focused on the prevention of pressure ulcers. Resident #17 had diagnoses including diabetes, hip fracture, and unspecified fracture to lower end of left femur. The 2/16/23 hospital transfer summary documented Resident #17 was non weight bearing to the left lower leg and wore a knee immobilizer. The 2/17/23 physical therapy (PT) evaluation documented the resident was admitted after a fall at home. It further documented resident was non weight bearing to left lower extremity. As per discharge instructions the resident was to wear the knee immobilizer when out of bed for the next 6 weeks. The immobilizer was not necessary during hygiene, skin checks and when the patient was asleep. The 5/16/23 nursing note documented, during activities of daily living (ADL) care the assigned certified nurse aide (CNA) showed the nurse the resident's left leg ecchymotic area noted under the left knee and under the ankle. The Nurse Manager was notified for further evaluation. The 5/16/23 incident report documented the resident was informed only to remove immobilizer when showering. The 5/17/23 nursing note (late entry) documented an accident/incident. The resident was noted with multiple ecchymotic areas to the left lower extremity (LLE) (left popliteal, left inner ankle, left heel). The physician was on the unit and an assessment was completed with CNA and licensed practical nurse (LPN). As per resident I had my immobilizer on the entire time, I haven't ever seen that. The physician ordered a wound consult and dry protective dressing. The 5/18/23 wound note documented wound to left posterior calf was a traumatic wound and measured 6 centimeters (cm) length x 6 cm width with no measurable depth. A small amount of serous drainage was noted which had no odor. The 5/18/23 late entry pressure ulcer care plan documented the resident was seen by the wound care physician for lower leg extremity calf trauma/hematoma, that measures 6.0 cm x 6.0 cm and light serous exudate (drainage). There was no documented evidence prior to 5/22/23 for physician orders addressing the use of and care of the left knee immobilizer for Resident #17. There was no documented evidence in the EMR for a care plan addressing the use of and care of the left knee immobilizer. There was no documented evidence in the EMR addressing the residents refusal to remove the immobilizer. During an interview on 6/20/23 at 12:32 PM Registered Nurse Unit Manager (RNUM) #2 stated the resident had an immobilizer that needed to be worn and the resident was resistant to staff performing hygiene care to the residents leg. RNUM #2 was asked for notes about Resident #17 refusing to remove the immobilizer and RNUM #2 stated they were unable to produce any notes. RNUM #2 stated the resident was more comfortable and felt more secure with the brace on. RNUM #2 stated the resident's left calf wound was caused by friction from not removing the immobilizer. RNUM #2 stated there were no previous orders for the bracer immobilizer prior to 5/22/23. During an interview with certified nurse aide (CNA) #1 on 6/20/23 at 1:56 PM, CNA #1 stated the resident was admitted with the immobilizer. CNA #1 stated the resident would refuse removing the immobilizer and CNA #1 would inform the nurse when this happened. CNA #1 stated that they did not document in the CNA accountability record that the resident refused removing the immobilizer. 415.12(c)(1)(2)

Based on record review and interview conducted during an abbreviated survey (NY 270), the facility did not implement an effective discharge plan that focused on progress towards discharge goals, arrangement of post discharge care and services and reduction of factors to prevent readmissions for 1 of 3 residents reviewed for discharge planning. Specifically, the facility did not make any referrals to appropriate entities to support the resident' interest in returning to the community. Resident #1 who is legally blind did not have any services in place at the time of discharge to assist with drawing up his insulin or setting up prefilled insulin injection syringes to maintain acceptable blood glucose levels. Resident was discharged from the facility on 7/13/2022 and was readmitted to the hospital on 7/15/2022 for low blood sugars. The findings are: Review of the facility policy and procedure titled Discharge Transfer Policy dated 9/27/2002 documented the facility will ensure each discharge of a resident from the facility is planned in an organized fashion with adequate time to prepare for a safe discharge to an appropriate setting. Resident #1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS a resident assessment tool) dated 5/23/2022 revealed resident with a Brief Interview for Mental Status (BIMS) of 14, which denotes resident was cognitively intact. The MDS documented that the resident required extensive assist of one-person physical assist with bed mobility, transfers, dressing, personal hygiene, and one-person physical assist with ambulation on and off the unit. A Comprehensive Care Plan Titled Discharge Planning initiated 5/20/2022 and updated 7/13/2022 documented interventions to arrange for medical follow up and/or other post discharge services needed included to teach self-administration of oral meds self-administration of injections and fingerstick. The Medical Doctor (MD) order dated 7/07/2022 documented Blind precautions right eye, blind left eye impaired. A Social Worker progress note dated 5/23/2022 documented resident will be discharged home upon completion with necessary services. Social worker will follow up with discharge planning needs. A nursing progress note dated 6/20/2022 documented writer spoke with patient' brother and Health Care Proxy (HCP) regarding wound care. HCP directed writer to the resident who stated that he previously has a nurse who came in daily to take care of the wound. she will take care of the wound. A referral was submitted by the social worker to a Certified Home Health Aide (CHHA) agency. Review of the resident' discharge scripts submitted to CVS pharmacy on 7/13/2022 at 9:16am indicated resident was to receive injectable insulin including [MEDICATION(S)] [MEDICATION(S)] u-100 insulin, [MEDICATION(S)] 100 units/ml subcutaneous pen inject subcutaneous route 4 times a day, [MEDICATION(S)] Kwik pen u-100 insulin 100 units 3 ml subcutaneous inject 20 units by subcutaneous route once daily at bedtime. A nurse's progress note dated 7/13/2022 documented resident was discharged to the community @ 11:28am left unit in stable condition accompanied by private aide. There was no documented evidence that Resident #1 received any teaching regarding medication, fingerstick, signs and symptoms of low or high sugar levels, drawing up insulin and administering insulin subcutaneously. During an interview on 7/21/2022 at 10am, the Director of Social Work (DSW) stated the HCP who was the brother was very involved. The resident was sent home with private care arrangement and a referral to Caring people which is a service for short term rehab residents. No physical medication was given to resident and no diabetic instructions were given to resident. Resident stated they had a friend who came in daily. The DSW stated the information provided by Resident #1 was not verified. During an interview on 7/21/2022 at 1:30pm with the AmeriCares home care a Medicare service they stated the agency provides nurses to residents at home. They were contacted to provide services for the resident after discharge on 7/13/2022. An appointment was made to see Resident #1 at home on 7/14/2022 for an assessment and they tried reaching out to the resident on 7/14/2022 but was unsuccessful. On 7/15/2022 they reached out again and were informed that resident was sent to the hospital and was admitted . During a telephone interview conducted on 7/21/2022 at 1:10pm with Resident #1's HCP, the HCP stated Resident #1 was discharged with a home health aide but not a Nurse and they got no instructions about his medication, how to check his sugar, no glucometer. The HCP stated resident went to the hospital because his blood sugar was low. I never told them I had someone to check the sugars at home. The facility never asked about the injections at home. During an interview on 7/21/2022 at 1:15pm with Assistant Director of Nursing (ADON), the ADON stated it is their protocol to do teaching before the resident goes home. The Resident had wound care teaching done but not diabetic teaching. The resident did not go home with a glucometer. During an interview with the Administrator on 7/21/2022 at 11:57am, the Administrator stated the social work Dept is responsible for discharge planning and if the resident needs service the social worker is responsible for arranging the services Attempts to contact the Registered Nurse who discharged resident on 10/3/2022 was unsuccessful. 483.21(c)(1)(i)-(ix)

