Every finding on record at Utica Rehabilitation & Nursing Center

Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for two (2) of four (4) medications carts (Unit 3 South and Unit 4 North) and one (1) of two (2) medications rooms (Unit 4) reviewed. Specifically, the Unit 3 South medication cart had expired eye drops and nasal spray; the Unit 4 North medication cart had opened unlabeled inhalers, expired or unlabeled eye drops, one insulin pen was missing the pharmacy label, the resident's name, and date opened and one insulin pen was not labeled with an opened date; and the Unit 4 medication room refrigerator was not maintained at an appropriate temperature.Findings included:The facility policy Storage and Maintenance of Medications, revised 05/2019 and effective 10/2020, documented the medication refrigerator must maintain a proper temperature of 36-46 degrees Fahrenheit. Medications with shortened expiration dates, such as insulin injections and ophthalmic drops, were to be dated when opened. The overnight medication nurse was responsible for checking the medication cabinet, carts, and refrigerator for expired medications every week.The facility policy Insulin Storage, effective 02/09/2024, documented upon first use of an insulin vial or pen it was labeled with the date opened, beyond-used date, and the nurse's initials. If the beyond date was not written, the product was to be discarded. Medication refrigerator temperatures were also logged daily, and any temperature outside 36-46 degrees Fahrenheit was reported immediately to the nursing supervisor and pharmacy.The facility reference guide Medication Storage and Expiration Quick Reference, dated 2016, documented Lantus (long-acting insulin) was to be discarded 28 days after opening. During an observation and interview with Licensed Practical Nurse #8 on 02/18/2026 at 8:45 AM, the medication refrigerator on Unit 4 had a temperature of 56 degrees Fahrenheit and 68 degrees Fahrenheit read from the facility thermometer inside the refrigerator by Licensed Practical Nurse #8. They stated temperatures were checked and documented by the night nurses. They were not sure what the temperature was supposed to be as they did not check it.The 02/2026 Unit 4 refrigerator temperature log documented on 02/2027 the refrigerator temperature was not greater than 40 degrees Fahrenheit during the month, and on 02/18/2026 the refrigerator temperature was 40 degrees Fahrenheit.During an observation and interview with Licensed Practical Nurse #8 on 02/18/2026 at 8:51 AM, the top drawer of Unit 4 North medication cart had Trelegy Ellipta (an inhaler used to treat asthma) that was not labeled with an open date. The bag the inhaler was kept in, documented a prescription date of 09/01/2025 and to discard after six weeks. Licensed Practical Nurse #8 confirmed there was no open date listed on the inhaler and there should have been. The nurse who opened the medication was responsible for putting the open date on. They were not sure when inhalers expired or why the medication did not have an open date. Additionally, there were two Lantus pens (long-acting insulin), one pen had no pharmacy label or label of any kind with the resident's name and when the pen was opened; and the second pen had a pharmacy label but was missing the opened date. Licensed Practical Nurse #8 stated they were unsure why there was no pharmacy label on one of the pens. They stated it was not a big deal that the Lantus pen did not have a resident name as there was only one resident it would have belonged to. Checking expiration dates was the responsibility of everyone. The third drawer had two Artificial Tears (eye drops for lubrication) and Visine (eye drops to reduce redness) that were opened on 11/11/25. During an observation and interview with Licensed Practical Nurse #8 on 02/18/2026 at 12:12 PM, the Unit 4 medication refrigerator had a temperature of 56 degrees Fahrenheit. Licensed Practical Nurse #8 stated they replaced the thermometer, and it read 44 degrees Fahrenheit.During an observation and interview with Licensed Practical Nurse #3 on 02/19/2026 at 3:39 PM, the medication refrigerator was 60.3 degrees Fahrenheit. Licensed Practical Nurse #3 stated the temperature on the facility thermometer read 38.5 degrees Fahrenheit.During an observation and interview with Maintenance Technician #11 on 02/19/2026 at 3:46 PM, the refrigerator temperature was 58 degrees Fahrenheit after it was in the refrigerator for five minutes. Maintenance Technician #11 confirmed the temperature and placed two facility thermometers in the refrigerator.During an observation and interview with Licensed Practical Nurse #3, on 02/19/2026 at 4:00 PM, they stated the two thermometers that were placed in the refrigerator by maintenance both read 54 degrees Fahrenheit.During an interview on 02/19/2026 at 4:09 PM Registered Nurse Unit Manager #10 stated the overnight shift checked the medication carts and discarded expired medications. Insulin, inhalers and eye drops needed to be labeled when opened. They expected staff to discard open medication that was not labeled with an opened date. An insulin pen without a pharmacy label should be discarded and not used. There was no way to ensure the pen was not used by someone else. The medication refrigerator temperature was checked by overnight nurses and was 36-46 degrees Fahrenheit.During an observation and interview with Licensed Practical Nurse #12 on 02/19/2026 at 3:17 PM, the top drawer of the Unit 3 medication cart had Refresh ophthalmic solution (eye drops) with an opened date of 11/04/2025. Licensed Practical Nurse #12 stated that the eye drops were expired and should have been thrown out. The third drawer in the medication cart had Fluticasone nasal spray with an open date of 12/18/2025. Licensed Practical Nurse #12 stated that they were unsure when it expired after it was opened, but it was probably expired and needed to be discarded. They stated that they tried to look through the medication cart every day and discard expired medication. Residents should not receive medication that was expired.During an interview on 02/23/2026 at 10:10 AM Registered Nurse Unit Manager #13 stated the night shift checked the medication carts for expired medications and they did monthly audits. They were not sure how long after eye drops or nasal sprays were opened that they expired. They needed to look at the policy, but policies were not readily assessable and had to call the Assistant Director of Nursing or the Director of Nursing to get the answer. Nasal spray that was opened on 12/18/2026 was probably expired and needed to be discarded, also Refresh eye drops that were opened on 11/04/2025 were expired and should not have been in the medication cart. They were unsure how these medications were missed during their monthly audits or the nightly checks by the night shift nurses. 10 New York Codes, Rules and Regulations 415.18(d)

Based on record review and interviews during the recertification survey (complaint #2738777) the facility failed to honor advance directive wishes for one (1) of one (1) resident (Resident #14) reviewed. Specifically, Resident #14 had a Medical Order for Life-Sustaining Treatment documenting do not resuscitate (do not attempt resuscitation, allow natural death). Cardiopulmonary resuscitation (chest compressions) was initiated, and an automated external defibrillator (a device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock, to help the heart re-establish an effective rhythm) was used when Resident #14 did not have a pulse. Findings included: The facility policy Advance Directives, revised 07/2019, documented Do Not Resuscitate as indicated under New York State law instructs medical professionals not to perform cardiopulmonary resuscitation in cases of cardiac arrest. If a resident was found to be in cardiac arrest (without pulse and respirations), cardiopulmonary resuscitation would not be initiated.Resident #14 had diagnoses including peripheral vascular disease (poor circulation) and atherosclerosis (plaque buildup in artery walls). The 01/08/2026 Minimum Data Set assessment documented the resident had intact cognition and their advance directives were do not resuscitate and do not intubate.The Medical Orders for Life Sustaining Treatment form, signed by Resident #14 and a medical provider on 05/17/2022 documented Do Not Attempt Resuscitation (allow natural death). The form was last reviewed by the medical provider on 11/04/2025 with no changes made. The 05/19/2022 medical order by Family Nurse Practitioner #6 documented do not resuscitate.The 01/02/2026 comprehensive care plan documented do not resuscitate status and the resident's wishes would be honored. Interventions were to verify code status with physician orders, health care proxy was in place, and the Medical Orders for Life Sustaining Treatment form was in place.The 02/27/2026 facility investigative summary documented:- At approximately 12:12 PM on 02/07/2026, Resident #14 was noted by Licensed Practical Nurse #3, to have experienced an acute change in condition in the dining room on the third floor.- Licensed Practical Nurse #3 found the resident sitting upright in their chair, able to move air and take a sip of their drink without distress. They were unable to visualize any food or foreign body obstruction.- Licensed Practical Nurse #3 attempted to perform the Heimlich (abdominal thrusts used when choking), however the resident went limp in their chair.- Staff removed the resident from the dining room and lowered them to the floor. The resident had no palpable pulse, a code blue (medical emergency) was called, and Licensed Practical Nurse #3 initiated (chest) compressions.-Registered Nurse Supervisor #4 arrived on the unit and placed the automated external defibrillator pads on the resident; no heart rate or rhythm was noted, and no shock was advised. -Registered Nurse Supervisor #4 was unable to feel a pulse and Licensed Practical Nurse #7 did not hear a heartbeat.-Licensed Practical Nurse #8 arrived for the code and verified that Resident #14 had an order do not resuscitate per their Medical Orders for Life Sustaining Treatment form.-Compressions were stopped and the resident was pronounced dead at 12:20 PM.The 02/07/2026 Licensed Practical Nurse #3 progress note documented they became aware the resident was coughing in the dining room. Back pats were given, and the resident was moving air and was able to drink. Resident #14 appeared to be in distress and the Heimlich was attempted; the resident went limp in the chair and had a grey color to the lips and face. The supervisor was notified, and a code was called at 12:13 PM. The resident was lowered to the floor, there was no pulse felt, cardiopulmonary resuscitation was initiated at 12:13 PM. Do not resuscitate status was verified and cardiopulmonary resuscitation was stopped. Time of death was called at 12:22 PM by the provider.The 02/07/2026 Registered Nurse Supervisor #4 progress note documented they were called to the unit, the resident was unresponsive, and Licensed Practical Nurse #3 was performing cardiopulmonary resuscitation. Automatic External Defibrillator pads were placed on the resident with no shock advised, and the resident was still without a pulse. Licensed Practical Nurse #7 was unable to hear a heartbeat, the resident's pulse continued to be absent, and cardiopulmonary resuscitation was stopped when the resident was confirmed to be do not resuscitate status.The 02/09/2026 Nurse Practitioner #9 progress note documented they pronounced the resident deceased via phone with nursing at 12:22 PM on 02/07/2026. The cause of death appeared to be a cardiopulmonary event.During an interview on 02/18/2026 at 9:58 AM Licensed Practical Nurse #3 stated if a resident started to choke, they would start back pats; if that did not work the Heimlich was performed. If the resident went unresponsive, they would start to perform cardiopulmonary resuscitation. They checked the pulse, did mouth sweeps, suctioned, and got help. If there was no change and they happened to be a do not resuscitate, then cardiopulmonary resuscitation stopped. Resident #14 was choking and coughing. Back pats were given; the resident became limp, cyanotic, unresponsive and was then lowered to the floor. Staff started compressions immediately and called a code. When the resident's code status was determined to be do not resuscitate, compressions were stopped.During a follow-up interview on 02/18/2026 at 11:19 AM Licensed Practical Nurse #3 stated they provided Resident #14 with a sip of water, and the resident attempted to stand up out of the chair. They went limp and chest compressions were started at 12:13 PM. It took over two minutes to verify the resident's code status; and when identified, they attempted to stop compressions. They were instructed by Registered Nurse Supervisor #4 to continue compressions so they could suction the resident and ensure nothing was left in their mouth. Compressions were stopped at about 12:19 PM.During an interview on 02/18/2026 at 12:19 Registered Nurse Supervisor #4 stated they arrived on the third floor after having been notified and Licensed Practical Nurse #3 was performing cardiopulmonary resuscitation. Ideally, the resident's code status was checked prior to initiating cardiopulmonary resuscitation; they assumed the code status was checked as the Licensed Practical Nurse was performing cardiopulmonary resuscitation. They hoped that staff would check the Medical Orders for Life Sustaining Treatment prior to initiating compressions. Compressions were stopped when it was found the resident was do not resuscitate status.\During an interview on 02/18/2026 at 3:56 PM Licensed Practical Nurse #11 stated they started cardiopulmonary resuscitation if a resident was found unresponsive prior to checking the code status. 10 New York Code, Rules, and Regulations 415.3(e)(1)(ii)

Based on observations, record reviews and interviews during the recertification survey, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for two (2) of five (5) residents (Residents #25 and #56) reviewed. Specifically, Resident #25 was on contact precautions and Activities Aide #14, and Certified Nurse Aides #15 and #16 entered the room without appropriate personal protective equipment; and Resident #56 was on enhanced barrier precautions and Licensed Practical Nurse #7 performed wound care without appropriate personal protective equipment. Findings include:The undated facility policy Contact Precautions for Infection Control, documented contact precautions were used for specific residents that were known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact. A contact isolation sign was placed on the door; gloves were worn when the resident's room was entered and removed prior to leaving the room. Gowns were worn when it was anticipated that they would have substantial contact with the resident, environmental surfaces, or items in the resident's room; or if the resident was incontinent, had diarrhea, an ileostomy, a colostomy or wound drainage that was not contained by a dressing.The facility policy Enhanced Barrier Precautions: Multidrug-Resistant Organisms, revised 04/28/2025 documented the purpose of enhanced barrier precautions was to protect staff and residents and to reduce spread through indwelling medical devices and wounds. Gowns and gloves were required during high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. 1) Resident #25 had diagnoses including diabetes, open wound on left hip, and morbid obesity. The 01/02/2026 Minimum Data Set assessment documented the resident had intact cognition, a surgical wound with wound care, was independent for bed mobility, dependent transfers, and did not have multidrug-resistant organisms. The 04/02/2025 Comprehensive Care Plan, revised 06/11/2025, documented the resident had methicillin-resistant staphylococcus aureus infection (a bacteria resistant to many antibiotics) in their left hip wound. Interventions included contact isolation precautions, wearing gown and masks when changing contaminated linens and place soiled linens in bags marked biohazard.The 08/01/2024 physician order documented contact precautions for methicillin-resistant staphylococcus aureus infection to the left hip.During an observation on 02/17/2026 at 12:55 PM the resident's room had a contact precaution sign posted with a personal protective bin outside the room. Activities Aide #14 entered the resident's room without a gown or gloves. While in the room they looked through drawers and in the closet for shoes the resident requested. They used a wet towel to clean the resident's shoe; exited the room and placed the wet towel into a bin on the unit; and performed hand hygiene with hand sanitizer outside the next door in the hallway.During an observation and interview with Activities Aide #14 on 02/17/2026 at 01:01 PM they stated Resident #25 was not on contact isolation and they just had a wound. They did not follow contact precautions when they entered the room as they did not see the contact isolation sign on the door. They only donned gloves for the wet towel. Activities Aide #14 then went back into the resident's room without any personal protective equipment and grabbed a bag and laptop off the resident's bed and left the room.During an observation on 02/20/2026 at 1:11 PM Certified Nurse Aides #15 and #16 entered Resident #25's room without gowns or gloves. The resident was seated in their wheelchair next to a mechanical liftDuring an interview on 02/20/2026 at 1:15 PM Certified Nurse Aide #15 stated they knew when residents were on precautions by the sign outside their door. They were required to wear a gown and gloves in a contact room. They were not sure if Resident #25 was on contact precautions but when they saw the sign they assumed they must have been. They did not wear a gown when they transferred the resident as they were unaware the resident was on precautions at that time.During an interview on 02/20/2026 at 1:19 PM Certified Nurse Aide #16 stated they knew a resident was on precautions by the sign on their door. They needed to wear a gown and gloves for a contact room and wash their hands with soap and water when they left. Staff wore gowns and gloves every time they were in contact with a resident during care. They performed perineum care on Resident #25 and was not sure if the resident was on precautions. They did not wear a gown while care was performed, and they should have. They stated they forgot to look at the sign over the door. 2) Resident #56 had diagnoses including diabetes and a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer of the right heel. The 12/19/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for all activities of daily living, and had a Stage 4 pressure ulcer on the right heel.The 09/10/2024 Comprehensive Care Plan revised 01/15/2026 documented the resident was on enhanced barrier precautions for the pressure ulcer to the right heel. Interventions included maintain contact precautions at all times, use gowns and gloves when performing contact activities including wound care or any activity with close contact, and post signage outside the resident's door.The 06/24/2025 provider order documented to maintain enhanced barrier precautions due to right heel wound.During an observation on 02/17/2026 at 10:29 AM Resident #56 was sitting in a chair in their room. There were gowns outside their room in the personal protective equipment caddy.During an observation on 02/20/2026 at 10:55 AM Licensed Practical Nurse #7 performed wound care to Resident #56's right heel wound. They donned gloves prior to starting the treatment and did not don a gown. During an interview on 02/20/2026 at 12:42 PM Licensed Practical Nurse #7 stated enhanced barrier meant that they had to use personal protective equipment when they encountered a catheter, tube feed, or wound. They knew when a resident was on precautions because there was a sign outside their door and in their chart. They did not believe Resident #56 was on enhanced barrier precautions because their wound treatment was skin prep (type of cleanser treatment). After they checked the resident's chart, they confirmed that Resident #56 was on enhanced barrier precautions, and they should have worn a gown when they performed their treatment.During an interview on 02/23/2026 at 10:36 AM Registered Nurse Unit Manager #10 stated enhanced barrier precautions were used for residents who had foley catheters, wounds, and ostomy bags and required staff to wear gowns and gloves when performing wound care. Resident #56 was on enhanced barrier precautions. It was not appropriate for staff to complete wound care without wearing a gown and they needed to follow the sign. Contact isolation was similar to enhanced barrier precautions. They were unable to remember exactly what the contact isolation sign instructed but believed staff needed to wear a mask, gown and gloves with direct care. Resident #25 was on contact precautions because of their chronic left surgical wound. They did not believe Activities Aide #14 needed to wear personal protective equipment while in the resident's room or when they assisting the resident with their footwear. Staff should wear a gown and gloves when performing perinium care for Resident #25.During an interview on 02/23/2026 at 12:24 PM Infection Control Nurse #17 stated residents were on enhanced barrier precautions if they were at risk for infection. It was an extra layer of protection for staff and residents who had feeding tubes, foley catheters, ostomies and open wounds. A gown and gloves were worn when providing wound care to a resident on enhanced barrier precautions. Contact isolation was similar, but an infection was identified. They recommended a mask, gloves, and gown for contact isolation. Staff looked at the sign to find out what type of precautions it was and what to do. Perinium care should be performed wearing a gown and gloves. They were unsure if a gown or gloves were needed while touching resident belongings or helping with footwear. 10 New York Codes, Rules and Regulations 415.19(a)(b)

