Every finding on record at Tupper Lake Center for Nursing and Rehabilitation

Based on interviews and record review during a recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure a Registered Nurse was scheduled for at least 8 consecutive hours a day, 7 days a week. Specifically, no registered nurse worked on 1/28/2024. This is evidenced by: Record review of the written working schedule for 1/28/2024 revealed no registered nurse was scheduled to be in the building that day. During an interview on 1/29/2024 at 1:58 PM, Scheduler #1 stated they made sure all the shifts were covered and was aware that a registered nurse needed to be scheduled for eight consecutive hours, seven days a week, per the regulation. The Scheduler could not explain why no registered nurse was scheduled on 1/28/2024, and stated they must have missed that. During an interview on 1/30/2024 at 2:10 PM, Administrator #1 stated they checked the schedule before leaving for the day and didn't notice that no registered nurse was scheduled for 1/28/2024. Administrator #1 stated it did not happen regularly and the facility should have found a registered nurse for that day. Administrator #1 confirmed the facility did not have any staffing waivers. During an interview on 1/29/2024 at 2:18 PM, Director of Nursing #1 stated they had worked 1/27/2024 as a registered nurse then returned home that evening. They stated they were not aware that the facility did not have a registered nurse scheduled for 1/28/2024 but that they were on-call and available by phone. Director of Nursing #1 stated the facility had a very low acuity, that there were no residents in the facility that required intravenous therapy (the administration of substances such as fluids, electrolytes, blood products, nutrition, or medications directly into a resident's vein), enteral feedings (nutrition delivered directly into the stomach or intestine through a tube), sterile dressings or vacuum assisted closure of wounds. Director of Nursing #1 stated the staffing on 1/28/2024 was not ideal but the event was a fluke and not common. 10 New York Codes, Rules, and Regulations 415.13(b)(1)

Based on observation, record review, and interviews during the recertification survey from 01/22/2024 to 01/30/2024, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety in the main kitchen and two (2) of 2 kitchenettes. Specifically, toxic vapor-emitting fly strips were used in food preparation areas, cleaning equipment was not stored properly, and equipment and floors were not clean. This is evidenced by: During observations of the main kitchen on 01/22/2024 at 11:37 AM, two toxic vapor-emitting fly strips were found near the 3-compartment sink; a broom and dust bin were stored next to the stove; and the can opener and holder, cooking line drawers, wall fan in the dishwashing machine area, and floor under and behind cooking equipment were soiled with food particles. During observations on 01/22/2024 at 12:13 PM in the [NAME] Unit kitchenette, the microwave oven and floor in corners were soiled with food particles; and in the [NAME] Unit kitchenette, the microwave oven and the floor in corners, next to walls, and under the refrigerator were soiled with food particles. The label of the fly strips used in the kitchen titled Fruit Fly BarPro was undated and documented in the section labeled Warnings that this product was not to be used in kitchens or any areas where food is prepared. There was no documented evidence that dietary staff received training or were tasked to clean the can opener and holder, cooking line drawers, wall fan in the dishwashing machine area, and floor under and behind cooking equipment. There was no documented evidence that dietary staff received training or are tasked to clean kitchenette microwave ovens or floors. There was no documented evidence that environmental services staff received training to clean kitchenette microwave ovens or floors. The undated environmental services task schedule for cleaning the unit kitchenettes documented that the unit kitchenettes were to be cleaned by the environmental services staff but did not specify the frequency or that the floors and microwave ovens were to be cleaned. During an interview on 01/22/2024 at 1:30 PM, Nutrition Manager #1 stated that the fly strips used to treat drain flies at the 3-compartment sink were discarded. Nutrition Manager #1 stated that the broom and dustpan should had been stored in their designated area, the soiled items found in the kitchen had been cleaned, the staff would be consulted on cleaning, and the cooking equipment would be moved to enable the floor behind the cooking equipment to be thoroughly cleaned. Nutrition Manger #1 stated that housekeeping staff were responsible for cleaning the kitchenette microwave ovens and floors. During an interview on 01/26/2024 at 2:38 PM, Administrator #1 stated that the cleaning items found in the main kitchen and kitchenettes would be addressed with the Food Service Director and the environmental services department, the dietary department would be assigned to clean the kitchenette microwave ovens, and the dietary and maintenance staff would be educated on not using prohibited fly strips in the kitchen. 10 New York Codes, Rules and Regulations 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1

Based on record review and interviews during the recertification survey from 01/22/2024 to 01/30/2024, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for one (1) of 3 residents reviewed. Specifically, the facility did not ensure Resident #111 received timely notification (2-day notification) of the termination of Medicare Part A services. This is evidenced by: The document titled, Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC and dated 09/08/2023, documented that Resident #111 last received rehabilitative services on 09/08/2023 and was provided the Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC to inform the resident of their right to an expedited review of service termination on 09/18/2023 (date signed), ten days after the termination of services. During an interview on 01/25/2024 at 10:46 AM, Regional Administrator #1 stated that the person responsible for issuing the Notice of Medicare Non-Coverage for Resident #111 was no longer is employed with the facility, and all persons having received Medicare Part A coverage would be reviewed to ensure they received proper notification. Regional Administrator #1 stated that the facility would educate the current person responsible for issuing the Notice of Medicare Non-Coverage on the two-day requirement to prevent recurrence. 10 New York Codes, Rules and Regualtions 415.3 (g)

Based on interviews and record review conducted during the recertification survey from 1/22/2024 to 1/30/2024, the facility did not ensure that written notification was sent to a representative of the Office of the State Long-Term Care Ombudsman of a resident's transfer or discharge for two (2) (Resident #17 and #57) of three (3) residents reviewed for hospitalization . Specifically, the written notice of transfers to the Ombudsman was not provided when Resident #17 and #57 transferred to the hospital. This is evidenced by: The Policy and Procedure titled, Facility Initiated Transfer or Discharge, dated 11/2017, stated if the transfer or discharge was facility initiated, the transfer-discharge notice would be faxed to the county Ombudsman program before or as close to the time of transfer/discharge as possible. The facility Policy and Procedure also stated this would be documented in the resident's medical record. Resident #17 Resident #17 was admitted to the facility with the diagnoses of atrial fibrillation (heart condition where the heart's upper chambers beat out of sync with the lower heart chambers), congestive heart failure, and arthritis. The Minimum Data Set (an assessment tool) dated 11/10/2023 documented the resident was understood, could understand others and was cognitively intact. The resident's Census record documented the resident was hospitalized [DATE] to 12/23/2023, and 12/24/2023 to 12/26/2023. The resident's medical record did not include documentation stating the ombudsman's office was notified of the resident's transfers to the hospital. Resident #57 The resident was admitted to the facility with the diagnoses of atrial fibrillation, cellulitis (a bacterial skin infection that may cause redness, swelling, and pain in the infected area of the skin), and chronic pulmonary obstructive disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems). The Minimum Data Set (an assessment tool) dated 8/13/2023 documented the resident was understood, could understand others and was cognitively intact. A Progress Note dated 10/25/2023 documented the resident was sent to the hospital for evaluation. The resident's medical record did not include documentation stating the Ombudsman's office was notified of the resident's transfer to the hospital. Interviews: During an interview on 1/30/2024 at 10:09 AM, Social Worker #1 stated they were not aware they had to inform the Ombudsman in writing of a resident's discharge or transfer. During an interview on 1/30/2024 at 11:00 AM, Administrator #1 stated they were not sure the Ombudsman's office needed to be informed in writing of a resident's transfer or discharge. 10 New York Codes, Rules and Regulations 415.3(h)(1)(iii)(a-c)

Based on record review and interviews during the recertification survey conducted from1/22/2024 to 1/30/2024, the facility did not ensure that the residents were free of unnecessary medications for 3 (Resident #'s 5, 16, 42) of 5 residents reviewed. Specifically for Residents #5 and #16, multiple medication orders did not include an indication for use; and for Resident #42, one medication did not have an indication for use, and a second medication with an order to administer as needed did not have parameters indicating what symptoms the as needed medication was for. This is evidenced by: Resident #5 Resident #5 was admitted to the facility with the diagnoses of Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), and diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels). The Minimum Data Set (an assessment tool) dated 1/6/2024 documented the resident was usually understood, could usually understand others, and had a moderate cognitive impairment. The Physician's Order report dated 1/29/2024 documented Resident #5 was prescribed the following medications: Acetaminophen 500 milligrams 2 tablets oral every 8 hours as needed Levothyroxine 88 micrograms 1 tablet oral every day Pimavanserin 34 milligrams 1 tab oral every day Senna tablet 8.6 milligrams 2 tablets oral at bedtime Nemanine 10 milligram1 tab oral twice a day Divalproex capsule delayed release sprinkle 125 milligrams amount 1000 milligrams oral at bedtime Donepezil tablet 5 milligrams 1 tablet oral once a day The Physician's Order report did not document the indication for the use of the prescribed medications. Resident #16 Resident #16 was admitted with the diagnoses of Parkinson's disease, diabetes mellitus, and psoriasis vulgaris (skin disease that causes a rash with itchy, scaly patches). The Minimum Data Set, dated dated dated [DATE] documented the resident was usually understood, could usually understand others, and had a moderate cognitive impairment. The Physician Order Report dated 1/29/2024 documented Resident #16 was prescribed the following medications: Acetaminophen 500 milligrams 1 tablets oral every eight hours as needed Allopurinol 300 milligrams 1 tab oral once a day at 5:00 AM Cholecalciferol 1250 micrograms 1 cap oral once a day on the 9th of the month Divalproex tablet delayed release 500 milligrams 1 tablet oral twice a day. Lactulose solution 10 grams per 15 milliliters 15 milliliters oral once a day Metformin 1000 milligrams 1 tab oral twice a day Metoprolol succinate tablet extended release 24 hour 100 milligrams 1 tab oral once a day Apixaban 5 milligrams 1 tab oral twice a day Tamsulosin capsule 0.4 milligrams 1 cap oral at bedtime Amantadine hydrochloride tablet 100 milligrams 1 tab oral once a day Fluticasone furoate-vilanterol blister with device 200=25 micrograms per dose 1 puff inhalation once a day Duloxetine capsule delayed release 20 milligrams 1 capsule oral once a day Lisinopril tablet 10 milligrams 1 tablet oral once a day Atorvastatin tablet 20 milligrams 1 tablet oral once a day The Physician's Order report did not document the indication for the use of the prescribed medications. Resident #42 Resident #42 was admitted with diagnoses of unspecified dementia, polyosteoarthritis (Polyarthritis is the medical term for having arthritis - inflammation or swelling of the joints - that affects five or more joints at the same time), and atrial fibrillation (an irregular and often very rapid heart rhythm). The Minimum Data Set, dated dated dated [DATE] documented that the resident could sometimes be understood and understand others, but with moderate cognition problems. The physician orders dated 12/28/2023 documented that the resident had Eliquis ordered twice a day without a diagnosis listed in the order. The physician orders dated 1/22/2024 - 2/5/2024 documented that the resident had Klonopin 0.5 milligrams ordered to be given every 12 hours as needed. There was no indication what parameters would require administration of the as-needed medication. The medication administration history dated 1/1/2024-1/29/2024 documented that Klonopin could be given every 12 hours as needed and did not indicate what behaviors required administration of the medication. Additionally, no reasons were documented why the medication was administered and what the results of administration were. Interviews During an interview on 1/29/2024 at 11:25 AM, Director of Nursing #1 stated each medication prescribed should have had a diagnosis attached for indication of use. Director of Nursing #1 did not know why some medications did not have an indication for use. During an interview on 1/29/2024 at 11:31 AM, Corporate Registered Nurse #1 stated when a medication order was entered, an applicable diagnosis should have been entered as well. Corporate Registered Nurse #1 stated there was a pull-down option in the order screen of the electronic medical record that would list the diagnoses of the resident with an option to enter a diagnosis such as a new onset infection. During an interview on 1/29/2024 at 1:00 PM, Pharmacist #1 stated that when doing medication reviews, the pharmacist looked at a particular resident's diagnosis list and attributed the orders written to the diagnosis list, and did not look specifically at the order as the order was written by the provider. 10 New York Codes, Rules and Regulations 415.12(l)(1) 48744