F609 Based on record review and interviews conducted during an Abbreviated Survey (NY 270), the Facility did not ensure that an injury of unknown origin was reported to the New York State Department of Health (NYSDOH) within the required 24-hour time frame for 1 of 3 residents (Resident #1), reviewed for injury of unknown origin. Specifically, on 1/25/2022, a Certified Nursing Assistant (CNA) reported to the Registered Nurse (RN) that Resident # 1 was observed to have mild swelling, yellowish discoloration to right thigh and the site was warm to touch. Resident #1 was confirmed by X-ray to have grossly displaced fracture of the femoral neck of right thigh that appears to be chronic. The incident was not reported to NYSDOH until 1/27/2022. The findings are: Review of the Facility Policy and Procedure titled Freedom from Abuse, Neglect, Misappropriation of Property and Exploitation dated 7/25/2005, revised 8/16/2017 documented that the purpose of the policy is to adhere to Federal and State regulations which require immediately reporting all alleged violations of Abuse, Mistreatment and Neglect including Injuries of Unknown Origin to the administrator and in accordance with state law, the Department of Health within 24 hours. Incident resulting in bodily injury reports within 2 hours. All other reportable incidents should be reported within 24 hours. DON/Administrator of designee will reportable incidents to NYSDOH. The State Agency (NYSDOH) Incident Reporting Manual dated 8/2016 documented at least one of the following elements must be present for an incident to be reportable to the NYS DOH: Abuse, Neglect, death related to an accident and/or injury of unknown origin. Resident#1 was admitted to facility 1/24/2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment tool) dated 11/19/21 documented that the resident has a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 3/15, associated with severe cognitive impairment. Resident required extensive assistance of two-person for bed mobility, total dependence of two-person assistance for transfer and toileting and requires extensive assist of one person for eating. Review of Activities of Daily Living (ADL) function/rehab/falls/pain Care Plan effective 1/25/19; documented Resident #1 required extensive assist of 1 person for eating, Extensive assist of 2 person for bed mobility, total assist of 2 persons for transfer and toileting, left neck contracture-interfere with bed mobility and transfer related to non-ambulatory, No history of fall or trauma. Assure wheelchair accessories are in place ROHO cushion. Review of the Accident/Incident Report Investigation dated 1/25/22 documented Resident was observed with mild swelling, yellowish discoloration to right thigh, site warm to touch. Resident was assessed by the nurse. Range of Motion (ROM) limited to right thigh. Denied pain. Medical Director (MD) notified and ordered X-ray and Ultrasound to rule out hematoma. Son notified. No evidence of Abuse, Neglect or Mistreatment. It appears that there was a delay in early recognition of the injury. Review of the Radiology Report dated 1/26/22 documented findings (femur-right 2 views): overall, osseous mineralization is decreased. This could reflect osteopenia, or [CONDITION(S)], in the correct clinical context, grossly displaced fracture of the right femoral neck. Age-indeterminate fracture of the femoral neck. Medical progress note dated 2/1/2022 documented that the ultrasound shows multiple hematomas. During an interview with CNA #1 on 6/9/22 at 12:42 PM, CNA #1 stated that s/he was providing care to Resident #1 on 1/25/22 during the 7AM-3PM shift. CNA#1 stated s/he reported to nurse that the resident had greenish yellowish discoloration to the right upper thigh. CNA #1 stated s/he also spoke to the Nursing Supervisor and the Director of Nursing (DON) that day. CNA #1 stated that when performing care, s/he transfers the resident via Hoyer lift with 2 people. CNA #1 stated the resident requires 2-person assist for care at all times. CNA #1 stated she never transfers resident without a second 2 person. CNA #1 stated that she never saw any marks on the right thigh prior to the date it was reported. CNA #1 stated they were informed to just be very careful with the resident. CNA #1 stated s/he was instructed to write a statement. During an interview with CNA #3 on 6/10/22 at 12:20 PM, CNA #3 stated s/he works nights and at night they make rounds, change/toilet and turn and reposition residents. CNA #3 stated s/he used extensive assist of 1 to change/toilet Resident#1. CNA #3 stated s/he uses a draw sheet to maneuver and move the resident in order to turn/reposition the resident. CNA #3 stated s/he do the changing/toileting by moving resident from one side to the other with the drawsheet and applies a clean diaper. CNA #3 stated s/he is able to perform this task alone. CNA #3 stated it was their understanding that Resident #1 was 1 person assist for toileting and s/he has always completed this task alone. After the fracture, CNA #3 stated they were informed to change/toilet resident with assist of 2 people. CNA #3 stated they never did transfers because they work the night shift and residents are in bed. CNA #3 stated after the incident, they were in-serviced to use assist of 2 people for toileting Resident #1. During an interview with Director of Nursing (DON) on 6/9/22 at 2:32 PM, DON stated that the delay in reporting to DOH was related to not being sure if it was a reportable incident and after discussion with Administrator, decided to report. DON sated it was her first week working at facility. 415.12 (h) (2)

F689 Based on record review and interview conducted during an Abbreviated Survey (NY 270), the facility did not maintain an environment as free of accident hazard as possible by ensuring Certified Nurse Assistant (CNA) follow the care guide instructions for 1 of 3 residents reviewed for injury of unknown origin. Specifically, Resident #1's plan of care noted that the resident required total dependence of two-person assist for transfer and toileting and required extensive assistance of two-person for bed mobility. On 1/25/22 Resident #1 had CNA accountability records dated 1/22/22-1/26/22 revealed that some CNAs were performing the task with one person assist and not following the care guide instructions for Resident #1. The findings are: Resident#1 was admitted to facility 1/24/2019 with a diagnosis of [CONDITION(S)], Malignant neoplasm of Medulla of unspecified adrenal gland, dementia, and Adult Failure to Thrive. The Minimum Data Set (MDS, an assessment tool) dated 11/19/21 documented that the resident has a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 3/15, associated with severe cognitive impairment. Resident required extensive assistance of two-person for bed mobility, total dependence of two-person assistance for transfer and toileting and requires extensive assist of one person for eating. Review of Activities of Daily Living (ADL) function/rehab/falls/pain Care Plan effective 1/25/19; documented Resident #1 required extensive assist of 1 person for eating, Extensive assist of 2 person for bed mobility and total assist of 2 persons for transfer and toileting. Left neck contracture-interfere with bed mobility and transfer related to been non-ambulatory. No history of fall or trauma. Review of the Side Rail for Bed mobility Care Plan effective 2/7/19 documented resident was unable to position self while in bed without assistance. Resident required assistance of 2 person for bed mobility and total assistance of 2 for transfers. The Facility Accident/Incident Report Investigation dated 1/25/22 documented resident was observed with mild swelling, yellowish discoloration to right thigh, site warm to touch by a CNA and reported the finding to the nurse. Range of Motion limited to right thigh. No witnesses. Denied pain. Medical Director (MD) and son notified. MD ordered X-ray and ultrasound to rule out hematoma. No evidence of Abuse, Neglect, or Mistreatment. Conclusion documented transfers and personal care were in line with the care plan. It appears that there was a delay in early recognition of the injury. Corrective action documented in-service CNAs on the importance of [NAME] inspection of skin changes and the impact of delayed recognition. Nursing progress note dated 1/25/22 12:18PM documented CNA#1 informed the nurse that during care, s/he observed Resident #1 with mild swelling and yellowish discoloration to right thigh and the area was warm to touch. Resident denied pain and no complaints. MD and son notified. X-rays and Ultrasound ordered. Review of the CNA statements dated 1/25/22 with follow up interview with Director of Nursing (DON) on 2/2/22, documented that 1 out of 4 CNA's statements revealed that they performed toileting task with one person assist for Resident #1. Review of the Radiology Report dated 1/26/22 documented findings (femur-right 2 views): overall, osseous mineralization is decreased. This could reflect osteopenia, or [CONDITION(S)], in the correct clinical context, grossly displaced fracture of the right femoral neck. Impression; Age-indeterminate fracture of the femoral neck. No previous examination for comparison. For persistent and worsening symptoms, repeat examination. Review of the Radiology report dated 1/28/22 documented nonvascular- right leg. Multiple real time images of the upper