Based on observations, record review, and interviews during the recertification survey conducted 2/3/2025- 2/11/2025, the facility failed to ensure the resident environment was free of accident hazards for three (3) of eight (8) residents (Residents #72, #75, and #98) reviewed. Specifically, Residents #72, #75, and #98 were served and Residents #72 and #98 consumed a cleaning solution stored in the kitchenette refrigerator in an unlabeled pitcher. This resulted in physical and psychosocial harm to Resident #72 that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury, or death to Residents #72, #75, and #98 and the additional 107 residents in the facility. Findings included: The facility policy, Food Receiving and Storage, dated 6/12/2023, documented foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer would be covered, labeled, and dated with use by date. Pesticides and other toxic substances and drugs should not be stored in the kitchen area or in the storerooms for food or food preparation equipment and utensils. Soaps, detergents, cleaning compounds, or similar substances should be stored in separate storage areas from food storage and labeled clearly. The Safety Data Sheet (a fact sheet describing the chemical properties of a product) for Orange- multipurpose cleaner/degreaser documented the chemical may cause eye and skin irritation. Acute hazard effects with ingestion may include irritation to the mouth, throat, and gastrointestinal system. Symptoms include nausea, vomiting, diarrhea, and cramps. The chemical should be stored in an original container, away from direct sunlight in a dry, cool and well-ventilated area, away from food and drinks. 1) Resident #72 had diagnoses including end stage renal (kidney) disease, hypertension (high blood pressure), and diabetes. The 11/28/2024 Minimum Data Set assessment (health screening tool) documented the resident was cognitively intact and required set up or clean up assistance with eating. The 9/18/2024 comprehensive care plan documented the resident required set up by staff to eat their meals. The 1/27/2025 at 6:30 PM Interim Director of Nursing progress note documented the resident inadvertently ingested a gulp of a diluted cleaning solution. The resident was assessed with no complaints of pain, denied any nausea or vomiting, vital signs were stable and there were no concerns other than the resident stated they had a terrible taste in their mouth. The 1/27/2025 Resident Accident/Incident Report for Resident #72 completed by the Interim Director of Nursing documented that on 1/27/2025 at 5:30 PM, Resident #72 was in the dining room and was inadvertently served a cup with a cleaning solution in it. The resident did not consume the entire cup, took a gulp and realized something was wrong. The incident was not witnessed. The resident was assessed without injury. The Medical Director and Poison Control were contacted for further directions. Upon investigation it was determined a pitcher was brought up from the kitchen that appeared to be a diluted mixture of an orange cleaner. As soon as it was identified, staff immediately assessed all the drinks that were served and found three (3) cups with suspect liquid. Residents were assessed with no negative findings or signs and symptoms of psychological harm. Resident #98 took a sip and immediately spit it out and stated it did not taste good. Resident #75 did not drink any of the liquid and had a full cup in front of them. The pitchers were not labeled. Staff education was done regarding proper mixing of chemicals and proper storage and labeling of pitchers. A full house audit was immediately conducted to ensure all pitchers were properly labeled and no other pitchers contained the mixture. The incident was not reported to the Department of Health. The investigation concluded there was no cause to believe resident abuse or mistreatment occurred. The investigation was signed by the Administrator on 2/4/2025. Nurse Practitioner progress notes for Resident #72 documented: -On 1/28/2025 at 9:45 AM Nurse Practitioner #30 documented a late entry progress note. On 1/27/2025 the resident inadvertently ingested a gulp of a diluted cleaning solution. The resident was assessed with no complaints of pain, denied nausea/vomiting, vital signs were stable. The resident had no concerns other than a terrible taste in their mouth. The Medical Director was updated. Nurse Practitioner #30 documented they were made aware on 1/28/2025. Poison control was called after the incident and continued monitoring was recommended. No acute abnormalities and the resident was asymptomatic. -On 1/29/2025 by Nurse Practitioner #30, the resident was complaining of intermittent nausea without vomiting or diarrhea. The resident was examined, and physical exam demonstrated no acute abnormalities. Labs were ordered and they included complete blood count, comprehensive metabolic panel, ammonia, magnesium, lipase, and amylase. -On 1/30/2025 by Nurse Practitioner #32, the resident was referred to them by the Nurse Manager. The resident had an incident, and they accidently swallowed some cleaning fluid. The resident did express some anxiety after the incident, but there were no serious consequences reported. -On 2/3/2025 by Nurse Practitioner #30, the resident complained to the nursing staff of having an intermittent sore throat. The resident stated they had an intermittent sore throat during meals for the last 24 hours. The resident's sore throat was intermittent, and they declined medications for the sore throat. -On2/4/2025 by Nurse Practitioner #30, the resident no longer complained of a sore throat. If they developed dysphagia (difficulty swallowing, respiratory compromise/distress), they would recommend a swallow evaluation, chest x-ray, and diet downgrade. During an interview on 2/5/2025 at 4:44 PM, Resident #72 stated on 1/27/2025 they were in the dining room eating. They picked up what they thought was apple juice and it was a little on the yellow side, but they did not think there was anything wrong with it. They took a big swallow, and their mouth burned and was sore. After they swallowed the liquid, they thought it tasted terrible and was spoiled. They stated since then their mouth was sore on and off and it was very hard to swallow because it hurt, but it was getting better. Since then, they only took small sips of fluids instead of taking a full swallow because they were little fearful when drinking. No one told them the liquid was cleaning solution. They stated they were really scared after they drank it because they felt really yucky, and they told the others not to drink it. 2) Resident #75 had diagnoses including hypertension and gastroesophageal reflux disease (acid backup into the esophagus). The 12/4/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition and required set up and clean up assistance with eating. The 9/24/2024 comprehensive care plan documented the resident required limited assistance for eating. The 1/27/2025 at 6:30 PM, Interim Director of Nursing progress noted documented the resident received a cup with a diluted cleaning solution in the cup. They were unable to determine if any had been consumed by the resident. The cup appeared to be full at the time it was removed from the resident. The 1/27/2025 Resident Accident/Incident Report for Resident #75 completed by the Interim Director of Nursing documented on 1/27/2025 at 5:30 PM Resident #75 was served a cup of liquid containing cleaning solution. The cup did not appear to have any of its contents gone and was removed immediately. The resident was unable to state their version of the event. The resident was assessed without negative findings. The Medical Director and Poison Control were notified, and the plan was to follow recommendations. Staff were educated regarding proper mixing and storage of chemicals and labeling of pitchers. The 1/28/2025 Nurse Practitioner #22 progress note did not include documented evidence they were notified the resident was served a cup containing cleaning solution or the resident was evaluated for possible side effects. 3) Resident #98 had diagnoses including dementia and anxiety. The 1/2/2025 Minimum Data Set assessment documented the resident had severely impaired cognition and required set up and clean up assistance with eating. The 7/3/2024 comprehensive care plan documented the resident required supervision for eating. The 1/27/2025 at 6:30 PM, Interim Director of Nursing progress note documented the resident received a cup of liquid that contained diluted cleaning solution. The resident stated they took a sip but did not swallow it because it tasted funny. The 1/27/2025 Resident Accident/Incident Report for Resident #98 completed by the Interim Director of Nursing documented on 1/27/2025 at 5:30 PM Resident #98 was inadvertently served a cup of liquid that contained cleaning solution. The resident stated they only took a sip but did not swallow the liquid because it tasted awful. The resident was assessed without negative findings. The Medical Director and Poison Control were notified, and the plan was to follow recommendations. Staff were educated regarding proper mixing and storage of chemicals and labeling of pitchers. The 1/28/2025 Nurse Practitioner #22 progress note documented the resident had chemical exposure, appears to adverse events, staff did assist and would continue to monitor. Investigative written statements for the incident involving Residents #72, #75, and #98 included: -On 1/27/2025 at 6:30 PM, Dietary Supervisor #35 documented they were checking the floor to make sure they were fine serving. They went to the 3rd floor and noticed the juice looked odd. They thought it looked like cranberry ginger ale. They smelled the liquid, and it had a chemical smell. They checked all the cups, and some residents had some of the liquid and Resident #72 said they drank it. They reported the occurrence to Licensed Practical Nurse #2. -On 1/27/2025 at 7:57 PM, Food Service Aide #34 documented they went upstairs to pour drinks; the liquid was in a juice container in the refrigerator along with other drinks. They did not remember it being there that morning. They assumed it was juice, poured the liquid, it looked like a light apple juice or cranberry mix, and put it on the cart with the other juices. They did not notice a scent. The container was not labeled or dated. They thought it was a new pitcher since it was not there that morning. The summary of the 1/27/2025 investigation reviewed on 2/4/2025 by the Administrator documented there was concern that possible cleaning solution was served to the residents at dinner on the third floor. Upon investigation, it was determined that a pitcher was brought up from the kitchen that appeared to be, based on its color and odor, a diluted mixture of Orange Cleaner. The staff immediately assessed all the drinks that were served to find three (3) cups with suspicious liquid which were immediately removed. The residents were assessed and there were no negative findings or signs and symptoms of psychological harm. The pitcher used to serve the liquid was not labeled. Staff education was done regarding proper mixing of chemical and proper storage and labeling of pitchers. A full house audit was immediately conducted to ensure all pitchers were properly labeled and no other pitchers were found with this mixture. Poison Control was contacted, and the Administrator and Medical Director were made aware. During an interview on 2/5/2025 at 10:12 AM, Food Service Aide #34 stated they worked on the third-floor dining room on the evening of 1/27/2025. They worked the 6:30 AM - 2:30 PM shift and then came in at 4:00 PM for extra time. They were not sure how cleaning fluid got into the juice pitcher. They took pitchers from the main kitchen downstairs and filled them up with juice in the main kitchen and brought them up to the dining room for meals. They stated on 1/27/2025 they went to the third floor kitchenette refrigerator to get more juice, and they poured six (6) mini cups of juice from the pitcher. They stated this was not a pitcher they put in the refrigerator during the day, and it looked like a mix of cranberry and apple juice. Certified nurse aides sometimes mixed the juices. They did not smell it, but the pitcher did not have a label on it and usually everything was labeled. They stated they should not have poured from the unlabeled pitcher. They stated the Dietary Cook/Supervisor #35 came to the unit to check on staff and asked what was in the pitcher as it looked like it had bubbles in it, and it smelled like soap. Food Service Aide #34 stated all cleaning products should stay in their original containers, and it was not safe to place chemicals into food service containers/pitchers. During an interview on 2/5/2025 at 11:08 AM, Dietary Cook/Supervisor #35 stated on 1/27/2025 they checked on the staff in all three dining rooms, and when they went to the 3rd floor, they asked the food service aide what was in the pitcher, because it looked funny. They stated it smelled like chemical cleaner. They reported this to the nursing staff and all the cups of juice were removed. Resident #72 had already drank some of the liquid. They told all food service aides to check the drinks in the refrigerator to ensure they were labeled and to get rid of anything unlabeled. Cleaning products should all have their own containers. All juice pitchers should be labeled and dated. If the pitcher was not labeled staff should pour it out. They found the pitcher used to pour the chemical under the coffee cart, the interim Director of Nursing removed it from the floor, brought it to the kitchen and began an incident report. They did not know how the cleaning product got in the refrigerator. During an interview on 2/5/2025 at 11:55 AM, the Food Service Director stated food service staff called them and reported they found liquid, believed to be diluted Orange cleaner in cups that were served to residents. They were not sure how a cleaning product ended up in a juice pitcher. The juice pitchers were clear and should have lids. Food service staff were required to dispense juice from the kitchen into pitchers, label the pitchers with the type of juice and the date, and put a lid on the pitcher before they were delivered to the units. They stated the food service aide should not have served this liquid to the resident because it did not have a label. Food Service Aide #34 received training on 1/29/2025 about cleaning products and food safety. During a telephone interview on 2/5/2025 at 4:30 PM, the Medical Director stated they were made aware on 1/27/2025 during the evening meal that three (3) residents were served cleaning solution as juice. They were not sure how this happened and told the Director of Nursing to call Poison Control. Housekeeping and maintenance should oversee where cleaning chemicals were stored, and they should be labeled, and in the appropriate containers. Cleaning products should not be in a refrigerator. They stated it could be harmful for a resident to swallow a cleaning chemical. During an interview on 2/5/2025 at 4:42 PM, the Administrator stated they were made aware of the incident on the evening of 1/27/2025 when three (3) residents ingested a cleaning chemical. The three residents were assessed that night and found to be okay. Nursing staff called Poison Control and Resident #72 was seen by the doctor every day to monitor. The Administrator stated they were not updated as to what the chemical was. Housekeeping should store chemicals in locked closet. All cleaning supplies should be behind locked doors and labeled. If nursing staff found food or drink items in an unlabeled container they should throw it away. Cleaning chemicals should not be stored in a refrigerator. The Interim Director of Nursing did an in-service that night on storage and mixing of chemicals and all the dietary staff received the education. They were unsure what the liquid was, and they still had not figured out how a cleaning product got in the kitchenette refrigerator. During an interview on 2/5/2025 at 4:51 PM, the Interim Director of Nursing stated on 1/25/2025 they received a call from nursing staff that residents were served cleaning solution during the evening meal. They went to the unit and had all beverages removed from the dining room. They went back through the dining room and looked at all the pitchers and pulled all poured drinks off the tables. They assessed all three (3) residents. There was no evidence Resident #75 drank the liquid, Resident #98 said they spit it out, and Resident #72 said they took a gulp of the liquid, and it did not taste right. Dietary Cook/Supervisor #35 pulled and dumped all the pitchers. They called the Medical Director and Poison Control. They did not have pictures of the pitcher, but it looked like the Orange cleaning solution but a lighter color. The residents did not have access to the kitchenettes, only nursing and food service staff did. If staff found an unlabeled container of liquid in a pitcher it should not be served and should be discarded. The Poison Control center said the Orange chemical was not likely to cause harm. They stated they were 100% sure the liquid was Orange cleaner because they smelled it, and it had a very distinct smell. They were unable to determine how the liquid got into the unit refrigerator. 10 NYCRR 415.12(h)(1)(2) ____________________________________________________ Immediate Jeopardy was identified, and the facility Administrator was notified on 2/6/2025 at 2:49 PM. The facility Administrator was notified on 2/7/2025 at 4:10 PM, that Immediate Jeopardy was removed on 2/7/2025 at 3:28 PM based upon the following corrective actions taken: - On 2/6/2025 at 6:38 PM, the Administrator provided an immediacy removal plan that was initiated on 2/6/2025 at 5:38 PM when all the chemicals were removed from the kitchenettes and secured in the locked service closet on the first-floor service corridor. All food service staff were to be educated on the process of taking cleaning chemicals from the secured chemical closet after meal service to clean the kitchenettes, and no chemicals were to be left in the kitchenettes. All staff were educated that any unlabeled drinks were to be disposed of immediately. The Certified nurse aides, food service staff, licensed practical nurses, and registered nurses were educated with emphasis on the fact drinks were to be identified with a label and date. The facility would educate 100% of staff prior to the start of their next scheduled shift. - On 2/7/2025 at 5:30 AM, the Dietary Cook/Supervisor completed an audit of all three kitchenettes to ensure there were no unsecured cleaning agents, or unlabeled drinks. At 9:00 AM, the Director of Food Services completed floor round and confirmed there were no chemical bottles in the kitchenettes, at 10:11 AM, the Food Service Director completed an audit of the first-floor kitchen and removed unsecured cleaning agents and placed them in the locked first floor corridor kitchen closet. At 10:47 AM, 86 of 147 employees (59%) were educated and the plan was to continue to educate employees over the phone and prior to their next scheduled shift. - On 2/7/2025 at 3:28 PM, 85% of staff, 125 had been educated about storing cleaning products in the kitchen and kitchenettes, labeling all resident drinks in pitchers with the date and juice type, and immediately disposing of anything unlabeled in a pitcher.

Based on observations and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups were posted in a form and manner accessible to residents and resident representatives. Specifically, 13 out of 13 anonymous residents present at the resident group meeting stated they did not know where to find the Ombudsman and New York State Nursing Home Complaint Hotline information. Additionally, there were no posted Ombudsman program or New York State Nursing Home Complaint Hotline numbers or posters observed in the facility. The findings include: The facility policy Resident Rights, dated 10/2017, documented the facility posted the names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups which included State Survey Agency, the Ombudsman, and the Medicaid Fraud Control Unit in a manner and form accessible and understandable to all residents and the resident representatives. The posting also contained a statement that the resident may file a complaint with the State Survey Agency concerning any violation of state or federal nursing facility regulation. During a resident group meeting on 2/3/2025 at 1:46 PM, 13 anonymous residents stated they did not know where to locate the contact information for the Ombudsman or the New York Nursing Home State Complaint Hotline. There were no New York State Nursing Home Complaint Hotline or Ombudsman Program postings observed: - on 2/3/2025 at 2:44 PM and 2/10/2025 at 3:54 PM in the main lobby. - on 2/5/2025 at 9:52 AM, 2/6/2025 at 9:34 AM, and 2/7/2025 at 12:57 PM on the 4th floor. During an interview on 2/07/2025 at 1:05 PM, the Social Services Director stated the New York State Nursing Home Complaint Hotline number, and the Ombudsman contact information were in the resident handbook given on admission. The signs for the State Complaint Hotline and the Ombudsman were not re-posted since the renovation. They were aware access to the numbers for both the State Complaint Hotline and the Ombudsman was a resident right. During an interview on 2/10/2025 at 12:49 PM, the Administrator stated during the facility's construction process the signs for the New York State Nursing Home Complaint Hotline and the Ombudsman were taken down. The signs they had were water damaged from being in storage or were missing. They were in the process of ordering some more signage and received new Ombudsman posters the week before, but they were not put up. They made paper versions of the signs and hung them up, but they were taken down either when the construction moved to that area or by residents on those halls. They stated it was important for the residents to have access to the New York State Nursing Home Complaint Hotline and the Ombudsman contact information because it was a resident right. 10 NYCRR 415.3 (d)(2)(i)(b)

Based on observations and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure the results of the most recent Federal and State surveys were posted in a place readily accessible where individuals who wished to examine the survey results did not have to ask for them. Specifically, the facility state inspection binder located in the front lobby did not include the most recent (3/3023) standard health survey results and any subsequent complaint survey results, and there was no posted notification of the availability of the previous 3 years of survey reports. Findings Include: The facility policy, Resident Rights, dated 10/2017, documented the residents had the right to examine the reports of any surveys, certifications, and complaint investigations made regarding the facility during the 3 proceeding years which included any plans of correction. The results were posted in a place that was readily accessible to residents, family members, and legal representatives. The facility posted the notice of availability of such report in a prominent and accessible area of the facility. The following observations were made of the facility state inspection binder: - on 2/4/2025 at 2:16 PM The New York State inspection results were at wheelchair height in a labeled black half inch binder in the lobby next to the receptionist. The binder contained the 3/7/2023 Life Safety survey results. There were no health survey results from 3/2023 or subsequent complaint survey results in the binder. There was no posted notification of the availability of survey reports during the 3 preceding years. - on 2/10/2025 at 11:23 AM The New York State inspection results were in the lobby on the side of the front desk. The book contained the star rating for the facility from the Medicare website and the statement of deficiencies with plan of correction for the 3/7/2023 Life Safety survey. There were no health survey results from 3/2023 or subsequent complaint survey results in the binder. There was no posted notification of the availability of survey reports during the 3 preceding years. During an interview on 2/10/2025 at 11:24 AM, Receptionist #20 stated the New York State inspection black half inch binder was the only binder they had that contained the state inspections. They were only in charge of making sure the binder was on the counter, not of the contents inside the binder. At 12:19 PM, they stated the Administrator was responsible for the contents of the binder. During an interview on 2/10/2025 at 12:49 PM, the Administrator stated the binder that contained the state inspections was their responsibility. They had just added the last complaint results recently, the star rating to the book within the last week and had verified all the correct information was in there. They only checked the binder when they added or changed information in the binder. The binder should include the last survey results and anything in-between that date and the next survey. 10NYCRR 415.3(1)(c)(1)(v)

Based on observations, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure a process was in place for residents to have their grievances addressed for 13 of 13 anonymous residents present at the resident group meeting. Specifically, all 13 residents stated they did not know who the grievance officer was or how to file a grievance. Findings include: The facility policy, Grievances, revised 2/2020, documented residents had the right to voice their grievances and concerns with the expectation of resolution. The Director of Social Services or the resident's social worker was designated as the Grievance Official. A copy of the grievance policy was provided upon admission. Information on how to file a grievance was given upon admission and was prominently posted in locations throughout the facility. Specific information to be included was the right to file a grievance anonymously, contact information for the grievance official with whom the grievance could be filed, a reasonable timeframe, the right to obtain a written decision, and independent entities for which a grievance could be filed such as the pertinent State Agency, Quality Improvement organization, and the Ombudsman. During a resident meeting on 2/03/2025 at 1:46 PM, 13 of 13 anonymous residents stated they were unsure of who the grievance officer was, did not know how to file a grievance, and were not given the facility's grievance policy. During an interview on 2/07/2025 at 1:05 PM, the Social Services Director stated they were the Grievance Officer, and it was communicated to residents through the handbook they received at admission. Residents filed a grievance by the Social Services Director going to speak with the resident and asking them if they wanted the Social Services Director to fix the issue or file a formal grievance. The only way a resident was able to file a grievance was by talking to the Social Services Director. If a resident wanted to file a grievance anonymously, the Social Services Director would not put their name on the form. They were aware it was a resident's right to file grievances anonymously and if a resident wanted to file a grievance anonymously and exclude them as well, they had the complaint hotline number they could call. During an interview on 2/10/2025 12:49 PM, the Administrator stated if a resident wanted to file a formal grievance, they went to the Social Services Director who was the Grievance Official. A form was filled out and then it went to the responsible department head. The grievance was not closed until all departments involved provided an answer to their part of the grievance. If the Social Services Director was not available, Social Worker #38 was responsible for grievances. Any supervisor could also take a complaint and inform the Social Services Director of the issue for a grievance. The residents knew who the Grievance Officer was as it was listed in the welcome packet. They stated they did not have signs that listed who the grievance officer was or how to file a grievance. They did not know how residents who did not have resident handbook were aware of how to file a grievance or who the grievance officer was. They did not know how a resident would file a grievance anonymously and was not aware it was a resident right to be able to file a grievance anonymously. 10NYCRR 415.3(C)(1)(ii)