Based on observation, interview and record review during abbreviated survey (NY00324981, NY00325409, NY00327186, NY00327811, and NY00327951), the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being for all residents in the facility. Specifically, the facility did not ensure there were sufficient staff to meet resident needs, including activities of daily living, meals, medications, and treatments. In addition, five of the complaints investigated onsite had an allegation of insufficient staff and during Residents' interviews on 11/13/2023 - 11/15/2023, multiple residents stated there were long waits for call lights, showers were not given, medications were late, and there were not enough staff to provide care. This is evidenced by: The facility's staffing policy revised on 11/2023, documented staffing numbers and skills requirements of direct care staff were determined by the needs of the resident's care plan. Resident #3 was admitted to the facility with diagnoses of muscle wasting (loss of muscle) and atrophy (thinning of muscle), moderate protein calorie malnutrition, and vascular dementia (caused when decreased blood flow damages brain tissue). The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. Resident #5 was admitted with diagnoses of chronic pain, unspecified abnormalities of gait and mobility, and obesity. The Minimum Data Set (an assessment tool), dated 8/16/2023, documented the resident could understand and be understood by others. Resident required extensive 2 assist with Activities of Daily Living. The Comprehensive Care Plan for Activities of Daily Living dated 9/25/2023 last edited on 11/03/2023 documented Resident #5 required 2 assist and dependent for bathing, 2 assist dependent for toileting, and 2 assist dependent for transfers with mechanical lift. The Treatment Administration Record dated September 2023 documented weekly shower on evening shift every Thursday. The Treatment Administration Record was blank on 9/07/2023, 9/14/2023, 9/21/2023, and 9/28/2023. Upon entrance to the facility on [DATE], there were 56 residents residing on 2 units. There were 38 residents on [NAME] unit and 18 residents on [NAME] unit. During an observation on 11/13/2023 at 12:14 PM, 2 Certified Nurse Aides were observed on the [NAME] unit. During an observation on 11/14/2023 at 9:00 AM, 2 Certified Nurse Aides were observed providing resident care on the unit. The facility's daily staffing schedule dated 11/1/2023-11/15/2023 documented the following: -11/3/2023 Day shift (6 AM - 2:00 PM) - 1 Licensed Practical Nurse and 2 Certified Nurse Aides on [NAME] Unit for 42 residents. 1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] unit for 18 residents. -11/11/2023 Day shift (6 AM - 2:00 PM) - 1 Licensed Practical Nurse and 2 Certified Nurse Aides on [NAME] Unit for 41 residents. 1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] unit for 18 residents. -11/12/2023 Day shift (6 AM - 2:00 PM) - 1 Licensed Practical Nurse and 2 Certified Nurse Aides on [NAME] Unit for 40 residents. -11/12/2023 Evening shift (2:00 PM - 10:00 PM) - 1 Licensed Practical Nurse and 1 Certified Nurse Aide until 6:00 PM on [NAME] unit for 17 residents. 1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] Unit for 40 residents. -11/12/2023 Night shift (10:00 PM - 6:00 AM) -1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] Unit for 40 residents. -11/13/2023 Day shift (6 AM - 2:00 PM) - 1 Licensed Practical Nurse and 2 Certified Nurse Aides on [NAME] Unit for 41 residents. -11/13/2023 Evening shift (2 :00 PM - 10:00 PM) -1 Licensed Practical Nurse and 1 Certified Nurse Aide on [NAME] unit for 41 residents. 1 Licensed Practical Nurse and no Certified Nurse Aide on [NAME] unit for 18 residents. -11/13/2023 Night shift (10:00 PM - 6:00 AM) - 1 Registered Nurse and 1 Certified Nurse Aide for [NAME] unit for 40 residents. During an interview on 11/13/2023 at 11:20 AM, Resident #8 stated they did not receive their shower for 2 weeks. They stated the facility had no staff to provide care to the residents' and medications were given late. Resident #8 stated their room was not cleaned over the weekend and the full garbage can was from 11/11/2023 and 11/12/2023. During an interview on 11/13/2023 at 11:00 AM, Resident #5 stated when they called to use the toilet, they had to wait for about an hour. They stated they sometimes had to ease themselves into the incontinence brief. Resident #5 stated they did not receive shower two weeks ago and no one explained to them why the shower was not given. They further stated they had not been washed on 11/13/2023. Resident #5 stated they did not get washed unless they begged for it. During an interview on 11/13/2023 at 11:55 AM, Resident #12 stated there were not enough staff to help the residents with care. They stated most of the time they had two Certified Nurse Aides for the whole [NAME] unit. The resident further stated there were no housekeepers on the weekend to clean their rooms. During an interview on 11/13/2023 at 12:27 PM, Resident #16 stated 1 Certified Nurse Aide was taking care of 20 residents. They stated it was not right for 1 Certified Nurse Aide to be doing four people's job. They further stated there were always 2 Certified Nurse Aides on the evening shift. During an interview on 11/13/2023 at 4:01 PM, Director of Nursing #1 stated they had been doing audits on residents' care provided by staff. They stated it was brought to their attention that residents were not getting their showers. They stated Resident #11 brought it to their attention that Resident #11 was not receiving their weekly showers. They further stated since they started in September 2023, staffing had always been an issue. During an interview on 11/14/2023 at 8:45 AM, Certified Nurse Aide #3 stated there were 37 residents on the [NAME] Unit with 2 Certified Nurse Aides assigned. They stated Licensed Practical Nurse did not help with resident care. They stated sometimes they could not toilet residents when the residents' requested to be toileted, residents had to wait for 30 minutes - 1 hour before they could be toileted. They stated there were times that they could not finish morning care until lunch time or could not pass out breakfast trays. They further stated resident showers were not given at times because they were busy and could not give residents their showers. During an interview on 11/14/2023 at 9:05 AM, Certified Nurse Aide #4 stated they had been working on the [NAME] unit with 2 Certified Nurse Aides on day shift for 40 residents which typically should be 4 Certified Nurse Aides. They stated the nurses did not help with residents' care, meals, and or feeding residents. They stated they had 5 residents on the [NAME] unit that required assistance with eating which was difficult with 2 Certified Nurse Aides. During an interview on 11/15/2023 at 8:00 AM, Resident #18 stated when they rang the call bell the night of 11/14/2023, no one showed up. They stated when they had to use the toilet it took forever for staff to come. Resident #18 stated the staff had many residents on their list to care for and staff did not have enough time to provide the care. They further stated they required 2 people to assist them to the toilet. During an interview on 11/15/2023 at 8:05 AM, Resident #19 stated there was not enough staff to respond when they needed assistance to the toilet. They stated they missed showers the previous week and was told by staff the facility did not have enough staff. An interview was conducted with the Administrator on 11/15/2023 at 8:59 AM regarding the status and information of a facility-wide assessment, such as what resources the facility had identified to competently care for its residents during day-to-day operations. During the interview, the Administrator stated they did not have a completed Facility Assessment but was working on one. They further stated that they started in their position on 10/30/2023 and residents had brought it to their attention the history of no staff at the facility. The Administrator stated they had been working on recruiting staff and had not looked at the facility's Assessment. They further stated they knew what the staffing looked like and should be. During an interview on 11/15/2023 at 10:23 AM, Licensed Practical Nurse #2 stated medications were given late because the facility went from 2 Licensed Practical Nurses to 1 Licensed Practical Nurse on the [NAME] unit. They further stated they were the only Licensed Practical Nurse administering medications to 37 residents. During an interview on 11/15/2023 at 9:51 AM, Certified Nurse Aide #5 stated they usually worked with 2 Certified Nurse Aides on the [NAME] unit on the day shift for 40 residents. Theystated they had 20 residents to provide care to and there were days that they could not assist residents with their shower due to short staff. They stated residents' have complained to them that they were not properly cleaned by staff. During an interview on 1/08/2024 at 11:04 AM, Licensed Practical Nurse #5 stated staffing was a major problem in the facility. They stated there were 2 nursing units in the facility, McAauley (upstairs) and [NAME] (downstairs). They stated there was usually 40 residents on the [NAME] unit, and the facility staffed 1 Licensed Practical Nurse on the unit daily and was to routinely staff 4 Certified Nurse Aides, but usually had only 2 or 3. They stated they were a somewhat new nurse, and 40 residents was too much for one nurse to provide care to. They stated there were several residents with behavioral issues and it was difficult to manage the behaviors and to provide care to the other residents. They stated the medication pass was always done late. They stated it was impossible to get the medications passed on time, even with having an hour window before and after the medication was due to be given. They stated the [NAME] unit had 18 residents and was staffed daily with 1 Licensed Practical Nurse and either 1 Certified Nurse Aide or none. They stated when there was no Certified Nurse Aide, they had to do everything. They had to perform their regular nursing duties; medication pass and treatments and the Certified Nurse Aide tasks; toileting and passing meal trays. They stated lately the facility had been staffing 1 Licensed Practical Nurse on the night shift to provide care to residents on both units. During an interview on 1/08/2024 at 4:10 PM, Certified Nurse Aide #6 stated the facility was extremely short staffed. They stated the facility currently had only 1 Licensed Practical Nurse and 1 Certified Nurse Aide to provide care to all the residents during the entire night shift, and there were no Registered Nurses in the building. They stated when facility was full, the [NAME] unit had 22 residents and the [NAME] unit had 42. They stated there were approximately 17 residents in the facility that were full code status and required cardiopulmonary resuscitation if they stopped breathing. They stated there was no way possible night shift staff could handle an emergency while providing care to the other residents. They stated at least half of the residents on the [NAME] unit required assistance of 2 staff. They stated they were generally assigned to either unit as needed. They stated the facility routinely staffed 1 Licensed Practical Nurse and 1 Certified Nurse Aide on the [NAME] unit during the day shift. They stated that sometimes there was no Certified Nurse Aide staffed on the [NAME] unit during the day and evening shifts and the Licensed Practical Nurse would have to do both jobs and would have administrative duties as well. On the [NAME] unit, the facility routinely staffed 1 Licensed Practical Nurse, 2 Certified Nurse Aides and 1 Hospitality Aide, and there were generally 40 residents on the unit. They stated the Hospitality Aides could not perform tasks done by the Certified Nurse Aide and essentially could only answered call lights. They stated that when they worked on the [NAME] unit and they were the only Certified Nurse Aide, it would take them almost one hour to pass out the meal trays and then would spend more time to run to the kitchenette to reheat the meals because they were cold. They stated the nurse assigned to the unit would not help to pass the trays. Occasionally, the Activities person would help. They stated it was dangerous during mealtimes on the upstairs unit because residents were not being supervised and the Licensed Practical Nurse was rarely available. They stated there were tasks that were not being done when they worked alone on the upstairs unit, such as not having enough time to brush resident's teeth, not toileting all residents, and weekly bedsheet changes. They stated they had to pick and choose who was more important to toilet. They stated there were several residents that were lying in the same sheets for several days, and only had time to do a full bed change when a resident soiled the bed. They stated they made sure they documented on every resident, every day and when they worked alone it would take them about one and a half hours to document, depending on which unit they worked. During an interview on 1/09/2024 at 2:14 PM, the Staffing Coordinator stated the [NAME] unit should have 1 Licensed Practical Nurse, 4 Certified Nurse Aide on day shift, 1 Licensed Practical Nurse, 3 Certified Nurse Aides on evening shift, and 1 Licensed Practical Nurse and 2 Certified Nurse Aides on night shift. The [NAME] unit should have 1 Licensed Practical Nurse and 1 Certified Nurse Aide on day shift, 1 Licensed Practical Nurse and 1 Certified Nurse Aide on evening shift, and 1 Licensed Practical Nurse and 1 Certified Nurse Aide on night shift. They further stated 5 out of 7 days they could only staff 3 Certified Nurse Aides on day shift for the [NAME] unit. They stated it was hard to find local people to work. During an interview on 1/15/2024 at 3:09 PM, Licensed Practical Nurse #4 stated that sometimes Resident #3's unit did not have an assigned Certified Nurse Aide. They stated there were several times when they were left without an assigned Certified Nurse Aide and had to perform the responsibilities of the Certified Nurse Aide in addition to their nursing responsibilities. They stated they would not have been able to monitor and/or document the amount the of fluids or food the residents had consumed. During an interview on 1/12/2024 at 11:09 AM, Medical Director #1 stated facility staffing was a challenge since the new company took over in July 2023. They stated the switch over was difficult and a bunch of nurses quit as well as kitchen staff. They stated the facility tried to get everybody they possibly could hired but no one wanted to drive to where the facility was located. They stated staffing was still a challenge in September 2023. They stated the facility more recently transitioned from inexperienced nurses to nurses who were capable, but the facility was understaffed. They stated that right now, the Director of Nursing and the Assistant Director of Nursing were running medication carts. They stated the facility tried to hire staff so they could do the double checks that needed to be done. They stated the facility was in the process of hiring Licensed Practical Nurses that used to work there. During an interview on 1/11/2024 at 4:09 PM, Registered Nurse Manager #1 stated they were the acting Assistant Director of Nursing and left the facility at the end of October 2023. They stated they did not have a lot of interaction with Resident #3 and stated they were on a medication cart the entire time they worked in the facility, which was about 3 weeks. They stated that for the most part, they were the only Registered Nurse in the building for much of the time and if the facility was full, there were 60 residents. During an interview on 1/19/2024 at 3:34 PM, Certified Nurse Aide #7 stated they were a traveler/agency and was familiar with Resident #3. They stated they worked on the resident's unit during the evening shift on 9/18/2023 and 9/20/2023 with Certified Nurse Aide #8. They stated things were very hectic on the unit because the facility was short-handed with facility staff. They stated they were not able to keep track of what the residents ate or drank and there was no time to document anything. They stated the nurses were working as aides in addition to their regular duties much of the time because there were no Certified Nurse Aides on the unit or not enough. They stated that often there was only 1 nurse to cover both nursing units. During an interview on 1/19/2024 at 3:46 PM, Certified Nurse Aide #8 stated they were a traveler and was not sure if they worked on the [NAME] or [NAME] nursing unit on 9/18/2023 and 9/20/2023. They stated they usually worked with Certified Nurse Aide #7. They stated that often it was only the 2 of them working on the [NAME] unit that had 50 residents, several with COVID, and there was only 1 nurse in the building. They stated they would not have been able to monitor how much residents were eating/drinking. 10 New York Codes, Rules and Regulations 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews conducted during an abbreviated survey (Case #s NY00324981 and NY00325409), the facility did not ensure that residents were free from any significant medication errors for 3 (Residents #s 3, 4, and 11) for 4 residents reviewed for not receiving their medications in a timely manner per physician orders. This is evidenced by: The facility Policy and Procedure for Medication Administration dated 12/2018, documented all medications should be administered one hour before or after the prescribed time. Medications should be given per facility's policy for times as well as recommended administration times. Medication Administration Records should be signed after administration. Resident #3: Resident #3 was admitted to the facility with diagnoses of atrial fibrillation, hypertension, and heart disease of native coronary artery. The Minimum Data Set, dated dated dated [DATE], documented the resident's Brief Interview for Mental Status score was cognitively intact. The Physician Order Report dated 9/01/2023 to 9/30/2023, documented: - 8/29/2023 Losartan 100 milligrams once a day at 6:30 AM. Special instructions: hold for systolic blood pressure less than 100. - 8/07/2023 Metoprolol Succinate tablet extended release 24 hour; 50 milligrams; amount 0.5; once a day at 6:30 AM. Special instructions: half tablet (25 milligrams) by mouth once daily for hypertension. Hold for systolic blood pressure less than 100 or heart rate less than 60. Review of the Medication Administration Record dated 9/01/2023 to 9/30/2023 documented the following: Losartan tablet 100 milligrams, once a day, hold for systolic blood pressure less than 100 at 6:30 AM. -9/01/2023 documented at 7:49 AM by Licensed Practical Nurse #5, not administered due to condition and documented heart rate 104, blood pressure 125/70. Metoprolol Succinate tablet, extended release 24 hours, 50 milligrams, once a day, half tablet 25 milligrams, for hypertension, hold for systolic blood pressure less than 100 or heart rate less than 60 at 6:30 AM -9/02/2023 documented at 3:54 PM by Licensed Practical Nurse #4, not administered other and documented DAYS. Blood pressure was documented as 128/70 and pulse was not documented. During an interview on 1/05/2024 at 3:09 PM, Licensed Practical Nurse #4 stated they worked 2:00 PM to 10:00 PM on 9/02/2023 and would not have administered the Metoprolol because it was scheduled to be administered at 6:30 AM. They stated they documented days and should have documented it was to be given on the dayshift. They stated they were not sure if it was given by the dayshift nurse and stated they would have contacted the physician through the named electronic messaging application to let the physician know. They stated they did not recall who the dayshift nurse was. During an interview on 1/08/2024 at 11:04 AM, Licensed Practical Nurse #5 stated it was probably an error when they did not give the Losartan on 9/01/2023. They stated they usually held it when the vital signs were outside of the parameters on the order. They stated they did not know why they documented due to condition and stated the facility had converted to a new computer system and they were not trained. They stated they were a new nurse, and 40 residents was too much for one nurse to provide care to. Resident #4: Resident #4 admitted with diagnoses of congestive heart failure (when the heart cannot pump enough oxygen-rich blood to meet the body's need, atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating of the atrial chamber), and diabetes type II. The Minimum Data Set (an assessment tool) dated 5/24/2023, documented the resident could be understood and could understand others. Physician order dated 5/27/2020 documented Xarelto (rivaroxaban) tablet 20 milligrams, one tablet by mouth once daily at 8:00 PM for A-FIB. Physician order dated 8/28/2023 documented the following: -Bumetanide tablet 0.5 milligrams, one tablet by mouth once daily for congestive heart failure at 8:00 AM -Digoxin tablet 250 microgram, one tablet by mouth daily for Atrial fibrillation at 08:00 AM -Entresto (sacubitril-valsartan) tablet 24-26 milligram, one half tablet (12-13 milligrams) by mouth twice daily for heart failure at 08:00 AM and 8:00 PM. -Farxiga (dapagliflozin propanediol) tablet, 10 milligrams, one tablet by mouth once daily for diabetes at 8:00 AM. Review of the Medication Administration Records (MAR) dated 10/2023 documented the following: Digoxin tablet 250 microgram (MCG), one tablet by mouth daily for Atrial fibrillation (A-FIB) at 08:00 AM -10/6/2023 documented administered at 12:36 PM and documented administered late, nurse running behind. -10/8/2023 documented administered at 09:56 AM and documented administered late. -10/18/2023 documented administered at 10:25 AM and documented administered late. -10/25/2023 documented administered at 2:39 PM and documented administered late. -10/29/2023 documented administered at 10:19 AM and documented late administration; assisting with care. Review of the Medication Administration Records dated 11/2023 documented the following: Entresto (sacubitril-valsartan) tablet 24-26 milligrams, one half tablet (12-13 milligrams) by mouth twice daily at 8:00 AM and 8:00 PM for heart failure were documented as administered late for the following dates: -11/04/2023 8:00 AM dose was administered at 10:49 AM and staff documented charted late. -1/04/2023 8:00 PM dose was administered at 10:43 PM and documented administered late. 1/09/2023 8:00 AM dose was administered at 11:22 AM and documented charted late. -11/9/2023 8 :00 PM dose was administered at 09:58 PM and documented administered late. -11/11/2023 8:00 PM dose was administered at 11:23 PM and documented administered late. 11/13/2023 8:00 PM dose was administered at 9:59 PM and documented administered late. Farxiga (dapagliflozin propanediol) tablet, 10 milligrams, one tablet by mouth once daily at 8:00 AM for diabetes. -11/02/2023 documented administered at 10:10 AM -11/06/2023 documented medication unavailable -11/09/2023 documented administered at 11:22 AM and charted late. -11/10/2023 documented administered at 10:32 AM. and charted late. Xarelto (rivaroxaban) tablet 20 milligrams, one tablet by mouth once daily at 8:00 PM. -11/04/2023 administered at 10:43 PM and documented administered late. -11/06/2023 administered at 10:28 PM and documented administered late. -11/09/2023 administered at 9:58 PM and documented administered late. -11/11/2023 administered at 11:50 PM and documented administered late. -11/13/2023 administered at 9:59 PM and documented administered late. Resident #11: Resident #11 was admitted with diagnoses of spinal stenosis (narrowing of the spinal canal), intervertebral disc degeneration, and depression. The Minimum Data Set (an assessment tool) dated 10/26/2023, documented the resident could be understood and could understand others. Physician order dated 8/30/2023 documented atenolol 25 milligrams. One tablet (25 milligrams) by mouth once daily Review of the Medication Administration Record dated 10/01-10/31/2023 documented the following: Atenolol 25 milligrams. One tablet (25 milligrams) by mouth once daily at 9:00 AM. -10/06/2023 administered at 11:11 AM and documented administered late, nurse running behind. -10/08/2023 administered at 10:21 AM and documented administered late. -10/19/2023 administered at 2:55 PM and documented late administration: charted late. -10/25/2023 administered at 2:22 PM and documented administered late. -10/27/2023 administered at 10:22 AM and documented and documented charted late. Physician order dated 8/10/2023 documented belbuca buccal film 150 microgram. 150 microgram in the cheek at bed time for chronic pain. Review of the Medication Administration Record dated 10/01-10/31/2023 documented the following: Belbuca buccal film 150 microgram. 150 microgram in the cheek at bed time for chronic pain at 8:00 PM. -10/04/2023 administered at 10:09 PM and documented administered late, Registered Nurse was assisting declining resident on other unit. -10/06/2023 administered at 9:14 PM and documented charted late. -10/11/2023 administered at 9:06 PM and documented late administration: charted late. -10/14/2023 administered at 9:16 PM and documented late administration: charted late. -10/15/2023 administered at 9:11 PM and documented late administration. Review of Medication Administration Record dated 11/1-11/15/2023 documented the following: Belbuca buccal film 150 microgram. 150 microgram in the cheek at bed time for chronic pain at 8:00 PM. -11/5/2023 administered at 9:55 PM and documented administered late. -11/11/2023 administered at 9:55 PM and documented administered late: arrived from pharmacy just now. -11/12/2023 administered at 9:01 PM and documented late administration. -11/13/2023 documented no administered: drug unavailable. Physician order dated 10/6/2023 documented fluoxetine tablet 10 milligrams; 2 tablets. Give 20 milligrams by mouth once a day for depression. Medication Administration Record dated 10/01-10/31/2023 documented the following: fluoxetine tablet 10 milligrams; 2 tablets oral. Give 20 milligrams by mouth once a day. -10/06/2023 administered at 11:11 AM and documented administered late: nurse running behind. -10/08/2023 administered at 10:21 AM and documented administered late -10/25/2023 administered at 2:22 PM and documented administered late. Review of Resident #11' progress notes dated 10/01-11/15/2023 did not have documented evidence that the physician was notified when medications were given late and also when resident did not receive their belbuca 150 milligrams on 11/13/2023. During an interview on 11/13/2023 at 12:49 PM, Resident #11 stated they did not receive their belbuca for 3 days last week because the pharmacy did not have the medication and was not sure if they were going to receive it on 11/13/2023. The resident stated they have been getting their other medications late. During an interview on 11/14/2023 at 11:00 AM, Resident #4 stated they received their 9:00 PM medications at 10:15 PM most of the nights. During an interview on 11/14/2023 at 3:30 PM, Licensed Practical Nurse #1 stated medications should be given one hour before or one hour after the time it was ordered. They stated resident medications were given late due to no staff and they were the only nurse administering medication to 35 residents. Licensed Practical Nurse #1 stated Administration knew that resident medications were given late. They further stated that they sometimes gave scheduled 9:00 PM medications at 11:00 PM. They stated they did not notify the physician that the medications were given late. During an interview on 11/15/2023 at 10:13 AM, Licensed Practical Nurse #2 stated they were the only nurse administering medications to 37 residents and that was why the medications were given late. They stated the physician should be notified when medications were given late and should be documented. During an interview on 11/15/2023 at 9:30 AM, the Director of Nursing stated the facility went from two Licensed Practical Nurses on day shift to one Licensed Practical Nurse. They stated medications were given late due to heavy medication pass with only one nurse. The Director of Nursing stated the physician should be notified and documentation completed when medications were administered late. They further stated residents brought to their attention when they started in September 2023, that they were not receiving their medications on time. The Director of Nursing further stated it was their responsibility and the Assistant Director of Nursing to ensure that the physician was notified when medications were given late. During a subsequent interview on 11/15/2023 at 10:45 AM, the Director of Nursing stated the physician should be notified when a medication was not given. They stated they could not find the documentation that the physician was notified on 11/13/2023 for Resident #11 belbuca 150 micrograms when the medication was not available. During an interview on 1/12/2024 at 11:09 AM, Medical Director #1 stated they did not recall the facility calling about Resident #11's Belbuca on 11/13/2023. They stated they have been called about the resident's Belbuca multiple times and stated the medication was difficult to obtain. They stated they tried to get the resident to take something else and the resident continued to request the Belbuca because it worked for them. They stated for any medication issue, they expected nurses to call them and tell them what happened so they could decide on a plan for the resident regarding their medication. They stated they did not recall being called about any medication issues with Resident #3. They stated it was a challenge back in September for the facility to hire nurses. They stated the facility had some inexperienced nurses who were also not trained on the new computer system. They stated mistakes were made and the medical record was not documented accordingly. They stated some nurses were holding medications for the wrong parameters and were holding blood pressure medications when the heart rate was high instead of holding it when the blood pressure was low. They stated it happened infrequently, but it was happening. They stated they expected nurses to call them and tell them what happened so they could decide on a plan for the resident regarding their medication. They stated they used a named electronic application for sending images when the fax machine was not working because sending through email was not secure. They stated nurses were not to use the application for medication issues, they had to call them per the regulation. 10 New York Codes, Rules and Regulations 415.12(m)(2)