right thigh were obtained. There are multiple complex hypoechoic masses in the thigh. not clear if this represents one large lesion or three separate [CONDITION(S)]. If three separate [CONDITION(S)], it measures 1.9 x 2.5 x 0.8 cm in the anterior lateral aspect, 4.1 x 1.7 x 1.5cm in the lateral aspect of the right lower thigh and 7.6 x 3.5 x 2.8 cm in the posterior aspect of the right thigh. Clinical correlation is suggested. These masses are predominantly well demarcated. Impression documented multiple complex masses in the thigh at three levels as described above. This could be multiple hematoma or abscesses. However, the possibility of complex masses itself cannot be excluded and further clinical correlation is suggested. Facility CNA Accountability sheets reviewed from 1/22/22 -1/25/22 documented that the task of toileting for Resident #1 was performed with 1-person physical assist on all shifts. CNA#6-1/22/22 7AM-11 AM CNA#1-1/23/22 7AM-11AM, 1/24/22 7AM-11AM, 1/25/22 7AM-11AM. CNA#3-1/24/22 11PM-3AM, 1/25/22 3AM-7AM, 1/25/22 11PM-3AM, 1/26/22 11PM-3AM 1/26/22 3AM-7AM. Review of the Medical Note dated 1/26/22 documented the resident X-ray showed femoral neck fracture. Discussion with emergency room (ER) and Orthopedics at the hospital, fracture is old and does not require intervention as resident is non ambulatory. Nursing note dated 1/27/22 at 4:05 AM documented resident returned from ER at 11:56 PM with diagnosis of displaced fracture of the right femoral neck. Swelling persist to right thigh discoloration subsiding. No grimacing or other signs or symptoms of pain/discomfort. The medical progress note dated 2/23/2022 documented that the resident was found to have a fracture on 1/26/2022 and based on review of findings and presentation and discussion with the PCP this fracture is determined to be consistent with a pathological fracture due to underlying bone disease During an interview with CNA #1 on 6/9/22 at 12:42 PM, CNA #1 stated that s/he was providing care to Resident #1 on 1/25/22 during the 7AM-3PM shift. CNA#1 stated s/he reported to the nurse that the resident had greenish yellowish discoloration to the right upper thigh. CNA #1 stated s/he also spoke to the Nursing Supervisor and the Director of Nursing (DON) that day. CNA #1 stated that when performing care, s/he transfers the resident via Hoyer lift with 2 people. CNA #1 stated the resident requires 2-person assist for care at all times. CNA #1 stated she never transfers resident without a second 2 person. CNA #1 stated that she never saw any marks on the right thigh prior to the date s/he reported. CNA #1 stated they were informed by the nurse to just be very careful with the resident. CNA #1 stated s/he was instructed to write a statement During an interview with Director of Nursing (DON) on 6/9/22 at 2:32 PM, when asked why there wasn't an [CONDITION(S)] care plan in place, DON stated that they saw the note of history of [CONDITION(S)] on x ray report and decided to put in the [CONDITION(S)] care plan at that time. DON stated the interventions put in place are based on the assessment of resident's needs. DON stated that RN manager will assess the resident and make note of any changes and will input new interventions as needed based on that assessment. DON stated they were unaware of whether there was an in-service prior to the incident on safe handling of residents who are fragile as they were recently hired. DON stated they did an in-service after the incident occurred on observing and reporting and safe handling of resident's who are fragile. DON stated staff were not written up and stated they are trying to implement education instead of being punitive to her staff to encourage staff to report incidents. DON stated they would prefer to give a verbal warning depending on the nature of the issue. DON did wonder why the CNA's did not see any marks when they were fresh and that 4 CNA's did care and only one reported it on the morning shift. DON stated she did see the discrepancies in the CNA documentation and was unable to determine where the oversight occurred. DON stated after reviewing the CNA documentation of assist of 1 person for toileting, they thought it may be related to resident's weight and ability to perform task with one person assist. DON stated they will discuss further with IDCP team how to clarify the CNA instructions for resident's care and determine what is appropriate for resident needs. DON stated that the delay in reporting to DOH was related to not being sure if it was a reportable incident and after discussion with Administrator, decided to report. (Stated it was her first week working at facility). During an interview with Medical Director (MD) on 6/9/22 at 3:16 PM, MD stated after speaking with staff and doing investigation it was found that resident does have a history of [CONDITION(S)]. MD stated the Primary Medical Doctor (PMD) saw the discoloration, but resident had no history of trauma, so they did not suspect a fracture. MD stated they felt confident that nothing traumatic happened. MD stated if that had been the case it would have been a different reaction. MD stated on reevaluation the PMD felt there was no vascular problem or hematoma and did x rays. MD stated from the result of x ray they were able to determine the resident had a history of [CONDITION(S)] with pathological fracture. MD stated [CONDITION(S)] is a risk factor for resident. During an interview with CNA #3 on 6/10/22 at 12:20 PM, CNA #3 stated s/he works nights and at night they make rounds, change/toilet and turn and reposition residents. CNA #3 stated s/he used extensive assist of 1 to change/toilet Resident#1. CNA #3 stated s/he uses a draw sheet to maneuver and move the resident in order to turn/reposition the resident. CNA #3 stated s/he do the changing/toileting by moving resident from one side to the other with the drawsheet and applies a clean diaper. CNA #3 stated s/he is able to perform this task alone. CNA #3 stated it was their understanding that Resident #1 was 1 person assist for toileting and s/he has always completed this task alone. After the fracture, CNA #3 stated they were informed to change/toilet resident with assist of 2 people. CNA #3 stated they never did transfers because they work the night shift and residents are in bed. CNA #3 stated after the incident, they were in-serviced to use assist of 2 people for toileting Resident #1. During an interview with CNA# 6) on 7/9/22 at 1:20 PM, CNA# 6 stated when they transfered or moved resident #1 in bed, they used 2 person assist. When asked why s/he documented using 1 person assist, CNA# 6 stated that s/he believes her documentation is incorrect and that s/he knows it is always 2 person assist for transfer with a Hoyer lift. CAN# 6 stated sometimes s/he does not get the chance to correct the mistake on their documentation, but s/he know it is 2 person assist with bed mobility for Resident#1. CNA 6 stated they never noticed any changes on resident's skin or any discoloration of skin. CNA 6 stated if they did notice changes in skin they would report to nurse, and the resident will be assessed by the nurse 415.12(h)(2)

F 689 Based on staff interviews and record review conducted during an abbreviated survey (NY 947), the facility did not ensure adequate supervision was provided and that residents were free from accident hazards to prevent falls and injuries for 1 of 3 residents reviewed for accidents. Specifically, Resident #1 who was severely cognitively impaired had multiple falls with injury and the facility did not implement all preventative measures and did not update the comprehensive care plan (CCP) to ensure the resident's safety. The findings are: The facility's Accident/Incident Policy dated 02/24/03 documented that the Nurse is responsible to evaluate the current care plan regarding problems goals and interventions relative to new accidents/incidents. Additionally, the policy documented that the nurse revises current plan or initiates a new care plan based on outcomes of evaluation or investigation to prevent recurrence. Review of the Facility Accident/Incident policy revealed that the nurse is responsible to evaluate current care plan regarding problems/interventions relative to new accidents/incidents. The nurse revises current plan or initiates new care plan based on outcomes of evaluations or investigations to prevent recurrence. The Facility assessment dated [DATE] documented the facility will have necessary personnel to meet the needs of persons served and to provide quality of care and services. It is the responsibility of the Director of Nursing to ensure appropriate staff. Director of Nursing/Supervisor will assess staff needs on the unit based on resident acuity, needs and census and adjust staffing pattern, as appropriate. Resident #1 was admitted to the facility on [DATE] with diagnoses that included poor cognition, status post falls, impaired balance, status post subdural hematoma, and dementia without behavioral disturbances. The Admission Minimum Data Set (MDS; a comprehensive resident assessment tool) dated 7/04/2021 the resident was unable