Based on observations, record review, and interviews during the recertification survey conducted 2/3/2025 - 2/11/2025, the facility did not ensure a system of records and accounts of all controlled drugs was maintained for 1 of 3 nursing units (Unit 3) reviewed. Specifically, a controlled substance reconciliation (a system of recordkeeping that ensures an accurate inventory by accounting for controlled medications that were received, dispensed, and administered) was not performed between the oncoming and outgoing nurse; the narcotic count log form was completed and signed without a count being performed; narcotic keys were not transferred between nurses in a secured manner; and Resident #65's Controlled Substance Record was not accurately reconciled after the medication was administered to the resident. Findings include: The facility policy, Storage and Maintenance of Medications, revised 5/2019, documented medications and biologicals were stored safely, securely, and properly and the medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The facility policy, Management of Controlled Medications, dated 11/2019 documented the facility ensured all controlled medications were maintained in a manner to guarantee accountability, security, and accessibility; at every change of shift, the outgoing and incoming nurses, together, would do a physical count of the remaining medication, assuring that the amount present matched the amount documented on the Resident Narcotic Record; and proper storage of controlled drugs were kept in a double-locked medication area and the nurse would carry the keys on their person at all times. The 1/30/2025 physician order for Resident #65 documented Klonopin 0.5 milligrams (clonazepam; a narcotic anti-anxiety medication) twice a day. The February 2025 Medication Administration Record documented Resident #65 was administered one clonazepam 0.5 milligram tablet on 2/3/2025 at 8:00 PM by Licensed Practical Nurse #43. During an observation on 2/4/2025 at 1:29 PM, the narcotic compartment of the Unit 3 North medication cart contained fifty-two (52) clonazepam 0.5 milligram tablets labeled with Resident #65's name. Resident #65's Controlled Substance Record form documented there should have been fifty-three (53) clonazepam 0.5 milligram tablets. During an interview on 2/4/2025 at 1:29 PM, Licensed Practical Nurse #13 stated the reason for the discrepancy between the number of pills in the medication pack and what was listed on the Controlled Substance Record form was due to a nurse not signing out the clonazepam the night before on 2/3/2025. The Controlled Substances Shift to Shift Count Log documented the oncoming medication nurse, Licensed Practical Nurse #1, and the outgoing medication nurse, Licensed Practical Nurse #2 signed the count had been done on 2/4/2025 at 6:00 AM for 8 different narcotic prescriptions, including Resident #65's clonazepam which documented fifty-four (54) tablets were present. During an interview on 2/4/2025 at 1:35 PM, Licensed Practical Nurse #1 stated all narcotics had to be counted off with another nurse before transferring narcotic keys to each other. They stated they came in at 6:00 AM that day to relieve Licensed Practical Nurse #2. They did not count narcotics with each other. Instead, Licensed Practical Nurse #2 handed them the narcotic keys and left because their ride was waiting. Before leaving, Licensed Practical Nurse #2 filled out the pill count on the Controlled Substances Shift to Shift Count Log form and signed it. Licensed Practical Nurse #1 stated they cosigned the log form after Licensed Practical Nurse #2 left for the day. They not noticed Resident #65's clonazepam count was incorrect because they did not look at their Controlled Substance Record to verify. They stated there were times on the night shift when a supervisor also worked as a floor nurse and had narcotic keys for the Third floor. The supervisor left those keys on the Second floor so when the day shift nurses arrived, they could pick up the keys and start the medication pass. A count with the supervisor was done later when the supervisor came to the unit. Counting narcotics was important because someone could lose their license, medications could go missing, and residents may not have the medications they needed. During an interview on 2/6/2025 at 2:23 PM, Licensed Practical Nurse Unit Manager #15 stated anytime there was a transfer of narcotic keys a count should be performed, but did not always happen. Currently, because there was not a full time 10:00 PM - 6:00 AM Nurse Supervisor, floor nurses were being utilized as both the house supervisor and a unit nurse. At 6:00 AM, the nurse should stay until they counted narcotics with the oncoming day nurse. If there was not a nurse to relieve them at 6:00 AM some nurses left the narcotic keys on the Second floor nursing station desk for the day shift nurse to pick up when they arrived. There was always a nurse in the building, but some were not agreeable to counting off narcotics on a floor they were not assigned to. It was not uncommon for them to get calls at 6:00 AM from one of the nurses asking them to come and count off the narcotics so they could leave. They spoke to the Director of Nursing twice within the last couple of weeks to address the issue. They stated the Director of Nursing was working on holding those nurses accountable and told them they could do the same to address the issue. Performing a count before transferring keys was important because the count could have been incorrect and could have fallen on whomever accepted those keys. If someone did not count, they should not sign the log sheets indicating that they had. During an interview on 2/7/2025 at 2:18 PM, Licensed Practical Nurse #14 stated they worked the day shift on Second floor. Many nurses came in whenever they wanted rather than coming in right at the change of shift. If the outgoing night nurse did not want to wait or could not wait for their replacement, they brought the narcotic keys to the Second floor nursing station, placed them behind the computer, gave a brief resident report to the Second floor day nurse and left. The keys were not secured and were accessible to anyone who wanted them. That practice had been going on for quite a while. They were not asked by other floor nurses to count off with them but would have if they had been asked. Narcotic keys should not be left unattended as narcotics could go missing and it could be considered abandonment. During an interview on 2/10/2025 at 11:28 AM, the Corporate Regional Director of Nursing stated anytime there was an exchange of narcotic keys there had to be a count and verification the count was correct. That was important to ensure that all narcotics were accounted for. If a nurse needed to leave and did not have someone to relieve them, they should call the supervisor and could not just leave. They were recently made aware of an issue of a nurse leaving without counting. That nurse left the narcotic keys on the Supervisor's desk on the Second floor which was kept locked if no one was in there. They spoke with that nurse, verified the count was correct, and was not aware of any ongoing issues. There were no problems with missing keys or with diversion. Nurses should not fill out the narcotic count sheets and sign it without counting and no one should be leaving without counting. During a follow up interview on 2/10/2025 at 3:38 PM, Licensed Practical Nurse Unit Manager #15 stated the Supervisor used the Second floor Nurse Manager's office. The key to that office was not on the floor nurses' narcotic key rings and therefore they would not have access to that office unless someone left it open. Their experience was the keys were always left at the nursing station not in the Second floor Nurse Manager's office. 10NYCRR 415.18

Based on observations, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 units (Units 2 and 3) observed. Specifically, Units 2 and 3 floors did not have proper signage for transmission based precautions, and personal protective equipment was not readily accessible. Additionally, Licensed Practical Nurse #37 performed gastrostomy tube (feeding tube) care without wearing required personal protective equipment, and Resident#31's suction equipment was not maintained or stored in a sanitary manner. Findings included: The undated facility policy, Standard Precautions for Infection Control, documented gloves were to be worn when touching blood, body fluids, secretions, excretions, and contaminated items. Gowns were worn to protect skin and prevent soiling of clothing during procedures that were likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. The undated facility policy, Contact Precautions for Infection Control, documented all personnel having direct contact with a resident on contact precautions was required to follow all standard and isolation precautions procedures. Contact precautions were used for specific residents known or suspected of having infected or colonized (germs present with no signs or symptoms) microorganisms that could be transmitted during direct care. An appropriate sign would be placed on the door of the resident's room. Gowns and gloves would be worn for potential direct resident contact. The facility policy, Cleaning and Disinfection of Resident Care Items and Equipment, revised 5/2023, documented devices such as respiratory equipment would be free from all microorganisms. The policy did not document how often the equipment should be disinfected or cleaned. The facility policy, Enhanced Barrier Precautions- Multidrug-Resistant Organisms, dated 4/1/2024, documented signage must be posted on the door or wall outside of the resident's room indicating enhanced barrier precautions and required personal protective equipment. A personal protective equipment station would be set up. The station placement should be near or outside the resident's room. Put on gowns and gloves before or upon entry to that room. Position waste receptacle inside the resident room and near the exit for discarding personal protection equipment. 1) Resident #100 had diagnoses including stroke, diabetes, and Parkinson's (a progressive neurological disorder). The 1/1/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, had a feeding tube, and a Stage 2 (partial thickness skin loss) pressure ulcer. The 2/3/2025 physician order documented contact isolation for Extended-spectrum beta-lactamases (antibiotic resistant organism) and Methicillin-resistant Staphylococcus aureus (antibiotic resistant organism). During an observation on 2/3/2025 at 10:12 AM, Resident #100's room had no precautionary signs or personal protective equipment on the door/doorway. During an interview on 2/7/2025 at 2:49 PM, the Director of Environmental Services #8 stated they were given a list of residents on contact precautions and enhanced barrier precautions on 2/3/2025 and they ensured the appropriate signs were placed outside the room doors. Any resident on contact/droplet precautions should have a full personal protective equipment station on their door. Anyone on enhanced barrier precautions should have a sign on the door and the equipment should kept in the clean linen room for staff to use. Equipment was also kept in the unit treatment cart. They stated prior to 2/3/2025, they stated their department was only responsible for ensuring the personal protective equipment was supplied to the units. They stated the nursing department performed random audits of the equipment and signage but did not know how often. They did not know why signs were not in place for Resident #100's room on 2/3/2025. During an interview on 2/10/2025 at 9:17 AM, Licensed Practical Nurse Infection Preventionist stated the nurses on the floor were responsible for ensuring the appropriate precautions signs were placed outside each resident's door that was on precautions. The Director of Environmental Services was responsible for putting up the personal protective equipment stations when a work order was submitted by the nurse who entered the physician order for precautions. Enhanced barrier precautions were for any resident with indwelling tubes or treatments. Residents were on contact precautions if they had an active infection. Enhanced barrier precautions and contact precautions meant staff should wear a gown and gloves with direct resident contact and a surgical mask should be worn with droplet precautions. These should be worn to prevent cross contamination of germs. All precautions rooms should have a red biohazard bags for soiled items. The Licensed Practical Nurse Infection Preventionist did not know why the proper signage and equipment were not readily available to staff. During an interview on 2/10/2025 at 9:54 AM, Registered Nurse Manager #28 stated the Unit Managers were responsible for ensuring signage and personal protective equipment stations were up. Environmental services supplied the units with the equipment stations. They did not know why the appropriate signage and stations were not in place on 2/3/2025. They stated if signage was missing, they should call the Infection Preventionist for signs and the Director of Environmental Services for personal protective equipment supplies and stations. Staff were required to wear gowns and gloves to provide direct care for any resident on contact or enhanced barrier precautions. They should also wear a surgical mask for residents on droplet precautions. The purpose of personal protective equipment was to prevent cross contamination of germs. During a wound treatment observation and interview on 2/10/2025 at 1:32 PM, Licensed Practical Nurse #37 went to the clean linen room and there was no personal protective equipment. They then went to the Unit Manager's office for the supplies. They obtained surgical masks from the nursing station and went to Resident #100's room. The door had a contact precautions sign in place, and there was no personal protective equipment station on or near the resident's door. The contact precaution sign documented staff were to wear a gown and gloves when providing care. The nurse put on a gown and gloves, performed the wound treatment, removed the personal protective equipment, and place the items in a regular garbage bag. There were no red biohazard bags available. The nurse stated the required equipment was supposed to be on the door and usually was in the clean linen room. 2) Resident #31 had a diagnosis of intracerebral hemorrhage (bleeding in the brain) and dysphagia (difficulty swallowing). The 11/21/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for most activities of daily living, and had a feeding tube. Physician orders documented: - on 8/24/2023 oral care every shift. - on 7/25/2024 the resident was on enhanced barrier precautions. The 7/25/2024 Comprehensive Care Plan documented the resident was on enhanced barrier precautions due to a tube feeding. Interventions included using gown and gloves when performing high contact activities including care of device or any activity with close contact. During an observation on 2/3/2025 at 10:36 AM, Resident #31 had an enhanced barrier precaution sign outside their door. The following observations of Resident #31's suction equipment were made on 2/3/2025 at 10:36 AM, 2/4/2025 at 9:56 AM, and 2/5/2025 at 11:24 AM: -the suction canister, tubing and Yankauer (a type of oral suction catheter) were connected, not dated, and sitting on the resident's nightstand. -the collection canister contained approximately 200 milliliters of clear, frothy fluid. -the Yankauer catheter was laying directly on the nightstand and not in a protective sleeve. During an observation on 2/5/2025 at 12:13 PM, Licensed Practical Nurse Manager #15 entered Resident #31's room to administer 1:00 PM medications. They applied a pair of latex gloves, disconnected the tube feeding, administered medications through the tube, flushed the tube, then reconnected the feeding tube. They performed a dressing change to the resident's gastrostomy tube site. They did not put on a gown prior to performing those activities. During an interview on 2/5/2025 at 12:26 PM, Licensed Practical Nurse Manager #15 stated residents who received a tube feed had an as needed suction order. If a suction collection canister was dirty or full it should be changed on evenings and the whole machine was washed and set up to dry every Sunday evening. The Yankauer should be left in the packaging sleeve or in a baggie dated and timed in between uses. Resident #31's canister was dirty; the tubing and canister were not dated; and the Yankauer was sitting next to the canister uncovered and undated. If the Yankauer was being set directly on their table it could be exposed to a multitude of organisms and bacteria and could cause illness. The resident was on enhanced barrier precautions because of their tube feeding. The dressing change and medication administration were considered high contact activity, and they should have worn a gown when they performed those activities. That was important to protect both themselves and the resident from exposure. During an interview on 2/7/2025 at 2:48 PM, the Licensed Practical Nurse Infection Preventionist stated the suction canister, and tubing should be changed after each use and the Yankauer should be changed daily, dated when opened, placed back in the packaging and remain covered between uses, and should not be sitting on a table unprotected. The suction collection canister should be changed and not sitting for several days with sputum in it. It could harbor germs and bacteria that could then enter the resident and lead to sickness. The resident should be on enhanced barrier precautions for the indwelling tube feed. Changing the gastrostomy dressing and administering medications and feeding via the tube was considered high contact activity. Nurses should not perform those activities without the required personal protective equipment on. That was important because it protected staff and the resident and prevented the introduction of any germs. 10 NYCRR 415.19(a)(b) 50561

49448 Based on record review and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 3 of 5 residents (Residents #59, #88, and #100) reviewed. Specifically, Resident #59's person-centered comprehensive care plan did not include the diagnoses of type 2 diabetes mellitus (the body does not use insulin properly causing high blood sugars) or the use of insulin (used to treat high blood sugars); Resident #88's person-centered comprehensive care plan did not include use of an anticoagulant (blood thinner); and Resident #100's person-centered comprehensive care plan did not include the diagnoses of diabetes or the use of insulin, anticoagulant, or psychotropic (used to treat mood/ behaviors) medications. Findings include: The facility policy, Comprehensive Care Planning, revised 2/2019, documented an individualized or person-centered comprehensive care plan was initiated by a registered nurse upon admission for all residents. The comprehensive care plan included measurable objectives that met the resident's medical, nursing, and psychosocial needs identified from admission assessments, and the Minimum Data Set assessments (a health status tool). The interdisciplinary team reviewed and revised care plans quarterly after the Minimum Data Set assessment was completed, with a significant change, following hospital return, annually, and as needed. Appropriate care plans were initiated based on nursing assessment findings and medical conditions. 1) Resident #59 had diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar). The 1/9/2025 Minimum Data Set assessment documented the resident was cognitively intact, had medically complex conditions, and received daily insulin injections. Physician orders documented the following orders for diabetes mellitus: - On 3/22/2023 metformin hydrochloride (regulates blood sugar) 1000 milligrams orally twice a day. - On 3/24/2023 Tresiba (long-acting insulin) 20 units subcutaneous (given in the fatty tissue under the skin) injection at bedtime. - On 12/19/2024 Insulin Lispro (short acting insulin) 22 units subcutaneous injection three times a day. - On 1/1/2024 weekly fingerstick (to test blood sugar levels) before meals and at bedtime. Call provider if blood sugar was lower than 60 or higher than 450. - On 1/24/2025 Ozempic (helps manage blood sugar) 1 milligram subcutaneous injection every Friday. A 10/24/2024 at 7:29 PM Nurse Practitioner #46 progress note documented the resident's A1C (a blood test that measures the average blood glucose over the past 2-3 months) level was maintained at the recommended level. Interventions included educate the resident and caregivers on signs and symptoms of hypoglycemia and appropriate management of symptoms related to diabetes. There was no documented evidence of a person-centered comprehensive care plan that included the diagnosis of diabetes with the need for insulin administration and oral diabetic agents, and monitoring for hyperglycemia and hypoglycemia (low blood sugar). During an interview on 2/10/2025 at 9:46 AM, Certified Nurse Aide #12 stated they were not sure what diabetes was but thought it had to do with sugar. If a resident was diabetic, it might be on their plan of care. They were supposed to reference the plan of care daily. They were not sure if Resident #59 was diabetic or what specifically they should monitor the resident for. During an interview on 2/10/2025 at 9:56 AM, Licensed Practical Nurse #4 stated if a resident was diabetic, it should be on their care plan because it indicated how to care for that resident. Insulin was a high-risk medication and too much insulin could drop the blood sugar and not enough could cause higher blood sugars. The Unit Manager was responsible for updating the care plans. During an interview on 2/10/2025 at 10:53 AM, Licensed Practical Nurse Unit Manager #15 stated Resident #59 was a diabetic and was on insulin. The resident did not have a diabetic care plan and should. The initial assessment should have triggered a diabetic care plan. The care plan would carry over to the care instructions for the certified nurse aides to know what signs and symptoms to monitor for. Care plans were reviewed quarterly, and they were not sure why this was missed for nearly two years. They reviewed care plans at the care plan meetings and at the weekly risk meetings. 2) Resident #88 had diagnoses including atrial fibrillation (irregular heartbeat). The 12/20/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required partial/moderate assistance with most activities of daily living, had one fall with injury, and was on an anticoagulant. The 5/29/2024 physician order documented Eliquis (blood thinner) 2.5 milligram tablet by mouth two times a day for atrial fibrillation. There was no documented evidence of a person-centered comprehensive care plan that included the use of an anticoagulant for a diagnosis of atrial fibrillation and monitoring for symptoms of anticoagulant use. During an interview on 2/10/2025 at 9:41 AM, Licensed Practical Nurse #26 stated if a resident was on an anticoagulant, the resident was monitored for bruising. They stated they did not know how to look at a care plan and if they had a question regarding the resident's care, they asked the certified nurse aides. During an interview on 2/10/2025 at 10:31 AM, Registered Nurse #28 stated use of an anticoagulant medication should be on the care plan, so staff knew to look for signs of bleeding or bruising. These residents were more fragile. Most of the care plans were initiated upon admission. They tried to update them during care planning meetings. Resident #88 came from another floor, so they did not catch there was not a care plan for anticoagulant use. 3) Resident #100 had diagnoses including diabetes mellitus, long term use of insulin, Parkinson's disease (a progressive neurological disease), and atrial fibrillation (irregular heartbeat). The 1/1/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment, did not exhibit behaviors, had medically complex conditions, was on an anticoagulant, received daily insulin injections and was on an antipsychotic since admission and a gradual dose reduction was documented as clinically contraindicated on 11/18/2024. Physician orders documented: - On 10/2/2024 Eliquis 5 milligram tablet by mouth twice daily for atrial fibrillation and fingerstick four times a day for diabetes mellitus monitoring. Contact provider if blood sugar less than 60 or greater than 450. - On 10/3/2024 dapagliflozin propanediol (used to control blood sugar) one 10 milligram tablet by mouth once a day for diabetes mellitus. - On 11/6/2024 Lantus (long-acting insulin) 10 units subcutaneously once daily for diabetes mellitus. - On 11/13/2024 quetiapine (antipsychotic) 25 milligram tablet, two tablets by mouth at bedtime for behaviors. - On 11/14/2024 quetiapine 25 milligram tablet by mouth once daily for behaviors. - On 11/26/2024 Bydureon (injectable, used to control blood sugars) 2 milligrams subcutaneously once daily on Tuesdays for diabetes mellitus. There was no documented evidence of a person-centered comprehensive care plan that included the use of an anticoagulant for a diagnosis of atrial fibrillation, the use of antipsychotic medications, or the diagnosis of diabetes with the need for insulin administration. During an interview on 2/7/2025 at 1:22 PM, Registered Nurse Unit Manager #36 stated they did not know if high-risk medications should be included in the care plan. High risk medications were important to be reviewed. If a resident was on a blood thinner and they fell , they could bleed. Psychotropic medications would be important to ensure behaviors were appropriately monitored. Insulin was important to ensure blood sugars were appropriately managed as they effected the entire body system. Resident #100 was on high-risk medications including an anticoagulant, psychotropic, and insulins and probably should be care planned for these medications because the care plan indicated interventions to care for the resident. The Minimum Data Set nurse was responsible to ensure care plans were initiated on admission and after care plan meetings. During an interview on 2/10/2025 at 9:44 AM, Minimum Data Set Licensed Practical Nurse #31 stated high risk medication care plans were initiated by the registered nurse Unit Managers, and they only completed the triggered portions. Care plans were discussed during the interdisciplinary team meetings. The purpose of a care plan was to ensure staff knew what care the resident needed, medications taken and potential side effects, and any disorders so the appropriate resident care was provided. High risk medications should have been included in the care plan because they required monitoring. During a telephone interview on 2/10/2025 at 11:43 AM, the Interim Director of Nursing stated the Nurse Managers were responsible for care plans, but the entire interdisciplinary team was involved. High risk medications such as insulin, anticoagulants, and psychotropics should be updated by nursing. The care plan should be reflective and alert staff for interventions or approaches to be implemented. A licensed practical nurse Unit Manager could update the care plan, but a registered nurse needed to initiate the care plan. During the care plan meetings staff should review diagnoses and medications to ensure the care plan was current and up to date. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for 3 of 4 medication carts (4th floor North, 4th floor South, and 3rd floor North medication carts). Specifically, the 4th floor medication carts (North and South carts) and the 3rd floor North medication cart had expired stock medications and insulin. Findings include: The facility policy, Storage and Maintenance of Medications, dated 10/2020 documented medications with shortened expiration dates, to include insulin and ophthalmic drops, must be dated when opened. Medications must be checked regularly for expiration dates and deterioration. Expired medications were to be removed from use. The overnight nurse was responsible for checking the medication carts, medication cabinets, and the refrigerator weekly for expired medications. During a medication storage observation on 2/4/2025 at 1:04 PM with Licensed Practical Nurse #13, the 3rd floor North medication cart's top drawer had the following medications: - Resident #17 had a Anoro Ellipta inhaler (used to treat lung disease) with no opened date and the medication was discontinued on 1/7/2025. - Resident # 86 had atropine eye drops with no opened date and the medication was discontinued on 12/24/2024. - Resident # 31 had tobramycin (antibiotic) 0.3% eye drops discontinued on 1/1/2025. - Resident # 11 had a Humalog quick insulin pen with no pharmacy label and no opened date and only the resident's name was written on the pen cap with a sharpie. - an unlabeled 30 milliliter plastic medicine cup was filled to the top with round white round tablets. Licensed Practical Nurse #13 stated they were acetaminophen (pain reliever) 500 milligram tablets. During an interview on 2/4/2025 at 1:17 PM, Licensed Practical Nurse #13 stated each medication should be labeled with the opened date, as that was considered the expiration date. Insulins expired within 28 to 60 days depending on the type of insulin. Opened expiration dates for eye drops, inhalers, and nose sprays varied based on the medication. An expired medication may not have the desired effect. By writing the opened date on the medication, it would alert the nurse if the medication was past the expiration date and should not be given. They stated they administered Resident #17 their Anoro Ellipta inhaler and Resident #11 their Humalog insulin that morning. During an additional interview at 1:34 PM, Licensed Practical Nurse #13 stated the acetaminophen was in the clear medicine cup when they came in that morning. The facility only purchased big bottles of the acetaminophen and was split between the 2 medication carts. One cart kept the large bottle and the other put them in a medicine cup for easier accessibility. The nurse stated they did not administer any medicine from the medicine cup that shift. During a medication storage observation and interview with Licensed Practical Nurse #26 on 2/4/2025 at 1:48 PM, the 4th floor North top drawer of the medication cart contained the following medications: - an opened bottle of Geri Care mucus relief with a manufacturer's expiration date of 9/2024 and a handwritten opened date of 11/2024 on the side of the bottle. - an opened bottle of aspirin 81 milligrams with no manufacturer's expiration date or opened date. Licensed Practical Nurse #26 stated they were not sure who was assigned to check the medications for expired dates, but each nurse should check them prior to administering a medication to a resident. The nurses were able to get new bottles of stock medication from the medication room or central supply if needed. During a medication storage observation and interview with Licensed Practical Nurse #27 on 2/4/2025 at 2:09 PM, the 4th floor South top drawer of the medication cart had an opened bottle of aspirin 81 milligrams that did not contain a manufacturer's expiration date and had a handwritten opened date of 1/17/2025 on the side of the bottle. Licensed Practical Nurse #27 stated the medication was considered expired since there was no readable expiration date on it. Each nurse was supposed to check expiration dates of each medication prior to giving it to a resident. An expired medication may not be effective. They stated Resident #77 received the medication that morning and was not sure why the expiration date was not checked. During an interview on 2/4/2025 at 2:18 PM, Registered Nurse Manager #28 stated each nurse was supposed to check each medication's expiration date prior to giving it to the resident. The Geri care mucus relief should never have been open as was expired prior to the opening date. They were not sure who was responsible for checking medication carts and rooms. 10NYCRR 415.18(d) 50561