Based on record review and interviews during an abbreviated survey (Case# NY00298857), the facility did not ensure that all alleged violations involving neglect were reported immediately-but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily harm-to the Administrator of the facility and to the State Survey Agency for 1 (Resident #1) of 3 residents reviewed. Specifically, on 7/6/2022 at 2:45 PM, Registered Nurse #1 was made aware that Resident #1 rolled out of bed when staff attempted to dry the resident's back. Upon arrival to the facility, Registered Nurse #1 found the resident lying flat on their back with legs partially extended toward the foot of the bed, an icepack on their forehead, a laceration approximately 2 centimeters long on the right forehead with minimal bleeding and significant swelling. Resident #1 was transferred to emergency room for evaluation. The incident was reported to the New York State Department of Health 5 days later on 7/11/2022 at 4:19 PM. This is evidenced by: The facility Policy and Procedure titled, Abuse & Neglect Policy; Section 1- Abuse Prevention and Reporting, revised 1/11/2023, documented all employees were required to report in accordance with Public Health laws when they had reasonable cause to believe that a person receiving care or services in a residential health care facility had been physically abused, mistreated, or neglected. Circumstances to be reviewed included but was not limited to the presence of a physical condition at variance with the history and course of treatment of the resident. The Director of Nursing/shift supervisor for the evening and night shifts would take these immediate steps once an allegation or abuse or neglect had been filed: promptly notify the Administrator, Medical Director, and Director of Nursing of alleged or confirmed abuse or neglect. It documented in response to an allegation of neglect the facility must ensure that all alleged violations involving neglect were to be reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, chronic kidney stage disease stage 3, and primary generalized osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time). The Minimum Data Set (an assessment tool), dated 6/15/2022, documented the resident's cognitive skills for daily decision making were severely impaired and that they never/rarely made decisions. The facility incident report dated 7/06/2022 at 2:45 PM by Registered Nurse #1 documented: -Registered Nurse #1 received a call at home from the Supervisor's cell phone where it was reported to them that Resident #1 rolled out of bed when staff attempted to dry their back. Upon arrival to the facility, Registered Nurse #1 found the resident lying flat on their back with legs partially extended toward the foot of the bed. An icepack had been placed on their forehead. A laceration that measured approximately 2 centimeters was noted on the right forehead with minimal bleeding but had significant swelling. The physician and resident's daughter were notified, and both agreed to transfer the resident to the emergency room for evaluation. -Other Information documented the resident had little control in positioning their legs. While they were rolled onto their side for staff to dry their back, their legs slipped off the bed. The staff who was assisting slipped on water at the bedside and lost their balance and the resident fell to the floor from bed, landing on their right side. The New York State Department of Health Intake Information form for Case # NY00298857 documented the facility incident occurred on 7/06/2022 at 2:45 PM, and the facility reported the incident to the New York State Department of Health on 7/11/2022 at 4:19 PM. It documented the incident was a result of a care plan violation and that the facility had completed their investigation. During an interview on 12/21/2023 at 11:46 AM, Licensed Practical Nurse #3 stated they called the provider and sent the resident to Emergency Department. They stated Director of Nursing #2 was on vacation and was reached by phone. During an interview on 12/28/2023 at 1:38 PM, Administrator #2 stated they did not recall why the facility did not report the incident until 7/11/2022 and stated they did not know about the incident until Director of Nursing #2 reported it to them and could not recall the date. During an interview on 12/28/2023 at 4:02 PM, Director of Nursing #2 stated they were on vacation on 7/06/2022, and that Licensed Practical Nurse #3 was in charge during their absence. Director of Nursing #2 stated they were not informed at the time of the incident, were made aware of the incident when they returned to work on 7/11/2022 and completed the investigation that was started by Registered Nurse #1 back on 7/06/2022. They stated they told Administrator #2 on 7/11/2022, and then reported to the New York State Department of Health. Cross-reference F656. 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on record review and interviews during an abbreviated survey (Case #s NY00298857 and NY00324981), the facility did not ensure it developed and implemented a comprehensive, person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 (Resident #s 1 and 3) of 3 residents reviewed. Specifically, (A) Resident #1's comprehensive care plan for Self-Performance Deficit documented the resident had limited mobility and required 2 staff to assist with bed mobility. The facility did not ensure the care plan intervention for 2 staff to assist with bed mobility was implemented when, on 7/06/2022, Certified Nurse Aide #1 did not wait for Certified Nurse Aide #2 to assist with bed mobility and turned the resident on their side towards the edge of the bed to dry them. As of result, the resident's legs slipped off the bed, Certified Nurse Aide #1 was unable to stop the resident from falling to the floor, the resident sustained a hematoma (solid swelling of clotted blood within the tissues) and laceration to their forehead, and was transferred to the emergency room for evaluation. (B) Resident #3 was assessed at moderate risk for dehydration and had an alteration in nutrition related to poor intake. There was no care plan to address their nutrition and hydration needs. This is evidenced by: The undated facility Policy and Procedure titled, Care Plans Comprehensive Person-Centered, documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident. The Interdisciplinary Team, which included the nurse aide who had responsibility for the resident, developed and implemented a comprehensive, person-centered care plan for each resident. Care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Record review of a facility document with the job description for job title, 'Certified Nursing Assistant - Long Term Care,' dated May 2018, documented the Certified Nursing Assistant would provide each of their assigned residents daily nursing care and services in accordance with the resident's assessment and care plan or directed by the nurse. They would perform all assigned tasks in accordance with the facility's established policies and procedures, and as instructed by their supervisors. They would review Kardex (an electronic medical record system) daily to determine if changes in each resident's daily care routine had been made on the Kardex. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, chronic kidney stage disease stage 3, and primary generalized osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). The Minimum Data Set (an assessment tool) dated 6/15/2022,documented the resident's cognitive skills for daily decision making were severely impaired, and they never/rarely made decisions. The Comprehensive Care Plan for Self-Performance Deficit related to limited mobility, stroke with residual weakness, non-ambulatory, and bowel and bladder incontinence, last revised 10/27/2022, documented Resident #1 required the assistance of 2 staff for bed mobility. The Visual/Bedside Kardex Report dated 6/26/2022, documented the resident required assistance of 2 staff for bed mobility. The incident report dated 7/06/2022 at 2:45 PM by Registered Nurse #1 documented: --Registered Nurse #1 received a call at home from the Supervisor's cell phone that the resident rolled out of bed when staff attempted to dry their back. Upon arrival to the facility, they found the resident lying flat on their back with legs partially extended toward the foot of the bed. An icepack had been placed on their forehead. A laceration that measured approximately 2 centimeters was noted on the right forehead with minimal bleeding but had significant swelling. The physician and resident's daughter were notified, and both agreed to transfer the resident to the emergency room for evaluation. -Witness statements documented: --On 7/06/2022, Certified Nurse Aide #1 stated they just finished showering the resident and started to turn the resident and dry them while the other aide was there. They stated that after the aide walked out, they slipped on water while they were trying to hold the resident and that was when the resident slipped from their hands and yelled. --On 7/06/2022, Certified Nurse Aide #2 stated they did not witness the fall. They heard someone scream and went right away. The resident was on the floor on their right side. During an interview on 12/20/2023 at 3:49 PM, Certified Nurse Aide #1 stated they worked for an agency and was assigned to Resident #1 on 7/06/2022. They stated they always looked at the resident's care plan that was in the computer and in the resident's closet to see if the resident was a 1 person or 2 person assist. They stated they were familiar with the resident and knew Resident #1 required 2 staff for care. They stated that on 7/06/2022, they gave the Resident #1 a shower and then they and Certified Nurse Aide #2 used the mechanical lift to place the resident in their bed. They stated Certified Nurse Aide #2 then left the bedside and pushed the mechanical lift outside the room. They stated Certified Nurse Aide #2 was only gone for a few seconds and then came back in the room. They stated they were at the head of the bed and Certified Nurse Aide #2 was at the foot of the bed drying the resident when suddenly the guard rail on the bed came down. They stated it was usually locked in place but did not think to check to see that it was secure. The resident then began to slide off the bed and they could not stop the resident from falling because the floor was wet. Certified Nurse Aide #1 stated their feet slipped, the resident landed on the floor their side and hit their head. Certified Nurse Aid #1 stated Resident #1 sustained a big bump on their head from the fall, and that the bed e guard rail was the cause for the resident falling. They stated they did have a second person, Certified Nurse Aide #2, who was in the room with them when the resident fell . They stated they tried to explain to Director of Nursing #2 that the bed guard rail was the problem, but Director of Nursing #2 did not agree with them. During an interview on 12/21/2023 at 9:43 AM, Certified Nurse Aide #2 stated they worked for an agency and was familiar with Resident #1 and their care needs. They stated it was on the resident's care plan that the resident needed 2 staff to assist with bed mobility. They stated the care plan was in the computer and in the resident's closet. They stated that on 7/06/2022, after the resident was showered, they helped Certified Nurse Aide #1 placed the resident back in their bed using a mechanical lift. They stated the resident required 2 staff for bed mobility because the resident could not turn themselves. They stated they told Certified Nurse Aide #1 to wait for them while they removed the mechanical lift from the room and Certified Nurse Aide #1 acknowledged what they said. They left the room with the mechanical lift to put in the storage area located close to the resident's room and then heard a scream. They stated they saw the resident on the floor and Certified Nurse Aide #1 in the room and screamed for the supervisor. They stated there was no one else in the room. They stated the resident had a head injury and was sent to the hospital. They stated that a few days after the incident, Director of Nursing #2 asked Certified Nurse Aide #1 why they turned the resident by themselves, and Certified Nurse Aide #1 said Certified Nurse Aide #2 was with them. Certified Nurse Aide #2 stated Resident #1 fell out of bed because Certified Nurse Aide #1 did not wait for them to help and turned the resident by themselves. They stated they did not hear anything about the guard rail falling before the resident fell out of bed. They stated Certified Nurse Aide #1 could not use the guard rail as a reason for why the resident fell because it was lowered by staff when care was provided, and the resident still needed 2 staff to turn them in bed. They stated Certified Nurse Aide #1 told them their feet slipped because there was water on the floor from the mechanical lift and they could not hold the resident up when the resident started to slide off the bed. They stated Certified Nurse Aide #1 was familiar with the resident and was aware they needed to look at the resident's care plan before providing care. They stated Certified Nurse Aide #1 made a mistake and should have owned up to it. During an interview on 12/21/2023 at 11:46 AM, Licensed Practical Nurse #3 stated when they worked in the facility, they were the admissions coordinator and worked on the units. They stated Resident #1 had a history of femur (thigh bone) fractures and their bones were very brittle. They stated that after the fractures, the resident was care planned to have 2 staff assist with transfers and bed mobility. They stated they did not have the facility's policy in front of them but knew Certified Nurse Aides were to review the resident's care plan prior to providing any care and stated it was a standard of care. They stated the resident had an enabler bar on the bed that would have been recommended by Physical Therapy following assessment and was used by the resident to assist with some care. The enabler bar was about 2.5 to 3 inches wide, attached to the bedframe, and was positioned between the resident's elbow and wrist. They stated the enabler bar was moved down when providing care to the resident and stated the knob had to be pulled to get the bar down. They stated the knob was pulled and twisted when raising it up and there was a locking mechanism to keep it secured. They stated they never experienced a problem with enabler bars and they were not aware of any issues with Resident #1's enabler bar. They stated the care plan for bed mobility was not adhered to when Certified Nurse Aide #2 removed the mechanical lift from the room and Certified Nurse Aide #1 attempted to turn the resident by themselves and the resident fell to the floor. They stated they called the provider and sent the resident to Emergency Department. During an interview on 12/28/2023 at 4:02 PM, the Director of Nursing #2 stated they recalled the incident with Resident #1 on 7/06/2022. They stated they and the nurse manager were on vacation at that time. They stated they talked to Certified Nurse Aide #1 when they returned to work, and Certified Nurse Aide #1 told them they gave the resident a shower and put the resident back to bed. While they were drying the resident, the resident slid off the bed. They stated Certified Nurse Aide #1 did not follow the care plan when they rolled the resident by themselves. They stated Certified Nurse Aide #1's initial training included looking at the Kardex prior to providing care to any resident. They stated that after the incident, they had a training conversation with Certified Nurse Aide #1 with what the expectation was for providing care to residents. They stated they were not aware of any issue with a guard rail, and that the resident had an enabler bar that the resident would hold onto while being positioned on their side. They stated Certified Nurse Aide #1 moved the enabler bar down to provide care. They stated if Certified Nurse Aide #1 had followed the care plan, there would have been a second Certified Nurse Aide in the room with them to help turn the resident. Director of Nursing #2 stated Certified Nurse Aide #1 did not wait for the second aide to help and the resident fell . They stated the mechanical lift took less than a minute to put outside the resident's door. They stated Certified Nurse Aide #1's employment contract was then terminated. They stated the resident returned to the facility following the emergency room visit and there were no long-term adverse effects from the fall. They stated direct care staff were re-trained following incident on reviewing the electronic medical record system and in using the mechanical lift. Resident #3: Resident #3 was admitted to the facility with diagnoses of muscle wasting (loss of muscle) and atrophy (thinning of muscle), moderate protein calorie malnutrition, and vascular dementia (caused when decreased blood flow damages brain tissue). The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. The Comprehensive Care Plan revised 6/27/2023 for Nutritional Problem related to decreased appetite, dementia, and low body mass index was reviewed. Care plan goals documented the resident would consume at least 75% of at least 2 of 3 meals daily and would have no signs and symptoms of malnutrition as evidenced by significant weight loss and muscle wasting. The care plan did not document the resident's hydration needs, risk for dehydration, and interventions to prevent dehydration. The Comprehensive Care Plan initiated on 8/08/2023 and revised 9/06/2023 for Nutritional Status documented an alteration in nutrition related to poor intake at times. Care plan goals documented the resident would be placed on the most appropriate diet for wellbeing, and care plan interventions documented the facility would complete nutritional evaluation, weigh the resident on admission and the day after admission and as ordered by the Medical Provider, obtain physician order for diet, and communicate to Dietary Department. The care plan did not document the resident's nutrition and hydration needs, risk for dehydration, and interventions to prevent dehydration. During an interview on 1/12/2024 at 2:48 PM, Director of Nursing #1 stated the facility transitioned to a new electronic medical record on 8/08/2023. During the interview, they reviewed the care plan for Nutritional Status in the current computer system and stated it was a bare bone care plan. Director of Nursing #1 stated it would have been up to nursing to place a person-centered care plan with interventions to prevent dehydration and weight loss. They stated the resident was still at risk for dehydration at that time. They stated Director of Nursing #3, who left the facility around 9/13/2023, was responsible for developing and implementing the care plan. During an interview on 1/11/2024 at 4:09 PM, Registered Nurse Manager #1 stated they were the acting Assistant Director of Nursing and left the facility at the end of October 2023. They stated they did not receive any training on the new electronic medical record and did not develop or update any care plans during the three weeks they worked at the facility. They stated they were not aware Resident #3 was at moderate risk for dehydration. Cross-reference F609 and F692. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on record review and interviews during an abbreviated survey (Case # NY00324981), the facility did not ensure acceptable parameters of nutrition were maintained for 1 (Resident #3) of 3 residents reviewed. Specifically, for Resident #3, who was admitted to the hospital by a family member on [DATE] with colitis and acute kidney injury, the facility did not recognize, evaluate, and address the nutritional needs of the resident who was at risk for dehydration. The Hospital Discharge Summary Report, dated [DATE], documented a final diagnosis of prerenal acute kidney injury in the setting of colitis and poor oral intake. This is evidenced by: The undated facility Policy and Procedure titled, Hydration and Prevention of Dehydration, documented the facility would strive to provide adequate hydration and to prevent and treat dehydration. The dietician would assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. Minimum fluid needs would be calculated and documented on initial, annual, and significant change assessments, using current standards of practice. The dietician and nursing staff would educate the resident and family regarding hydration and preventing dehydration. Nursing would assess for signs and symptoms of dehydration during daily care. Nurse Aides would provide and encourage intake of bedside snack and meal fluids, on a daily and routine basis as part of daily care. Intake would be documented in the medical records and aides would report intake of less than 1000 milliliters per day to nursing staff. If potential inadequate intake and/or signs and symptoms of dehydration were observed, intake and output monitoring would be initiated and incorporated into the care plan and the physician would be notified. The dietician, nursing staff, and the physician would assess factors that may be contributing to inadequate fluid intake. Orders for medications that may exacerbate dehydration (e.g., diuretics) would be reviewed and held if medically appropriate. Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration. If laboratory tests were consistent with actual dehydration, the physician may initiate intravenous hydration. hospitalization would be recommended as necessary. Nursing would monitor and document fluid intake and the dietician would be kept informed of the status. The Interdisciplinary Team would update the care plan and document the resident's response to interventions until the team agreed that fluid intake and relating factors were resolved. Resident #3: Resident #3 was admitted to the facility with diagnoses of muscle wasting (loss of muscle) and atrophy (thinning of muscle), moderate protein calorie malnutrition, and vascular dementia (caused when decreased blood flow damages brain tissue). The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. The facility document titled, Dehydration Risk Assessment 2, and dated [DATE] by Registered Dietician #2 documented the resident was at moderate risk for dehydration. The facility document titled, Nutritional Assessment I/A, and dated [DATE] documented the resident required a minimum of 1500 milliliter of fluids daily. The Comprehensive Care Plan was revised [DATE] for Nutritional Problem related to decreased appetite, dementia, and low body mass index, with goals that the resident would consume at least 75% of at least 2 of 3 meals daily and would have no signs and symptoms of malnutrition as evidenced by significant weight loss and muscle wasting. The care plan did not document the resident's hydration needs, risk for dehydration, and interventions to prevent dehydration. During an interview on [DATE] at 2:48 PM, Director of Nursing #1 stated the facility transitioned to a new electronic medical record on [DATE], and that on [DATE], the resident was still at risk for dehydration. The Comprehensive Care Plan was revised on [DATE] for Nutritional Status related to alteration in nutrition because of poor intake at times, with a goal that the resident would be placed on the most appropriate diet for wellbeing. The care plan did not document measurable objectives and timeframes to meet the resident's nutritional needs and did not document the resident's hydration needs, risk for dehydration, and interventions to prevent dehydration. The Treatment Administration Record dated [DATE] to [DATE] documented the following order: [DATE] Fluids with Medication Pass, twice a day, from 5:45 AM to 2:15 PM and from 2:15 PM to 10:15 PM: -On [DATE], 240 milliliters and 120 milliliters of fluids were documented by Licensed Practical Nurse #2 and Registered Nurse #4, respectively. -On [DATE], 240 milliliters and 120 milliliters of fluids were documented by Registered Nurse Manager #1. -On [DATE], 240 milliliters and 240 milliliters of fluids were documented by Licensed Practical Nurse #2. -On [DATE], 120 milliliters and 120 milliliters of fluids were documented by Licensed Practical Nurse #2 and Licensed Practical Nurse #6, respectively. -On [DATE], 240 milliliters and 120 milliliters of fluids were documented by Registered Nurse #6 and Registered Nurse #5, respectively. Review of the Vitals Report dated [DATE] for percentage of meals and total fluids consumed from [DATE] to [DATE], documented the following: -On [DATE], breakfast was documented at 9:45 AM as ,d+[DATE]% and at 1:31 PM as ,d+[DATE]%. Lunch was also documented at 1:31 PM as ,d+[DATE]%. The dinner meal was not documented. Supplements were documented as ,d+[DATE]%. The total fluids documented was 1440 milliliters: 96% of the daily minimum. -On [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], the total fluids documented in milliliters, and percentage of the daily minimum of 1500 were 360 (24%), 840 (56%), 360 (24%), 480 (32%), 240 (16%), and 120 (8%), respectively. On [DATE] at 1:45 PM, Certified Nurse Aide #9 documented both breakfast and lunch as ,d+[DATE]%. The dinner meal was not documented and there was no documentation Nursing staff was made aware. -On [DATE] at 12:54 PM, Certified Nurse Aide #10 documented breakfast as ,d+[DATE]% and at 12:55 PM documented ,d+[DATE]% of lunch and AM snack ,d+[DATE]%. The dinner meal was not documented and there was no documentation Nursing staff was made aware. -On [DATE], [DATE], [DATE], [DATE] there was no documentation by the Certified Nurse Aide of the percentage of meals consumed for breakfast, lunch, and dinner. There was no documentation Nursing staff was made aware of the resident's food intake. The Nursing Progress Note dated [DATE] at 9:15 PM by Registered Nurse #2, documented the family member approached them with concerns about the resident. Specifically, loss of appetite, sleeping almost all the time during the past 2 days and vague complaints of back pain. Registered Nurse #2 documented the resident stated they were sleeping because they were tired and there was nothing to do. They documented the resident said the back pain was general, and they blamed it on the bed. It was documented the resident had no other evident symptoms. It documented returned a call to the family member and they requested follow up by the Registered Nurse on [DATE]. There was no documentation in Nursing Progress Notes that the resident's nutritional status was evaluated on [DATE], when it was reported the resident had loss of appetite and was sleeping most of the time over the past 2 days. There was no documentation the physician was notified. Review of the facility report titled, 24 Hour Report (Nursing 24 Hour Report), dated [DATE], did not document a report for Resident #3. The Nursing Progress Note dated Saturday, [DATE] at 10:27 PM by Registered Nurse Manager #1, documented the resident was assessed per the family's wishes. They documented the family stated the resident had a urinary tract infection and the resident denied pain or discomfort in the lower abdomen, pelvic area, or lower back and with urination. The resident denied nausea, vomiting, or diarrhea and stated they felt okay. The resident was noted to have a non-productive cough, had a slight wheeze in left side and a chest x-ray was ordered for [DATE]. Resident stated they slept a lot because they were bored, with nothing to do and they needed fresh air. They documented the physician was made aware of the concerns, and a new order for breathing treatments was given. There was no documentation in Nursing Progress Notes that the resident's nutritional status (food/fluid intake) was evaluated on [DATE]. Review of the facility report titled, 24 Hour Report (Nursing 24 Hour Report), dated [DATE], did not document a report for Resident #3. The Nursing Progress Note dated [DATE] at 2:30 PM by Licensed Practical Nurse #4 documented the resident's family came to pick up the resident for lunch. The resident was gone for approximately 1 hour when they received a call from the Emergency Department stating the family brought the resident to the hospital due to complaint of severe lower abdominal pain that the resident had complained for a week to the family. They documented the resident was assessed on [DATE] by the Registered Nurse and had contacted the physician and was awaiting new orders. The Emergency Department Provider Report dated [DATE], documented: -The resident presented to the Emergency Department on [DATE] with their family member. They reported they visited the resident and found them to be ill, the resident had been anorexic (lack or loss of appetite for food) for 4 days and had not been out of bed in 4 days. They reported the resident had very little to eat or drink that week, had a cough and had been complaining of dizziness, back pain, and abdominal pain. The resident had 8 episodes of diarrhea on [DATE] and had been incontinent of stool. The family member also noted an increase in the resident's dementia this week. The resident had small (blood) vessel dementia because of a (history of) stroke. The neurological examination documented the resident was confused and showed evidence of dementia with their statements, as they talked about their deceased spouse as if the spouse were present. -The Medical Decision Making Progress Note documented the resident had leukocytosis (increase in the number of white blood cells, especially during infection), diagnostic imaging showed some mild colitis (inflammation of the colon), and the resident currently had diarrhea. Laboratory testing showed the resident had acute kidney injury. -The Emergency Department Departure Clinical Impression documented a primary impression of colitis and a secondary impression of acute kidney injury. The Hospital Discharge Summary Report dated [DATE] documented: -Hospital Course documented: For the colitis, the resident was given antibiotics. With antibiotic treatment, abdominal discomfort and diarrhea resolved and the leukocytosis down trended. For the acute kidney injury, the resident was treated with intravenous fluids as presentation was consistent with prerenal (occurring in the circulatory system before the kidney is reached) etiology in the setting of diarrhea and poor oral intake. Renal function improved with intravenous fluid administration. At the time of discharge, laboratory retesting showed improvement to the kidneys. It documented although the levels were still above the resident's baseline, given continued improvement on oral fluids, the resident was felt stable and appropriate for discharge back to the facility with close follow up of renal function. Final Diagnosis documented prerenal acute kidney injury in the setting of colitis and poor oral intake. The Nursing Admission Observation Note dated [DATE] at 2:50 PM by Director of Nursing #1 documented the resident was readmitted on [DATE] after a brief hospital stay due to diagnoses that included prerenal acute kidney injury. During an interview on [DATE] at 3:09 PM, Licensed Practical Nurse #4 stated they documented fluids given during a medication pass and there was a specific place in the computer system for the documentation. They stated they generally documented 120 milliliters for the medication pass. They stated Certified Nurse Aides were responsible for documenting all other fluids consumed, such as with meals and documented the amount of the meal they consumed. They stated if there was a change in the amount the resident usually ate or drank, the Certified Nurse Aide was responsible for reporting to the Licensed Practical Nurse, and then the Registered Nurse would assess the resident and notify the physician. They stated they did not know if Dietary was to be notified. They stated that sometimes Resident #3's nursing unit did not have an assigned Certified Nurse Aide. They stated there were several times when they were left without an assigned aide and had to perform the responsibilities of the Certified Nurse Aide in addition to their nursing responsibilities. They stated they would not have been able to monitor and/or document the amount of fluids or food the resident had consumed during their assigned shift. During an interview on [DATE] at 11:04 AM, Licensed Practical Nurse #5 stated they only documented fluids that were given to a resident during a medication pass and stated the assigned Certified Nurse Aide was responsible for documenting fluid intake at meals. They stated they were familiar with Resident #3, and they often needed encouragement to drink. They stated the Certified Nurse Aide was responsible for reporting to the Licensed Practical Nurse when the resident would not comply, and the Registered Nurse would assess the resident and call the physician if necessary. They stated they would not be able to keep track of what residents had consumed and relied on the Certified Nurse Aide. During an interview on [DATE] at 4:10 PM, Certified Nurse Aide #6 stated they were responsible for monitoring and documenting the total fluids the resident consumed in between and at meals, as well as the percentage of the meal eaten. They stated the Certified Nurse Aides were responsible for letting the nurse know about a change in fluid/food consumption because a resident could be sick. They stated they were familiar with Resident #3 and the resident had dementia and needed encouragement to eat and drink. They stated the resident would do better with eating and drinking when they were not left alone in their room and were brought to the dining area for meals. They stated if a Certified Nurse Aide did not have access to the computer system, it was the aide's responsibility to report it to the nurse. During an interview on [DATE] at 12:51 PM, Registered Nurse #2 stated they were working in another unit when Resident #3's family member approached them about Resident #3. They stated the resident's family member asked them to look at the resident because they were concerned about them and did not recall what the concern was. They stated they documented no evident symptoms because the resident did not appear acutely ill. They stated they did not review the resident's food/fluid intake and did not recall being notified by the Certified Nurse Aide about the intake. They stated they called the resident's family member to let them know the findings. During an interview on [DATE] at 3:21 PM, Registered Dietician #4 stated they had not provided services to the facility for the past few months. They stated they provided coverage 2 days a week and would call into morning meeting on those days. They stated they did not recall being called about Resident #3 and if they were called and had communication with the physician, they would have documented a note. They stated they spoke with the Interdisciplinary Team about Resident #3 after they were readmitted to the facility on [DATE]. During an interview on [DATE] at 4:09 PM, Registered Nurse Manager #1, stated they were the acting Assistant Director of Nursing and left the facility at the end of [DATE]. They recalled that the resident's family member picked the resident up for lunch and then took them to the Emergency Department instead. They stated that when they assessed the resident on [DATE], the family member said they were not doing anything about their complaint and stated they did not recall what their complaint was. They stated the resident answered their questions during the assessment and there was no indication of any cognitive issues. They recalled calling the physician but could not recall the details. They stated the resident would pick and choose what they wanted to eat, and they did not review their fluid/food intake. Registered Nurse Manager #1 stated they were responsible for monitoring the resident's intake/output and reporting any changes to the physician. They stated they were not informed by the Certified Nurse Aide about Resident #3's food/fluid intake. They stated they did not know why the Certified Nurse Aides did not document the intakes/outputs and stated most of them were travelers. They stated a few of the Certified Nurse Aides that came in did not have logins for days and could not document in the electronic medical record and had to rely on the other aides to document for them. Registered Nurse Manager #1 stated they submitted multiple requests for logins for the Certified Nurse Aides to Administrator #2 and did not receive any response. They stated they did not have a lot of interaction with Resident #3 and stated they spent most of their 3 weeks of employment in the facility on a medication cart. They stated that for the most part, they were the only Registered Nurse in the building for much of the time and if the facility was full, there were 60 residents. During an interview on [DATE] at 11:09 AM, Medical Director #1 stated they were not made aware on [DATE] and [DATE] of Resident #3's poor oral intake. They stated they typically gave intravenous fluids in the facility and Registered Nurse Manager #1 could have administered them. They stated if they were notified of the poor oral intake and the concern from the resident's family member, they would have ordered orthostatic blood pressures, intravenous fluids or hypodermoclysis (fluids that are administered subcutaneously) or would have sent the resident to the Emergency Department if warranted. During an interview on [DATE] at 2:00 PM, Resident #3's Family Member #1 stated that when they visited the resident on [DATE], the Certified Nurse Aide told them the resident had diarrhea. They did not recall who the Certified Nurse Aide was and stated the facility had agency staff for months and they never saw the same Certified Nurse Aide twice. They stated they did not know how severe the diarrhea was or if the nurse was aware. They stated they spoke to Registered Nurse #2 on [DATE] about the diarrhea and that Resident #3 was sleeping most of the time. They stated Registered Nurse #2 was covering both floors that day and they had to go upstairs to find them. They stated the nurse was overwhelmed and said they would assess the resident. They stated they tried to tell the nurse something was wrong with the resident, and the nurse was saying the resident was staying in bed because they were depressed. Family Member #1 stated the resident was usually very active and was involved with staff and activities. They stated they were sick and were unable to visit the resident during that time. They stated when they visited them on [DATE], they stated the Certified Nurse Aides told them the resident had refused all food and had not eaten or drank in 4 days. They did not recall who the aides were. They stated they signed the resident out of the facility and then brought them to the Emergency Department. They stated they were convinced the resident would have died within a few days if they had not taken them to the hospital. They stated the facility had a changeover in staff in one week's time including the kitchen staff. They stated they felt the resident was not eating because the quality of the food being served was not good. During an interview on [DATE] at 2:48 PM, Director of Nursing #1 stated the Certified Nurse Aide's documentation included residents' intake and output. They stated meals, fluids, and snacks were to be documented, and that Certified Nurse Aides also had a reporting role and were to tell the assigned nurse when the resident was not eating or drinking as per usual. They stated the assigned nurse was to document a progress note and monitor the resident. If poor oral intake was consistent, then the nurse would let the Registered Nurse know and the physician would be notified. Once the physician was notified the Registered Dietician would get involved. They stated a nutritional assessment would be done and there would be low-fluid monitoring by Nursing and Dietary and weights ordered. They stated the facility transitioned to a new electronic medical record on [DATE]. During the interview, they reviewed the care plan for Nutritional Status in the current computer system and stated it was a bare bones care plan and it would have been up to nursing to put in a person-centered care plan with interventions to prevent dehydration and weight loss. They stated Director of Nursing #3, who left the facility around [DATE], was responsible for developing and implementing the care plan. They stated they were not aware of Resident #3's hospitalization on [DATE], until they spoke to the resident's family member at the time of readmission to the facility. They stated the resident had intermittent confusion, was a light eater and did not refuse to eat or drink. They stated the nurse was able to monitor the resident's fluid intake because the Certified Nurse Aide's documentation of fluids was in the computer during the current shift, and it was available to the nurse. They stated travelling agency Certified Nurse Aides would get access to the electronic medical record when they arrived in the facility. They stated they would often forget their password and then they were issued a new one by them. They stated they needed computer access to document and stated no one else was to document for them. During an interview on [DATE] at 3:34 PM, Certified Nurse Aide #7 stated they were a traveler/agency and was familiar with Resident #3. They stated they worked on the resident's unit during the evening shift on [DATE] and [DATE] with Certified Nurse Aide #8. They stated things were very hectic on the unit because the facility was short-handed with facility staff. They stated they were not able to keep track of what the residents ate or drank and there was no time to document anything. They stated Resident #3 usually ate and drank with no problems. They stated if there was a change in what a resident ate or drank, they were to report it to the nurse. They stated they did not have any interaction with the resident's family member. They stated the nurses were working as aides in addition to their regular duties much of the time because there were no Certified Nurse Aides on the unit or not enough. They stated that often there was only 1 nurse to cover both nursing units. They stated that when the facility transitioned to the current electronic medical record system, it was a difficult system to use and some of the traveler/agency Certified Nurse Aides did not have access to the computer system, the system was not operational, or they were locked out of it and would not be able to document. They stated there was a period when the small portable computers were not charged for days because the charger was missing, and they had to bring their own chargers to charge them. They stated the facility was aware of the issues with the new computer system. They stated there was no formal training and were told to figure it out themselves. Cross-reference F656 and F725. 10 New York Codes, Rules and Regulations 415.12(i)(1)