to be scored during the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. The resident required extensive one-person assistance for bed mobility, transfer, eating, dressing, personal hygiene, and toileting. The resident had history of falls and used a wheelchair for mobility. The Fall Risk Assessment completed on the Admission Assessment of 6/23/2021 determined the resident was in the high- risk category due to his/her history of falls. Upon admission the fall risk assessment scored the resident at 26 indicating resident was a high risk for falls. Interventions were not updated beyond the admitted after falls on 6/26/2021; 7/25/2021 and 8/23/2021. A Comprehensive Person- Centered Care Plan for the resident was initiated on 6/23/2021 that identified falls due to impaired mobility and history of falls as a problem. The interventions initiated in the care plan were help with wheelchair mobility and use, resident will be free of further falls/accidents and educate resident/family regarding safety factors. There were no further updates added to the falls care plan after the fall incidents on 6/26/2021; 7/25/2021 and 8/23/2021. A Fall Incident report dated 6/23/2021 documented that at 12:30 AM Nurse was on the north unit administering medications and 1 CNA was in the room with another resident. Resident walked out of he/her room to the nurse's station and fell resulting in a laceration on the bridge of the resident's nose. Physician was notified and Resident #1 was sent to the hospital and family was notified. Review of the supervisor's nurses note indicated the resident was admitted with diagnoses of head trauma. A Fall assessment dated [DATE] identified Resident #1 as high risk for falls with a score of 26 but there was no documented evidence that the care plan was updated. A Fall Incident report dated 7/25/2021 documented that at 7PM Resident was in the lounge after dinner in his/her wheelchair. Nurse was passing out medications and the 1 CNA on the unit was preparing a resident for bed. Resident #1 was found on the floor at the foot of his/her chair. Physician was notified and Resident #1 was transferred to the hospital. Hospital records revealed Resident #1 had a fractured pelvis. The Fall assessment dated [DATE] identified the resident as high risk for falls with increased score of 27 due to [CONDITION(S)] Accident [CONDITION(S)]/ Trans Ischemic Accident TIA but no documented evidence that the care plan was updated. The Fall Incident report dated 8/23/2021 at 2:35 AM documented the nurse heard a sound coming from resident' room and upon entering found the resident on the floor on his/her right side on the left side of the bed. The bed was in the lowest position. Physician was notified and resident was sent to the hospital and did not return. Nursing progress notes dated 8/23/2021 documented resident had a fracture of the spine. Review of the Certified Nurse Aide (CNA) care guide had no documented evidence that assistance for toileting, toileting every 4 hours or monitoring the resident closely were assessed to ensure implementation or to evaluate their effectiveness. During an Interview conducted on 3/2/2022 at-10:05 AM with CNA #1 who works on 2 south Rehab regarding the resident. CNA#1 stated the resident had some dementia and sat in the chair in the lounge. CNA#1 stated s/he never saw the resident seated at the table upon start of shift. CNA#1 stated residents are placed in the TV area. Occasionally, a staff is assigned to sit with confused residents. If resident is confused, we will do 1:1 for a while. CNA#1 stated the Resident#1 never had 1:1 observation. An interview was conducted on 3/3/2022 at 9:05 AM with Registered Nurse (RN#1) the night supervisor on duty on 6/27/2021 when the resident fell the first time. RN#1 stated s/he was called to see a patient following the fall. RN#1 stated it was reported to her/him that the resident came out of the room and was found on the floor at the nurses' station. The fall was not witnessed. RN#1 stated we instruct the CNA's not to move the resident until the RN assessment is complete after a fall. Staff provided support to the resident (checked her extremities) and there was adequate movement but there was a laceration on his/her face. Due to possible head trauma, Resident #1 was sent to the hospital for evaluation. It is the protocol that call bells are within reach of the resident and the beds are in the lowest position. RN#1 stated the bed was in the lowest position. RN#1 stated s/he supervises the rehab, but and two geriatric units in the [NAME] made building. RN#1 stated s/he does not recall which building s/he was in at the time of the accident but believes s/he was on the rehab unit. A telephone interview was conducted on 3/3/22 at 11:10 AM with CNA #1 who was on duty on 6/27/2021, the first time the resident fell . CNA #1 stated s/he went into Resident #1's room to take her vitals and change the resident around 12 AM and lowered the bed. CNA #1 stated as s/he left the room the resident was lying down. No one ever saw the resident trying to get out of bed. The resident was a quiet lady and didn't try to get up. CNA#1 went into the next room to provide care for another resident. CNA#1 came back out to get water and as I came out of the room; s/he saw Resident #1 lying on the floor at the nurse's station. CNA#1 stated s/he was shocked because the resident has never been one to get out of bed. CNA#1 called out for the nurse and did not move the resident until the nurse arrived. The supervisor came out and assessed the resident and the resident was assisted and placed in a chair and the nurse did what they needed to do. Usually on the night shift I have between 8-10 residents, the maximum is 25 on the unit. A telephone interview was conducted on 3/16/22 at 11:52 AM with RN #5 who was the former Supervisor on the rehabilitation unit. RN#5 stated that the resident's interventions were updated by therapy. RN#5 stated she will be emailing the surveyor the residents' updated interventions. The care plan sent by the facility on 3/16/2022 was dated 8/12/2020. A telephone interview was conducted on 3/16/22 at 12:25 PM with the Director for Rehab (DR) regarding any information or training the CNAs receive regarding caring for a rehab resident as well as caring for a rehab resident who has fallen while in rehab and sent to the hospital. DR stated when rehab residents are admitted they are assessed by rehab and the therapist working with the resident educates the CNAs on safety for transfers, fall prevention and positioning for that resident. DR stated that when a resident returns from a hospital stay the resident is reassessed. DR stated that the rehab depends on the CNAs passing on information about residents to the other staff on the other shifts. DR admitted that there is no process to ensure the information is passed on from CNA to CNA or that it is being done. A telephone interview was conducted on 3/16/21 at 3:31 PM with the Director of Nursing (DON) regarding the inconsistencies of CNA documentation related to times required versus times entered in the EMR. The DON stated that CNAs should be documenting when their tasks are completed. DR stated the facility has identified that staff are entering the information outside the required times. The facility wants the CNAs reviewing the CNA record and signing off for the task at the appropriate time. DR states we have identified that as a problem. DR stated s/he was not working in the facility at the time the resident was in the facility. 415.12(h)(1)(2)

Based upon observation, interview, and record review conducted during a recertification survey the facility did not ensure labeling, dating, and monitoring of refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. This was identified during the initial tour of the kitchen. The facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes. The findings are: A facility policy and procedure titled Food Supply and Storage dated ,d+[DATE] and revised ,d+[DATE] documented: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures included but were not limited to: Most, but not all products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed: do not sell products in the retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by, sell-by, best-by, or enjoy by date should be discarded. Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use Medvantage/Freshdate or other approves labeling system. Products are good through the close of business on the date noted on the label. Refer to the Food Storage Chart in this policy to determine dates for food items. The Food Storage Chart titled Refrigerated Storage Life of Food documented: Use manufacturer's expiration date for products before they are open. If there a is no expiration date on the package, add the time listed here to the date the food is received. Add the time in the opened column to the date the food is prepared or opened. Label when product is opened. The time listed is added to today's date. The initial tour of the kitchen was conducted on [DATE] at 10:20 AM with the Food Service Director (FSD #1) in attendance. Observations revealed: Fifteen 32-ounce containers of liquid egg whites containing an expiration date of [DATE] were stored in the dairy box. At that time, FSD 1# was interviewed and reported that the liquid egg whites should have been tossed out, the supervisor should have checked on AM and PM shift for expired food items, and the egg whites would be discarded. One 5-pound Hormel natural choice premium roast beef containing a manufacturers packed-on date of [DATE] and a small red label dated ,d+[DATE], was stored in a refrigerated unit. FSD #1 was interviewed at that time and reported that the red label was the received date, the product should not have accepted and should have returned to the vendor, then proceeded to check the guidance for refrigerated storage life of foods, and reported the unopened product should have been used within +1 month from the packing date. Three Natural Choice defrosted seasoned deli meat containing a use or freeze by date of [DATE] and weighing 7.1# each were stored in a refrigerated unit. 2 of the deli meats were stored in unopened cardboard box which contained an orange label dated [DATE]. FSD #1 was interviewed at that time and revealed that [DATE] was the date the deli meat was received, and further revealed that the deli meat would be discarded. Four 5-pound bags of raw, boneless chicken breast and two 10-pound, bone-in raw turkey breasts each containing a small red label dated ,d+[DATE] were stored in refrigerated unit. At that time Cook #1 was interviewed and reported he did not know who pulled the chicken dated ,d+[DATE] from the freezer, it should have been dated with pull date, and then defrosted and used within 4 days. Also, at that time, FSM #1 was interviewed and reported the chicken and turkey should have been dated with a pull date and use by date and would be discarded. One unopened, 5-pound container of low-fat cottage cheese containing a use by date of [DATE] was stored in a refrigerated unit. Cook #2 was interviewed on [DATE] at 11:32 AM and revealed that the red label was the date the chicken was pulled from the freezer, then proceeded to check the facility Refrigerated Storage Life of Foods and reported that the chicken should have been used within 4 days. 415.14(h)

Based on observation, record review, and interview conducted during a recertification survey, the facility did not develop a person-centered care plan with measurable objectives, time frames and appropriate interventions based on comprehensive assessments for 1 of 1 resident (Resident #93 ) reviewed for [CONDITION(S)] and 2 of 6 residents (Residents # 97 and #368) reviewed for unnecessary medications. Specifically, there were no care plans to address End Stage [CONDITION(S)] on Hemodialysis or Anticoagulation with [MEDICATION(S)] use for Resident # 93, Hypertension or Anticoagulation with [MEDICATION(S)] and Aspirin use for Resident # 97, or Chronic Obstructive Pulmonary Disease (COPD) or Diabetes Mellitus for Resident # 368. The findings are: The facility Policy and Procedure titled, Care Plans dated 8/27/2001 and revised 1/7/2020 documents the Baseline Care Plan will be developed and implemented within 48 hours of admission which will include the minimum healthcare information necessary to properly care for a resident including but not limited to initial goals based on admission, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 93 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum data Set (MDS) admission assessment dated [DATE] documented the resident had intact cognition and received 3 days of anticoagulant therapy. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 5/13/21, there was no evidence of a documented care plan for this resident admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #97 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The MDS admission assessment dated [DATE] documented the resident had intact cognition and received 3 days of anticoagulant therapy. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 5/13/21, there was no evidence of a documented care plan for Cardiovascular Function for this resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 368 was admitted on [DATE] for left leg fracture status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS admission assessment dated [DATE] documented the resident had intact cognition, and received 6 days of insulin therapy. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 05/13/21, there was evidence of a documented care plan for this resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/14/21 at 8:30 AM an interview was conducted with Registered Nurse Unit Manager (RNUM#1) on the rehab unit. S/he stated on admission, the admissions nurse writes a baseline care plan on the paper form, and initiates the care plan in the resident's Electronic Medical Record (EMR). S/he stated for Resident # 93, End Stage [CONDITION(S)] on Hemodialysis and Risk for Bleeding on [MEDICATION(S)] should have been care planned, for Resident # 97, Cardiovascular Function and the risk for Bleeding on [MEDICATION(S)] and Aspirin should have been care planned, and for Resident # 368, Chronic Obstructive Pulmonary Disorder (COPD) and Diabetes Mellitus should have been care planned. S/he stated that within 72 hrs, s/he or the Assistant RNUM should review the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/14/21 at 12:30 PM an interview was conducted in the Director of Nursing (DON#1)'s office with the Director of Nursing (DON#1). S/he stated care plans for medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 415.11 (c)(1)

Based on observation, record review and interview conducted during a recertification survey the facility did not ensure that the care planning team 1. established and implemented the frequency by which a nasal cannula with tubing should have been changed for two of two residents reviewed for respiratory care (Residents #84 and #268) using oxygen, and 2. for 1 of 2 residents (Resident #268) the facility did not ensure that a resident who needed respiratory care, including [CONDITION(S)] care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for Resident #84, there was no evidence to indicate the oxygen tubing/cannula was being changed, labeled with date and initialed. For Resident #268, no protocols were ordered for oxygen monitoring and care of the nasal cannula (nc) and tubing, and Resident #268 was not accepting continuous oxygen as ordered by the Medical Doctor (MD) and the MD was not notified. The findings are: A facility policy and procedure titled Oxygen Administration and dated 3/13/2014 with revision 8/14/2018 documented: Oxygen will be administered as per MD order to aid in breathing. Face masks, nasal cannulas and oxygen tubing will be changed weekly and dated. Date and initial tubing and humidifier bottle, if used. A facility policy and procedure titled Respiratory Function and dated 4/27/2011with revision 6/30/2018 documented: It is the policy that a resident's respiratory function will be optimized. Procedures included Responsibility #4: Nurse/Physician/Rehabilitation Therapist assesses potential to decrease /change use of medications, oxygen, or specialized equipment if resident's condition warrants, and notifies physician as appropriate. Resident #84 was admitted on [DATE] from an acute hospital. The Admission Minimum Data Set (MDS, an assessment tool) dated 4/4/2021 documented that Resident #84 was moderately cognitively impaired for decision making, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident's Comprehensive Care Plan dated 3/29/21 and titled Health Status documented decline in health status related to [CONDITION(S)], Respiratory Failure, alteration in Cardiovascular function, and alteration in respiratory status/ineffective oxygenation, as evidenced by SOB/labored breathing, activity intolerance, and uses O2 continuously. Goals included the Resident will be free of respiratory distress. Interventions included Administer O2 as per MD order and change tubing weekly as per protocol. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Protocol: Check O2 saturation 5 min after O2 administration and 5 minutes off oxygen (indicate whether at rest or during activity). Change tubing q weekly on Sunday as needed. Monitoring: Oxygen saturation. Review of the Resident's Treatment Administration Record (TAR) for April 2021 and May revealed there was no designated area for documentation of tubing change and labeling with date and initial, and there was no documented evidence that tubing was being changed/labeled. Observations revealed: 5/10/21 at 02:46 PM tubing was dated 5/2/21 and was not initialed and 5/13/2021 tubing was found without labeling of date or initials. Review of nurse's notes dated 4/1/2021 to 5/6/2021 revealed no record of tubing change and labeling. An interview of Nurse Manager #1 (NM #1) on 5/13/21 at about 11:30 AM revealed that oxygen tubing should be changed weekly on Sundays and as needed and should be dated and initialed. At that time, NM #1 checked the resident's record and reported that the changing of the tubing is not a separate order and is not signed for. Also, at that time NM #1 and Surveyor went to see Resident #84, Resident gave permission for NM #1 and Surveyor to check tubing, and tubing was found not to be labeled with date or initials. NM #1 further reported that the order should not be every Sunday as needed and should be weekly every Sunday. NM #1 then revealed that her expectation is that nurses should be checking tubing when changing oxygen to ensure they are in compliance with the weekly order. The Registered Nurse (RN #1) assigned to Resident #84 was interviewed on 5/13/21 at 12:08 PM and reported that oxygen tubing is changed every Sunday and labeled with that date. When asked how the change of oxygen tubing is documented on the resident's TAR, RN #1 reviewed the record and reported that tubing is to be changed on the 11-7 shift, there is no one place to document the date the tubing is changed, only the dating on the tubing could really tell you when the tubing was changed, and there should be a place on the TAR to show when the tubing was changed. A Registered Nurse (RN #2, 11 PM - 7 AM shift) was interviewed on 5/17/21 at 4:34 PM and reported that she/he worked every other weekend and worked on 5/2/2021, she/he changed and dated the tubing on 5/2, and that the change of tubing goes with the oxygen order. Resident #268 was admitted on [DATE] from an acute hospital. The Admission MDS dated [DATE] revealed the resident was cognitively intact for decision making, had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident's Comprehensive Care Plan dated 4/28/2021 and titled Health Status documented decline in health status related to Chronic Respiratory Failure and [CONDITION(S)], alteration in cardiovascular status, alteration in respiratory status/ineffective oxygenation, and SOB/labored breathing. Goals included: Resident rights will be respected thru discharge and resident will be free from further decline in health status related to Chronic Respiratory failure thru discharge. Interventions included: Monitor vital signs and Administer O2 as per MD order. Care plan did not document protocols for oxygen administration or care of the nasal cannula and tubing. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not document protocol for oxygen monitoring or care of nasal cannula and tubing. The TAR for 4/2021 and 5/2021 was reviewed and no protocol for oxygen administration or care of nasal cannula and tubing was documented. Review of nurse's notes 4/27/21 to 5/13/21 at 12:00 PM revealed no record of tubing change and labeling, and no documentation of resident declining oxygen therapy. Observation: Following interview of RN #1 at 12:08 PM as above noted, Surveyor requested to observe an additional resident receiving continuous oxygen and review TAR. At that time RN #1 reviewed the TAR for Resident #268 and reported that there was no order found for change of tubing. At approximately 12:15 PM Surveyor and RN #1 visited Resident #268 who was found not to have oxygen in place. Resident #268 was interviewed at that time and reported he did not use O2 yesterday or today, he is feeling ok, and in the hospital, they told him if O2 was above 90 he did not need to use oxygen. A follow up interview conducted with RN #1 on 5/13/21 at 12:29 PM revealed she had signed for resident continuous oxygen this morning and resident was not wearing it at that time. When asked why, RN #1 reported she signed because the resident puts the O2 on and off. When asked if the MD was notified that the resident was not consistently using oxygen, RN responded that the MD was not notified. An interview with NM #1 was conducted on 5/13/2021 at 12:55 PM. At that time, NM #1 checked the record for resident #268 and reported there was no order for oxygen removal, oxygen was documented as administered, and O2 saturation for today was not documented yet. NM #1 further reported that if the resident has been taking oxygen off, RN could have checked pulse ox and informed MD, then MD could make decision whether or not to change the order. Also, at that time, NM #1 and surveyor spoke with RN #1 who reported she had checked O2 saturation and did not document it as the comment box did not open. At that time, NM #1 provided guidance to RN #1 on how to document 02 saturation. 415.12(k)(6)

Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that current acceptable professional standard of practice regarding storage of multi-dose insulin injection medication were followed. Specifically, (1) Multi-dose Insulin Pens were opened, undated and not discarded after the recommended 28-day period per manufacture specifications; and (2) A multi-dose Insulin Pen was not stored in the refrigerator according to the manufacture specification. This was evident during review of the facility's medication storage for two of six facility units (3 West and 1 South Units). The findings are: -Observation of 3 West unit was conducted on [DATE] at 2:11PM. An opened, undated, and in use multi-dose [MEDICATION(S)] Kwik Pen Insulin ([MEDICATION(S)]) assigned to resident #25 was found in the low side medication cart. The pen had no dispense date. Review of Resident #25 current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The manufacturer of [MEDICATION(S)] Insulin recommended that opened and unrefrigerated insulin must be dated when opened and discarded after 28 days, even if the vials still contain the medication. Licensed Practical Nurse (LPN #1) was interviewed on [DATE] immediately following the above observation and stated that the insulin should have been dated when opened and discarded after 28 days. -Observation of 1 South Unit was conducted on [DATE] at 2:18 PM. An opened, undated, and in use [MEDICATION(S)] [MEDICATION(S)] Insulin Pen assigned to Resident #219 was found in the medication cart. The instructions inscribed on the [DATE] pharmacy label stated that the insulin should be discarded after 28 days when opened. A second multi-dose [MEDICATION(S)] [MEDICATION(S)] Insulin Pen assigned to Resident #219 was also found in the same medication cart. The Insulin had an opened date of [DATE] written by a facility staff member, and a dispensed date of [DATE] inscribed on the pharmacy label. Review of both insulin pen showed one should have been stored in the refrigerator if not in use. Review of Resident #219 current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the manufacturer of [MEDICATION(S)] [MEDICATION(S)] Insulin [MEDICATION(S)], in-use (opened) [MEDICATION(S)] vials and [MEDICATION(S)] [MEDICATION(S)] pens should be stored at room temperature below 86-degree Fahrenheit and must be used within 28 days or be discarded, even if they still contain the [MEDICATION(S)] medication. Unopened [MEDICATION(S)] should be stored in the refrigerator between ,d+[DATE] degree Fahrenheit. LPN #2 was interviewed on [DATE] immediately following the above observation and stated that opened insulin should be dated when opened and discarded when expired. He stated if insulin is not in use, it should be stored in the refrigerator. LPN #2 stated one of the 2 insulin should have been stored in the refrigerator, but he was not sure which one. 415.18 (d)

Based on observation, interview and record review conducted during a Recertification Survey, the facility did not ensure that facility staff followed proper hand hygiene and gloving techniques to prevent cross-contamination and the spread of infection. Specifically, (1) cross-contamination of wounds and wound supplies was observed; and (2) removal of soiled gloves and hand hygiene were not observed during wound care procedures for 2 of 5 residents (Residents #52 and #73) reviewed for pressure ulcer/injury. The findings are: 1.Resident #52 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 3/8/2021 Admission Minimum Data Set (MDS; a resident assessment and screening tool) showed that Resident #52 had Stage II, III, and IV PUs that were present on admission. Review of Resident #52's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a subsequent physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . One-time order for 5/13/2021 on the 7A-3P shift. Review of Resident #52's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a subsequent physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . One-time order for 5/13/2021 on the 7A-3P shift. Review of Resident #52's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Actual Pressure Injury Care Plan initiated on 6/20/2019, updated on 3/3/2021 for a recent admission, and last updated on 5/6/2021, revealed that Resident #52 had multiple wound sites that were either vascular or pressure ulcer in nature. Goals included that the resident would not develop additional pressure ulcers. Interventions included were, but not limited to, heel booties, monitoring of skin during cares, pressure relieving devices while in bed and while in chair and repositioning every two hours. A wound dressing observation was conducted on 5/13/2021 at 11:53AM for Resident # 52 and the following was observed: Licensed Practical Nurse (LPN #3) donned (applied) a pair of gloves to remove the soiled dressing from