Based on observations, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 2 of 3 unit kitchenettes (Units 3 and 4) and the main kitchen. Specifically, there were unclean surfaces in the Units 3 and 4 floor kitchenettes and main kitchen; moldy bread in the 4th floor kitchenette; and inaccurate thermometers in the walk-in cooler off the kitchen and the economy refrigerator in the main kitchen. Findings include: The undated facility policy, Cleaning and Sanitizing of Small Equipment, documented small equipment such as blender bases, vegetable choppers, and grinder slicers were cleaned and sanitized to prevent the spread of harmful bacteria to residents and staff. The undated facility policy, Food and Supply Storage documented all food and supply items were held and stored safely and securely and maintained quality and protected against contamination, spoilage, and theft. All storage areas were kept clean and in good working condition at all times. The undated facility policy, Procedure-Freezer and Refrigeration, documented coolers and freezers were thermostatically controlled and monitored for proper temperature control by appropriate properly working thermometers. Refrigerator temperatures were maintained between 33 -41 degrees Fahrenheit. Freezers were maintained at 0 degrees Fahrenheit or below. Temperatures of all coolers and freezers were documented twice daily on the appropriate logs. During operating hours, the temperatures were observed throughout the day. Any deviation outside the appropriate temperature range was immediately reported to the supervisor or director. MAIN KITCHEN The following observations were made in the main kitchen on 2/3/2025: - At 9:21 AM, there were multiple sugar packets, food scraps, and other debris on the floor in the dry storage room. - At 9:24 AM, there were two cases of frozen vegetables and packaging debris on the freezer floor. The walk-in cooler just outside of the freezer had food debris and packaging debris on the floor. - At 9:26 AM, there was debris and grime, behind, under, and around the ice cream freezer and dried food debris on the slicer. - At 9:28 AM, there was dried debris under and around the kitchen cook line and dried on spills in and under the economy refrigerator at the end of the cook line. The ice machine's scoop was directly on top of the ice inside the machine and there was an empty pitcher on top of the ice machine. - At 9:39 AM, the walk-in freezer had food and packaging debris under the shelving. The following observations were made in the main kitchen on 2/4/2025: - At 1:07 PM, there was food debris in the walk-in freezer. - At 1:08 PM, the mop boards were in disrepair along the back wall to the left of the dry storage room. There were dried food spills and debris under the cook line equipment. - At 1:17 PM, the walk-in cooler off the kitchen measured at 38 degrees Fahrenheit and the thermometer in the cooler read 32 degrees Fahrenheit while the exterior thermometer read 20 degrees Fahrenheit. There was food debris and packaging on the floor under the shelving. - At 1:28 PM, the slicer had dried food debris. - At 1:29 PM, there was grease, grime, and food debris behind the coffee maker. - At 1:40 PM, the economy refrigerator contents measured between 43-45 degrees Fahrenheit, and the thermometer read 30 degrees Fahrenheit. KITCHENETTES: The following observation was made in the third-floor kitchenette on 2/4/2025: - At 12:40 PM, there were food spills and debris in the white residential refrigerator. The following observations were made of the fourth-floor kitchenette on 2/4/2025: - At 12:17 PM, there was a small amount of orange colored liquid spilled in the cooler. - At 12:18 PM, there was moldy bread in the cabinet behind the service line. TEMPERATURE LOGS The February 2025 facility temperature logs documented the following out of range temperatures of the small walk-in cooler: -on 2/4/2025 24 degrees Fahrenheit -on 2/5/2025-2/7/2025 32 degrees Fahrenheit -on 2/8/2025 and 2/9/2025 there were no documented temperatures -on 2/10/2025 30 degrees Fahrenheit -on 2/11/2025 32 degrees Fahrenheit. During an interview on 2/4/2025 at 1:22 PM, The Food Service Director stated they went by the thermometers on the outside of the cooler. They agreed the thermometers did not match and were not accurate. They should be accurate, but they only looked at them and there were no other checks in place. During a telephone interview on 2/10/2025 at 12:46 PM, the Food Service Director stated the cooks did rounds of the kitchen coolers, units, and storage areas when they came in for the day. The dietary aides were responsible to ensure the kitchenettes were cleaned and mopped after each shift. There should not be moldy bread in the kitchenettes because it could make someone sick. The kitchen was supposed to be cleaned after using equipment or tables. The walk-in cooler floors and floors under and around the equipment were cleaned daily by the dishwasher. The slicer should have been cleaned by the cook after each use. The tiles along the walls, missing mop boards, and missing tiles on the electrical/ janitor's closet were not smooth and therefore not easy to clean. It was important kitchen preparation equipment and service areas were kept clean and easily cleanable for sanitation and prevention of bacteria growth that could make the residents sick. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 5 resident units (Units 2 North, 2 South, and 3 South) reviewed. Specifically, the stove/oven in Unit 2's activity room had accessible and operational knobs; Resident #31 on Unit 3 had an unclean tube feeding pole; and Resident #6 on Unit 4 had an improperly secured enabler bar (a device attached to the bed to aid in positioning). Findings include: The facility policy, Resident Rights dated 10/2017, documented the facility would maintain a safe, sanitary, clean, comfortable and homelike environment for the residents. The facility policy, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 5/2023, documented resident care equipment, including reusable items and durable medical equipment would be cleaned and disinfected according to current Center for Disease Control recommendations for disinfection and the Occupational Safety and Health Administration Bloodborne Pathogens Standard. Unit 2- Teresian Room/Oven The following observations were made on Unit 2 in the Teresian Room: - On 2/2/2025 at 12:27 PM, there was a stove with an artificial plant in the middle of the four burners. The stove was operational and became hot when the knobs were turned on. - On 2/3/2025 at 2:42 PM, an activity was taking place in the Teresian room with 2 activity staff present. The stove was plugged in, and the burners were hot when tested . From 5:51 PM- 6:06 PM, the Teresian room doors were closed and unlocked. - On 2/4/2025 at 1:58 PM, the Teresian room was in use by residents and staff playing bingo. The oven was used and there were cookies on a baking pan on top of the stove. - On 2/4/2025 at 3:51 PM, the Teresian room door was closed and unlocked. There were baked cookies on top of the stove. There were no staff or residents in the room. During an interview on 2/5/2025 at 3:15 PM, the Director of Activities stated the second floor Teresian room was the main activity room. The room was never locked, but the doors were closed between 4:00 PM and 5:00 PM, when the activity staff left the facility. The oven and stove were used by the facility activity staff during baking activities. The oven was always plugged in and ready to be used. The activity room was not locked because the door in the back of the Teresian room was the fire exit. Residents were not permitted to go in the Teresian room unless there was staff present. They stated the residents had access to the room since it was unlocked and the plugged in stove/oven could be unsafe if residents entered the room unsupervised. During an interview on 2/5/2025 at 5:10 PM, the Director of Environmental Services stated the stove was not a safety stove/oven. It was accessible to staff and residents, and they were not aware of any safety features. This stove/oven was installed with the facility renovations. The oven doors did not have a safety lock. Unit 3 -Unclean Resident Medical Equipment Resident #31's tube feeding pole (used to hold tube feeding formula) was observed with a large amount of splattered, tan residue on the base and lower portion of the pole: - on 2/3/2025 at 10:36 AM, - on 2/4/2025 at 9:56 AM, - on 2/4/2025 at 2:51 PM, - on 2/5/2025 at 11:24 AM. During an interview on 2/5/2025 at 12:38 PM, Licensed Practical Nurse Unit Manager #15 stated housekeeping was responsible for keeping equipment clean, including tube feeding poles, but nursing should clean them if needed. Resident #31's pole was unclean and could be growing bacteria. Anyone who noticed it was dirty should have cleaned it. It was undignified for the resident to have dirty equipment. During an interview on 2/5/2025 at 1:50 PM, Housekeeper #6 stated every resident room was cleaned every day and included the cleaning of equipment poles. They cleaned Resident #31's room two days ago and did not notice the pole was dirty. They noticed it today and planned to clean it. It was important to keep poles clean to keep the germs off. During an interview on 2/7/2025 at 2:35 PM, the Director of Environmental Services stated resident rooms were cleaned every day and included equipment poles. In between cleaning they should be wiped down by nursing or environmental services. It was a joint effort to keep equipment clean. If nurses spilled something on a pole, they expected them to wipe it up. It was important to keep equipment clean for infection prevention purposes. Unit 4- Resident Enabler Bar Not Maintained Resident #6's Comprehensive Care Plan initiated 12/27/2023 documented the resident had an activities of daily living self-care deficit related to limited mobility. Interventions included limited assistance of 1 for bed mobility, bed with bilateral enabler bars. The following observations were made: - on 2/3/2025 at 10:20 AM, Resident #6 was in bed watching television. Their enabler bar on the window side of the bed was not connected to the bed. The bar moved up and down and was not tight to the frame. - on 2/5/2025 at 9:42 AM, Resident #6's enabler bar on the widow side of the bed, had black electrical tape wrapped around the curve of the bar. The bar was not in the upright position. The bottom of the enabler bar was missing a bolt to keep it in the up position. Resident #6 stated the bar was broken, and the staff were aware that it was broken. - on 2/6/2025 at 8:57 AM, Resident #6's enabler bar was missing the bolt and was not connected to the bed. The enabler bar was hanging down on the side of the bed and unable to be used. - on 2/7/2025 at 12:56 PM, the enabler bar on the window side of the bed was not connected to the bed and unable to be used. Facility work orders dated 8/11/2024-2/7/2025 did not include an open or completed work order for Resident #6's broken/or unsecure enabler bar. During an interview on 2/7/2025 at 2:04 PM, Maintenance Worker #42 stated they were made aware of work orders or broken equipment through a computerized work order program. They did not receive a work order for Resident #6's enabler bar. Maintenance worker #42 observed Resident #6's enabler bar on the window side of the bed, and stated the bar was not attached. They stated the bar could not be used if it was not properly attached to the bed. During an interview on 2/7/2025 at 2:26 PM, Certified Nurse Aide #7 stated they noticed Resident #6's enabler bar was not attached on one side and it had been that way for a while. They did not submit a work order because sometimes residents had one bar on and one bar off. During an interview on 2/10/2025 at 10:31 AM, Registered Nurse Unit Manager #28 stated staff could put work orders in the computer when something needed to be repaired. They were not aware of Resident #6 enabler bar not being attached to the window side of the bed. They said that was the resident's strong side and the enabler bar should be in place for safety. During an interview on 2/10/2025 at 1:44 PM, the Director of Environmental Services stated they inspected beds biannually, and the enabler bars were part of the inspection. They did not have a record of request to fix Resident #6's enabler bar. All the beds were inspected in September 2024. Resident #6's bed was inspected on 9/3/2024 and there no side rails or enabler bars in place. 10 NYCRR 415.29(j)(1) 48052 50561

Based on observation, record reviews, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for 2 of 3 residents (Residents #6 and #31) reviewed. Specifically, clinical nutrition staff did not assess Resident #6 following significant weight changes; and Resident #31's ordered enteral feeding (a feeding tube) water flushes were not provided as ordered. Findings include: The facility policy, Nutrition Assessment, revised 3/17/2023, documented a full nutrition assessment would be completed on each resident after admission and no less than every three months thereafter to assess and evaluate the need for nutrition care according to each person's individual medical condition, needs, desires, and rights. The registered dietitian would complete or cosign initial nutritional assessments, annual nutritional assessments, and significant change assessments. All pertinent information and the rationale for the nutritional plan of care would be evaluated/summarized. The facility policy Gastrostomy Tube Feeding, revised 12/2019, documented the flow rate on the feeding pump would be adjusted according to the physician's order. The procedure documented review physician order for feeding and flushing. 1) Resident #6 had diagnoses including hypertension (high blood pressure), congestive heart failure (insufficient pumping), and adult failure to thrive (overall physical decline). The 9/27/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, required setup or clean up assistance with eating, weighed 209 pounds, had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, was not on a physician-prescribed weight-loss regimen, and received a mechanically altered diet. The Comprehensive Care Plan documented: - 12/27/2023 the resident required supervision at meals. - 1/5/2024 the resident had a nutritional problem related to a history of intakes at meals of less than 75% and a diagnosis of failure to thrive. Interventions included regular diet with thin liquids, monitor intakes and record at each meal, provide supplements as ordered, and weigh per policy. The resident's weight record documented: - on 6/28/2024 238.1 pounds. - on 7/25/2024 209 pounds (12.1% weight loss in 1 month) The was no documented evidence the resident's nutritional needs were re-assessed after the significant weight loss of 29.1 pounds/ 12.1% in 1 month. There was no documented evidence the resident was weighed in 8/2024. A 9/2/2024 Nurse Practitioner #22 progress note documented the resident was seen for a 60 day follow up visit. The resident received 2 milligrams of bumetanide (diuretic) one time daily for heart failure and had edema (fluid retention). There was no documentation of the resident's weight loss. The resident's weight record documented they weighed 209 pounds on 9/7/2024. The 9/17/2024 Nurse Practitioner #24 progress note documented the resident's body mass index was 31.77 (obese) and their last weight was obtained on 9/7/2024. No edema was noted. The resident had protein calorie malnutrition as noted by a weight loss greater than 7.5% over the past 3 months with a documented weight loss from 238.1 pounds on 6/28/2024 to 209 pounds on 9/7/2024. The resident was to continue a mechanically soft diet, protein supplements, and would continue to be followed by dietary staff. Intakes were to be monitored at every meal and if weight loss continued both dental and speech evaluations would be considered. The 9/27/2024 Nurse Practitioner #24 progress note documented the resident had a 30-pound weight loss since 7/25/2024. Recent laboratory values were reviewed, the resident had no edema present on exam, and they would attempt to decrease 2 milligrams of Bumetanide (diuretic) one time daily to 1 milligram once daily. The 9/27/2024 physician order documented to provide 0.5 tablet of 2 milligrams of Bumetanide (diuretic) one time daily for heart failure. The 9/29/2024 physician orders documented weekly weights on Mondays and was discontinued on Monday 9/30/2024. The 9/29/2024 Diet Technician #29 Quarterly Nutrition Assessment documented the resident received a regular diet, mechanically soft with finely chopped fruit and vegetables, and thin liquids. Supplements included 6 ounces of fortified cereal at breakfast, 4 ounces of ice cream at lunch and dinner, and 30 milliliters of liquid protein once daily. Their weight was 209 pounds, a 34-pound decrease/ 14% loss at 6 months. The resident had no documented edema (fluid retention), their estimated nutritional needs were based on their actual body weight of 209 pounds and were 1880 calories, 76 - 95 grams protein, and 2375 - 2700 milliliters of fluids. The resident would be placed on weekly weights related to significant weight decrease. The resident's weight record documented they weighed 240.4 pounds on 10/1/2024 (a 15% weight increase in one month). The 10/2/2024 Comprehensive Care Plan documented the resident had a potential for fluid deficit/dehydration related to diuretic (water pill) usage. Interventions included to provide medications as ordered and monitor/document side effects. The resident's weight record documented they weighed 240.4 pounds on 10/2/2024, 10/3/2024, and 10/4/2024. On 10/6/2024 Diet Technician #29 documented they were aware of several re-weights documenting weight of 240.4 pounds and they were going to strike out inaccurate recorded weight of 209 pounds on 7/25/2024 and 9/7/2024. There was no documented evidence the resident's nutritional needs were reassessed after a 31.4 pound/ 13% gain after their 9/27/2024 nutrition assessment was completed. On 10/7/2024 the resident's record documented they weighed 233.7 pounds. There was no documented evidence the resident had a re-weight obtained after a weight loss of 6.7 pounds in 3 days. The 10/12/2024 Medical Director progress note documented they saw the resident for a 60 day follow up. The resident received 1 milligram of Bumex (diuretic) once daily, had no edema (fluid retention), weighed 234 pounds, their weight was stable, and the resident requested their diet order be upgraded to a regular diet. On 10/14/2024 the resident's record documented they weighed 204.4 pounds. There was no documented evidence the resident was re-weighed, or their nutritional needs were re-assessed after a documented weight loss of 29.7 pound/ 12.7% weight loss in 2 weeks. The 10/16/2024 Nurse Practitioner #22 progress note documented the resident received 1 milligram of Bumex (diuretic) once daily, had no edema (fluid retention), and weighed 234 pounds. The note did not address the residents weight loss of 29.7 pound/ 12.7% weight loss in 2 weeks. The 10/16/2024 physician order documented the resident was to consume all meals in the dining room for monitoring. The 10/27/2024 Diet Technician #29 progress note documented the resident was re-weighed on 10/24/2024, 10 days after the 10/14/2024 recorded weight of 204.4 pounds. The resident had a documented weight loss of 29.7 pound/ 12.7% weight loss. The resident weighed 204.4 pounds, had a significant weight loss of 12.5% at 1 month. The resident continued weekly weights. Medical notes documented edema on 10/3/2024, but the resident currently had no noted edema. Weight loss was likely related to fluid fluctuations related to edema. The resident had potential for weight fluctuations related to fluid status changes. There was no documented evidence the resident's nutritional needs were re-assessed. The 12/3/2024 Medical Director progress note documented the resident weighed 206 pounds, had no edema (fluid retention), and was down 40 pounds in the last year. This was likely related to Bumex (diuretic). The resident appeared nutritionally sound. The 1/2/2025 Registered Dietitian #10 Annual Nutritional Assessment documented the resident was on a regular diet with thin liquids. Their documented weight on 12/30/2024 was 199.8 pounds, they were 118% of their recommended weight range, their weight ranged from 200-204 pounds over the past 3 months, they were down 38.3 pounds/16.1% over the past six months, there were some weights struck out in error, and the weight loss rationale was unknown. The resident had edema at times, and currently had no edema. The resident continued weekly weights. Intakes were adequate to meet their estimated needs, and they would discontinue the liquid protein supplement. During an observation on 2/3/2025 at 1:05 PM, the resident was in the main dining room. Their plate included beef stroganoff, carrots, and noodles, a slice of cake, and 2 cups of juice. At 1:42 PM, the resident consumed 100% of their cake and 100% of their juice, and 0-25% of the beef stroganoff, noodles, and carrots. No staff encouragement was observed. During an interview and observation on 2/5/2025 at 3:16 PM, the resident stated they were hungry and did not eat lunch because they thought they slept through the meal. At 3:18 PM, the resident turned on their call bell and an unidentified staff responded. The resident stated they were hungry. At 3:22 PM the unidentified staff brought the resident their meal tray. During an observation on 2/6/2025 at 8:53 AM, an unidentified staff asked the resident if they wanted to go to the dining room and the resident replied no and they just wanted cranberry juice. At 8:59 AM, Nurse Aide in Training #44 brought the resident their cranberry juice and told the resident if they were going to eat, they needed to eat in the dining room. The resident stated they just wanted their juice. At 9:16 AM, an unidentified staff attempted to bring the resident out into the hallway to eat and they refused and wanted to return to their room. At 9:30 AM, the resident was observed in the dining room eating bacon and eggs. During an interview on 2/7/2025 at 2:45 PM Registered Nurse Unit Manager #28 stated all residents should be weighed the same way, either standing or sitting. The dietitian or diet technician let staff know if a resident needed to have a re-weight obtained. Staff should obtain the re-weight within 24 hours. They stated Resident #6 had a poor appetite and their diet was upgraded to regular consistency to help improve with intakes. They were unsure why the weights had been struck from the record and thought the weight changes could be related to staff not taking the resident's wheelchair weight into consideration. During a telephone interview on 2/10/2025 at 10:07 AM Diet Technician #29 stated the weight lists were sent out every Sunday and Wednesday. The nurses entered the resident's weights into the computer and the computer generated a note if the resident had a significant weight change. If a resident had a significant weight change or a weight was missing, they sent an email to the Nurse Manager to obtain a re-weight. Resident #6 weighed 238.1 pounds in July 2024 and weighed 209 pounds in September 2024. In October 2024 their weight was between 233- 240 pounds. They stated medical saw the resident and noted edema and diuretic usage, and a nutrition note was completed. They did not believe the resident weighed 209 pounds in September 2024 and spoke to the Nurse Manager about it. The resident's intakes were documented as stable. They stated they did not re-assess the resident's needs after they had a significant weight gain in October 2024, and it was important to assess the resident nutritional needs to ensure optimal nutritional status. During an interview on 2/10/2025 at 11:31 AM Registered Dietitian #10 stated Diet Technician #29 followed the resident's weights and did quarterly assessments. They stated they saw the residents on an annual basis and with a significant change. If a resident had a significant weight change the diet technician should let them know and Diet Technician #29 did not discuss Resident #6's weight changes with them. They thought Diet Technician #29 struck out the recorded weight of 209 pounds because it was inaccurate and did not see the medical note attributing the weight loss to the usage of diuretics. The resident's chart did not document they were reviewed for their significant weight changes. It was difficult to follow weight trends if there were missing weights. 2) Resident #31 had a diagnosis of intracerebral hemorrhage (bleeding in the brain) and dysphagia (difficulty swallowing). The11/21/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for most activities of daily living, did not have a swallowing disorder, had a feeding tube, and had an average daily fluid intake of 501 cubic centimeters or more. The Comprehensive Care Plan revised 8/25/2023 documented the need for a feeding tube related to dysphagia and an activities of daily living self-care performance deficit. Interventions included assistance with tube feeding and water flushes. The Comprehensive Care Plan revised 8/30/2023 documented the resident had the potential for dehydration. Interventions included monitor and report any signs of dehydration and monitor lab work as ordered. Physician orders documented: - 8/24/2023 the resident was to have nothing by mouth. - 2/28/2024 full strength Glucerna 1.2 (tube feeding formula) at 60 cubic centimeters per hour for 24 hours the resident was to receive 30 milliliters of water every hour via auto flush via the feeding tube (24 hours/day). The 11/26/2024 at 2:23 PM Registered Dietitian #10 quarterly nutritional assessment documented the resident was to receive 30 milliliters of water every hour and their estimated fluid needs were 1925-2310 milliliters a day. The following observations were made of the resident's water flush settings on their feeding pump: -on 2/3/2025 at 10:36 AM 30 milliliters every 4 hours. -on 2/5/2025 at 11:24 AM 30 milliliters every 2 hours. -on 2/6/2025 at 8:30 AM 30 milliliters every 4 hours. -on 2/6/2025 at 2:13 PM 30 milliliters every 4 hours. The February 2025 medication administration record documented the resident received 30 milliliters of water flush every hour via auto flush every shift from 2/3/2025-2/6/2025. During an observation on 2/6/2025 at 8:30 AM, Licensed Practical Nurse #1 entered Resident #31's room, and placed the feeding tube pump on hold while they administered the resident's medications. Licensed Practical Nurse #1 restarted the pump. The pump was set at 30 milliliters water flush every 4 hours. During an interview on 2/5/2025 at 12:13 PM, Licensed Practical Nurse Manager #15 stated the resident was receiving 30 milliliters of water flushes every 2 hours via the pump. During an interview and observation on 2/6/2025 at 2:15 PM, Licensed Practical Nurse Manager #15 stated the fluid recommendations were made by the registered dietitian and required a physician order. They expected nurses to check the pump settings were correct when signing the medication administration record. Resident #31's water flush was set for 30 milliliters every 4 hours but should have been set to 30 milliliters every 2 hours. After changing the pump to 30 milliliters every 2 hours, they checked the order and stated the order was 30 milliliters every 1 hour and was effective on 2/28/2024. The nurses were signing the resident received 30 milliliters of water every one hour when they did not. It was important the resident's water flush settings were correct otherwise they could become dehydrated. During an interview on 2/10/2025 at 11:03 AM, Registered Dietitian #10 stated they were responsible for determining a resident's feeding and fluid needs. They made that determination based on variables such as height, weight, and laboratory values. Their recommendations required a physician order, and it was the responsibility of nursing to make sure the resident received what was recommended. Resident #31 had been stable and had no issues with weight loss or dehydration. The resident depended solely on the gastrostomy tube for hydration and nutrition and should have been receiving 30 milliliters of water every hour. They were at risk for dehydration due to their dependence on staff, and staff should always ensure the resident was getting the necessary fluids. The resident's fluid needs were 1925-2310 milliliters a day. If the resident's pump had been set at 30 milliliters every 4 hours that would have decreased their 24-hour fluid intake and the resident would not meet their hydration needs. Inadequate fluid could cause overall health decline, constipation, and dehydration. 10NYCRR415.12(i)(1) 48052