Based on interview and record review during an abbreviated survey ( NY00324981, NY00325409, NY00327186, NY00327811, and NY00327951), the facility did not ensure that the Facility Assessment was completed and available to determine what resources were necessary to care for its residents. This is evidenced by: Upon entrance on 11/13/2023 at approximately 2:00 PM, the Administrator was asked for the Facility Assessment (a facility-completed document required to establish staffing levels and competencies based on residents' assessed needs). The Administrator provided a binder with words, 'Facility Assessment' written on the front. Record review of the binder revealed it did not include the Facility Assessment. On 11/13/2023 at 4:00 PM, the Administrator stated they had not looked at the Facility Assessment. On 12/08/2023, the Administrator supplied a copy of a Facility assessment dated [DATE] to the New York State Department of Health. Record review of the Facility assessment dated [DATE] identified the minimum staffing requirement (for both nurses and Certified Nurse Aides) that was needed to provide resident care to a daily average census of 39 residents. Record review of facility daily census from 11/13/2023 to 11/15/2023 revealed the average daily census was 55 residents per day. During a subsequent interview on 11/15/2023 at 8:59 AM, the Administrator stated they did not have a completed Facility Assessment but was working on one. They further stated that they started in their position on 10/30/2023 and residents had brought it to their attention the history of no staff at the facility. The Administrator stated they had been working on recruiting staff and had not looked at the Facility Assessment. 10 New York Codes, Rules and Regulations 483.70(e)(1)-(3)