Resident #52's left hip wound, then discarded it along with the soiled gloves. No hand hygiene was observed upon doffing (removal) of the gloves. LPN #3 then used ungloved hands to remove multiple sterile 4x4 gauze pads from a gauze package. LPN #3 proceeded to place the gauze pads on the outside of the 4x4 gauze package. LPN #3 then saturated the gauze pads with Normal Saline and proceeded to cleanse the left hip wound. Prior to the completion of care to Resident #52's left hip wound, LPN #3 removed the soiled gloves and left the room without performing hand hygiene. LPN #3 was observed walking in the hallway. LPN #3 then returned to the treatment cart located outside of Resident #52's room and obtained additional supplies, without performing hand hygiene. LPN #3 then reentered Resident #52's room, donned a pair of gloves and completed the wound care procedure to Resident #52's left hip. LPN #3, without doffing the soiled gloves and performing hand hygiene, then removed soiled dressings from the two wound sites on Resident #52's right foot and discarded them in the soiled receptacle. The soiled wound dressings were observed to have drainage and the wound beds had black tissue. LPN #3 donned new gloves, cleansed the two foot wound sites and applied the new treatment without performing hand hygiene. During this procedure, LPN #3 used a pair of scissors to cut the Xeroform dressing (a sterile, non-adhering protective dressing consisting of absorbent, fine-mesh gauze impregnated with a [MEDICATION(S)] blend) and applied them to both right foot wounds. Upon completion of care to the right foot wounds, LPN #3 doffed the soiled gloves, went outside to the treatment cart without performing hand hygiene and obtained [MEDICATION(S)] dressing. LPN #3 reentered Resident #52's room, donned a new pair of gloves and proceeded to saturate multiple 4x4 gauze pads with Normal Saline on top of the outer 4x4 package. LPN #3 used the saturated gauze to cleanse the resident's left great toe wound and to apply the new dressing. Following the completion of the left great toe procedure, LPN #3 doffed the soiled gloves and donned new gloves without performing hand hygiene. LPN #3 removed the soiled dressings from Resident #52's left sacrum and discarded them. LPN #3 donned a new pair of gloves without performing hand hygiene, then proceeded to perform wound care to the resident's sacral wound. Following completion of the left sacral wound care, LPN #3 wore the soiled gloves to assist another staff member to reposition Resident #52 in bed. After this, LPN #3 used the soiled gloves to wipe the pair of scissors with a piece of dry 4x4 gauze. LPN #3 then picked up a tube of Santyl topical ointment and placed it in a plastic bag. LPN #3 returned the uncleansed scissor and the tube of Santyl topical ointment to the treatment cart that contained other residents' treatment supplies. LPN #3 was interviewed on 5/13/2021 immediately following the wound procedure above and stated that she recognized her errors. LPN #3 stated that she should have changed the soiled gloves in between the dressing change and performed hand hygiene. LPN #3 stated that she/he had not done wound care on this unit before, only on other units and that she/he was nervous. 2.Resident #73 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 10/6/2020 Significant Change Minimum Data Set (MDS; a resident assessment and screening tool), the resident had impaired cognition and required staff assistance with Activities of Daily Living (ADLs). The MDS coded the resident at risk for pressure ulcers (PU), and actual stage two PU. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse left lateral knee with Normal Saline, apply Skin Prep Wipes, and cover with dry protective dressing daily. An Actual Pressure Ulcer Care Plan initiated 11/19/2019, and updated multiple times, including 5/13/2021 reflected the resident's wounds. Goals included the resident's PU would decrease in size. Interventions included monitoring of skin during cares, pressure relieving devices in bed and chair, and repositioning every two hours. A wound observation was conducted on 5/13/2021 at 12:38PM for Resident #73 and the following were observed: LPN #3 donned a pair of gloves and cleaned Resident #73's over-over-bed table to prepare the ordered wound supplies. Without removing the soiled gloves and performing hand hygiene, LPN #3 used the soiled gloves to open multiple 4x4 gauze packages and a small bottle of Normal Saline. LPN #3 placed the clean gauze sponges on the wrapper of the 4x4 gauze package and saturated them with Normal Saline. LPN #3 removed the soiled gloves, donned a new pair of gloves and removed the soiled dressing from Resident #73's sacrum. LPN #3 then discarded the soiled dressing and proceeded to cleanse and apply the clean dressing to the resident's sacral wound. No hand hygiene was observed. Next, LPN #3 removed a soiled dressing from Resident #73's left lateral knee. Without changing gloves or performing hand hygiene, LPN #3 cleansed the wound. During this procedure, LPN #3 used a pair of unclean scissors (observed being used earlier to cut a different resident's dressing during a wound care procedure) to cut excess Kling wrap applied to Resident #73 left lateral knee wound. After completion of the sacral and knee wound care, LPN #3 placed the unclean scissors in a box. LPN #3 then returned the box to the treatment cart that contained other residents' treatment supplies. LPN #3 was interviewed on 5/13/2021 immediately following the wound care procedures about the process of preparing and cleaning reusable items. LPN #3 stated that he/she recognized the errors as described above but offered no explanation as to the cause of her failure to adhere to proper infection control procedures. 415.19 (b) (4)

Based on record reviews and interviews conducted during an Abbreviated Survey (# 6), it could not be ensured that the facility protected resident's rights to be free from abuse for 2 of 6 residents reviewed for abuse. Specifically, Resident #1 pushed Resident #2 after Resident #2 called Resident #1 a [OBSCENITY] . As a result of Resident #1's physical aggression, Resident #2 fell to the ground and hit her head causing a laceration. Resident #2 was transferred to the emergency room for evaluation and required sutures to her head. The findings are: Resident #1 was originally admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Quarterly MDS (Minimum Data Set; a resident assessment and screening tool) dated 11/25/2020 documented no verbal, physical or other behavioral symptoms. The Quarterly MDS dated [DATE] documented that Resident #1 had intact cognition with a BIMS (Brief Interview for Mental Status) score of 13. The MDS also documented that Resident #1 required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. A Risk for Resident Abuser/Victim Care Plan (CP) for Resident #1 was initiated on 12/13/2020 with goals and interventions including education about coping skills and to monitor behaviors. Resident #2 was originally admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Quarterly MDS dated [DATE] documents intact cognition with a BIMS score of 13 MDS. The Quarterly MDS dated [DATE] documented that Resident #2 has displayed no physical, verbal or other behavioral symptoms. The MDS also documented that Resident #2 requires setup assistance for bed mobility, transfers, ambulation, dressing, eating, and personal hygiene. Resident #2 also required extensive assistance of one person for toilet use. A Potential for Resident Abuse/Victim CP for Resident #2 was initiated on 1/21/2015. Review of the CP revealed goals and interventions to educate Resident #2 on coping skills, provide reassurance as well as emotional support, monitor behavior, affirm appropriate behavior, administer and assess effectiveness of medications as ordered and consult with psychiatry. Review of a Resident Accident Report dated 1/1/2021, signed by the Licensed Practical Nurse (LPN #3) and the supervising Registered Nurse Unit Manager (RNUM #1) on duty documented that Resident #1 told LPN #3 that Resident #2 called her a [OBSCENITY] so she knocked her down. The report concluded that Resident #1 did not call for staff assistance when Resident #2 called her a [OBSCENITY] and showed poor impulse control. The report documented that Resident #2 told LPN #3 that Resident #1 pushed her down. A Certified Nursing Assistant (CNA #2) documented that she had heard a commotion and saw Resident #2 stumble but was unable to catch her before she fell . The report documented that Resident #2 sustained a bleeding laceration to the head as a result of the fall. Resident #2 was transferred to the hospital emergency room for evaluation, the physician, the families and 911 were called. Resident #1 was also removed from the area. Review of a Quality Assurance Investigation dated 1/5/2021 and signed by the Director of Nursing showed that Resident #2 admitted to pushing Resident #1 after Resident #2 called her a [OBSCENITY] . The investigation noted that there was no prior history of resident to resident abuse from either resident and