Based on observations and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did not post daily current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent location readily accessible to residents and visitors for 6 of 6 days reviewed. Specifically, daily nurse staffing was not posted daily at the beginning of the shift as required on 2/3/2025, 2/4/2025, 2/5/2025, 2/6/2025, 2/7/2025 and 2/10/2025 as required. Findings include: The facility policy, Staffing, effective 4/1/2022, documented staffing was evaluated at the beginning of the shift and adjusted as needed by the Nurse Manager/designee. Staffing analysts were available and supported the designee during hours they were available and included providing timely accurate data to the staffing office when needs changed, and daily full-time equivalent was posted in the glass display case by the night supervisor with updates made by the shift supervisors as needed. The daily nurse staffing and resident census information was not posted in the main lobby, on the main entrance doors, or on the reception desk during the following observations: - on 2/3/2025 at 9:15 AM. - on 2/4/2025 at 8:00 AM. - on 2/5/2025 at 8:31 AM. - on 2/6/2025 at 7:40 AM. - on 2/7/2024 at 8:20 AM. - on 2/10/2025 at 8:15 AM. During an interview on 2/10/2025 at 9:25 AM, the Administrator stated staffing, and the resident census should be posted in the front lobby. They stated things came up missing from the front desk. During an interview on 2/10/2025 at 10:02 AM, Human Resources/Staffing Scheduler #25 stated they were aware staffing should be posted. They observed the front desk and stated posted staffing was not where it was supposed to be. They stated it should have been posted there, and it was usually in a clear frame on the receptionist desk. They did not what happened to it. They stated it was important to have daily nurse staffing posted to know what the facility census was and to ensure a registered nurse was in the building. 10 NYCRR 415.13

Based on observation, record review, and interviews during the recertification survey conducted 2/3/2025-2/11/2025, the facility did provide each resident with a nourishing, well-balanced diet that considered the preferences of each resident for 1 of 2 residents (Resident #24) reviewed. Specifically, Resident #24 was not provided their preferred meal choices. Findings include: The facility policy, Obtaining/Recording Food Preferences, effective 4/5/2020, documented the facility identified and recorded each resident's food/beverage preferences to coordinate meal preparation/service to promote adequate nutrition. The food service director, diet technician, or registered dietitian would complete a dietary interview with the resident and complete sections on likes and dislikes and information would be entered into the nutrition management system for incorporation into meal tickets. During the interview residents would be provided with a copy of the cycle menu and the alternate menu. The facility policy, Substitutions, dated 1/2022, documented all substitutions were noted on the menu and filed in accordance with established dietary policies and residents' likes and dislikes would be considered when making substitutions. Resident #24 had diagnoses of diabetes and chronic obstructive pulmonary disease (lung disease). The 1/23/2025 Minimum Data Set assessment documented the resident had intact cognition, required set up assistance for eating, and did not receive a therapeutic diet. The Comprehensive Care Plan documented: - revised 11/15/2022 the resident had diabetes and was non-complaint with their diet and frequently ordered out. Interventions included offer substitutions for foods not eaten. had a nutritional problem or potential nutritional problem related to diabetes. Interventions included to provide and serve supplements as ordered. - revised 10/27/2024 the resident had nutritional problems related to therapeutic diet, history of non-compliance, and ordered take-out food frequently. Interventions included encourage diet compliance, no added salt, low concentrated sweets, regular texture diet, meals in room, monitor intake, and provide and serve supplements as ordered. The 1/21/2025 at 7:08 PM Dietetic Technician #29 Quarterly Nutritional Assessment documented the resident was to receive 4 fried eggs and 4 ounces of yogurt at breakfast. The resident had weight fluctuations due to fluid changes. During an observation and interview with Resident #24 on 2/6/2025 at 9:44 AM, the resident's breakfast meal ticket documented 4 fried eggs, yogurt, and cold cereal. The resident's tray had one fried egg, and no yogurt or cold cereal. Resident #24 stated if they received the yogurt and cereal they would have eaten it. During an interview on 2/6/2025 at 9:48 AM, Certified Nurse Aide #7 stated the dietary department put all the food on the trays and the aides checked for accuracy and served the trays to the resident. Sometimes it was a mixture of both departments placing food items on the tray. They delivered Resident #24's breakfast that day and did not notice the cereal and yogurt were missing. The resident should have received four fried eggs but did not. If the items were short the resident would not receive the calories they needed. During an interview on 2/6/2025 at 9:55 AM, Dietary Aide #39 stated they thought they gave Resident #24 four fried eggs but may have confused them with another resident. During an interview on 2/7/2025 at 1:09 PM, Resident #24 stated staff did not ask them what they wanted to drink, did not provide them a menu, and did not tell them about food alternatives. They asked for soup and salads, and they would not get them, or they would receive a salad that only had lettuce. They felt it was important to have the option of choosing their meals. During an interview on 2/7/2025 at 1:20 PM Certified Nurse Aide #12 stated residents often asked what was being served for that day and they would have to ask dietary staff because menus were not posted anywhere. Activities used to hand out menus, but they did not think they were doing that anymore. There was always an alternate such as hot dogs or hamburgers and they usually ran out of the alternatives. They had never seen an alternate list but knew there was always a soup and a sandwich option too. During an interview on 2/7/2025 at 1:28 PM, Unit Manager #15 stated they used to have the menu and substitutes posted on a bulletin board in the dining room, but they were removed when the remodeling started and were never put back up. Residents asked them every day what was being served for each meal. The dietary ticket was based on dietary preferences and Resident #24 should get what was on their ticket. During an interview on 2/10/2025 at 10:47 AM, Dietetic Technician #29 stated menus were distributed to residents on admission. Menus and a list of alternatives were previously posted on the units, but because of the remodeling they were taken down and never went back up. Residents could ask for a menu or call downstairs to find out what was on the menu. It was important for residents to know what was on the menu so they could ask for something different. Resident #24 ordered out a lot and asked for extra food. They usually wanted something different than what was on their ticket. The items listed on their ticket should be provided. 10NYCRR 415.14 50561

Based on record review, observation, and interviews during an abbreviated survey (NY00367007), the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #1) reviewed. Specifically, Dietary Aide #4 witnessed Certified Nurse Aide #8 abuse Resident #1 and did not report the incident for three days. Additional staff were identified as having knowledge of the incident and failed to report to facility Administration timely. The facility's failure to protect residents from abuse resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 104 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death. Findings include: The facility policy Seven Components of a Systemic Approach to Abuse Prohibition, effective 8/2020, documented abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, and pain and/or mental anguish. Some forms of abuse were physical, which included hitting or slapping; verbal, which included derogatory language and threats intended to frighten a resident; and mental, which included intimidation and deprivation of any goods or services. The facility policy Abuse- Investigation, protection and Reporting - Components #5, #6 and #7, effective 10/24/2022, documented all allegations/occurrences of all types of staff-to-resident abuse must be reported to the Administrator and to other officials, including the State Survey Agency and Adult Protective Services, where state law provided jurisdiction to nursing homes. During abuse investigations, residents would be protected from harm. Employees accused of participating in the alleged abuse would be immediately reassigned to duties that did not involve resident contact or would be suspended until the findings of the investigation had been reviewed by the Administrator. Resident #1 had diagnoses including dementia, unspecified psychosis, and anxiety disorder. The 9/20/2024 Minimum Data Set assessment documented the resident had intact cognition, did not exhibit behaviors, did not wander, and was independent with transfers and ambulation. The comprehensive care plan, initiated 4/1/2024, documented the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions included to identify oneself at each interaction, face the resident when speaking, make eye contact, reduce distractions, use consistent, simple sentences, and stop and return if agitated. When revised on 10/30/2024, it documented the resident had the potential to be abused by others as they demonstrated kleptomaniac behaviors (kleptomania, an impulse control disorder that resulted in an urge to steal items) that had the potential to annoy others. Interventions included assess for causative factors to their kleptomania, redirect impulsive behavior, and encourage resident to seek staff assistance with problems with other residents. The undated and unsigned Facility Investigative Summary documented: - On 12/31/2024, at approximately 12:00 PM, Dietary Aide #4 reported to the Director of Nursing, they observed Certified Nurse Aide #8 strike Resident #1 with an open hand on their face on 12/28/2024 between 11:30 AM and 12:00 PM. - Dietary Aide #4 reported Resident #1 knocked on the door leading from the dining room to the kitchen and asked them for ice and ginger ale. - Certified Nurse Aide #8 then approached Resident #1 and asked them why they were there and told the resident to go sit down. - Resident #1 re-stated to Certified Nurse Aide #8 they wanted ice and ginger ale, Certified Nurse Aide #8 replied, No and struck Resident #1 one time on their cheek with an open hand. - Resident #1 struck Certified Nurse Aide #8, and then sat down. - The Director of Nursing and Administrator were notified of the incident on 12/31/2024. The Director of Nursing assessed Resident #1 immediately once the report was made and there were no injuries or signs of psychological distress. The Director of Nursing and Administrator interviewed staff witnesses on 12/31/2024. Verbal statements from two employees, Dietary Aide #4 and [NAME] #5, verified they had observed physical contact from Certified Nurse Aide #8 towards Resident #1. Dietary Aide #4 witnessed Certified Nurse Aide #8 slap Resident #1 on the face one time with an open hand. [NAME] #5 witnessed Resident #1 push Certified Nurse Aide #8, then Certified Nurse Aide #8 pushed Resident #1 back in the shoulder area. Certified Nurse Aide #8 denied striking Resident #1. Written staff statements obtained during the facility investigation included: - Certified Nurse Aide #11 stated they were working on Resident #1's unit and heard about the incident, but they did not witness any arguments or altercations between Resident #1 and Certified Nurse Aide #8. - [NAME] #5 (statement dated 1/1/2025), reported they observed Certified Nurse Aide #8 slamming the door to the unit kitchen multiple times but did not see any hands-on physical contact (this statement was not consistent with the reported verbal statement given on 12/31/2024 during the facility investigation). - [NAME] Supervisor #7 stated they observed Resident #1 asking for something from Dietary Aide #4. As Dietary Aide #4 was getting what Resident #1 asked for, Certified Nurse Aide #8 slammed the door to the kitchen and yelled at Resident #1. They were unable to see what was going on behind the door. Certified Nurse Aide #8 came back through the door to the kitchen and told [NAME] Supervisor #7 Resident #1 was not to get anything until after lunch. - Housekeeper #10 reported that when they got on the service elevator on 12/31/2024, Dietary Aide #4 was also on the elevator and told them they witnessed a resident get slapped by a certified nurse aide over ice and ginger ale. The housekeeper told Dietary Aide #4 they had to report that, and because of what they were just told, the housekeeper also had to report the incident. - Licensed Practical Nurse #3 reported Resident #1 told them at lunch time on 12/28/2024 that someone had shoved them. When the licensed practical nurse asked the resident what happened, they stated they were going to call the State and not to worry about it. Resident #1 was visibly upset but had no injuries. - Dietary Aide #4 stated they were in the kitchen pouring drinks. Resident #1 knocked on the door, they opened the door, and gave them a cup. Thirty seconds later, Certified Nurse Aide #8 asked Resident #1 why were they there and told them to go sit down. The resident replied to Certified Nurse Aide #8, ice and ginger ale. Certified Nurse Aide #8 stated, No, screamed at them, slapped the resident on their face, then slammed the door in their face. - Certified Nurse Aide #8 stated that on 12/28/2024 at approximately 11:45 AM, Resident #1 was trying to enter the kitchen. They told the resident they could not go in there and the resident got upset. They told the resident as soon as there was soda brought to the kitchen they would bring it to them. Resident #1 tried to hit the aide, the aide backed up, and the resident could not hit them, which made them angrier. The supervisor abuse rounding form was completed 12/28/2024 and no abuse was reported to the supervisor on that date. There was no documented evidence Dietary Aide #4, [NAME] #5, [NAME] Supervisor #7, Licensed Practical Nurse #3, or Certified Nurse Aide #11 reported any concerns related to an alleged incident of staff to resident abuse on 12/28/2024. Certified Nurse Aide #8's Employee Timecard Report documented they continued to work and had access to all residents on 12/28/2024 (until 2:00 PM) and 12/31/2024 from 5:36 AM to 11:21 AM. During an interview on 1/6/2024 at 11:52 AM, Resident #1 stated there was a certified nurse aide on the unit (they did not know their name and was understood to be Certified Nurse Aide #8) that was recently terminated from employment. The unidentified certified nurse aide would throw ice cream cups at them and never give the resident coffee creamers or juice when they asked for them. The resident was not allowed in the kitchen on the unit. The certified nurse aide accused Resident #1 of stealing money from somebody. No staff had ever hurt them physically, but the certified nurse aide was very disrespectful. During an interview on 1/7/2025 at 10:03 AM, [NAME] #5 stated that on 12/28/2024, they were wiping down tables on Unit 4 when they saw Certified Nurse Aide #8 and Resident #1 talking by the kitchen door. The conversation got loud, and Certified Nurse Aide #8 went into the kitchen and closed the door. Certified Nurse Aide #8 gave Resident #1 a cup. The kitchen door opened and closed three times as the conversation between Certified Nurse Aide #8 and Resident #1 got louder. The resident eventually sat down at a table. They did not see Certified Nurse Aide #8 place their hands on the resident. [NAME] #5 was called in by Administration on 12/31/2024 to be interviewed about the 12/28/2024 incident. During an interview on 1/7/2025 at 10:25 AM Dietary Aide #4 stated that on 12/28/2024 they were in the Unit 4 kitchen pouring drinks and Resident #1 was requesting ice and ginger ale. Seconds later, Certified Nurse Aide #8 was screaming at Resident #1, telling them to sit down. Certified Nurse Aide #8 swung their hand towards Resident #1 and hit them on their face. Resident #1 hit Certified Nurse Aide #8 back. Certified Nurse Aide #8 yelled to Resident #1 that they were not getting ginger ale and told them to sit down, using profanities. There was another certified nurse aide behind the steam table during the incident, but they did not know who it was or if they saw anything. Dietary Aide #4 got on the elevator with [NAME] Supervisor #7 a few minutes later. [NAME] Supervisor #7 had been helping them pour drinks on Unit 4. Dietary Aide #4 told [NAME] Supervisor #7 what had happened, and they asked, are you serious? Dietary Aide #4 stated they thought by telling their supervisor they were doing the right thing and later realized they should have reported the incident to a nursing supervisor. On 12/31/2024, they told a nurse on another unit about the incident on 12/28/2024. The nurse told them to report it to the Director of Nursing right away and they did so. During an interview on 1/7/2025 at 11:15 AM [NAME] Supervisor #7 stated that on 12/28/2024, they were helping Dietary Aide #4 and [NAME] #5 on Unit 4. Right before lunch, they heard a commotion outside the kitchen door between Certified Nurse Aide #8 and Resident #1. Resident #1 asked for a drink with ice and Certified Nurse Aide #8 came in the door screaming to not give them any ice or soda until after supper. [NAME] Supervisor #7 stated they did not report the 12/28/2024 incident in a timely manner. On 12/31/2024, they reported the incident to Food Service Director #25 who directed them to go to the Administrator. During an interview on 1/7/2025 at 12:46 PM Licensed Practical Nurse #3 stated that on 12/28/2024, they overheard Resident #1 telling another resident someone had pushed them. When they asked the resident for more details, Resident #1 stated they had been pushed by someone, they would not say who, and they would, take care of it and would be, calling the state. Licensed Practical Nurse #3 had not heard or seen anything and was not sure if the resident was referring to another resident or staff. During an interview on 1/8/2025 at 10:50 AM Resident #1 stated a certified nurse aide (they did not know their name, but it was understood they were referring to Certified Nurse Aide #8) slammed the kitchen door on them when another staff was giving them juice. The certified nurse aide told them they did not need the juice and were very rude and inconsiderate to them. The resident and Certified Nurse Aide #8 were opening and closing the kitchen door and then the aide pushed them back. They could not recall being slapped on the face by staff. They were afraid of the certified nurse aide and were relieved that they no longer worked at the facility. They could not recall speaking with a social worker or psychologist about the incident. During a phone interview on 1/8/2025 at 4:30 PM, the Administrator stated they were notified of the 12/28/2024 incident just before lunchtime on 12/31/2024. The Corporate Administrator was also in their office at the time. Dietary Aide #4 told them they saw Certified Nurse Aide #8 slap Resident #1 on the face 12/28/2024. The Administrator asked Dietary Aide #4 if there were any other staff witnesses and the dietary aide provided staff names. Certified Nurse Aide #8 denied slapping Resident #1 and they suspended Certified Nurse Aide #8. When they interviewed [NAME] #5 (via phone interview) the cook stated they saw Certified Nurse Aide #8 and Resident #1 pushing back and forth. [NAME] #5's story changed after the initial interview between seeing the pushing versus not seeing the pushing between Certified Nurse Aide #8 and Resident #1. [NAME] #5 and Certified Nurse Aide #8 were friends outside of work. They concluded abuse occurred based on statements made by Dietary Aide #4 and [NAME] #5. Dietary Aide #4 was a good employee and had no reason to make the incident up. The Director of Nursing assessed Resident #1 on 12/31/2024 and the resident had no injuries and denied being slapped. The surveillance cameras in the dining rooms did not always work and they attempted to view footage from the 12/28/2024, but there was none. During an interview on 1/8/2025 at 5:05 PM, Director of Nursing stated that on 12/31/2024, Dietary Aide #4 reported they observed staff slap a resident on Unit 4 on 12/28/2024, but did not know their name. Dietary Aide #4 identified Certified Nurse Aide #8 as the staff in question upon going to the unit with the Director of Nursing. Certified Nurse Aide #8 was immediately removed from the unit and interviewed. Certified Nurse Aide #8 denied the allegation and stated there had been a disagreement with Resident #1 in the kitchen: the resident pushed them, but they did not push back. [NAME] #5 reported Certified Nurse Aide #8 and Resident #1 were pushing each other. [NAME] #5 was asked why they did not report the incident and they stated they did not think Certified Nurse Aide #8 was hurting Resident #1, just directing them to sit down. [NAME] #5's written statement the next day changed, stating they did not see any physical contact between Certified Nurse Aide #8 and Resident #1, and that they were confused when asked about the discrepancy. They had heard Dietary Aide #4 had told their supervisor, [NAME] Supervisor #7, about the 12/28/2024 incident on that day, and [NAME] Supervisor #7 should have notified the nursing supervisor. During a phone interview on 1/13/2025 at 10:05 AM, Medical Director stated they were notified of the 12/28/2024 incident involving Resident #1 on 12/31/2024 when the Administration became aware. They heard the story had changed between some of the staff who were interviewed. It was reported to them Resident #1 was slapped by staff, and there was some pushing and shoving involved, and then the story changed where there was no physical contact. Resident #1 denied being slapped and never told any staff who interviewed them that it happened. This incident should have been reported promptly by the staff involved. 10 NYCRR 415.4(b)(1)(i) _______________________________________________________ Immediate Jeopardy was identified, and the Director of Nursing was notified on 1/8/2025 at 6:34 PM. Immediate Jeopardy was removed on 1/10/2025 at 4:02 PM prior to survey exit based on the following corrective actions taken: -Certified Nurse Aide #8 was terminated. -All staff that were aware of the abuse and failed to report it were terminated. -All staff working on 1/8/2025 were educated on abuse and reporting abuse, and education occurred shift to shift until 100% of all staff working were educated by 1/9/2025. -Resident #1 was assessed by the medical provider and seen by the psychiatric nurse practitioner. -All residents on the affected unit were evaluated to determine if they were victims of abuse or witness to any abuse. -As of 1/10/2025 88% of all staff received education on abuse, types of abuse, requirements for reporting abuse, the timeframe in which to report abuse, and the ramifications of not reporting abuse timely. Any staff who were not present during the training will be educated on their first day back to work prior to beginning their shift. - Verification interviews were completed with multiple staff from multiple departments to ensure understanding of the abuse education.