Based on record review and interviews during an abbreviated survey (Case #NY 178), the facility failed to ensure each resident was free from abuse for 1 (Resident #3) of 4 residents reviewed. Specifically, the facility failed to ensure Resident #3, who had severely impaired cognition related to dementia, was free from sexual abuse by Pastoral Care Volunteer #1 on 7/16/2022 as witnessed by Certified Nursing Assistant (CNA) #1. CNA #1 witnessed the Pastoral Care Volunteer leaning over Resident #3's bedside with their hand inside the resident's incontinence brief and witnessed the brief making an up and down motion. CNA #1, along with CNA #5, immediately stopped the Pastoral Care Volunteer, and removed them from the resident's room. The Pastoral Care Volunteer was brought to an area on the unit away from residents and was supervised by staff. Staff notified Administration and 911. The Pastoral Care Volunteer was removed from the unit and brought to the front lobby to wait for police. The Police arrived and removed the Pastoral Care Volunteer from the facility. Resident #3 was transported to the emergency room for evaluation. The sexual abuse allegation was reported to the New York State Department of Health on 7/16/2022. Pastoral Care Volunteer #1 had their own badge to access the facility 24 hours a day, 7 days a week and was not supervised by staff when they were in the facility. Additionally, the facility did not develop and implement effective Policies and Procedures to adequately supervise, train, and educate volunteers to prevent or reduce the likelihood of resident abuse. This resulted in, or had the potential to result in, psychosocial harm that is Immediate Jeopardy and substandard quality of care to resident health and safety as defined by the reasonable person concept referenced in the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity Guide. This had the potential to affect 27 of the 41 residents in the facility with cognitive impairments. The Immediate Jeopardy was lifted on 8/12/2022. This is evidenced by: The Policy and Procedure (P&P) titled Abuse and Neglect Prevention dated 5/2021, documented residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Finding #1: The facility failed to ensure Resident #3, who had severely impaired cognition related to dementia, was free from sexual abuse by a Pastoral Care Volunteer #1 on 7/16/2022 witnessed by Certified Nursing Assistant (CNA) #1. Resident #3: Resident #3 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 5/18/2022 documented the resident had severe cognitive impairment, could understand others, and could make themselves understood. The Comprehensive Care Plan for Impaired Cognitive Function related to progressive dementia, and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Activity Volunteer file for Pastoral Care Volunteer #1 included a Volunteer Application dated 11/19/2010, that documented the applicant was applying to be a volunteer as a eucharistic minister and their availability was 9:00 AM - 10:00 AM on Monday, Tuesday, and Friday. The Application documented the maximum hours per week would be 3 hours and the maximum days per week would be 3 days. The Pastoral Care log in sheets dated 7/2/2022 - 7/16/2022 documented Pastoral Care Volunteer #1 entered the facility on 5 evenings, as early as 7:00 PM and leaving as late as 8:00 PM. Each visit was documented to be between 45 and 60 minutes. The log in sheets documented the Pastoral Care Volunteer passed communion to 11 or 12 residents each evening they were in the facility. The log in sheets did not indicate which residents the Pastoral Care Volunteer visited and the facility did not have a list of residents Pastoral Care Volunteer #1 saw each visit. The Nursing Home Incident Form dated 7/16/2022 at 7:23 PM, documented staff witnessed the Pastoral Care Volunteer in Resident #3's room, leaning over the bedside of Resident #3. The staff witnessed the volunteer's hand inside of the resident's Attends (incontinence brief) up to the wrist and seeing an in and out/back and forth motion. The staff stepped back into the hallway to grab another CNA and together stopped the volunteer and removed them from the situation. The staff immediately called down the hall for the Registered Nurse (RN) who notified the Director of Nursing (DON) and instructed staff to call 911. The volunteer was removed from the unit and detained until police arrived to take over the investigation. Resident #3 was taken to the emergency room (ER) for evaluation and the police planned to collect clothing and incontinence brief the resident was wearing at the time of the attack. A Progress Note dated 7/16/2022 at 11:30 PM, written by RN #1 documented RN #1 was called by 2 Certified Nursing Assistants (CNAs), and it was reported the person passing communion was inappropriately touching Resident #3. The person was removed from the resident's room and escorted to the sitting room next to nurses' station. RN #1 notified the DON. The police were called, and the person was escorted to front lobby until police arrived. The resident was transported by Emergency Medical Services (EMS) to ER for evaluation. An ER note documented the patient was nonverbal in the presence of the writer (a Physician Assistant), did not recognize the presence of the writer, and did not answer direct questions. The ER note documented a SANE (Sexual Assault Nurse Examiner) exam was conducted on 7/17/2022 at 12:05 AM for evidence collection. There was no evidence of bruising, abrasion or laceration to the labia, vagina, or cervix. During an interview on 7/21/2022 at 10:45 AM, CNA #1 stated they had cleaned Resident #3 up for bed on 7/16/2022 and took the dirty linen out of the resident's room to the soiled utility room. CNA #1 was barely gone 15 minutes from the resident's room before they were going back into the room to care for the resident's roommate. When CNA #1 entered the room, they saw the Pastoral Care Volunteer #1 bending over Resident #3's bed. CNA #1 stated the Pastoral Care Volunteer was someone who came to the facility and gave communion to the residents. The CNA stated they saw that the white sheet was down, and they could see the resident's pull up. CNA #1 knew CNA #1 had pulled the sheet up when they had just dressed the resident for bed. CNA #1 stated the resident's pull up and pajama pants were up when CNA #1 had finished the resident's care, and the white sheet was up and covered the resident. When the CNA saw the Pastoral Care Volunteer bending over the resident, the resident had their pull up on, but the resident's pants were down a little and the white sheet was pulled down. The Pastoral Care Volunteer's hand was in the resident's pull up and the CNA saw that the pull up making an up and down motion. CNA #1 stated they pulled their coworker over, who was standing right next to them, so the coworker could see the same thing. The 2 CNAs immediately stopped the Pastoral Care Volunteer and the Pastoral Care Volunteer tried to pull the sheet back up to cover the resident. CNA #1 stood with the Pastoral Care Volunteer while CNA #5 went to get the RN. The staff brought the Pastoral Care Volunteer out of the room and away from all residents. CNA #1 stated Resident #3 was acting like they were asleep. Their eyes were closed but when the Pastoral Care Volunteer yanked their hand out of the resident's pull up, the resident was startled and grabbed the Pastoral Care Volunteer's wrist. CNA #1 stated Resident #3 could not make their needs known. During an interview on 7/21/2022 at 2:20 PM, the Administrator stated the Pastoral Care Volunteer had been coming to the facility for 40+ years before any procedures were implemented for volunteers. Pastoral Care Volunteer #1 had their own badge and came in the evening. The staff knew the Pastoral Care Volunteer to pass bedside communion. The Administrator stated when the police came, they took over the investigation. During an interview on 7/21/2022 at 4:23 PM, RN #1 stated they were passing medications on the unit when the CNAs were yelling the RN's name. The CNAs told RN #1 what happened. The staff removed the Pastoral Care Volunteer from the room and brought the Pastoral Care Volunteer out by the nurses' station to the sitting room where there were no other residents in the area. The Administrator, DON and 911 were called. Another staff member and RN #1 took the Pastoral Care Volunteer upstairs to wait in the lobby for the police. During an interview on 7/22/2022 at 9:15 AM, the Social Worker (SW) stated they updated Resident #3's care plan to include a trauma care plan after the incident on July 16th. The SW stated Resident #3 did not know, or it did not appear that the resident remembered or had any knowledge of what happened. The SW stated even if the resident had not shown signs and/or symptoms of trauma, it did not mean the resident would not show signs of trauma in the future. Resident #3 had dementia, but it was still a traumatic event even if the resident was not showing signs. The SW stated Resident #3 had no ability to consent and the resident was severely cognitively impaired. During an interview on 7/22/2022 at 9:30 AM, RN #2 stated they did not think Resident #3 recalled anything and could not respond appropriately if they did. Resident #3 had absolutely no ability to consent. It was a traumatic event, and the trauma care plan was now in place because they did not know what the resident was feeling or thinking based on the event, or the resident did not know how to express it if they did recall what happened. During an interview on 7/22/2022 at 10:28 AM, the Resident Representative (RR) stated the incident involving Resident #3 and the Pastoral Care Volunteer was definitely upsetting. The RR stated this would be a traumatic event for Resident #3. The resident did not seem to have a sense of what went on, but it would have been traumatic for Resident #3 if they knew what had happened. The RR stated Resident #3 could not really communicate, could not make their needs known, and their dementia was progressing. The RR stated the resident did not always know who the resident representative was to them were due to the resident's dementia. The RR stated Resident #3 was not a resident who would receive communion and they did not know the Pastoral Care Volunteer came to the facility or went into Resident #3's room. During an interview on 7/22/2022 at 11:45 AM, the Medical Director (MD) stated Resident #3 was admitted to the facility with dementia and the dementia had somewhat progressed. The resident could not comprehend or understand the gravity of situations and had poor insight. In a limited way, Resident #3 was able to express their choice of things like what they wanted at a meal but did not have reasoning or logic. Resident #3 could not fully understand to give consent for a procedure or sex. The MD stated the resident had poor recall and they were not sure the resident recalled the event. During an interview on 7/22/2022 at 1:00 PM, the DON stated they were called the evening of the incident and was told the Pastoral Care Volunteer was out of the patient care area, 911 was called, and the Administrator was called. When the DON arrived at the facility the police, Administrator, and Unit Manager were there. The police took the Pastoral Care Volunteer. During an interview on 8/10/2022 at 10:42 AM, the Administrator stated during the COVID-19 pandemic, the Pastoral Care Volunteer was not coming to the facility but started coming to the facility again when the facility reopened for visitors. The Administrator did not know the Pastoral Care Volunteer had started coming back into the facility until they saw the Pastoral Care Volunteer one evening in the facility. The Administrator could not say when this was. The Pastoral Care Volunteer had their own badge to come in and out of the facility and they did not know how long the Pastoral Care Volunteer had the badge or what year it was issued. Additionally, at 10:55 AM, the Administrator stated they did not know which residents the Pastoral Care Volunteer typically saw or what rooms they went into. The Administrator stated if they had been on the Pastoral Care Volunteer's tail this would not have happened or would have decreased the chances of it happening. Finding #2: The facility did not develop and implement effective Policies and Procedures to adequately supervise, train, and educate volunteers to prevent or reduce the likelihood of resident abuse. The Policy and Procedure (P&P) titled Pastoral Care- Community Clergy Visits dated 3/23/2017, documented the corporate health center (named) facilitated and encouraged local clergy visitation of patients and provided referrals to the clergy upon request. The Switchboard/Communications Center provided clergy with a listing of patients who had expressed a desire to be seen by a member of the clergy while hospitalized and provided them with an ID nametag. The facility did not provide a Pastoral Care/Clergy Visit P&P specific to the nursing home. The Policy and Procedure (P&P) titled Abuse and Neglect Prevention dated 5/2021, documented all volunteers would be trained through volunteer orientation with the Volunteer Coordinator. Training would include but not limited to what constituted abuse, neglect, and misappropriation of resident property. An undated Volunteer Packet for Prospective Volunteers documented the following Volunteer Program Requirements: -An adequate orientation would be offered for all volunteer positions. -Scheduling regular hours of service allowed nursing home staff and volunteers to get to know each other and to become a more effective team. Hours for volunteer assignments depended upon the nature of the assignment. The times varied from 9:00-5:00 PM Monday through Sunday. However, there were assignments that needed to be done in the evening, so usually a schedule of service could be arranged to fit whatever time the applicant was available. -It was important to document the time spent volunteering. Sign in when reporting for duty & out when finishing for the day. -Once yearly an in-service was held for volunteers to review important competencies or skills that applied throughout the nursing home. This in-service was required training for all volunteers. A review of the Activity Volunteer file for Pastoral Care Volunteer #1 included a Volunteer Application dated 11/19/2010, that documented the applicant was applying to be a volunteer as a eucharistic minister and their availability was 9:00 AM - 10:00 AM on Monday, Tuesday, and Friday. The Application documented the maximum hours per week would be 3 hours and the maximum days per week would be 3 days. The Volunteer File included a Volunteer Checklist to obtain signed copies of the following: the mission quality, volunteer orientation and rules of conduct, abuse prevention statement, and the senior crime stopper oath. None were checked to indicate the facility had received signed copies by Pastoral Care Volunteer. The Volunteer File for Pastoral Care Volunteer did not include documentation of: Orientation, Annual trainings, or Abuse and Neglect prevention education. A review of the Activity Volunteer file for Pastoral Care Volunteer #2 included a Volunteer Application dated 10/1/2018, that documented the Pastoral Care Volunteer #2 was applying to be a volunteer for resident activities including Religious Activities and visiting 1:1 with a dog. The Application documented the Volunteer's days and times were flexible. The Volunteer file did not include documentation of: Orientation, Annual trainings, or Abuse and Neglect prevention education. During an interview on 7/21/2022 at 11:06 AM, Licensed Practical Nurse (LPN) #1 stated Pastoral Care Volunteer #1 gave communion to the residents and offered it to the staff. The LPN stated staff just knew who Pastoral Care Volunteer #1 was, and no one followed them around. The staff did not know which residents the volunteer gave communion to. During an interview on 7/21/2022 at 2:20 PM, the Administrator stated the Pastoral Care Volunteer #1 had been coming to the facility for 40+ years before any volunteer procedures were implemented for volunteers. Pastoral Care Volunteer #1 came to the facility four to seven days a week to give communion. During the COVID-19 pandemic, Pastoral Care Volunteer #1 was not coming to the facility but resumed coming when the facility reopened for visitors. The Administrator did not know Pastoral Care Volunteer #1 had started coming back into the facility until they saw Pastoral Care Volunteer #1 one evening. Pastoral Care Volunteer #1 had their own badge. The Administrator stated staff knew Pastoral Care Volunteer #1 to pass bedside communion. During an interview on 7/21/2022 at 2:45 PM, LPN #2 stated Pastoral Care Volunteer #1 did not have a set schedule, came on evenings, and there were no set days of the week. The Pastoral Care Volunteer let themselves in and passed out communion. LPN #2 did not know which residents they passed communion to and there was not a set list of residents Pastoral Care Volunteer #1 saw. During an interview on 7/21/2022 at 4:23 PM, Registered Nurse (RN) #1 stated Pastoral Care Volunteer #1 came on the weekends in the evening to pass communion. When RN #1 started working at the facility, they never received a rundown of who came in and who did what. Pastoral Care Volunteer #1 had their own badge and came in and out of the facility on their own. During an interview on 7/22/2022 at 9:55 AM, Administrator stated Pastoral Care Volunteer #1 was grandfathered in as a volunteer. The Administrator stated there was another volunteer, Pastoral Care Volunteer #2 who did Bible study. Pastoral Care Volunteer #2 had been volunteering there about a year or two. The Administrator stated Bible study and individuals from the church did not go through the volunteer process. Volunteers did not have annual in-services. During an interview on 7/22/2022 at 11:55 AM, the Activities Manager stated as the Volunteer Coordinator, they were aware there was process for when someone wanted to volunteer at the facility but since they were hired, there had been no new volunteers. The Pastoral Care Volunteer #1 and Pastoral Care Volunteer #2 were the only 2 volunteers the facility had. There were other Pastoral Care visitors who were priests that came in to do mass, but they were visitors, not volunteers. There were no volunteer folders for the priests who came into the facility. The Activities Manager had never seen the Pastoral Care Volunteer #1 and did not realize how often they came to the facility. They did not have a list of residents who communion was passed to. The Activities Manager stated Pastoral Care Volunteer #2 came to read the bible to residents in a group every other week for 1 hour and then visited a few residents 1 to 1. The Activities Manager stated volunteers received abuse training when they went through orientation and abuse training was also in the volunteer binder for volunteers. During an interview on 7/22/2022 at 11:35 AM, the Administrator stated the Pastoral Care Volunteer #1 just went bed to bed passing communion and did not have a list of residents who they saw. No one supervised the Pastoral Care Volunteer #1, and everyone just knew who they were. The facility did not have a list of residents Pastoral Care Volunteer #1 saw each visit. During subsequent interviews on 8/10/2022 at 10:55 AM, the Administrator stated going forward, the facility was going to have a list of residents if there was a volunteer who was doing 1:1 visits and make sure the volunteer had closer supervision. That meant the volunteer could not come when it fit their schedule, but there would be scheduled visits to provider closer supervision. The staff would know when the volunteers would be in the building and have a list of residents who the volunteers were seeing. The Administrator stated this procedure had not been implemented because the facility did not have any volunteers who were doing 1:1 visits. At 12:30 PM, the Administrator stated the policy provided for Pastoral Care was a corporate policy and was not specific to the nursing home. The facility needed to add an addendum to the corporate policy for the nursing home and stated the corporate policy was not implemented in the facility. The facility did not have a pastoral care policy that they could find. The Administrator stated the Pastoral Care Volunteers should have had training on abuse, neglect, and mistreatment and should have been trained yearly. Based on the volunteer files provided, they did not have yearly trainings including abuse, neglect, and mistreatment. During an interview on 8/10/2022 at 11:54 AM, Pastoral Care Volunteer #2 stated they did not recall going through trainings or abuse training when they started volunteering at the facility 4 years ago. Pastoral Care Volunteer # 2 stated there were not yearly trainings provided at the facility. The Administrator was informed of the Immediate Jeopardy and provided the Immediate Jeopardy Template on 8/10/2022. On 8/12/2022, the facility submitted an allegation letter for the Removal of the Immediate Jeopardy. On 8/12/2022, an onsite survey was conducted, and it was determined that the IJ was removed based on the following corrections taken by the facility: - An audit list of individuals who visit residents other than family/friends/representatives was created to identify all volunteers or those who may qualify as a volunteer. - All volunteer access to the facility was discontinued. This included notifications made to volunteers of discontinued access, volunteer badge access terminated by Human Resources, and the Interdisciplinary Team and other staff in-serviced that volunteers were not to have access to the facility until further notice. - As of 8/12/2022, fifty-three of sixty-three employees were in-serviced. A read and sign face to face discussion was provided by the Administrator to the Interdisciplinary team and a read and sign discussion by department head or supervisor to staff was completed with 100% of staff working. The remaining staff will receive education prior to the start of their next shift. - A thorough investigation of sexual abuse commenced by instructing staff that should an allegation of sexual abuse be raised, or incident of sexual abuse be discovered they were to immediately notify the Administrator and Director of Nursing so an investigation could immediately begin, protect the resident/victim by removing and separating the abuser, and calling 911 if/as instructed. As a result of this survey, it was determined that the Immediate Jeopardy for F600 was abated as of 8/12/2022, prior to the exit date of 8/17/2022. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #NY 178), the facility failed to ensure alleged violations of abuse, mistreatment, and neglect, including an injury of unknown source were thoroughly investigated for 1 (Resident #3) of 4 residents reviewed. Specifically, for Resident #3, the facility failed to complete a thorough investigation for an allegation of sexual abuse by a Pastoral Care Volunteer #1 on 7/16/2022 witnessed by Certified Nursing Assistant (CNA) #1. CNA #1 witnessed the Pastoral Care Volunteer leaning over Resident #3's bedside with their hand inside the resident's incontinence brief and witnessed the brief making an up and down motion. CNA #1, along with CNA #5, immediately stopped the Pastoral Care Volunteer and removed them from the resident's room. The Pastoral Care Volunteer was brought to an area on the unit away from residents and was supervised by staff. Staff notified Administration and 911. The Pastoral Care Volunteer was removed from the unit and brought to the front lobby to wait for police. The Police arrived and removed the Pastoral Care Volunteer from the facility. Resident #3 was transported to the emergency room for evaluation. The facility did not continue to investigate the alleged sexual abuse after reporting the alleged abuse to the New York State Department of Health on 7/16/2022 and after the police had removed Pastoral Care Volunteer #1 from facility. The facility failed to implement a system to identify other potential victims who had contact with Pastoral Care Volunteer #1 and monitor those residents for psychosocial harm. As a result, the facility did not thoroughly collect evidence to determine what actions or systems were necessary to prevent sexual abuse by a volunteer from recurring. This resulted in Immediate Jeopardy and substandard quality of care to resident health and safety and had the potential to affect 27 of the 41 residents in the facility with cognitive impairments. The Immediate Jeopardy was lifted on 8/12/2022. This was evidenced by: The Policy and Procedure (P&P) titled Abuse and Neglect Prevention dated 5/2021, documented upon knowledge of a report the Administrator or Director of Nursing would begin an internal investigation using the facility investigation form. The Physician or designated representative would conduct a physical exam on the resident when alleged physical or sexual abuse, neglect, or mistreatment was suspected. The internal investigation conducted would include the following information: Physical findings; Statements that were dated and signed by involved staff; Eyewitness statements; Statement from the resident (if obtainable); Physician report; Review of any recent incident reports; and any other pertinent information/documentation that could be of use for the investigation conclusion. Resident #3: Resident #3 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 5/18/2022 documented the resident had severe cognitive impairment, could understand others, and could make themselves understood. The Nursing Home Incident Form dated 7/16/2022 at 7:23 PM, documented staff witnessed the Pastoral Care Volunteer in Resident #3's room, leaning over the bedside of Resident #3. The staff witnessed the volunteer's hand inside of the resident's Attends (incontinence brief) up to the wrist and seeing an in and out/back and forth motion. The staff stepped back into the hallway to grab another CNA and together stopped the volunteer and removed them from the situation. The staff immediately called down the hall for the Registered Nurse (RN) who notified the Director of Nursing (DON) and instructed staff to call 911. The volunteer was removed from the unit and detained until police arrived to take over the investigation. Resident #3 was taken to the emergency room (ER) for evaluation and the police planned to collect clothing and incontinence brief the resident was wearing at the time of the attack. During an interview on 7/22/2022 at 11:35 AM, the Administrator stated in terms of the investigation, the police took it over when they arrived. The Administrator assumed the police talked to the resident, but they had not. The Administrator did not go resident to resident to see if other residents had similar encounters with the Pastoral Care Volunteer. During an interview on 8/9/2022 at 1:22 PM, the Administrator stated there were not any other victims identified to their knowledge. The police did the investigation, and the police were interviewing the resident and staff. The facility did not interview the victim or other residents related to the incident on 7/16/2022. The Administrator stated there was no further investigation on the part of the facility. The Administrator did not want to run a concurrent investigation with the police. During a subsequent interview on 8/10/2022 at 10:55 AM, the Administrator stated the police took over the investigation when they arrived, and it did not dawn on them to continue with an investigation. The Administrator stated, based on past experiences, they handed the [NAME] over to the police and stated it was not helpful to do a concurrent investigation. The Administrator stated the facility was going to have a list of residents if there was a volunteer who was doing 1:1 visits and make sure the volunteer had closer supervision. That meant the volunteer could not come when it fit their schedule, but there would be scheduled visits to provider closer supervision. The staff would know when the volunteers would be in the building and have a list of residents who the volunteers were seeing. The Administrator stated this procedure had not been implemented because the facility did not have any volunteers who were doing 1:1 visits with residents. The Administrator was informed of the Immediate Jeopardy and provided the Immediate Jeopardy Template on 8/10/2022. On 8/12/2022, the facility submitted an allegation letter for the Removal of the Immediate Jeopardy. On 8/12/2022, an onsite survey was conducted, and it was determined that the IJ was removed based on the following corrections taken by the facility: - An audit list of individuals who visit residents other than family/friends/representatives was created to identify all volunteers or those who may qualify as a volunteer. - All volunteer access to the facility was discontinued. This included notifications made to volunteers of discontinued access, volunteer badge access terminated by Human Resources, and the Interdisciplinary Team and other staff in-serviced that volunteers were not to have access to the facility until further notice. - As of 8/12/2022, fifty-three of sixty-three employees were in-serviced. A read and sign face to face discussion was provided by the Administrator to the Interdisciplinary team and a read and sign discussion by department head or supervisor to staff was completed with 100% of staff working. The remaining staff will receive education prior to the start of their next shift. - A thorough investigation of sexual abuse commenced by instructing staff that should an allegation of sexual abuse be raised, or incident of sexual abuse be discovered they were to immediately notify the Administrator and Director of Nursing so an investigation could immediately begin, protect the resident/victim by removing and separating the abuser, and calling 911 if/as instructed. As a result of this survey, it was determined that the Immediate Jeopardy for F610 was abated as of 8/12/2022, prior to the exit date of 8/17/2022. 10 NYCRR 415.4(b)