that both residents had recent and regular visits from mental health professionals. Immediate interventions were put into place to address the physical injury to Resident #2. Furthermore, both residents were monitored and kept separated from each other. The investigation also documented that the physician was notified, the families were notified and that 911 was called. The police and an ambulance arrived at the facility. The ambulance transferred Resident #2 to the hospital. CPs for Resident #1 and Resident #2 were updated to prevent any further abuse situations. The facility concluded based on all the information collected and reviewed, that verbal abuse by Resident #2 and physical abuse by Resident #1 had occurred. The incident of abuse was reported to the Department of Health via the Health Commerce System on 1/5/2021. An interview was conducted on 3/5/2021 with RNUM #1 on the 4 North Unit at 9:45AM, who was the supervising Registered Nurse on 1/1/2021. RNUM #1 stated that Resident #1 has had verbal but not physical outbursts in the past and is seen regularly by Psychiatry as well as Psychology. An interview was conducted on 3/5/2021 on the 4 North Unit at 10:05AM with LPN #1 who stated she was familiar with both Resident #1 and Resident #2. LPN #1 stated that Resident #1 was in a bad mood at times but to her knowledge, has never attempted to strike out or push anyone. LPN #1 stated that Resident #2 has cursed at staff at times. An interview was conducted on 3/5/2021 on the 4 North Unit at 10:20AM with Resident #1. During the interview, Resident #1 could not recall the incident from 1/1/2021. An interview was conducted on 3/5/2021 on the 4 North Unit at 10:15AM with CNA #1 who stated that she was familiar with Resident #1 for approximately 3 years. She stated that Resident #1 has not attempted to hit, push or strike out at her or anyone else. An interview was conducted on 3/5/2021 on the 3 West Unit at 10:30AM with RNUM #2. RNUM #2 stated that Resident #1 had not physically lashed out at staff or other residents. RNUM #2 stated that there were no indicators that Resident #1 was at risk for physical altercation directed at anyone. The RNUM #2 stated that Resident #2 has at times said inappropriate words, then apologizes. An interview was conducted on 3/5/2021 on the 3 West Unit at 10:40AM with LPN#2. LPN #2 stated she was familiar with Resident #1. LPN #2 explained that she had never seen Resident #1 have any physically aggressive behaviors towards staff or other residents. LPN #2 stated that she was very familiar with Resident #2 who has occasionally said bad words to staff, but she has not seen the resident say bad words directly toward another resident in the past. An interview was conducted on 3/5/2021 with Resident #2 at 10:45 AM in her room on the 3 West Unit. Resident #2 stated, A lady pushed me, and I fell . I don't know why she pushed me. I had to go to the hospital. I'm better now. A phone interview was conducted on 3/9/2021 at 2:00PM with LPN #3. LPN #3 stated that she was giving medications at the other end of hallway at the time of the incident on 1/1/2021. LPN #3 stated that CNA #2 told her that she had heard an argument between Resident #1 and Resident #2. CNA #2 also told LPN #3 that a resident was on the floor. LPN #3 stated that upon arrival to the room, she saw Resident #2 lying on the floor, on her back in a pool of blood. LPN #3 also stated that she asked Resident #1 what had happened, and Resident #1 told her that Resident #2 called her a [OBSCENITY] so she knocked her down. A phone interview was conducted with CNA #2 on 3/9/2021 at 2:30PM. CNA #2 stated that she was in the hallway at the time of the incident on 1/1/2021. CNA #2 stated that she had heard a commotion and saw Resident #1 raise her hand up but she didn't see her hit Resident #2. CNA #2 stated that she saw Resident #2 falling but she could not get to her fast enough and Resident #2 fell . CNA #2 stated that Resident #1 told her and LPN #3 that she pushed Resident #2 when Resident #2 called her a [OBSCENITY] . 483.12 (a)(1)

Based on interview and record review conducted during an abbreviated survey (#NY 130), it could not be ensured that the facility took measures to protect residents after an alleged incident of abuse or neglect and mistreatment, including injuries of unknown origin for 1 of 3 residents reviewed. Specifically, the facility did not complete an immediate assessment of the alleged victim, did not initiate an investigation immediately, interview and obtain statements from the staff involved or others necessary as per facility policy and procedure. The findings are: Resident #1 is an [AGE] year old male who was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS; an assessment tool) dated 2/4/19 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating that Resident #1 is severely cognitively impaired. Resident #1 also requires extensive assistance of 1 with dressing and personal hygiene, extensive assistance of 2 with toilet use, bed mobility and transfer; uses a wheelchair for mobility and is incontinent of bowel and bladder. Nursing Progress Notes signed by LPN #1 dated 2/10/19 at 11:23pm documented that Resident #1 was noted with mild swelling to his left hand and complained of pain only to touch. The Nursing Supervisor was informed, and the Physician was notified. Subsequently, an order was received for Tylenol 650mg, twice per day for 3 days and an x-ray to be completed the following morning (2/11/19), same scheduled as ordered. Will continue to monitor. Vital signs: 97.4-68-16, 129/71. Nursing Progress Notes signed by LPN, dated 2/11/19 documented that the X-ray was taken of Resident #1's left hand due to swelling, result shows left hand fracture of the 4th proximal phalanx at its proximal portion with extension into the 4th metatarsophalangeal joint. There is slight separation of fracture fragment and severe [CONDITION(S)]. The Physician was made aware and requested that an ace bandage be applied to the hand. The Physician noted that he will see Resident #1 on 2/12/19. Review of the Accident/Incident Report signed by the Director of Nursing and dated 2/12/19 documented that the Accident/Incident occurred on 2/11/19 and that the type of incident was a fracture of the left hand. Review of the facility's policy and procedure on Accidents, revised 6/3/13 documented that an accident refers to any unexpected or unintentional incident, which may result in injury or illness to a resident such as injuries of unknown origin or fractures. When an accident occurs, involved staff are to notify the charge nurse immediately and the nurse will examine the resident performing a full body check and first aid will be administered as required. The RN Manager/Supervisor will also be notified and the RN will perform a full physical assessment including for pain and provide the recommended intervention per MD order. The charge nurse in conjunction with the RN Manager/RN Supervisor will complete an accident form and an investigation will be initiated immediately with all accidents. The RN Manager/RN Supervisor will interview and obtain statements from staff involved or others necessary prior to the end of the shift. All residents will have supportive documentation in interdisciplinary notes describing the occurrence, the vital signs, full physical assessment and therapeutic interventions provided. There is no documented evidence that Resident #1 was assessed by an RN following the report of swelling of the left hand. Furthermore, no evidence was available to show that the incident report was completed by the RN Manager. No evidence of staff interviews or statements or that the investigation was initiated immediately was available for review. In an interview with the DON on 12/11/19 at 10:14am, she stated that the incident was first reported on 2/10/19 and not 2/11/19 as recorded on the incident report. On 12/11/19, 10:40am, RN #1 was interviewed. She stated that Resident #1 is occasionally combative, but not recently. She went on to explain that most of the time they put him in an area visible for the staff to observe him and leave him alone because otherwise he becomes combative. On 12/11/19 at 3:20pm during a phone interview with CNA #1 she stated that while Resident #1 was sitting in a wheelchair across from the nurses' station, she saw that his left hand was swollen, and she called LPN #1. CNA #1 also noted that she noticed the swollen hand after dinner, likely between 7pm and 8pm. On 12/13/19 during a phone interview with RN #2, he stated that on 2/10/19, LPN #1 reported to him that Resident #1's hand was swollen. RN #2 then instructed LPN #1 to call the physician to obtain an x-ray to rule out fracture. RN #2 could not recall how Resident #1 fractured his hand however, RN #2 offered that Resident #1 could have hit it against something. RN #2 reported that although he is sure he did visit with Resident #1 as a result of the swelling, he did not document an evaluation. He said that there should have been an assessment on the resident by an RN. RN #2 then confirmed that he failed to generate the incident report.