Based on record review and interviews during an abbreviated survey (NY00367007), the facility failed to ensure an incident of staff abuse toward a resident was reported to the State Agency and to law enforcement for 1 of 3 residents (Resident #1). Specifically, Dietary Aide #4 witnessed Certified Nurse Aide #8 abuse Resident #1 and did not report the incident to Administration for three days. Multiple staff were identified who were made aware of the abuse allegations and did not report to Administration. Upon receipt of the reported incident, the facility did not report the allegation of abuse to the State Agency or law enforcement as required. Additionally, Certified Nurse Aide #8 continued to have access to residents following the witnessed abuse. The facility's failure to report abuse by staff to Administration, the State Agency, and law enforcement resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 104 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death. Findings include: The facility policy, Seven Components of a Systemic Approach to Abuse Prohibition, revised 10/24/2022, documented all cases, wherein there was a suspicion that a crime had been committed, facility staff must call local law enforcement immediately, but no later than two hours, if the violation involved abuse or resulted in serious bodily injury. Resident #1 had diagnoses including dementia, unspecified psychosis, and anxiety disorder. The 9/20/2024 Minimum Data Set assessment documented the resident had intact cognition, did not exhibit behaviors, did not wander, and was independent with transfers and ambulation. The facility incident investigation for an incident occurring on 12/28/2024 and reported to Administration on 12/31/2024, documented: - On 12/31/2024, at approximately 12:00 PM, Dietary Aide #4 reported to the Director of Nursing, they observed Certified Nurse Aide #8 strike Resident #1 with an open hand on their face on 12/28/2024 between 11:30 AM and 12:00 PM. - Dietary aide #4 reported Resident #1 knocked on the Unit 4 door leading from the dining room to the kitchen, asked them for ice and ginger ale, and handed the dietary aide their cup. - Certified Nurse Aide #8 approached Resident #1 and stated to them, why are you here? and to go sit down. - Resident #1 re-stated to Certified Nurse Aide #8 they wanted ice and ginger ale, Certified Nurse Aide #8 stated to them, No and struck Resident #1 one time on their cheek with an open hand. - Resident #1 struck Certified Nurse Aide #8 back, and then sat down. - The Director of Nursing and Administrator were notified of the incident on 12/31/2024. The Director of Nursing assessed Resident #1 immediately once the report was made and there were no injuries or signs of psychological distress. Certified Nurse Aide #8 continued to work 12/28/2024 and 12/31/2024. Certified Nurse Aide #8 was suspended on 12/31/2024 once Administration was notified of the alleged abuse that had occurred on 12/28/2024, and subsequently was terminated on 1/3/2025. There was no documented evidence Certified Nurse Aide #8 was immediately removed from resident contact on 12/28/2024. There was no documented evidence law enforcement was notified of the alleged abuse. During a phone interview on 1/8/2025 at 4:30 PM the Administrator stated once they were notified on 12/31/2024 of the alleged abuse that occurred towards Resident #1 on 12/28/2024, they immediately began a facility investigation and did not think to call local law enforcement. The administrator was notified of the alleged abuse on 12/31/2024. The facility did not report the allegation to the State Agency until January 2, 2024, which is not in keeping with the required timeframe for reporting. During an interview on 1/8/2025 at 5:05 PM, the Director of Nursing stated it did not occur to them to notify law enforcement on 12/31/2024 after they were made aware of the allegation Certified Nurse Aide #8 abused Resident #1. They stated they realized at a later time that law enforcement should have been contacted immediately. During a phone interview on 1/13/2025 at 10:05 AM the Medical Director stated they were notified of the alleged abuse towards Resident #1 by the Director of Nursing on 12/31/2024. They heard the story changed a few times by staff witnesses. They were not aware the police were supposed to be called for all alleged abuse incidents. 10 NYCRR 415.4 ____________________________________________________________________ Immediate Jeopardy was identified, and the Director of Nursing was notified on 1/8/2025 at 6:34 PM. Immediate Jeopardy was removed on 1/10/2025 at 4:02 PM prior to survey exit based on the following corrective actions taken: -Local law enforcement was notified of the alleged abuse toward Resident #1 on 1/8/2025. -Resident #1 was assessed by the medical provider and assessed by the psychiatric nurse practitioner. -All residents on the affected unit were evaluated to determine if they were victims of abuse or witness to any abuse. No other residents identified. -The Administrator and Director of Nursing were educated by the Corporate Administrator on the need to report all allegations of staff abuse towards a resident to local law enforcement. Education included the process for reporting, whom to report, the timeframe in which to report, and the professional and criminal ramifications of not reporting. - On 1/10/2025 the Administrator and Director of Nursing reported they had received the education. -Certified Nurse Aide #8 was terminated. -All staff that were aware of the abuse and failed to report it were terminated. -All staff working on 1/8/2025 were educated on abuse and reporting abuse, and education occurred shift to shift until 100% of all staff working were educated by 1/9/2025. -As of 1/10/2025 88% of all staff received education on abuse, types of abuse, requirements for reporting abuse, the timeframe in which to report abuse, and the ramifications of not reporting abuse timely. Any staff who were not present during the training will be educated on their first day back to work prior to beginning their shift. - Verification interviews were completed with multiple staff from multiple departments to ensure understanding of the abuse education.

Based on record review and interviews during the abbreviated survey (NY00330966), the facility failed to ensure that residents were free from sexual abuse and failed to protect residents from further abuse for 1 of 7 residents (Residents #4) reviewed. Specifically, Resident #5 had intact cognitive function, a history of sexually inappropriate behaviors, and continued to exhibit sexually inappropriate behaviors, including making verbal sexual requests to residents. There were no documented interventions to address the resident's ongoing behaviors or to protect other residents from abuse. Resident #4, a cognitively impaired resident, was found in Resident #5's room engaging in a sexual act. Resident #4 was not assessed timely, notifications to their representative, medical provider, and the police were not made timely, and interventions to protect Resident #4 and other vulnerable residents were not implemented timely. The facility's failure to protect residents from sexual abuse resulted in harm that is Immediate Jeopardy and Substantial Quality of Care for Resident #4 which had the likelihood to affect 114 residents in the facility. Findings include: The facility policy, The Seven Components of a Systematic Approach to Abuse Prohibition, effective 8/2020, documented: - Verbal abuse was defined as the use of oral, written, or gestured language in a derogatory and disparaging manner. - Sexual abuse included, but was not limited to, the use of sexual coercion, sexual harassment, or sexual assault. - Prevention of Abuse included: identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. This included an analysis of the assessment, care planning, and monitoring of residents with needs and behaviors, which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, entering other residents' rooms, self-injurious behaviors, communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Resident #4 had diagnoses including dementia and anxiety disorder. The 12/1/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, exhibited behaviors of wandering, and was independent for transfers and walking. Resident #5: Resident #5 had diagnoses including cerebral infarction (stroke), dementia, and impulse disorder. The 10/11/2023 Minimum Data Set assessment documented the resident had intact cognition, exhibited verbal behaviors toward others which impacted others by significant intrusion of privacy or activity and significant disruption of care or the living environment, was independent with propelling their wheelchair, and required supervision for transfers. The residents Medical Orders for Life Sustaining Treatment documented the resident made their own decision related to resuscitation and preferred medical interventions. Resident #5 signed as the decision-maker on 12/22/2022. Resident #5's admission records included medical and psychiatric provider notes from the long-term care facility from where they were transferred. On 8/21/2023 and 9/11/2023, Nurse Practitioner # 25 (also a provider for the current facility) documented the resident made very explicit inappropriate comments to residents and staff. The resident was redirected and stated they could not help themselves. The 8/30/2023 progress note from Resident #5's prior facility, completed by Psychiatric Nurse Practitioner #24 (also a provider at the current facility) documented the resident had a history of sexually inappropriate behaviors, a history of touching other residents in a sexual manner and remained verbally inappropriate. Staff were advised to ignore the resident's comments and keep the resident away from female residents. The resident appeared to have impulse control disorder and was noted to make very explicit vulgar sexual comments to female staff. The resident was prescribed Depakote (seizure medication sometimes used for psychiatric disorders) and failed a trial of Tagamet (antacid sometimes used to treat hypersexuality) for sexually inappropriate behaviors. The 10/6/2023 at 2:50 PM facility Admission Evaluation completed by Registered Nurse Supervisor #13 documented the resident was alert and oriented to person, place, and time, was able to understand and be understood. The 10/7/2023 Social Worker #23 progress note documented a Brief Interview for Mental Status was completed. The resident's score was 14 (range 0-15, a score of 13-15 indicates intact cognitive function). The 10/9/2023 at 8:04 PM Licensed Practical Nurse #11 progress note documented the resident was very inappropriate to another (unidentified) resident, asking them for sexual favors. The 10/9/2023 at 3:03 PM Social Worker #23 progress note documented they met with the resident after multiple reports of inappropriate comments to staff. On 10/9/2023 Nurse Practitioner #25 (who was also the resident's provider at their prior facility) documented in a progress note the resident was transferred from another facility. Staff reported the resident had been sexually inappropriate with female staff since their admission. The resident continued to do so despite being asked not to. This was an ongoing issue while at the previous facility. The 10/10/2023 at 9:51 AM Director of Social Services progress note documented they reviewed reports from the previous facility and determined Resident #5 did not do well with roommates and did not get along with peers. The Director of Social Services offered the resident a private room on the fourth floor (unit designated for residents with dementia). The resident agreed and was moved to the fourth floor. The Comprehensive Care Plan initiated 10/11/2023 documented the resident made sexual comments toward staff and others, related to dementia, ineffective coping skills, mental/emotional illness, and poor impulse control. Interventions included: administer medications as ordered; analyze key times places, circumstances, triggers, what de-escalates behavior and document; assess and anticipate needs, food, thirst, toileting needs, comfort level, body positioning, pain; positive feedback for good behavior; psychiatric/psychology consult as needed; and redirect when inappropriate. On 10/28/2023, Psychiatric Nurse Practitioner #24 documented Resident #5 attempted to touch female residents inappropriately and was noted to make frequent very explicit vulgar sexual comments to female staff. On 11/1/2023 at 12:08 PM, Licensed Practical Nurse #10 documented the resident made sexual comments to two (unidentified) female residents stating, come sit on my mustache. When addressed, the resident stated one of the residents showed them their breasts. There was no documented evidence of an investigation of the 11/1/2023 incident or of the identification of the two residents involved. The 11/2/2023 at 2:12 PM Director of Social Services progress note documented they spoke to the resident about recent reports of speaking inappropriately in a sexual manner. Today, a resident (later identified as Resident #4 in an interview) was reportedly wandering into Resident #5's room and Resident #5 requested Resident #4 disrobe. Staff intervened, and Resident #5 said they could not help themselves. The Director of Social Services suggested they learn to change this behavior as this would lead to someone pressing charges and the resident certainly would not want to deal with that at this age. Resident #5 agreed and assured the Director of Social Services they would change. The Director of Social Services suggested if the resident could not change, the next step would be issuing a discharge notice. There was no documented evidence of steps taken to protect Resident #4 following the report of Resident #5 asking them to undress in their room. There were no documented interventions for Resident #5 to address Resident #4 or any other residents who may wander into Resident #5's private room. The 11/10/2023 at 1:37 PM Licensed Practical Nurse Manager #3 documented Resident #5 was moved to the south end of the Fourth Floor, the male end of the unit. The 11/13/2023 at 8:19 PM Social Worker #23 progress note documented the resident continued to make vulgar comments to staff and to other residents. The social worker told the resident if they continued to make others feel uncomfortable in the dining room, the resident would be asked to eat in their room. When speaking to the resident about their behavior, they often brushed it off. The 11/14/2023 Nurse Practitioner #20 progress note documented the resident had ongoing sexual inappropriate behaviors at the current and former facility. They were managed with Depakote for impulse control disorder. Nursing staff did not think the Depakote was effective and the resident frequently made sexually inappropriate comments to staff and residents. The resident had been found asking female residents with dementia for sexual favors. The plan was to start Tagamet, monitor behaviors closely, and continue follow-up with psychiatry. The 11/15/2023 Psychologist #26 evaluation documented Resident #5 was referred for making sexually inappropriate comments to staff and residents. Staff were particularly concerned that Resident #5 was inviting female residents with dementia to go to their room, apparently for sexual favors. The resident admitted to making comments, found it funny, and reported they had no interest in changing their behavior. The resident was at moderate risk of sexual offense with concern about them sexually abusing non-consenting demented females. Recommendations included close supervision, refrain from overreaction, as any reaction could reinforce their behavior, keep them busy, encourage them to work on model cars. There was no documented evidence of steps taken to address Psychologist #26's recommendations and no documented evidence the evaluation was reviewed by the Director of Social Services, nursing staff, or the medical provider. There were no documented care plan updates or interventions. The 12/2023 Documentation Survey Report documented the resident exhibited sexually inappropriate behaviors on 12/7, 12/16, 12/17, 12/23, 12/26, and 12/29/2023. The 12/17/2023 at 10:22 PM Licensed Practical Nurse #16 progress note documented the resident asked another (unidentified) resident to go to their room and sleep with them. The 12/20/2023 at 8:17 PM, Social Worker #23 documented they met with Resident #5 again over their inappropriate language. The resident often agreed they would no longer make these comments but continued with this behavior. The social worker reminded the resident they could be in a lot of trouble if they continued with this behavior. The 12/30/2023 at 5:30 PM Licensed Practical Nurse #16 progress note documented staff reported a resident was observed in Resident #5's room, acts being performed by the other resident, and they were taken out of the room immediately. The supervisor was made aware. The untimed 12/30/2023 Resident Accident/Incident Report documented Resident #5 was observed with another resident (Resident #4) in their bed. Certified Nurse Aide #15 was assigned to Resident #5 and Resident Assistant #14 and reported the occurrence. There was no documented statement from Resident #5 and their mental status was noted as oriented, with behaviors present noted as perversion (sexual behaviors that are considered abnormal, repulsive, or obsessive). Registered Nurse Supervisor #12 was notified on 12/30/2023 at 4:59 PM. The report included recommendations for preventative measures, and documented actions taken were a comprehensive psychiatric evaluation, placement in a psychiatric facility, and one-to-one staff monitoring. The care plan and the certified nurse aide accountability were updated, a psychiatric referral was made, and abuse and neglect were not suspected. This section of the report was signed by Registered Nurse Supervisor #12, dated 12/30/2023. The medical provider was notified on 12/31/2023 at 7:50 AM, and Resident #4's relative was notified on 12/31/2023 at 7:15 AM. The form was signed by Registered Nurse Supervisor #12 and dated 12/31/2023 at 7:15 AM. There was no documented evidence Resident #4 was assessed immediately following the incident. There was no documented evidence Resident #4's family and medical provider were notified on 12/30/2023, or that the police were notified on 12/30/2023. There was no documented evidence that Resident #5 was placed on one-to-one supervision or moved to another unit on 12/30/2023. There was no documented evidence of steps taken to protect Resident #4 and other residents on 12/30/2023. Resident Assistant #14's written statement, dated 12/31/2023, documented they found Resident #4 on Resident #5's bed and Resident #4 had their hand on Resident #5's penis. Resident Assistant #14 asked Resident #4 to go with them and had to get another staff member as Resident #5 had their hand on Resident #4's hand and said [Resident #4] does it so good. Certified Nurse Aide #15's written statement, dated 12/31/2023, documented on 12/30/2023 at 10:45 AM, they were notified by Resident Assistant #14 that Resident #4 was in Resident #5's room. Certified Nurse Aide #15 went to Resident #5's room and observed Resident #4 playing with [Resident #5's] private parts. Certified Nurse Aide #15 took Resident #4 out of the room and reported to the nurse. The 12/31/2023 at 7:18 AM Registered Nurse Supervisor #12 progress note documented Resident #4's representative was notified of the incident. The 12/31/2023 at 7:52 AM Registered Nurse Supervisor #12 progress note documented Nurse Practitioner #27 was notified of the new incident involving Resident #5. The Nurse Practitioner was informed that administration was currently deliberating a plan of action, and the resident was on one-to-one supervision. The undated/unsigned Investigative Summary documented on 12/30/2023 at approximately 10:45 AM, Certified Nurse Aide #15 entered Resident #5's room and witnessed Resident #5 on their bed with their pants pulled down, penis exposed, and Resident #4 sitting on the side of the bed with their hand on Resident #5's penis. Certified Nurse Aide #15 immediately escorted Resident #4 from the room, and Resident #5 stated Resident #4 was doing a good job. Resident #5 had a history of sexual comments directed at staff. All recommendations by psychiatric providers were carried out. Resident #4 had advanced dementia and often ambulated the halls of the unit. The residents were separated and assessed with no signs of distress or injuries. Resident #5 was placed on one-to-one monitoring. The police were notified, and a police report was filed. During an interview with Licensed Practical Nurse #10 on 9/11/2024 at 1:00 PM, they stated Resident #5 asked staff and residents for sexual favors almost daily while on the Fourth Floor. The resident appeared to be aware of their inappropriate behaviors, such as looking around for staff when they made inappropriate comments to other residents. The nurse was unaware of the reason Resident #5 was on the unit, which was primarily for residents with dementia. It was common for multiple residents to walk the unit, often going in and out of other resident rooms, including Resident #4. Resident #4 did not seek out attention in an inappropriate manner and did not exhibit sexually inappropriate behaviors. Licensed Practical Nurse #10 observed Resident #4 wandering into Resident #5's room prior to 12/30/2023. Licensed Practical Nurse #10 could not recall the 2 female residents noted in their 11/1/2023 progress note. They recalled the incident and thought they reported it to a supervisor. One of the female residents was moved to the Third Floor to keep them away from Resident #5. The nurse was unaware of any interventions to address Resident #5's behaviors or to address Resident #4 wandering into rooms. It was expected residents who wandered were monitored, but there was nothing specific such as making sure they did not go into Resident #5's room. During an interview on 9/16/2024 at 3:31 PM the Director of Social Services stated when Resident #5 was admitted , they had intact cognitive function and made their own healthcare decisions. The decision to move Resident #5 to the Fourth Floor was based on their potential to have an altercation with a roommate and they were provided with a private room. They were aware of Resident's #5's history, and knew they had to be worried about females on the unit. They determined the resident's behavior toward females could be better managed than a potential physical altercation with roommates. Resident #5 received constant counseling and reminders about their inappropriate behaviors, and they thought the resident understood. The verbal intervention was not effective as the resident continued to exhibit a pattern of sexually inappropriate behaviors. There were no other interventions in place to protect other residents or address Resident #5's behaviors. The Director of Social Services stated their 11/2/2023 progress note about Resident #5 asking a female resident to undress was referring to Resident #4. Resident #4 was known to wander at times. They were unaware of any interventions put in place to protect Resident #4 after the 11/2/2023 incident, aside from redirection. The Director of Social Services was responsible for behavioral care planning and coordination of behavioral health services. The Director of Social Services reviewed Resident #5's 11/15/2023 evaluation completed by Psychologist #26. They did not recall if there were any recommendations and did not recall discussing Resident #5 with the psychologist. When asked if steps should have been taken to address Psychologist #26's note that Resident #5 was at risk of sexually offending on demented, non-consenting females, the Director of Social Services stated they were unaware of how to respond. They were unaware of the reason Resident #5 remained on the Fourth Floor despite the risk to female residents with dementia. During an interview on 9/16/2024 at 4:51 PM, the Administrator stated the residents on the Fourth Floor primarily had dementia. Generally, a resident with intact cognitive function would not be placed on the Fourth Floor. Resident #5 was at risk being on the Fourth Floor due to their history of sexually inappropriate behaviors and intact cognition. The residents on the Fourth Floor were at risk of being abused due to cognitive decline and being more vulnerable. Resident #5 should have been moved from the Fourth Floor following incidents when they were inappropriate or attempted to be sexually inappropriate with female residents. Additionally, following the 11/15/2023 Psychologist #26 evaluation, the resident was not appropriate to remain on the Fourth Floor. The Administrator stated staff should have acted sooner to prevent sexual abuse. During a telephone interview on 9/17/2024 at 12:09 PM, Registered Nurse Supervisor #12 stated on 12/30/2023, they were notified of the incident at the time as noted on the incident report and assessed Resident #4 then. They did not recall the incident occurring at 10:45 AM, as they responded at 4:59 PM. The Registered Nurse Supervisor was unaware of the reason the notifications and interventions were all documented on 12/31/2023 and stated they addressed everything on 12/30/2023. During a telephone interview on 9/19/2024 at 9:57 AM, Licensed Practical Nurse #16 stated on 12/30/2023, they were alerted by Resident Assistant #14 that Resident #4 was in Resident #5's room engaging in a sexual act. Certified Nurse Aide #15 walked Resident #4 out of the room and the nurse called Registered Nurse Supervisor #12. The supervisor arrived and spoke to Resident #5 and assessed Resident #4. The nurse could not recall the time the supervisor arrived. They could not recall if the police were notified, if Resident #5 was moved to another floor, or if one-to-one supervision was implemented on 12/30/2023 or 12/31/2023. Resident #4 often walked about the unit halls and went in and out of other resident rooms. Resident #5 appeared to have intact cognitive function and Licensed Practical Nurse #16 was unaware of the reason they were moved to a unit with residents with dementia. Resident #5 required ongoing redirection for their inappropriate comments to residents. The nurse was unaware of any other interventions in place to address residents who wandered into other rooms or to monitor Resident #5 when near female residents. During an interview on 9/20/2024 at 12:27 PM, Licensed Practical Nurse Manager #3 stated they covered the Fourth Floor from 10/2023 through 12/2023. They were aware of Resident #5's sexually inappropriate behaviors when the resident was moved to the Fourth Floor. Resident #5 frequently asked female residents for sexual favors and asked them to go into Resident #5's room. Licensed Practical Nurse Manager #3 was aware of Psychologist #26's evaluation on 11/15/2023 as they read it in the resident's record. The psychologist did not speak to nursing staff related to their evaluations and there was no process for evaluations to be communicated to medical or social services staff. The Nurse Manager attempted to address the concerns noted in the evaluation with the Director of Social Services who stated Resident #5 was not going to change. The Nurse Manager was concerned that Resident #5 was at risk to abuse females with dementia on the Fourth Floor and discussed their concerns with the Director of Social Services multiple times. The Nurse Manager also addressed their concerns at morning meetings when multiple department managers were in attendance. The resident remained on the Fourth Floor despite the Nurse Manager's concerns. There were no specific steps taken to protect the residents on the Fourth Floor, as the social services staff responded by going and speaking to Resident #5. During an interview with Certified Nurse Aide #15 on 9/20/2024 at 4:13 PM, they stated Resident #5 exhibited sexually inappropriate behaviors since they were moved to the Fourth Floor in 10/2023. Resident #5 asked female residents for sexual favors, attempted to, or did touch them, and asked female residents with dementia to go in their room. They constantly redirected Resident #5 and reported their concerns multiple times. The resident remained on the unit and the aide was unaware of any interventions in place, aside from monitoring and redirection. On 12/30/2023, Resident Assistant #14 approached Certified Nurse Aide #15 at the nurse's desk and stated Resident #4 was in Resident #5's room. Certified Nurse Aide #15 went to Resident #5's room, which was toward the far end of the hall. The nurse aide observed Resident #4 sitting on the edge of the bed, Resident #5 was lying on the bed with their pants down and Resident #4 was touching Resident #5's penis. The aide immediately brought Resident #4 out of the room and reported to Licensed Practical Nurse #16. Certified Nurse Aide #15 was certain this occurred prior to lunch, as they noted the time in their statement of 10:45 AM. They did not work past 2:00 PM, and it could not have occurred later in the afternoon. The aide did not recall seeing a supervisor come to the unit following the incident. The following day, on 12/31/2023, Resident #5 remained on the unit and there was no one-to-one supervision for Resident #5. 10NYCRR 415.4(b)(1)(i) _____________________________________________________________________________________ Immediate Jeopardy was identified, and the Administrator was notified on 9/16/2024 at 7:08 PM. Immediate Jeopardy was removed on 9/20/2024 at 5:17 PM prior to survey exit based on the following corrective actions taken: 1. A comprehensive review of the past 90 days of all current residents' records (progress notes, incidents) was completed on 9/20/2024, by the Corporate RN. The review included direct care staff interviews by the Corporate RN to identify any potential unidentified behavioral concerns. 2. A review of all behavioral consults the past 30 days was completed by 9/20/2024 to ensure any recommendations were for addressed. 3. A Regional Administrator/Licensed Master Social Worker and telehealth psychology services were identified for availability for consultation as needed. 4. As of 9/20/2024, 100% of all staff currently working have been educated on abuse, sexual abuse prevention, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse. 5. As of 9/20/2024, 86% of the total staff population have received education, with education planned to continue until 100% is reached. 6. As of 9/20/2024, 100 % of all supervisors were educated on response to abuse allegations, including documentation and protection of residents. 7. The remaining staff will be educated prior to the start of their next shift or upon return from their leave. 8. Staff education sign in sheets were reviewed and compared to the current staff list and no discrepancies were identified. 9. Staff education was verified during an onsite visit 9/20/2024. Multiple staff including nursing, therapy, dietary, housekeeping, and activities were interviewed. 10. Staff were able to report content of education and confirmed the day they received the education and the facility staff who presented the education (Corporate Registered Nurse, Educator/Assistant Director of Nursing, and the Director of Social Services.)