Based on interview and record review during an abbreviated survey (Case #s NY 997 and NY 632), the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #s 2 and 4) of 4 residents reviewed for accidents. Specifically, for Resident #2, the facility did not ensure the resident was transferred by 2 staff, as determined necessary by the comprehensive care plan, who were adequately supervised or competent to use a full mechanical lift for transfers on 4/16/2021. Subsequently, bruising was identified on 4/17/2021 along the right side of the resident's body that included bruising to their face, upper lip, neck, arm, hip area, above their knee, and on their ankle and on 4/19/2021, a CT scan (medical imaging) revealed the resident had a right hip fracture; and for Resident #4, the facility did not ensure the facility's Policy and Procedure was implemented for Suicidal Precautions when staff did not notify the Physician and Administration of the resident's expression of suicidal ideations to staff on 2/4/2022 and Registered Nurse (RN) assessments were not documented in the progress notes every shift from 2/4/2022 through 2/8/2022. Additionally, a person-centered comprehensive care plan was not developed and implemented to provide individualized interventions related to Resident #4's suicidal ideations and suicide attempt on 2/8/2022 that required hospitalization . This was evidenced by: Resident #2: Resident #2 was admitted with the diagnoses of transient cerebral ischemic attack, pressure ulcer stage 4, and end stage [CONDITION(S)]. The Minimum Data Set (MDS- an assessment tool) dated 3/15/2021, documented the resident had severe cognitive impairment, could understand others and could make themselves understood. The Policy & Procedure (P&P) titled Accident/Incident Reporting dated 10/20/2020, documented the facility was committed to providing the best possible working conditions and protecting all residents from any unusual event or situation involving safety and well-being of residents which was not consistent with the routine operation of the facility. The Comprehensive Care Plan for Self Care Performance dated 4/1/2019, documented the resident transferred with 2 assist using a full lift and for toilet use/incontinence care the resident was a 2 assist supine (lying face upward) in bed. The facility Job Description for a Certified Nurse Aide Trainee dated 11/2014, documented a Nursing Assistant Trainee team members assisted with ensuring the health and well-bring of our residents by participating as a student in a Nursing Assistant 100-Hour Training Program. After receiving appropriate instruction and demonstrating skill competency, the CNA Trainee would provide personal and nursing care to meet the physical and emotional needs of residents, under the direct supervision of a Clinical Supervisor or Program Coordinator. An undated document titled CNA Trainee Provisional with Supervision Duties documented the CNA Trainee could do the following with supervision: give incontinence care when a resident was in their bed (ask for assistance from a certified CNA when in need of a 2 person for repositioning during incontinence care) and may assist certified CNAs with simple transfers (may push the button on the Hoyer lift (full mechanical lift) while the Certified CNA guided the resident in the Hoyer to the bed, chair, etc.). An email dated 4/3/2020 at 4:11 PM, written by the Administrator to Administrative Staff, documented Certified Nursing Assistant (CNA) Trainees (individuals who passed the class and the class test, but were not able to take the NYS test due test site closures) were able to work independently as a CNA for 120 days and the facility would work internally to ensure the CNA Trainees met the competencies. A progress note dated 4/18/2021 at 9:00 AM, documented when dayshift arrived on 4/17/2021 at 7:15 AM, the CNAs entered the resident's room and noticed bruising along the right side of the resident's face and arm. There was a red/maroon discolored area previously mentioned on the right side of the neck that measures 3.5 centimeters (cm) x 2.6 cm. The resident's right upper lip was swollen from outer corner to midline, faint bluish discoloration, the right elbow area was noted to have deep purple bruised area that measures approximately 12 cm in length x 2 cm in width. It was difficult to get an exact measurement as the elbow was bent and would not fully extend the arm. The area went across the upper outer forearm and across the elbow extending to the lower upper arm. The area on the outer forearm was superficially abraded. The area on the right upper jawline/check measuring 3 cm x 1.5 cm area was slightly elevated with a small dry scabbed center and pale purple in color. After lunch two other area were noted on the right leg. The right trochanter (hip area) with a very pale flat purple area measuring 4.5 cm x 4cm and approximately 4 inches about the right knee on the lateral aspect of the leg notes to have a flat faintly purple 7 cm x 4.5 cm L shaped bruise. A progress note dated 4/18/2021 at 11:58 AM, documented the resident was noted to have a 10 cm x 13 cm deep purple bruise on the right outer ankle and 1.5 cm superficial abrasion to the right knee. A CT exam note dated 4/19/2021, documented the resident had a nondisplaced impacted right sub-capital femoral neck fracture (hip fracture). The Facility Investigation documented the date of the (probable) event was 4/16/2021 and the event was discovered on 4/17/2022 on the 6:00 AM to 2:00 PM shift. The investigation documented the Director of Nursing reviewed the resident's care plan, medications, treatments and interviews with staff in regards to finding bruises, the Emergency Department reports, x-rays, and CT scans and found that the information provided by two staff (CNA Trainee #1 and CNA Trainee #2) was inconsistent and there was a concern the resident may have had a care plan violation on 4/16/2021, as well as the 2 staff not being able to give a complete detailed description of the staff who participated with the transfer, the use of the Hoyer lift, the placement in bed as well as the resident requiring 2 staff assistance for bathing and incontinence care. Further review of resident's diagnoses did not provide information that could affect the investigation or justification for the bruising on the right side of the resident's body and the fracture of the resident's right femoral head (hip). The last interview completed with the 2 staff of concern occurred on 4/26/2021. CNA Trainee #1 explained when CNA Trainee #1 and CNA Trainee #2 were transferring the resident from the stretcher and putting the resident into bed, the staff rolled over a pillow casing (this was a Heelz up device- a positioning device) which caused the Hoyer lift to rock resulting in the resident hitting against the IV pole with their upper part of their torso/head areas and then when positioning the Hoyer lift at the bedside, they hit the edge-side of the mattress with the resident's right lower torso-lower extremity. CNA Trainee #1 clarified CNA Trainee #2 was steering the Hoyer lift and CNA Trainee #1 was holding the resident (guiding their legs while in the Hoyer sling). CNA Trainee #2's statement admitted they had hit the resident's leg against the side of the bed. The facility did not provide documentation of competencies completed for CNA Trainee #1 and CNA Trainee #2 for use of the full mechanical lift. During an interview on 7/21/2022 at 2:20 PM, Administrator stated a CNA Trainee was supervised on the unit. A CNA Trainee passed the CNA course but did not take the CNA test. It was during COVID when CNA Trainee #1 and CNA Trainee #2 were CNA Trainees, and they were in a training capacity on the unit. The trainees needed to meet particular competencies before they could work on their own. During an interview on 7/22/2022 at 9:30 AM, Registered Nurse (RN) #2 stated a CNA trainee had not taken the CNA test yet. They could not do anything by themselves and had to have another licensed or certified staff with them. Two trainees should absolutely not be doing a Hoyer lift alone without a licensed or certified staff with them. RN #2 stated the CNA trainees did not do hands on care, did not do transfers, and did not feed residents. The nurse on the unit was responsible for supervising and monitoring the staff including CNA trainees. During an interview on 7/22/2022 at 9:55 AM, Administrator stated the trainees were able to work independently based on competencies and it depended on the competencies if there were cleared to be independent working with the residents and providing care. The Administrator stated CNA Trainee #2 was not cleared to work on their own, but CNA Trainee #1 had been cleared to work independently. During an interview on 7/26/2022 at 12:40 PM, CNA Trainee #2 stated they were a CNA Trainee at the facility in April of 2021. They helped the CNAs but did not do caretaking. CNA Trainee #2 stated they were more assigned to laundry, cleaning, feeding, and helping the CNA's move residents. CNA Trainee #2 stated they recalled the incident when they were with CNA Trainee #1, who they believed was a CNA, and they were using a full mechanical lift to transfer Resident #2 into bed. The resident was in the sling of the lift and when CNA Trainee #1 and CNA Trainee #2 transferred the resident into bed, the resident bumped their leg on the side of the bed. CNA Trainee #2 stated it was so long ago they did not remember any other details. During an interview on 7/29/2022 at 1:07 PM, the CNA Class Instructor stated CNA Trainee #1 and CNA Trainee #2 were CNA Trainees, who passed the CNA class and were working in an assistive capacity to sort linen and assist CNAs. They were not operating independently, and definitely were not to be working together without other staff present. CNA Trainee #1 showed more capacity to perform care responsibilities. CNA Trainee #2 was not capable of performing any hands-on care and was not in a position to do hands on care. CNA Trainee #2 was not to do direct care and definitely was not working under the Centers for Medicare & Medicaid Services (CMS) waiver for hands-on care. As their instructor, having trained both of them, under no circumstances should they have been transferring a resident or in a room alone together. It should have been CNA Trainee #1 and another CNA or nurse. The CNA Class Instructor stated they had made it known to Administration and to the staff on the units that CNA Trainee #2 was not to do hands-on care. The CNA Class Instructor stated in the CNA class, they reviewed full mechanical lifts and used the full lifts during clinicals, but it was not a required competency for the class. There were no competencies for CNA Trainee #1 and CNA Trainee #2 on full mechanical lifts. During an interview on 7/29/2022 at 3:40 PM, RN #3 stated they observed the bent IV pole and did now know what happened, but their immediate thought was it must be someone bumped it with the lift. Resident #2 transferred with a full mechanical lift with 2-assist of staff. Typically, a CNA trainee functioned as a hospitality CNA, but everything was a little different during COVID and the trainees functioned as CNAs. However, RN #3 stated CNA Trainee #2 was not working as a CNA. RN #3 had made it clear to the Administrator and the CNA Class Instructor that they did not want CNA Trainee #2 transferring residents. RN #3 had CNA Trainee #2 assist them with a 2-assist stand pivot transfer of a resident and it did not go well. RN #3 stated CNA trainees were allowed to be in the room to assist with operating the lift and they would maneuver the lift. The Certified CNA would do the hands-on guiding of the resident. The CNA Class Instructor completed the CNA competencies and trainings and did a good job communicating with the unit about where CNAs were with their care abilities. During an interview on 8/11/2022 at 5:11 PM, RN #6 stated CNA Trainees could assist with feeding, assist with care but trainees could not use a Hoyer lift alone. A CNA and a CNA trainee could use the lift and the trainee was there to help guide. CNA Trainee #1 and CNA Trainee #2 should have never used a Hoyer lift by themselves. They were trainees and would need a licensed or certified staff to use a Hoyer lift to transfer a resident. It would be the responsibility of the nurse on the unit to supervise the staff so that 2 trainees did not use a lift together. CNA Trainee #2's role was more for social interaction and included duties such as filling water pictures and answering call lights but nothing care related. During an interview on 8/15/22 at 1:15 PM, RN #8 stated CNA Trainee #2 had trouble following step by step instructions to complete tasks and needed monitoring to do things like laundry. RN #8 stated CNA Trainee #2 needed step by step instructions and required a lot of monitoring and a lot of training to complete tasks. During an interview on 8/15/2022 at 2:38 PM, CNA #6 stated they remembered they were going out on their lunch as Resident #2 was coming back from [CONDITION(S)] on 4/16/2021. When CNA #6 returned from lunch the resident was in bed. CNA #6 stated they did not provide Resident #2 care that evening. The care would have been done by CNA Trainee #1 and CNA Trainee #2 because there were no other CNAs on the unit. CNA #6 stated that evening, in addition to themself, it was CNA Trainee #1, who as working as the 2nd CNA, and CNA Trainee #2, who was working as the support aide. CNA #6 stated CNA Trainee #2 was a trainee but was more in the role of a support aide and could not do hands on care. During an interview on 8/16/2022 at 11:20 AM, Director of Nursing (DON) stated the CNA Class Instructor was responsible for completing the CNA clinicals. CNA Trainee #2 should not have been transferring the resident. A CNA Trainee would work with a certified CNA who was tenured, and the nurses were responsible for supervising the staff on the floor. During an interview on 8/16/2022 at 11:32 AM, the Administrator stated during the investigation there was no evidence that the resident hit the floor from the lift but stated it made sense the resident hit something. The Administrator stated whatever competencies the CNA Trainees did in the CNA class were in place when they were working on the unit, but the trainees did not have authorization to work independently. After the CNA class was over, the trainees would work with supervision, but it had been so long before the trainees could take the test due to COVID that CNA Trainee #1 was able to work independently as a CNA was under the CMS waiver. CNA Trainee #2 was not able to work independently. The nurses on the unit supervised the CNA Trainees. It was the Administrator's understanding that CNA Trainee #2 could assist with the lift and be the 2nd person when staff were using the lift for transfers. Although the Administrator stated staff had brought to their attention that there were issues with CNA Trainee #2's ability to provide care and they were limited in what they could do. The Administrator stated CNA Trainee #2 had been removed from hands-on care and CNA care. Staff told Administration they did not trust CNA Trainee #2 to do hands-on care. The Administrator stated there was theme with CNA Trainee #2 and the concerns raised with their ability to provide care. CNA Trainee #2 needed so much direction. The Administrator stated the facility would not have hired CNA Trainee #2 as a CNA but could not prevent them from taking State test since they passed the CNA class. There was a lack of skill with CNA Trainee #2, and it was known the facility would not consider CNA Trainee #2 for a CNA position. During an interview on 8/16/2022 at 11:52 AM, the Medical Director stated to a degree, superficial bruising could happen by being bumped into the bed, but the hip fracture was probably caused by something a bit more. It was not reported to the Medical Director that the resident fell but the Medical Director stated it had to be more than just a brushing up against the bed. Resident #4: Resident #4 was admitted to the facility with the diagnoses of personal history of suicidal behavior, major depressive disorder, and generalized anxiety disorder. The Minimum Data Set (MDS-an assessment) dated 03/08/2022, documented the resident was able to make themself understood, able to understand others and was cognitively intact. The Policy & Procedure titled Suicide Prevention dated 6/26/2019, documented residents who were potentially dangerous to themselves were closely observed to prevent them from harm. Suicidal precautions were initiated immediately by staff when a resident verbalized suicidal ideation and/or made an overt suicidal attempt and/or gesture. An order for suicide precautions was received from the physician and must include reason and duration. Documentation of the specific behavior necessitating precautions must be made in the progress notes. If visual checks were ordered, they would be documented on the visual check sheet. The order for suicide precautions would be reviewed by physician daily. Upon a suicidal statement, staff would complete a room safety check for sharp objects, glass, bottles, belts, etc. The assessment would be documented by the Registered Nurse (RN) after each shift using interdisciplinary notes. Social Service and/or nursing would implement suicide precautions in the care plan. The Comprehensive Care Plan (CCP) titled I have expressed suicidal ideations dated 01/20/2021, documented according to staff, family, volunteers, I have said I have the means or mode for suicide, by making statements of means and mode of suicide. Interventions included: kitchen to ensure that all utensils used at mealtimes will be plastic; suicidal precautions are initiated immediately by staff when a resident verbalizes suicidal ideation and/or makes an overt suicidal attempt and/or gesture; an order for suicide precautions is received from the physician and must include reason and duration; documentation of the specific behavior necessitating precautions must be made in the progress notes. The CCP was not updated following a suicidal ideation statement on 02/04/2022 and was not updated after an actual suicide attempt of using scissors to cut their wrist and subsequent hospitalization on [DATE]. A nursing progress note dated 02/04/2022 at 10:02 PM, written by a Registered Nurse (RN) documented CNA (certified nurse aide) stated at 9:15 PM, Resident #4 stated, I wish I could kill myself. The resident was interviewed, and denied having a plan and stated, I know I really could not do it here. When asked what was troubling the resident, they stated it was about an appointment they went to regarding they shoes and an insert. The resident was brought out to the common room for observation. The resident's room was searched, call bell cord was removed and a tap bell was provided. The resident's phone was removed, and they could make calls anytime at the nurse station. All sewing supplies were removed as well. A bed alarm was placed on resident bed. The resident had also been placed on every 15-minute checks for safety. The supervisor was updated on the current plan. There was no documentation that the physician or administration were notified. A review of physician orders did not include any new orders or suicide precaution orders from 02/04/2022 through 02/08/2022. The Suicide Prevention Environmental Safety Check form dated 02/04/2022, documented the items that were removed and/or secured from Resident #4's room following the suicidal ideation statement. The Patient Observation Monitor forms dated from 02/04/2022 through 02/08/2022 included documentation that every 15 minutes the resident was observed for safety. The Behavior Monitoring Record forms dated from 02/04/2022 through 02/08/2022 included documentation that every shift the nurse on duty monitored the resident and documented the resident behavior. A record request was submitted to the facility on [DATE] for all physician progress notes dated February 2022. There were no Physician notes for February 2022. A review of the nursing progress notes from 02/04/2022 through 02/08/2022 for the monitoring of Resident #4 following the suicide statement included: -02/05/2022 at 5:07 AM written by an LPN, documented 15-minute checks maintained. No further suicidal statements. -02/05/2022 at 9:42 PM written by a Registered Nurse, documented 15-minute checks maintained. Resident thinks the staff are punishing them. The resident seems very depressed and does not understand why the staff are doing this. There were no additional progress notes that documented an RN assessment of Resident #4 every shift in accordance with the facility policy from 02/04/2022 through 02/08/2022. A nursing progress note dated 02/08/2022 at 11:18 AM, documented the writer was called into resident's room at 7:50 AM where resident was found by staff cutting their wrist with a pair of scissors. The writer noted a cut on top of left wrist going almost around the wrist. Resident #4 was noted to be yelling, kicking, trying to bite and hit the writer and staff when they were trying to hold pressure to the cut. The writer applied a pressure dressing to left wrist. The RN assessed resident's mental status and wound. Resident #4 stated I want to die, they took all my stuff. 911 was called and the hospital emergency room was called to give report. Resident #4 left the facility at 8:30 AM to go to hospital via ambulance. The hospital discharge note dated 02/28/2022, documented the resident was admitted to the inpatient psychiatric unit on 02/08/2022 following an attempted suicide by cutting their wrist with sewing scissors. The hand injury was repaired in the emergency department. The patient underwent psychopharmacologic management. Following therapy and medication changes, the patient's condition improved, and it was felt they were safe and stable for discharge. During an interview on 08/15/2022 at 2:00 PM, the Social Worker (SW) stated they were on vacation at the time of the suicidal statement and the suicidal attempt. On 02/04/2022, the physician, SW, Director of Nursing (DON), Nurse Practitioner Psychiatrist, and Administrator should have been notified. The physician would see the resident every day. The behavior tracking forms were filled out by the nurses who should be talking to the resident every day. SW stated the care plan should have been updated after both incidents and the care plan should have noted the ideation and the attempt. SW did not update the suicidal care plan and would update it now. During an interview on 08/15/2022 at 2:20 PM, Registered Nurse Manager (RNM) #2 stated the physician, DON and Administrator should have been notified of the suicidal ideation statement on 02/04/2022. The physician would have given the order to begin suicidal precautions which would have included 15-minute checks. The physician should then have been notified each day following the incident about the precautions, because the physician would make the decision whether to continue the suicide precautions. The nurses documented on the behavior monitoring record every shift and they should have also written a narrative nursing progress note. The Social Worker was responsible for the suicidal care plan. RNM #2 was present for the suicidal attempt. The resident had the scissors open with the wrist between the top and bottom blades. Resident #4 had broken the skin and was bleeding enough that RNM had to apply pressure. RNM had no idea where the resident got the scissors and the room had been searched again after the attempt. The Physician was notified after the attempt and gave the order to send the resident to the emergency room . During an interview on 8/16/2022 at 9:10 AM, the DON stated there was no documentation that the physician was notified of the suicidal ideation statement on 02/04/2022 or gave the order for suicide precautions. The physician also should have been contacted every day following the incident until the suicide precautions were removed. The DON stated the facility policy was not followed. The suicide ideation statement occurred on a Friday evening and the DON and Administrator were not aware of the incident until Monday morning (02/06/2022). Monday morning the interdisciplinary team (IDT) met for morning report and the DON and Administrator were present, they talked about the suicidal ideation statement and what was done. The 15-minute checks were being done and the behavior sheets were being done every shift by the nurses. There should have been RN assessment notes in the chart every shift as well, according to the policy. The DON thought the Registered Nurse Manager would have reached out to the physician after the Monday morning report. The DON did not know why the physician was not notified and they should have been. The DON's assumption was that the RNM was speaking to the physician daily about the suicide prevention and was not sure why it was not done. The IDT talked about the staff being aware and the care plan being updated. The DON did not know the care plan had not been updated. During an interview on 08/16/2022 at 9:45 AM, RNM #2 stated they did not call the physician on Monday morning (02/06/2022), and further stated that if they had called the physician, it would have been documented. The RNM was not aware of the physician being notified each day following the suicidal ideation statement. RNM could not explain why this was not done. During an interview on 08/16/2022 at 10:00 AM, the Administrator (Adm) stated if they had been notified of the suicidal ideation statement on 02/04/2022, they would have asked the nurse if the physician was notified and what was the response from the physician. The Adm would have asked all the details of what was done and if the DON was notified and would have wanted to know everything. The physician, Adm and DON should have been called. The Adm would have expected the RNM would have overseen everything that should have been taking place. The Adm stated we did not follow our policy. The Adm stated they talked about these things in morning report and talked about the care plan being updated. The care plan should have been updated. During an interview on 08/16/2022 11:00 AM, the Medical Director (MD) stated they did not want to swear they did not have a conversation about this. The nurses speak to them about many things. The MD did not specifically recall talking about Resident #4. Ideally, the MD would have wanted to be notified of the suicidal ideation statement on 02/04/2022. 10 NYCRR 415.12(h)(2)