Based on record review and interview during the abbreviated survey (NY00340854, NY00335730, NY00340963, NY00330996, and NY00344094), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 6 of 12 residents reviewed (Residents #1, #2, #3, #4, #5, and #6). -Resident #3, had episodes of vaginal/rectal bleeding, was not assessed by a qualified professional, and the medical provider was not notified timely of the bleeding (8 hours and 15 minutes following onset of bleeding). The provider ordered STAT (immediate) labs, the blood specimen could not be obtained from the resident, and the provider was not notified timely. - Resident #2 had an intact left heel blister and a treatment was ordered. There was no documentation the resident's wound was monitored or assessed after the treatment was ordered, and the care plan was not updated to include interventions. - Resident #1's ordered Lidocaine Pain Patch was not obtained or administered timely. - Resident #4, a cognitively impaired resident, was found in Resident #5's room engaging in a sexual act and Residents #4 and #5 were not assessed timely by a qualified professional. - Resident #5 was pulled from their wheelchair to the floor by Resident #6 and was not assessed timely by a qualified professional. The facility's failure to complete timely assessments, notify the provider, and respond timely to Resident #3's change in condition placed 113 residents in the facility at risk. This resulted in actual harm that was Immediate Jeopardy and Substantial Quality of Care to resident health and safety. Findings include: The facility policy, STAT Orders, dated 6/2022, documented a STAT order was a medical order that needed to be executed immediately due to the urgency of the resident's medical condition. The provider determined the resident's condition required immediate medical intervention, and the provider clearly designated the order was STAT when issued either verbally or in writing. The nurse performed the ordered action as quickly as possible, and documented the exact time the intervention was performed. Any issues related to STAT order execution, such as delays, must be reported to the Director of Nursing for review and potential process improvements. The facility policy, Laboratory, Radiology and Other Diagnostic Services, revised 11/2020 documented if a STAT blood draw was required, the nursing supervisor could draw the lab, call the currier for pick up, or call the lab technician to draw STAT. The medical provider would be notified if a lab test could not be obtained in a timely manner. The medical provider would send resident to the hospital or emergency room as needed for follow up. The facility policy, Change in Resident Condition, dated 3/7/2022 documented the Nurse Manager/Nursing Supervisor/designee would notify the resident's medical provider or medical provider on-call when there was significant change in the resident's physical/emotional/mental condition, or any situation which required a change in the resident's plan of care, medication, or treatment regimen; including the following: need for restraints, exacerbation of known condition, onset of new condition, abnormal labs, behavior, intake and output, appetite, weight loss, appointments, elopement and skin breakdown. A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. 1) Resident #3 had diagnoses including cerebral infarction (stroke), anemia in chronic kidney disease, and atrial fibrillation (irregular heart rhythm). The 11/28/2023 Admission Minimum Data Set assessment documented the resident has moderately impaired cognition, required substantial/maximal assistance with activities of daily living, and did not take anticoagulants (blood thinner). The 12/19/2023 physician order documented clopidogrel bisulfate (anticoagulant medication-blood thinner) 75 milligrams one time daily for stroke and aspirin (blood thinner) 81 milligrams daily for stroke. The 12/20/2023 Medication Administration Record documented clopidogrel bisulfate and aspirin were administered at 8:00 AM and scheduled again in 24 hours (12/21/24 at 8:00 AM). A 12/20/2023 at 9:55 PM Licensed Practical Nurse #17 progress note documented Resident #3 was noted with loose bloody stools and the supervisor (unidentified) was notified. There was no documented evidence the resident was assessed by a qualified professional until the following morning, over 11 hours after onset of bleeding, and no evidence the provider was notified until over 8 hours after the onset of bleeding. There was no evidence of a plan for continued monitoring of bleeding or when staff should notify the provider. The resident was prescribed anticoagulant medications and there was no evidence the medication was reviewed by the provider to determine if it should be held. The 12/20/2023 Perfect Serve Interaction Detail Report (on-call provider call log) documented no calls were received regarding the resident. During a telephone interview on 9/16/2024 at 10:13 AM, Licensed Practical Nurse #17 stated they could not recall what supervisor they notified on 12/20/2023 or if the supervisor assessed the resident. They were not sure if a provider was notified. The 12/20/2023 nursing schedule documented Registered Nurse Supervisor #12 was the evening shift Supervisor. During an interview on 9/16/2024 at 10:21 AM, Registered Nurse Supervisor #12 stated if they were notified about the resident's bleeding on the 12/20/2023 evening shift, they would have assessed the resident, called the provider, and documented a progress note. They stated they first heard about the resident's bleeding episode the next day. A 12/21/2023 at 5:41 AM, Licensed Practical Nurse #18 progress note documented the resident continued to bleed copious amounts of blood from the vaginal area. Licensed Practical Nurse Supervisor #19 was notified and saw the resident. The 12/21/2023 at 5:49 AM Licensed Practical Nurse Supervisor #19 documented the resident continued with one episode of loose bloody stools. The 12/21/2023 at 6:10 AM Licensed Practical Nurse Supervisor #19 progress note documented Nurse Practitioner #21 was called, and they were awaiting a return call. The 12/21/2023 at 6:27 AM provider order entered by Licensed Practical Nurse Supervisor #19 documented to hold clopidogrel and aspirin, and STAT Complete Blood Count (blood test) and Basic Metabolic Panel (blood test). The 12/21/2023 untimed Nurse Practitioner #20 note documented the resident was seen that morning for blood in their brief and bleeding that started last night. The on-call provider was notified overnight (6:24 AM) and ordered to hold clopidogrel and aspirin and obtain STAT blood work. Staff were not able to draw labs this morning due to difficulty and staff stated the resident's fingers were blue. Staff showed them a saturated brief filled with blood and reported the resident had been passing large clots. Assessment: quite pale, fingers cool and capillary refill delay (indicative of poor blood flow). The plan was to send the resident to the hospital. There was no documented evidence a provider was notified timely that STAT labs could not be obtained. The 12/29/2023 hospital discharge summary documented the resident was admitted on [DATE] with gastrointestinal bleeding with acute blood loss anemia and received 3 Units of packed red blood cells (blood transfusion). During a telephone interview on 9/16/2024 at 12:57 PM, Nurse Practitioner #20 stated when the resident had their first episode of bleeding on 12/20/2023, they expected the resident to be assessed, the assessment documented, and a provider notified. If they had been notified, they would have held the resident's clopidegrel and aspirin, ordered vital signs, and ordered STAT labs. They would have also considered sending the resident to the hospital. They assessed the resident on 12/21/2023 around 9:30 AM and was shown the resident's blood and urine filled brief. STAT labs were to be drawn immediately, and they expected to be notified if the labs could not be obtained. A provider was not notified timely. During a telephone interview on 9/17/2024 at 2:16 PM, former Registered Nurse Manager #13 stated STAT labs should be obtained within an hour and if staff were not able to obtain the lab, they should notify a provider. They were not aware a provider was not called when the resident's STAT lab could not be obtained, and the provider should have been notified. During a telephone interview on 9/25/2024 at 11:33 AM, the Medical Director stated if a resident was found with rectal bleeding, they expected the resident to be assessed. If that resident was on anticoagulants and was stable during the middle of the night, staff did not need to notify a provider until the morning. However, if a resident's brief was full of blood and vital signs were abnormal, they expected to be notified. They believed the facility contracted with a local lab and the turnaround times for STAT labs was defined by the lab. When it took over 8 hours for a provider to be notified of the resident's bleeding, they stated there was a breakdown in communication between nursing staff and it was the supervisor's responsibility to assess the resident when notified. If the Registered Nurse Supervisor did not assess the resident, they expected the licensed practical nurse to reach out to the next person in the chain of command. They reviewed the resident's record recently and did not see any signs the resident was unstable on 12/20/2023 and 12/21/2023 and the resident's vital signs and oxygen levels were stable. Procedurally, they thought there was an issue however from a clinical standpoint, they did not find any concerns with the resident during chart review. 2) The facility policy, Pressure Injury Prevention and Management/Wound Rounds, revised 12/2023, documented when a resident had an actual pressure injury identified, the nurse in conjunction with the Comprehensive Care Plan Team would review and revise the preventative care plan interventions, implement a care plan for the care of the actual pressure ulcer, and conduct periodic evaluation of the care plan interventions with additional revisions, as appropriate. The nurse was responsible for initiating a Skin Tracking Assessment Sheet. The Registered Nurse Manager/designee was responsible for monitoring and assessing healing/deterioration, minimally on a weekly basis, during Pressure Injury/Wound Rounds. Resident #2 had diagnoses including dementia and heart failure. The 2/21/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required partial/moderate assistance with rolling right/left, was dependent with transfers, was at risk for pressure ulcers, and had no unhealed pressure ulcers. The 2/22/2024 Comprehensive Care Plan documented the resident had potential for skin impairment and was incontinent. Interventions included turning and positioning every 2 hours, pressure relieving cushion in wheelchair and pressure relieving mattress, and check and change every 3 hours. The 3/4/2024 at 8:40 PM Registered Nurse Supervisor #12 progress note documented the resident had a left heel fluid filled blister found during care. Skin prep (protective skin barrier) was to be applied twice daily. The resident's foot was to be elevated and soft boots applied while at rest. The 3/4/2024 physician order documented to apply skin prep to left heel blister twice daily and leave open to air twice daily. There was no documented evidence the resident's Comprehensive Care Plan was updated to include the skin impairment, or to elevate the resident's foot and apply soft boots at rest. The 3/6/2024 Nurse Practitioner #20 progress note documented the resident's skin was visualized dry and intact and was fragile secondary to natural effects of aging. There was no documentation the resident had a left heel blister. Nursing progress notes dated 3/7/2024 to 3/18/2024 did not include assessments or monitoring of the resident's left heel blister. The March 2024 Treatment Administration Record documented the resident received skin prep twice daily to their left heel blister from 3/5/2024-3/18/2024. There were 3 opportunities the treatment was not documented as completed. A 3/19/2024 at 2:50 PM former Registered Nurse Supervisor #13 progress note documented the resident was discharged to home with ARC (a national organization that advocates for people with intellectual and developmental disabilities) caregivers. The resident was in stable condition and had no noted skin issues, During a telephone interview on 9/17/2024 at 12:15 PM, Registered Nurse Supervisor #12 stated when a resident was found with a potential pressure ulcer, the provider should be notified to get a treatment order. The Nurse Manager and the Director of Nursing, who oversaw wound care, should also be notified. The team would become aware of skin impairments during morning report as notes were reviewed there. A blister on a bony prominence could lead to a pressure ulcer. On 3/4/2024, they left a note for the Nurse Manager in their office, and they notified the Director of Nursing about the blister on Resident #2's heel. They were not aware the resident's wound had no further follow up and it should have. The care givers should have been made aware of the blister upon discharge so they could continue care. During a telephone interview on 9/26/2024 at 10:39 AM, the Director of Nursing stated when a resident was found with a skin impairment a registered nurse needed to assess and notify the provider for a treatment order. The Nurse Manager was responsible for notifying the wound provider who would assess the resident on wound rounds. They stated they did not recall if they were notified by Registered Nurse Supervisor #12 of the resident's skin impairment and did not recall if the resident's skin impairment was reviewed during morning report the day after the note was written, all progress notes were reviewed during morning report. They stated the resident's skin impairment was a pressure ulcer and should have been monitored weekly by the wound provider. The resident's care plan should have been updated to include interventions noted in Registered Nurse Supervisor #12's note. During a telephone interview on 9/26/2024 at 12:13 PM, former Registered Nurse Manager #13 stated wounds should be assessed and the provider notified to determine a treatment. An Incident Report was also needed when a new wound was found. They did not recall if Registered Nurse Supervisor #12 notified them of the resident's skin issue. The resident should have followed up with the wound care provider and they were not sure why they did not. 3) Resident #1 had diagnoses including dementia and osteoarthritis. The 7/4/2024 Minimum Data Set assessment documented the resident had intact cognition, was independent with most activities of daily living, received a scheduled pain regimen, had occasional pain, and pain occasionally made it hard to sleep at night. The 6/27/2023 physician order documented Lidocaine Pain Relief Patch 4%, apply to back topically one time a day for back pain and remove per schedule. The 7/27/2023 Comprehensive Care Plan documented the resident had potential for pain. Interventions included to administer analgesics as per orders. A 4/5/2024 Medical Director progress note documented the resident had arthritis and pain appeared controlled with the use of Tylenol, Lidocaine Patch, and Voltaren gel. The 5/2024 and 6/2024 Medication Administration Record documented Lidocaine Pain Relief External Patch 4%, apply to back topically one time a day at 8:00 AM and remove at 8:00 PM. The Lidocaine Pain Relief Patch 4% was documented as not available on: - 5/1, 5/4, 5/5, 5/6, 5/24 and 5/27/2024 by Licensed Practical Nurse #4; - 5/2, 5/9, 5/23, 5/26, 6/4-6/7, 6/11, 6/13, 6/14, 6/20, and 6/25/2024, by Licensed Practical Nurse #28; - 5/12/2024 by Registered Nurse Supervisor #12; - 5/13/2024 by Licensed Practical Nurse #29; - 5/14/2024 by Licensed Practical Nurse #9; and - 5/3 and 6/9/2024 by Licensed Practical Nurse #30. The resident was on a leave of absence with family from 5/15/2024 through 5/21/2024. There were no corresponding nursing notes documenting why the Lidocaine Pain Relief Patch was not available. During a telephone interview on 9/25/2024 at 10:32 AM, Licensed Practical Nurse #28 stated they let a Supervisor or Nurse Manager know if a medication or treatment was not available. They did not recall any issues with the Lidocaine Pain Patches not being available and stated the resident refused the patches most of the time and they should have documented it as a refusal and not as unavailable. During a telephone interview on 9/25/2024 at 12:40 PM, Licensed Practical Nurse Manager #3 stated if a medication was unavailable, the provider should be notified to determine if there was an alternative that could be used. Lidocaine Pain Patches were ordered in bulk by the facility through a distributer and not obtained through the pharmacy. When a resident refused a medication, the nurse would choose option 4 on the Medication Administration Record. This indicated refusal and prompted the nurse to document a note. Option 9 on the Medication Administration Record indicated not available, other, see progress notes, and prompted the nurse to document a progress note. Licensed Practical Nurse Manager #3 reviewed the Medication Administration Record during the telephone interview and stated Licensed Practical Nurse #4 mostly documented on the May 2024 and June 2024 Medication Administration Record the Lidocaine Patch was not available with no corresponding note. Licensed Practical Nurse #28 documented the Lidocaine Patch was on order and there were no corresponding notes. They stated they were only made aware on one occasion in May or June the Lidocaine Patch was not available. During a telephone interview on 9/25/2024 at 4:02 PM, Licensed Practical Nurse #4 stated when a medication or treatment was not available, they ordered it, let the Nurse Manager know or notified the pharmacy. They stated the resident's Lidocaine Pain Patch was frequently unavailable. They believed they let Licensed Practical Nurse Manager #3 know. During a telephone interview on 9/26/2024 at 10:39 AM, the Director of Nursing stated if a medication or treatment was not available the pharmacy should be notified. They were not aware the resident had multiple instances when their Lidocaine Patch was not available. During a telephone interview on 9/26/2024 at 12:13 PM, former Registered Nurse Manager #13 stated the facility utilized a warehouse to order multiple over the counter medications and treatments that were kept in Central Supply. There were issues with ordering those supplies because staff in charge changed hands over the course of several months and supplies ran out. Registered Nurse Manager #13 stated they were made aware that resident's Lidocaine Patch had run out. They checked with Central Supply when they were told, and Central Supply told them the supplies were on order. The physician should have been notified for an alternate treatment. They stated they told the Director of Nursing and the Assistant Director of Nursing on multiple occasions of the shortage. 10 NYCRR 415.12 ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified, and the Administrator was notified on 9/18/2024 at 4:28 PM. Immediate Jeopardy was removed on 9/20/2024 at 5:17 PM prior to survey exit based on the following corrective actions taken: - As of 9/20/2024, 83% of nursing staff (registered nurses, licensed practical nurses, and certified nurse aides) and therapy staff had been educated on recognizing a change in condition, actions for staff to take when a change in condition was identified, notification of the registered nurse, notification of the medical provider, monitoring and follow-up, and follow-up responsibilities. - The remaining staff would be educated prior to the start of their next shift. - Staff education sign in sheets were reviewed and compared to the current nursing/therapy staff list and no discrepancies were identified. - 100% of nursing staff and therapy staff currently working on 9/20/2024 received education. - Staff education was verified during an onsite visit on 9/20/2024, multiple nursing staff on multiple units along with therapy staff were interviewed. - Staff were able to report content of education. - 30 days of 24-hour reports were reviewed to identify other affected residents related to change in condition.