Based on interview and record review during an abbreviated survey (Case #NY 632), the facility did not ensure they immediately consulted with the resident's physician; and notified, consistent with their authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #4) of 4 residents reviewed. Specifically, the facility did not ensure the facility's Policy and Procedure was implemented for Suicidal Precautions when staff did not notify the physician of Resident #4's expression of suicidal ideations to staff on 02/04/2022. This was evidenced by: The Policy & Procedure titled Suicide Prevention dated 6/26/2019, documented residents who were potentially dangerous to themselves were closely observed to prevent them from harm. Suicidal precautions were initiated immediately by staff when a resident verbalized suicidal ideation and/or made an overt suicidal attempt and/or gesture. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for suicide precautions would be reviewed by physician daily. Resident #4: Resident #4 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment) dated 03/08/2022 documented the resident was able to make themself understood, able to understand others and was cognitively intact. The Comprehensive Care Plan (CCP) titled I have expressed suicidal ideations and dated 01/20/2021, documented according to staff, family, volunteers, the resident had said they had the means or mode for suicide, by making statements of means and mode of suicide. Interventions included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 02/04/2022 at 10:02 PM, written by a Registered Nurse (RN) documented CNA (certified nurse aide) stated at 9:15 PM, Resident #4 stated, I wish I could kill myself. The resident was interviewed, and denied having a plan and stated, I know I really could not do it here. When asked what was troubling the resident, they stated it was about an appointment they went to regarding they shoes and an insert. The resident was brought out to the common room for observation. The resident's room was searched, call bell cord was removed and a tap bell was provided. The resident's phone was removed, and they could make calls anytime at the nurse station. All sewing supplies were removed as well. A bed alarm was placed on resident bed. The resident had also been placed on every 15-minute checks for safety. The supervisor was updated on the current plan. There was no documentation that the physician was notified. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record request was submitted to the facility on [DATE] for all physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the nursing progress notes from 02/04/2022 through 02/08/2022, did not include documentation the physician was notified that the resident stated they wished they could kill themself or notified that precautions had been implemented for continued monitoring related to the resident's statement. During an interview on 08/15/2022 at 2:20 PM, Registered Nurse Manager (RNM) #2 stated the physician, the Director of Nursing (DON) and Administrator should have been notified of the suicidal ideation statement on 02/04/2022. The physician would have given the order to begin suicidal precautions which would have included 15-minute checks. The physician should then have been notified each day following the incident about the precautions, because the physician would make the decision whether to continue the suicide precautions. During an interview on 8/16/2022 at 9:10 AM, the DON stated there was no documentation that the physician was notified of the suicidal ideation statement on 02/04/2022 or gave the order for suicide precautions. The physician also should have been contacted every day following the incident until the suicide precautions were removed. The facility policy was not followed. The suicide ideation statement occurred on a Friday evening and the DON and Administrator was not aware of the incident until Monday morning (02/06/2022). Monday morning the interdisciplinary team (IDT) met for morning report and the DON and Administrator were present, they talked about the suicidal ideation statement and what was done. The 15-minute checks were being done and the behavior sheets were being done every shift by the nurses. DON thought that the Registered Nurse Manager would have reached out to the physician after the Monday morning report. DON did not know why the physician was not notified. During an interview on 08/16/2022 at 9:45 AM, RNM #2 stated they did not call the physician on Monday morning (02/06/2022), and further stated that if they had called the physician, it would have been documented. The RNM was not aware of the physician being notified each day following the suicidal ideation statement about the precautions. RNM could not explain why this was not done. During an interview on 08/16/2022 at 10:00 AM, the Administrator (Adm) stated if they had been notified of the suicidal ideation statement, they would have asked the nurse if the physician was notified and what was the response from the physician. The Adm would have asked all the details of what was done and if the DON was notified. The physician, Adm and DON should have been called. Adm would have expected the RNM would oversee everything that should have been taking place. The Adm stated we did not follow our policy. During an interview on 08/16/2022 11:00 AM, the Medical Director (MD) stated they did not want to swear they did not have a conversation about this as the nurses speak to them about many things. The MD did not specifically recall talking about Resident #4. Ideally, the MD would have wanted to be notified of the suicidal ideation statement on 02/04/2022. 10 NYCRR 415.3 (e)(2)(ii)(b)

Based on observation, record review and interviews during a recertification survey and abbreviated survey (Case #NY 055) on 06/14/2022 through 06/17/2022, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #144) of 5 residents reviewed for accidents. Specifically, for Resident #144, who fell 5 (five) times between 9/29/21 and 10/16/2021, the facility did not ensure the reasons for each of the resident's 5 falls were identified and interventions developed and implemented to prevent further falls. Additionally, the facility did not follow their policy for Accident and Incident reporting that documented that the root cause of the incident must be determined, and immediate interventions put in place to decrease or eliminate risk for recurrence. This was evidenced by: The Policy & Procedure (P&P) titled Accident/Incident Reporting dated 01/03/2013 documented to; identify, control, reduce and eliminate unsafe acts/conditions. An Accident and Incident Report Form is initiated at the time of an incident by the Charge Nurse/Supervisor. The root cause of the incident must be determined, and immediate interventions put in place to decrease or eliminate risk for recurrence. All Accident/Incident Reports require the Registered Nurse to update the care plan and Kardex at the time of Incident with appropriate interventions. Resident #144: Resident #144 was admitted to the facility with the diagnoses of status post right below the knee amputation, diabetes mellitus, and anxiety. The Minimum Data Set (MDS-an assessment tool) dated 10/01/2021, documented the resident's cognition was intact and the resident understood and could understand others. The CNA (Certified Nursing Assistant) Kardex dated 10/01/2021, documented the following for safety; resident is able to control height of bed, encourage lowest position before sleep. The Kardex did not include documentation of other interventions for fall prevention. Resident #144's Kardex (care instructions for staff) had not been updated to include each fall and interventions to prevent falls. The Kardex did not include fall mats. The comprehensive care plan (CCP) titled I am at risk of fall related to recent right below knee amputation dated 9/25/2021 documented the following interventions; encourage resident to keep bed in lowest position, keep call light and personal items within reach, appropriate footwear, and activities to promote exercise. Resident #144's comprehensive care plan (CCP) did not include additional interventions to prevent falls and/or injury and had not been updated to include each fall and interventions to prevent falls after 09/25/2021. The facility's Fall Reports/Post Fall Assessments for the 5 falls during the period of 9/29/21 through 10/16/2021 documented the following: The Fall Report dated 09/29/2021 at 5:45 PM documented; arrived in resident's room and resident was crying, face down next to his bed. Resident stated that he got dizzy and was weaving back and forth on the bed and just lost his balance and fell over. -Post Fall assessment dated [DATE] at 5:45 PM documented; unobserved, resident cognitively intact. -Fall prevention items in place at the time of incident documented; no interventions in place. -Steps were taken immediately to prevent recurrence and maintain resident safety documented; Resident's neuros, pain and range of motion assessed, and resident placed back in bed. There was no documented intervention to prevent recurrence. The Fall Report dated 10/03/2021 at 07:30 AM documented; resident was lying face down on mattress next to bed crying. Resident stated that he was trying to pee and just fell forward. Resident put self on floor-resident was exhibiting behaviors. When staff walked out he rolled onto the mattress next to the floor. -Post Fall assessment dated [DATE] at 07:30 AM documented; unobserved, resident cognitively intact. -Fall prevention items in place at time of incident documented; fall mat. For what steps were taken immediately to prevent recurrence and maintain resident safety documented; Residents range of motion, neurovitals and pain assessed, and resident assisted back into bed. There was no added documentation of further interventions to prevent recurrence. The Fall Report dated 10/09/2021 at 8:40 PM documented; resident was lying on the floor underneath his bed face down. -Post Fall assessment dated [DATE] at 8:40 PM documented; unobserved, resident cognitively intact. -Fall prevention items in place at time of incident documented; fall mat. -Steps were taken immediately to prevent recurrence and maintain resident safety documented; range of motion, pain and neurovitals were assessed and resident was placed back in bed. There was no documented intervention to prevent recurrence. The Fall Report dated 10/12/2021 at 7:45 AM documented; writer heard a crash, resident was lying face down on the floor and contents of breakfast tray was spread all over the floor. Resident stated that he was leaning over to put his urinal on the floor and the table tipped and he fell over. -Post Fall assessment dated [DATE] at 7:45 AM documented; unobserved, resident had impaired decision making. -Fall prevention items in place at time of incident documented; no fall interventions in place. -Steps were taken immediately to prevent recurrence and maintain resident safety documented; range of motion, pain and neurovitals were assessed and resident was assisted back in bed. There was no further documented intervention to prevent recurrence. The Fall Report dated 10/16/2021 at 5:50 AM documented; resident was laying half on crash mat with legs on the bare floor. Resident was assessed, vital signs obtained, range of motion evaluated. Resident unable to give description. -Post Fall assessment dated [DATE] at 5:50 AM documented; unobserved, resident had impaired decision making. -Fall prevention items in place at time of incident documented; fall mat. -Steps were taken immediately to prevent recurrence and maintain resident safety documented; resident was assessed, range of motion within normal limits, neuros started, lifted to recliner with 2 assist staff. There was no further documentation of interventions to prevent recurrence. Review of the Accident Incident Reports dated 10/9/2022 and 10/16/2022 documented that fall mats were in place at the time of fall, however there is no documentation in the resident record regarding the date this intervention was put in place and fall mats were not documented in the resident's Kardex. During an interview on 06/16/2022 at 02:16 PM, the Director of Nursing (DON) stated the incident reports should have documented a plan to prevent recurrence. The Incident Reports needed to have more clear and accurate documentation. The care plan should have been updated with each fall and the fall mat should be in the care plan and the CNA Kardex. During an interview on 06/17/2022 at 9:50 AM, Registered Nurse Manager #1 stated the incident reports need some work with documentation. The care plans were normally updated immediately after a fall, Resident #144 should have had the care plan updated following the falls. During an interview on 06/17/2022 at 10:15 AM, the Administrator stated, we did re-educate staff on incident reports in August 2021. The nurse who initially discovers the incident can place a new intervention, and there is always someone on call for advice. The Interdisciplinary Team (IDT) does review all the incident reports and if they are not completed, they would be sent back to the staff member responsible for completion. When the care plan was updated, there was a button to push to send the interventions to the CNA Kardex. The care plan and Kardex should have been updated for Resident #144. The Policy & Procedure was in place for Incident reports and should have been followed. 10NYCRR 415.12(h)(2)

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping services. Specifically, floors were not clean on 2 of 2 resident units. This is evidenced as follows. Observations of the resident units on 11/21/2019 at 9:15 AM, revealed that the floors were not clean in the McAuley resident unit hallways and in resident rooms #'s 107, 117, 122, 123, 124, 206, 210, and #216. The Environmental Services Manager stated in an interview on 11/21/2019 at 9:45 AM, that the floors should have been kept clean, and will ensure that the floors are cleaned. 483.10(i)(2)

Based on observation, record review, and interview during a recertification survey, the facility did not provide the resident and their representative with a written summary of the baseline care plan for 10 (Resident #'s 6, 13, 19, 27, 36, 44, 46, 50, 51 and #249) of 10 residents reviewed. Specifically, for Resident #'s 6, 13, 19, 27, 36, 44, 46, 50, 51 and #249, the facility did not ensure a written summary of the baseline care was provided to the residents and resident representatives. This is evidenced by; The policy and procedure titled Care Plans: Creation and Maintenance of Baseline and Comprehensive Care Plans dated 11/28/18, documented the facility must provide the resident and their representative with a summary of the baseline care plan. Resident #6: The resident was admitted to the facility with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 8/14/19, documented the resident had moderately impaired cognition, could understand others and could make self-understood. The medical record did not include documentation that a written summary of the baseline care was provided to the resident and resident representative. Resident #13: The resident was admitted to the facility with a [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident had severely impaired cognition, could understand others and could make self-understood. The medical record did not include documentation that a written summary of the baseline care was provided to the resident and resident representative. Resident #27: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident had severely impaired cognition, could understand others and could make self-understood. The MDS documented the resident had the [DIAGNOSES REDACTED]. The medical record did not include documentation that a written summary of the baseline care was provided to the resident and the resident representative. Interviews: During an interview on 11/19/19 at 3:05 PM, Registered Nurse Unit Manager RNUM #1 stated they had admitted new residents to the facility, initiated the resident's care plan, but had not provided a summary of the baseline care plan to the resident or resident representative within 48 hours. During an interview on 11/19/19 at 3:27 PM, RNUM #1 stated care plans were reviewed during family care plan meetings. RNUM #1 stated that they did not provide a summary to the resident or resident representative at that time. During an interview on 11/20/19 at 9:00 AM, the Director of Nursing stated they develop the baseline care plan when the resident is admitted . The facility cannot provide documentation that summaries of baseline care plans were provided to the resident's and their representatives. 10NYCRR415.11

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the Monthly Medication Regimen Review (MRR) that included timeframes for the different steps in the process. Specifically, the facility did not ensure there were timeframes established documented in the policy for steps in the MRR process concerning actions the pharmacist and facility needed to take when an irregularity was identified. This is evidenced by: The Policy and Procedure titled Medication Regimen Review dated 6/3/19, documented resident-specific irregularities and/or clinically significant risks resulting from or associated with medications were documented in the resident's active record and reported to the Director of Nursing (DON), Medical Director, and/or prescriber as appropriate. Notification mode was dependent on severity of the irregularity and was determined through consultation between the consultant pharmacist and the DON. During an interview on 11/21/19 at 12:44 PM, the DON stated the pharmacist notified the facility immediately when a irregularity was identified. The DON reviewed the facility's MRR policy. The DON was not aware timeframes needed to be established for the different steps in the MRR process. 10NYCRR415.18(c)(2)

Based on record review and interview, the facility did not ensure menus met the nutritional needs of the residents in accordance with national guidelines and were reviewed by the facility's dietitian for nutritional adequacy. Specifically, the facility did not ensure menus met basic nutritional needs by providing enough fruits and vegetables based established national guidelines, and that menus were reviewed and revised as needed to ensure nutritional adequacy after changes were made to the menu. This is evidenced by: The (YEAR)-2020 Dietary Guidelines for Americans documented the recommended amounts of food on a 2,000 calorie diet: - 2 1/2 cups of vegetables per day - 2 cups of fruit per day - 6 ounces of grains per day - 3 cups of dairy per day - 5 1/2 ounces of protein per day A review of the facility menu documented the following: - 1 1/2 cups of vegetables or less served per day on 4 of 7 days - 1 cup of fruit or less served per day on 7 of 7 days During an interview on 11/20/19 at 12:51 PM, the Registered Dietitian (RD) stated the United States Department of Agriculture (USDA) nutrition guidelines were used to determine the nutritional adequacy of the menu, and the facility did not have a diet manual. The RD stated the facility used the 2,000 calorie USDA meal pattern as a guide for the menus, and the current menu does not include 2 cups of fruit per day, and the residents do not consistently receive 2 1/2 cups of vegetable daily. During a subsequent interview on 11/21/19 at 8:30 AM, the RD stated she had not reviewed the current menu for nutritional adequacy. The RD stated the menu was reviewed a year and a half ago, and since then, the menu changed as items were taken off due to plate waste, and these items were not replaced. The RD stated the menu was not reviewed again after the changes to ensure nutritional adequacy. 10NYRR415.14(c)(1-3)

Based on observation, staff interview and medical record review, the facility failed to ensure residents were free of any significant medication errors for 4 (#s 30, 37, 60, 115) of 19 residents reviewed during the extended recertification survey. Specifically, the facility failed to ensure that residents received all physician ordered medication, failed to identify significant medication errors, failed to monitor residents for adverse reactions when significant medications were not administered and failed to notify the physician when significant medications were not administered. Additionally, the facility failed to ensure that medications were administered according to accepted standards of practice. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. This is evidenced by: The facility's policy entitled "Medication/Treatment Administration Errors" initially dated 3/2006 and most recently updated 1/25/12 documented the definition of a error included the following: 1. Omission: Any dose of medication or provision of treatment with medication, NOT GIVEN by the time the next prescribed dose (if any) is due, or NOT GIVEN at all if the medication /treatment is a single dose order. 2. Incorrect Time: Any drug not given within 1 hour before or after the time ordered to be given, except for STAT( to be given as soon as possible) orders. The facility's policy titled "Medication Administration" initially dated 9/2005 and most recently revised 1/25/12, documented "all medications shall be prepared and administered in accordance with the physician's orders [REDACTED]. hour of the designated time of administration." Resident #37 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident rarely understands and was rarely understood and had severely impaired cognitive skills for daily decision making. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. This same MAR indicated [REDACTED]. This indicated the medication was not administered. The nurses' notes for 4/4/12 through 4/23/12 documented no evidence the resident's [MEDICATION NAME]/L-Dopa was not administered as ordered. During interview on 4/23/12 at 2:05pm the Licensed Practical Nurse #1 (LPN #1) who was administering medications stated she tries to administer the medications on time, but if she can't then she will hold a dose, as the medications can't be administered too close together. During interview on 4/25/12 at 8:48 am this same LPN #1 stated on 4/23/12 she held the resident's 1:00pm dose of [MEDICATION NAME]/L-Dopa, as the 9:00am dose was late. This same LPN #1 stated this happens a lot. Review of the medication error reports provided by the facility showed no documented evidence medication error reports were completed for the doses that were not administered. During interview on 4/24/12 at 9:30am the registered nurse unit manager (RNUM) stated she was unsure why medication errors were not completed when medications are late or held. During interview on 4/24/12 at 2:03 pm, the physician stated he had not been advised and would expect to be notified if medications or treatments were not administered as ordered. Resident #30 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. During interview on 4/24/12 at approximately 4:00pm the LPN #4, who administers medications, stated she had held the 4:00pm dose of Keflex as the morning dose was late. Resident #60 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During interview on 4/24/12 at approximately 4:00pm LPN #4 stated she has had to hold the resident's [MEDICATION NAME] at least once during the past week because the morning dose was given late. Resident #24 The facility did not ensure the resident's medications were administered within the an hour before or an hour after the time indicated on the Medication Administration Record. The resident was admitted to the facilty on 2/2/12 with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident sometimes understands and is usually understood, and has intact cognitive skills for daily decision making. The physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 4/24/12 at 10:15 am the licensed practical nurse (LPN) was observed to administer these medications. (2hrs after scheduled time) During interview on 4/24/12 at 10:40am, the LPN stated she knows the medications are late, but she gets to them when she can. This same LPN also stated she tried to prioritize what medications are administered late, and if she knows a resident receives their medications more than once a day, she will try to do those medications first, so the second dose is not affected. Finding #1 During interview on 4/23/12 at 11:23 am LPN#1)stated she is not able to administer all of the medications on time for the 40 bed unit (with a census of 37 on 4/23/12 at 10:15am) when there is only one nurse passing medications for the day. The LPN#1 also stated sometimes the 10:00am medications are not administered until 4:00pm, and she has reported this to the Registered Nurse Unit Manager (RNUM) about a week and a half ago, and the RNUM stated "I know, I know". LPN#1 also stated she notified the Director of Nursing (DON) as recently as last week and was told there was no one to help. LPN#1 also stated the Acting Administrator (AA) was told about medications being late, and the AA told LPN#1 if the work is not done, you have to stay until it's finished. Finding #2 During interview on 4/23/12 at 3:02 pm LPN #2 stated the day nurse often reports that treatments and medications are not done. LPN #2 stated she tries to help the day nurse get caught up on the evenings if she can. LPN#2 stated sometimes the day nurse has to do physician rounds and sometimes medications and treatments just can't be given, so they get skipped. LPN #2 also stated if she is running late with medications, some of the Registered Nurse Supervisors (RNS) will help, other RNS will say "there's nothing that can be done, if they are late, they're late." Finding #3 During interview on 4/24/12 at 8:16 am LPN#3 stated she works per diem on the unit. LPN #3 stated if she is the only nurse on the Warde Unit, she can not get the medications administered on time. LPN#3 also stated on 4/5/12 she was the only nurse on the Warde unit and the medications were late. LPN#3 stated when she reports this to the RNUM, the RNUM will say "I know". LPN#3 stated if a resident gets medications at 8:00am and 12:00pm, she will try to get them administered on time. If she can't administer the medications on time, LPN #3 stated she will hold the medication. Finding #4 During interview on 4/24/12 at 9:30am the RNUM stated staff nurses have told her repeatedly that one nurse cannot do all the medications and treatments for the Warde Unit and finish them on time. The RNUM stated she cannot help the nurses every time, but she tries to help when she can. The RNUM stated she has administered medications twice, and both times the medications and treatments were late. The RNUM stated she did tell the DON who told her "do the best you can". Finding #5 During interview on 4/24/12 at 9:46 am the DON stated the facility is trying to get more staff. The DON stated both the DON and the AA are aware medications are administered late on the Warde Unit when there is only one nurse assigned to the unit. Finding #6 During interview on 4/24/12 at 10:00am the AA stated she is aware that on days when there is only one nurse on the Warde Unit, medications are not being administered on time. Having the nurses stay past their usual work hours to complete the work is not ensuring the medications and treatments are completed on time. The AA also stated she has not received any medication errors in the past 2 weeks, although she is aware there have been days when medications have been administered late in the past 2 weeks. The AA stated she was aware of this and has not done anything with this information. Finding #7 During interview on 4/24/12 at 2:03 pm, the physician stated he was not advised and would expect to be notified if medications or treatments were not administered as ordered. The Immediate Jeopardy situation was removed on 4/25/12, based upon the following corrective actions taken by the facility: ? The Medication Administration Policy was revised, including clarification of responsibility of the Licensed Practical Nurse and Registered Nurse. ? Scheduling of two nurses for day and evening shifts on the 40 bed unit, beginning 4/24/12 day shift. This staffing pattern will continue until further evaluation of long term solutions is completed. In the event of a staff person calling out, all licensed staff not on duty at the time will be asked to work the open shift. If none are able to do so, the Nurse Manager or Director of Nursing will work that shift. ? All licensed nurses received inservice training on facility expectations for the medication pass on 4/25/12. Only one nurse was not available for the education session and she will be provided with the inservice eduction prior to her next scheduled shift. ? Medication Competency exam was administered to all licensed nurses in attendance on 4/25/12. ? Observation audits were started on 4/25/12 for all nurses passing medications. This process will continue until all nurses have successfully completed medication pass according to facility policy and procedure. 10NYCRR415.12(m)(2)

Based on medical record review, observation and staff interview, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 2 units reviewed during the extended recertification survey. Specifically, the facility failed to provide sufficient nursing staff on the Warde unit to ensure that resident's medications and treatments were administered at the time indicated on the Medication Administration Record/ Treatment Administration Record. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. This is evidenced by: Resident #24 The resident was admitted to the facilty on 2/2/12 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident sometimes understands and is usually understood, and has intact cognitive skills for daily decision making. The physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 4/24/12 at 10:15 am the licensed practical nurse (LPN) was observed to administer these medications. (2hrs after scheduled time) During interview on 4/24/12 at 10:40am, the LPN stated she does not document anything differently when a resident's medications are administered late. The LPN also stated she does not notify the physician when the medications are administered late. Resident #28 The facility did not perform a treatment as ordered by the physician. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident sometimes understands and is sometimes understood, and had severely impaired cognitive skills for daily decision making. This same MDS assessed the resident was totally dependent on staff and required assistance of 2 staff for bed mobility, and extensive assistance of 2 staff for transfers. The physician's orders [REDACTED]. During interview on 4/23/12 at 3:02pm a licensed practical nurse (LPN#2) who works evenings, stated she often comes in to work and the day nurse reports that treatments and medications are not completed. This same LPN also stated she will try and catch up on these things on her shift if she can. The LPN also stated she does not notify the physician, as the facility does not have a consistant physician to call, and the physician's assistants that are covering don't seem to care, so why would I call them? During interview on 4/24/12 at 3:30pm, this same LPN stated there have been times when she has been unable to complete this resident's dressing as ordered. During interview on 4/24/12 at 2:03pm, the physician stated he was not advised and would expect to be notified if medications or treatments were not administered as ordered. Finding #1 During interview on 4/23/12 at 11:23am licensed practical nurse #1 (LPN#1) stated she is not able to administer all of the medications on time for the 40 bed unit (with a census of 37 on 4/23/12 at 10:15am) when there is only one nurse on for the day. The LPN#1 also stated sometimes the 10:00am medications are not administered until 4:00pm, and she has reported this to the registered nurse unit manager (RNUM) about a week and a half ago, and the RNUM stated "I know, I know". LPN#1 also stated she notified the director of nursing as recently as last week and was told there is no one to help. LPN#1 also stated the Acting Administrator (AA) was told about medications being late due to insufficient staff, and the AA told LPN#1 if the work is not done, you have to stay until it's finished. Finding #2 During interview on 4/23/12 at 3:02pm LPN #2 stated the day nurse often reports that treatments and medications are not done. LPN #2 stated she tries to help the day nurse get caught up on the evenings, if she can. LPN#2 stated sometimes the day nurse has to do physician rounds and sometimes medications and treatments just can't be completed, so they get skipped. LPN #2 also stated if she is running late with medications, some of the registered nurse supervisors (RNS) will help, other RNS will say "there's nothing that can be done, if they are late, they're late." Finding #3 During interview on 4/24/12 at 8:16am LPN#3 stated she works per diem on the unit. LPN #3 stated if she is the only nurse on the Warde Unit, she can not get the medications administered on time. LPN#3 also stated on 4/5/12 she was the only nurse on the Warde unit and the medications were late. LPN#3 stated when she reports this to the RNUM, the RNUM will say "I know". Finding #4 During interview on 4/24/12 at 9:30am the RNUM stated staff nurses have told her repeatedly that one nurse cannot do all the medications and treatments for the Warde Unit and finish them on time. The RNUM stated she cannot help the nurses every time, but she tries to help when she can. The RNUM stated she has administered medications twice, and both times the medications and treatments were late. The RNUM stated she did tell the Director of nursing (DON) who told her "do the best you can". Finding #5 During interview on 4/24/12 at 9:46am the DON stated the facility is trying to get more staff. The DON stated both the DON and the Acting Administrator are aware medications are administered late on the Warde Unit when there is only one nurse assigned to the unit. Finding #6 During interview on 4/24/12 at 10:00am the AA stated she is aware that on days there is only one nurse on the Warde Unit, medications are not being administered on time, and having the nurses stay past their usual work hours to complete the work is not ensuring the medications and treatments are completed on time. The AA stated she was aware of this, and has not done anything with this information. Finding #7 During interview on 4/24/12 at 2:03pm, the physician stated he was not advised and would expect to be notified if medications or treatments were not administered as ordered. Finding #8 During interview on 4/24/12 at 1:42pm the staffing coordinator stated nurses have come to her many times to say that the assignments on the Warde Unit cannot be completed with just one nurse. The staffing coordinator also stated "we try to find staff but there just aren't enough bodies". The staffing coordinator also stated she had informed the Acting Administrator and the Director of Nursing about the staffing concerns. On 4/25/12 at 11:24am the "Daily Staffing List"s for the month of April were reviewed with the Acting Administrator (AA). The AA identified 11 days during the month of April where there was only 1 nurse scheduled for the Warde Unit, and 10 evening shifts during the month of April when there was only one nurse scheduled for the Warde Unit. The Immediate Jeopardy situation was removed on 4/25/12, based upon the following corrective actions taken by the facility: ? The Medication Administration Policy was revised, including clarification of responsibility of the Licensed Practical Nurse and Registered Nurse. ? Scheduling of two nurses for day and evening shifts on the 40 bed unit, beginning 4/24/12 day shift. This staffing pattern will continue until further evaluation of long term solutions is completed. In the event of a staff person calling out, all licensed staff not on duty at the time will be asked to work the open shift. If none are able to do so, the Nurse Manager or Director of Nursing will work that shift. ? All licensed nurses received inservice training on facility expectations for the medication pass on 4/25/12. Only one nurse was not available for the education session and she will be provided with the inservice eduction prior to her next scheduled shift. ? Medication Competency exam was administered to all licensed nurses in attendance on 4/25/12. ? Observation audits were started on 4/25/12 for all nurses passing medications. This process will continue until all nurses have successfully completed medication pass according to facility policy and procedure. 10NYCRR415.13(a)(1)(i-iii)

Based on medical record review and staff interview the administration failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident reviewed during the extended recertification survey. The Administrator failed to have systems in place to ensure sufficient staffing was provided to ensure the residents medications and treatments were administered as ordered by the physician. Additionally, The Administrator failed to have systems in place to ensure that residents were free from significant medication errors. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to residents health and safety. This is evidenced by: See F333 and F353 Scope and Severity K Finding #1 During interview on 4/24/12 at 10:00am the AA stated she is aware that on days there is only one nurse on the Warde Unit, medications are not being administered on time, and having the nurses stay past their usual work hours to complete the work is not ensuring the medications and treatments are completed on time. The AA stated she was aware of this, and has not done anything with this information. During interview on 4/24/12 at 2:03pm, the physician stated he was not advised and would expect to be notified if medications or treatments were not administered as ordered. During interview on 4/24/12 at 1:42pm the staffing coordinator stated nurses have come to her many times to say that the assignments on the Warde Unit cannot be completed with just one nurse. The staffing coordinator also stated "we try to find staff but there just aren't enough bodies". The staffing coordinator also stated she had informed the Acting Administrator and the Director of Nursing about the staffing concerns. The Immediate Jeopardy situation was removed on 4/25/12 prior to exit from the facility. The removal of the Immediate Jeopardy was based upon the following corrective actions taken by the facility: ? The Medication Administration Policy was revised, including clarification of responsibility of Licensed Practical Nurse and Registered Nurse. ? Scheduling of two nurses for day and evening shifts on the 40 bed unit, beginning 4/24/12 day shift. This staffing pattern will continue until further evaluation of long term solutions is completed. In the event of a staff member calling out, all licensed staff not on duty at the time will be asked to work the open shift. If none are able to do so, the Nurse Manager or Director of Nursing will work that shift. ? All licensed nurses received inservice training on facility expectations for the medication pass on 4/25/12 beginning a 6:00 pm. Only one nurse was not available for the education session and she will be provided with the inservice eduction prior to her next scheduled shift. ? Medication Competency exam was administered to all licensed nurses in attendance on 4/25/12. ? Observation audits were started on 4/25/12 for all nurses passing medications. This process will continue until all nurses have successfully completed medication pass according to facility policy and procedure. 10NYCRR415.26

Based on interview and medical record review the facility failed to maintain a Quality Assessment and Assurance (QA) committee which identified and implemented appropriate plans of action to correct quality deficiencies which had the potential to cause serious harm to residents during the extended recertification survey. Specifically, the QA committee failed to identify issues involving lack of sufficient staff to administer medications and treatments to residents as ordered by the physician. Additionally, the QA committee failed to identify issues to ensure that residents were free from significant medication errors. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to resident health and safety. This is evidenced by: See F333 Significant Medication Errors, Scope and Severity K During interview on 4/26/12 at 9:59am the Acting Administrator (AA) stated the QA committee meets every month with another facility. The AA stated the QA committee reviews medication error statistics, but does not specifically review medication errors. The AA stated the Director of Nursing (DON) reviews the medication error reports. The AA was shown the medication error reports provided to the survey team for the past 4 months (2 reports total), and stated there seems to be too few reports for that period of time. The AA also stated in the 3 weeks since being the AA, she has not seen any medication/ treatments error reports. During interview on 4/24/12 at 2:03pm, the physician stated he was not advised and would expect to be notified if medications or treatments were not administered as ordered. See F353 Sufficient Staffing, Scope and Severity K During interview on 4/26/12 at 9:59 am the AA stated the QA committee has not reviewed staffing concerns. The Immediate Jeopardy situation was removed on 4/25/12, based upon the following corrective actions taken by the facility: ? The Medication Administration Policy was revised, including clarification of responsibility of the Licensed Practical Nurse and Registered Nurse. ? Scheduling of two nurses for day and evening shifts on the 40 bed unit, beginning 4/24/12 day shift. This staffing pattern will continue until further evaluation of long term solutions is completed. In the event of a staff person calling out, all licensed staff not on duty at the time will be asked to work the open shift. If none are able to do so, the Nurse Manager or Director of Nursing will work that shift. ? All licensed nurses received inservice training on facility expectations for the medication pass on 4/25/12. Only one nurse was not available for the education session and she will be provided with the inservice eduction prior to her next scheduled shift. ? Medication Competency exam was administered to all licensed nurses in attendance on 4/25/12. ? Observation audits were started on 4/25/12 for all nurses passing medications. This process will continue until all nurses have successfully completed medication pass according to facility policy and procedure. 10NYCRR415.27(a-c)

Based on medical record review and staff interviews, it was determined that the facility did not ensure that the resident maintained acceptable parameters of nutritional status, such as body weight for 1 ( Resident #60) of 2 residents reviewed during an abbreviated survey ( # NY 623). Specifically, the resident was assessed to be at risk for weight loss and care planned to have feeding ability and percentage of food intake monitored. The facility did not ensure that consistent monitoring of food and fluid intake was recorded or monitored. The resident sustained [REDACTED]. The facility did not have a process for ensuring the food and fluid intake worksheets were completed or monitoring the food and fluid intake worksheets for percentages of consumed food. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: The facility policy titled Food and Fluid Intake dated 12/04 with a revision date of 9/09, documented that the Food and Fluid intake is documented for all resident's meals and planned snacks/nourishments in order to monitor and identify inadequate nutrients, fluid intake that may result in weight loss, skin breakdown and or [MEDICAL CONDITION]. Resident #60: The resident was admitted [DATE] to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have moderately impaired cognition and not able to make needs known. The Comprehensive Care Plan (CCP) titled "Altered nutritional status" dated 2/2/12 documented that the resident was at risk for weight loss, dehydration and skin breakdown. Documented approaches included: calorie count as needed, monitor need for a diet supplement, daily fluid intake of 2000 cubic centimeters (cc), monitor weights, encourage oral intake and dietary consults. There were no additional changes made when reviewed on 4/2/12. The residents admission weight was documented as 180.6. The residents diet was documented as a no added salt 2000 calorie mechanically altered. An additional CCP titled Resident is edentulous dated 2/2/12 documented that the resident's weight will be maintained within acceptable parameters. Documented approaches included: monitor for weight loss, monitor and record percentage of food intake, determine if having no dentures is the resident's choice, consult with the Registered Dietician and follow recommendations. Review of the resident's care card (undated) (which personal caregivers use to determine care needed) documented that the resident feeds self after set up and should be fed to finish the meal. The facility form titled Food & Fluid Monthly Flow Sheet for February 2012, were reviewed and did not have documentation for meal consumption for 31 of 87 meals. Sixteen of the remaining 56 meals, documented that the resident consumed 50% or less of the meal. The facility form titled Food & Fluid Monthly Flow sheets for March 2012, were reviewed and did not have documentation for meal consumption for 41 of 93 meals. Thirty five of the remaining 52 meals, documented that the resident consumed 50% or less of the meal. The RD wrote an assessment dated [DATE] and documented that the resident was admitted from the hospital, ate well, but needed to be fed. The resident had poor vision and was edentulous (without teeth). The resident was observed feeding himself but required continual cues from the therapist as to food placement. The resident had not lost any weight, but does have a [DIAGNOSES REDACTED]. The RD documented on 1/19/12 that the resident was using straws and a lip plate due to being legally blind. The resident requires assistance as to food placement. The resident is on weekly weights. The resident's medical record was reviewed on 4/2/12 and documented weights as the following: 2/29 -181 pounds, 3/7 -182 pounds, 3/2012- 170 pounds, 3/26/12 -164 pounds. This represents a seventeen pound or 9.4% weight loss in one month. A Certified Nursing Assistant (CNA #1) was interviewed on 4/2/12 at 12:20 pm and stated that the resident just started eating in the small dining room since he went on a calorie count last Friday (3/30/12). The RD was interviewed on 4/2/12 at 3:00 pm and stated she was not aware of the resident's weight loss until last Thursday (3/29/12). She was covering for the regular RD who was on maternity leave. She stated on 3/29/12 she had a calorie count implemented to see what the resident's eating behavior was like. When shown the facility form titled Food & Fluid Monthly Flow sheets for the months of February and March, the RD stated she was not aware of the resident's limited intake or the lack of documentation. When asked whose responsibility it was to monitor the intake sheets, the RD stated she thought it was nursing. The Licensed Practical Nurse (LPN) was interviewed on 4/2/12 at 3:15 pm and stated she had never been instructed to check the intake sheets for completion. The Registered Nurse Manager (RNM) was interviewed on 4/2/12 at 3:30 pm and stated she was not aware of who checks the intake sheets and has only worked at the facility for a few weeks. 10 NYCRR 415.12 (i)(1)

Based on medical record review and staff interview during a complaint investigation (Case #NY 322), it was determined that for one (Resident #1) of three residents reviewed, the facility did not ensure that the resident environment remained as free of accident hazards as possible and did not supervise the resident adequately. Specifically, the facility did not complete a fall assessment for a resident at risk for falls, did not develop a care plan with interventions to prevent falls and to protect the resident in the event of falling, and upon the resident falling, did not assess/reassess the resident. New interventions documented on the Accident and Incident report were not initiated or implemented for the resident. Subsequently, the resident fell a second time from bed and was admitted to the hospital with [REDACTED]. This was evidenced by: 1. Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with long and short term memory impairment, severely impaired decision making skills, a fall within the past 30 days and a hip fracture within the last 180 days. The MDS also assessed that the resident required the assistance of one with bed mobility and ambulation. The MDS Resident Assessment Protocol (RAP) Summary dated 9/9/10 documented that the resident triggered for falls and documented that the Care Planning Decision was addressed in the care plan. The RAP note documented that the resident had a history of [REDACTED]. The Falls Risk assessment dated [DATE] prepared by the Registered Nurse Manager (RNM) was incomplete as sections 6 - 8 and section 10 were not completed and the Total Score was not calculated. The resident's medical record did not include a care plans for Falls. The resident's care card (undated) documented that the fall prevention approach being utilized for the resident was a low bed. The nurse's note dated 10/11/10 at 8:48 am, signed by RN #1, documented that at 12:30 am, the Certified Nurse Aide (CNA #1) reported that Resident #1 had rolled out of bed onto the floor and complained of pain in her back and legs. The Fall Accident/Incident (A&I) Report signed by RN #1 dated 10/11/10 at 1:00 am documented that Resident #1 was found sitting on the floor complaining of back and leg pain. The Corrective Action Taken portion of the form documented, Bed in lowest position - in place, and crash pad to right side of bed. A second Falls A&I dated 10/19/10 at 12:00 am signed by CNA #1 documented that CNA #1 heard the resident calling for help, responded to her room and found the resident face down on the floor at the foot of the bed, with a tab alarm in her hands, not sounding. Interventions documented were, that the resident was treated with first aide and transported to the hospital for further evaluation. The Corrective Action Taken portion of the form documented "bed alarm should be used along with tab alarm, possible crash mats used (will be discussed with nurse manager)" These interventions were not implemented as previously documented on the I&A dated 10/11/10. This I&A was signed by the DON who added bed sensors as a preventative measure for falls. Nurse's note dated 10/19/10 at 2:21 am signed by Licensed Practical Nurse (LPN) #1 documented that CNA #1 walked out of the resident's room to report to her that the resident was agitated and when CNA #1 returned to the room, the resident had fallen on the floor. The LPN #1 documented that the resident's right eye was swollen with a laceration above the right eye with a moderate amount of bleeding and that LPN #1 noted swelling on the medial aspect of the left leg, the rescue squad was called and the resident was transferred to the hospital at 12:00 am. The resident was admitted to the hospital for bleeding into the brain. During an interview on 11/5/10 at 3:00 pm the RNM stated that it was her responsibility to complete all resident assessments upon admission, for the residents on her unit. The RNM stated that she realized after the fall on 10/19/10, that she did not complete the Fall Assessment that she began on 8/23/10, and that based on what she had completed, the resident would have been a fall risk. The RNM stated that a care plan had not been developed for fall prevention for this resident. The RNM reviewed the A&I of 10/11/10 and stated that she did not specifically recall the incident, however, she stated that she reviewed all A&I reports for her unit and that the Interdisciplinary Team (IDT) meets each day following the incidents to discuss the reports. The RNM stated that she would bring the A&I, the resident's care plan and care card to the IDT meeting so corrective action plans could be made and the care plans updated to include additional interventions as needed. The RNM stated that she was not aware that this resident did not have a Falls Care Plan in place until after the fall of 10/19/10 and was unable to determine when the tab alarm was initiated for the resident. During interview on 11/5/10 at 4:15 pm the Director of Nursing (DON) stated that the IDT reviews all incidents daily from the last 24-hour period for the purpose of determining corrective action for a particular incident. The DON stated that all care plans and care cards should be brought to the IDT meeting, and stated that this happens in a, "hit or miss" fashion. The DON stated that on 10/19/10 there was no Falls Care Plan in place for Resident #1 and therefore after the fall on 10/11/10, the Care Plan could not have been reviewed and there is no evidence that interventions were in place to prevent falls. The DON stated that after the fall on 10/19/10, a falls care plan was initiated and included a bed sensor. During interview on 12/7/10 at 2:30 pm the Medical Director (MD) stated that newly admitted residents should be assessed for Falls and for those residents with a history of falls, fall precautions should be put into place and the care plan should address ways to prevent falls. The MD stated because every resident is different and every fall can be different, each fall incident should be reviewed and approaches to prevent falls examined and changed as needed. During interview on 1/10/11 at 4:10 pm the Registered Nurse Supervisor (RNS) stated that she was the Supervisor for the facility on 10/19/10 and was called to assess Resident #1 due to a fall. The RNS stated that she was not familiar with the resident, and observed the resident with a significant injury and no apparent fall prevention interventions in place. The RNS stated that she made a notation on the I&A in the corrective action taken portion of the form "bed alarm should be used along with tab alarm, possible crash mats used (will be discussed with nurse manager)" because, based on her experience, these were routine interventions for a resident at risk for falls and she did not observe any of them in place when she responded to the call to assess the resident. 10NYCRR 415.12(h)(1)(2)