Based on observation, record review, and interview conducted during the abbreviated survey (NY 309), it was determined for 1 of 4 residents reviewed for abuse (Resident #2), the facility did not ensure residents had the right to be free from abuse, neglect, mistreatment, and involuntary seclusion. Specifically, Resident #2 was physically abused, mistreated, and confined to a corner for an extended period of time and the facility did not prevent the abuse nor did facility staff report the abuse to the Administrator. This resulted in actual harm that was not immediate jeopardy to Resident #2. Findings include: The facility's Abuse: Identification policy, dated 7/2018, documented an indicator of possible abuse included visual or auditory observations of an act or condition of abuse, mistreatment, or neglect. All indicators of abuse were to be reported immediately to a Supervisor. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's comprehensive care plan (CCP), initiated on 11/8/2018, documented he was cognitively impaired and had confusion. The facility's investigation initiated 11/28/2018 documented that during physical therapy, Resident #5 reported alleged abuse that was occurring on the night shift that involved staff members and Resident #2. The facility began an investigation at that time. On 11/29/2018 at 9:10 AM, the Administrator stated in an interview, when she became aware of the allegation by Resident #5, she immediately initiated an investigation and started watching video surveillance footage. She identified some abuse from the videos she watched so far and was calling certified nurse aides (CNA) #3 and 4 today to suspend them based on what she watched last night. She planned to continue watching video and addressing issues as she saw them. The Administrator stated no staff reported the alleged abuse. Review of the facility's video surveillance from the night shift beginning on 11/21/2018 and ending in the morning of 11/22/2018, revealed the resident was physically abused, mistreated, and confined to a corner for 4 hours and 33 minutes. - On 11/21/2018 beginning at 10:52 PM, the resident attempted to stand multiple times. When he stood, CNA #3 pointed her finger at him (almost touching his face with her finger) and pushed him back into the chair by pushing her hand(s) against one or both of his shoulders. The resident landed roughly in the chair. One of the times the resident stood, CNA #3 pushed him into the chair with one hand on his shoulder while CNA #4 grabbed the back of his gown and pulled him forcefully into the chair. - At 10:54 PM, CNA #4 punched the resident in the right upper back with a closed fist while CNA #3 was present. - At 10:55 PM, CNA #3 pointed her finger in the resident's face and pushed him by his shoulders into the chair. - At 10:59 PM, CNA #4 raised a closed fist at the resident twice, he then removed his hospital gown, and she raised a fist at him again in a threatening manner. - At 11:04 PM, the resident stood and CNA #4 pulled him back into the chair by pulling on the strings on the hospital gown that were tied around his neck. CNA #4 held the resident in the chair for 8 minutes by holding the strings tied around his neck. The resident pulled at the hospital gown and attempted to loosen the fabric from around his neck. - At 11:15 PM, the resident stood and licensed practical nurse (LPN) #15 and CNA #4 forcibly put him back into the chair. His feet lifted off the floor when his buttocks hit the chair. CNA #4 raised her closed fist at the resident in a threatening manner with LPN #15 present. - At 11:30 PM, CNA #4 flicked the resident in the right ear with her pointer finger and thumb and CNA #3 kicked the resident's shin. - At 11:34 PM, the resident stood up near the nurse's station and CNAs #3 and 4 pushed his wheelchair against the back of his legs. They held the chair in place against his legs, the resident tried to move, and CNA #3 locked the wheelchair brakes. The resident stood in the corner until 11:42 PM, when he turned himself around and sat down in the chair that was facing the wall. - From 11:42 PM on 11/21/2018 through 4:07 AM on 11/22/2018, the resident sat in the wheelchair facing the wall (4 hours and 33 minutes). During that time, the resident looked straight ahead at the wall, slept for short intervals, and when he tried to stand at 1:46 AM, CNA #4 placed him back in the chair and held the chair in place with her body weight for 5 minutes so that he could not move the chair. CNA #3 then sat next to the resident and positioned an overbed table behind the resident's wheelchair. Review of the facility's video surveillance for the night shift starting on 11/26/2018 and ending in the morning of 11/27/2018 revealed the resident was physically abused and mistreated by CNA #4. - At 11:58 PM on 11/26/2018, CNA #4 held the resident's left hand down with her right hand. She then took his left hand (that she was holding) and used the resident's left hand to hit him on his right arm. After doing this a few times, she continued to hold his left hand down until 12:01 AM on 11/27/2018. - On 11/27/2018 at 2:09 AM, the resident attempted to remove his gown and CNA #4 pulled the gown back down to stop him and very roughly pulled him back in the chair. At 2:11 AM, CNA #4 took the resident's right arm in her right hand and swung his right arm around his body, using it to hit himself in the torso. Residents #5 and 6 were present on video surveillance footage at varying times during the above-mentioned shifts. On 12/3/2018 at 8:20 AM, the Director of Nursing (DON) stated in an interview, herself and the Administrator watched more video and suspended LPN #15 for being aggressive and rough with the resident. On 12/6/2018 at 10:50 AM, the attending physician stated in an interview, he was not aware of the allegations made on the night shift until they were brought to the attention of the Administrator. He stated the Administrator and DON were in the process of investigating the reports. On 12/12/2018 at 12:05 PM, CNA #3 stated in an interview, on the night shift that started on 11/21/2018 and ended on 11/22/2018, the resident tried to stand repeatedly and when he did, they assisted him back to his chair. She stated she never kicked the resident, did not witness CNA #4 punch the resident, and was not forceful with the resident. She stated when the resident stood up in the corner, she went behind him with the wheelchair and must have startled him because he would not sit down. She stated she waited for him to sit and did not hold the wheelchair in place or lock the wheelchair brakes. She stated when the resident sat down and faced the wall, they left him there because he was calm. She stated the resident took cat naps that night in the chair and could have turned the chair around anytime that he wanted to as they did not hold the chair in place and did not block him in the corner. On 12/12/2018 at 1:40 PM, Resident #6 stated in an interview, he witnessed the staff become frustrated with Resident #2 during the night shift. He stated one night he saw a staff member flick the resident in his ear and he demonstrated flicking his pointer finger and thumb together. On 12/12/2018 at 2 PM, Resident #5 stated in an interview, when Resident #2 stood up, CNAs #3 and 4 yelled and screamed and swore at him stating sit the (expletive) down. He stated Resident #2 seemed scared when they did this. Resident #5 stated on the night shift of 11/21 to 11/22/2018, he was out of his room all shift and saw CNA #4 hold the resident in his chair by the strings on the hospital gown that were tied around his neck. He stated when she did this, Resident #2 pulled at the gown to loosen it. On 12/13/2018 at 10:05 AM, LPN #15 stated in an interview, on the night shift of 11/21 through 11/22/2018, she did not see any abuse occur. She did not feel anyone was forceful with the resident and did not call the Supervisor for help during the shift as she thought they handled the situation well. On 12/13/2018 at 11:05 AM, CNA #4 stated in an interview, she may have pulled the resident down into the chair by his gown when he tried to stand up but she never punched him or held his gown by the neck area. She stated she never yelled or swore at the resident and did not recall holding him in the corner with the wheelchair. She stated on the night shift of 11/21 into 11/22/2018, when the resident did sit down, he was facing the wall and they did not move him because he was happy there and did not try to stand. On 12/21/2018 at 10:48 AM, the attending physician stated in an interview, he heard that there was physical abuse towards the resident including someone punching him. He stated he had not seen the video surveillance footage from the alleged physical abuse but would like to review it as it was not an apporpriate way to treat the resident. 10NYCRR 415.4(b)

Based on record review, interview, and observation conducted during the abbreviated surveys (NY 809, NY 806 and NY 339), the facility did not ensure care was provided that prevented residents from developing pressure ulcers and/or did not ensure residents with pressure ulcers received the necessary treatments and services needed to promote healing and prevent infection for 3 of 3 residents (Resident's #1, 2 and 3) reviewed for pressure ulcers. Specifically, For Resident #3 the facility did not ensure: treatments and pressure relief interventions were implemented as planned; newly identified and worsening pressure ulcers were communicated to the appropriate staff; and routine monitoring of pressure ulcers were completed to promote healing. Subsequently, the resident developed Unstageable (full thickness tissue loss in which the base of the wound cannot be visualized) pressure ulcers on his ankle and his buttock. Resident #2 did not have timely treatment of [REDACTED].#1's multiple pressure ulcers were routinely assessed. This resulted in actual harm that is not immediate jeopardy to Resident #3. Findings include: 1)Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5/7/2018 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, he did not exhibit rejection of care behaviors and he was totally dependent for all activities of daily living. The comprehensive care plan (CCP) dated 5/2/2018 documented the resident had a self-care deficit and required total dependence for care. Interventions included to turn and reposition the resident every 2 hours. A revision to the CCP on 5/9/2018 documented the resident had an alteration in skin integrity and interventions included an air mattress, treatment to affected areas and limit out of bed schedule. A nursing admission assessment dated [DATE] completed by registered nurse (RN) #11 documented the resident had multiple wounds and pressure areas as per above diagram and they were to be evaluated by the skin team. The resident was currently bed ridden and required frequent positioning. The diagram on the assessment form showed a circle drawn around the resident's coccyx (lower end of spine) area, both front and back of the lower legs, and both front feet, ankles and heels. The diagram on the assessment form did not include a description or Stage of the multiple wounds and pressure ulcers. The 4/30/2018 admission physician orders did not include any treatments to the multiple wounds and pressure ulcers identified on the admission assessment. There was no documented evidence in the Treatment Administration Record (TAR) any treatments were administered to the multiple wounds and pressure ulcers from 4/30/2018 - 5/3/2018. Physician orders dated 5/2/2018 included: -Cleanse the left and right lateral (outer) ankles with foam cleanser and apply [MEDICATION NAME] border and change every 2 days and as needed. -Cleanse the coccyx bilateral (both sides) ischial (lower and back part of the hip bone) wound with normal saline, pack with lightly moistened gauze, cover with dry dressing and change daily and as needed. A physician progress notes [REDACTED]. A weekly pressure wound flowsheet initiated on 5/17/2018 documented the resident had a Stage III pressure ulcer on the left buttock and a Stage II (partial thickness skin loss) pressure ulcer on the right buttock. There was no weekly pressure wound flowsheet for the left and right outer ankles that required a treatment on 5/2/2018 or for the 3rd pressure ulcer observed by the physician on 5/15/2018. There resident was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. A nursing admission assessment dated [DATE] at 9 AM documented a coccyx/sacral wound measured 1.5 cm x 1.5 cm x 1.3 cm. The right ischial wound measured 1.6 cm x 3 cm x 0.1 cm. Both areas had a pink, granulated (newly formed) tissue. The left ischial wound measured 6 cm x 3 cm x 3 cm and was a Stage IV that was mechanically debrided (removal of dead tissue) in the hospital. A wound vac (vacuum assisted wound closure) was applied per physician orders. Both heels were dry and a moisture barrier was applied. There was no documentation of wounds on the resident's ankles. The weekly pressure ulcer flowsheet documented on 7/6, 7/12 and 7/20/2018 the left ischial wound continued to improve with the wound vac. A physician order dated 8/3/2018 documented to discontinue the wound vac to the left ischial pressure ulcer and apply an [MEDICATION NAME] dressing and change every 3 days and as needed. The 8/2018 Treatment Administration Record (TAR) documented the wound vac had been discontinued on 8/3/2018 and an [MEDICATION NAME] border dressing was applied to the left ischium by registered nurse (RN) #4. There were no further initials on the TAR indicating the treatment to the left ischium had been changed on 8/6/2018 or as needed. The unit assignment sheet for the 6:00 AM - 2:00 PM shift for 8/6 identified that LPN #5 was the only nurse working that shift. During a skin and treatment observation on 8/8/2018 at 10:20 AM with licensed practical nurse (LPN) #1 and CNA #2 the resident was observed lying in bed on his right side with his legs drawn up in the fetal position. The resident did not have any heal booties (used to offload pressure on the heels) in place and his right ankle was lying directly on the mattress. The LPN exposed the dressing on the left ischium and written on top of the dressing were the initials of RN #4 and the date 8/3. The LPN stated she did not know why the dressing was dated for 8/3/2018 as it was supposed to be changed every 3 days. She removed the dressing and there was a large amount of brownish/blackish drainage saturating the dressing and it had a foul odor. Under the dressing there were two pressure ulcers, both with moist bright red wound beds. The LPN applied [MEDICATION NAME] silver dressings to both wound beds and covered the areas with a large [MEDICATION NAME] dressing. The LPN and the CNA then rolled the resident over onto his left side and he had an open area directly over the right outer ankle. The LPN stated the wound on the ankle had been there, and he received skin prep to the ankle daily. She then applied skin prep to the open wound. She stated he was supposed to have heel booties on that would provide pressure relief to the ankles and she did not know why he did not have them on. The CNA stated she was not assigned to the resident, she was just helping the LPN and she did not know why he was not wearing the booties. Physician orders in place on 8/8/2018 included: -[MEDICATION NAME] to left ischium and change every 3 days and as needed. -Apply [MEDICATION NAME] with silver to right ischial wound and cover with [MEDICATION NAME] dressing and change every 3 days and as needed. - Apply [MEDICATION NAME] with silver to right sacral wound and cover with [MEDICATION NAME] dressing and change every 3 days and as needed. -The physician orders did not document any treatments for the resident's ankles. The certified nurse aide (CNA) Kardex (care instructions) in place on 8/8/2018 documented the resident required total assistance for bed mobility, had a low air-loss mattress, heel floats, out of bed for one hour twice daily and was to be repositioned from side to side every hour. During an interview with CNA #3 on 8/8/2018 at 10:50 AM she stated she was assigned to Resident #3. She did not know of any pressure relief interventions for the resident and stated it would be on his Kardex. She stated she had not been in his room since the start of her shift at 6:00 AM and did not know if he had his heel booties on and she had not turned and repositioned him yet. During an interview with RN #4 on 8/9/2018 at 10:37 AM she stated she was responsible for doing skin rounds on each resident in the facility and Resident #3's pressure ulcers were monitored weekly. The resident's pressure ulcer on the left ischium had healed and was closed on 8/3/2018 so she had discontinued the wound vac and changed the treatment to an [MEDICATION NAME] dressing to be changed every 3 days. She stated she had applied the [MEDICATION NAME] dressing on 8/3/2018 and she confirmed those were her initials on the TAR indicating she had changed the dressing. The [MEDICATION NAME] dressing was for protection only. The resident had heel booties in place to protect his ankles and he did not have any pressure ulcers on his ankles. She had not been notified the area on the left ischium had reopened nor had she been notified the resident's dressing had not been changed as planned. That could place the resident at risk for the pressure ulcer worsening or getting infected. The treatment nurse was responsible for notifying her or the Unit Manager of any changes in pressure ulcers that are observed during treatment changes. She could not recall if the resident had any pressure ulcers on his ankles and she had provided the surveyor with all there was for the weekly assessments done on the resident. During an interview with RN #8 on 8/9/2018 at 10:58 AM she stated she had not been notified that Resident #4 had skin changes or that it was noted the resident's dressing had not been changed as planned. During an interview with LPN #5 on 8/9/2018 at 11:02 AM he stated when he worked alone he was not always able to get treatments done and he would verbally pass on to the next shift what treatments still needed to be completed. He reviewed the TAR for Resident #3 and stated he did not do the treatment to the resident's left ischium on 8/6/2018, as he would have signed for it if he had. He thought the resident had a wound vac on at that time. He did not recall the resident having any wounds or open areas to his ankles or treatments. If he observed any changes in a resident's skin condition he would notify the Director of Nursing (DON). A treatment/wound round observation with the Director of Nursing, RN #4 and RN #8 was completed on 8/9/2018 at 11:30 AM for Resident #3. RN #4 stated she was not aware of any open areas on the resident's right ankle. She removed the plastic heel float bootie, there was no dressing on the ankle and the wound was in direct contact with the plastic heel bootie. She stated Oh, I did not know that was there and stated it was a pressure ulcer that was Unstageable as the wound bed contained 100% slough (moist dead tissue). She measured it at 1.3 cm x 1.5 cm. She stated she would expect the nurse who noted it to report there had been a change in skin condition as the wound needed to be treated. RN #4 stated the treatment to the left ischium was [MEDICATION NAME] only and just for protection as newly healed pressure ulcers were fragile and susceptible to reopening. She stated [MEDICATION NAME] should not be applied to the area as it was intact skin. She removed the [MEDICATION NAME] and [MEDICATION NAME] dressings to the left ischium and stated the [MEDICATION NAME] should not be there. She looked at the area and stated the resident's pressure ulcer had reopened and she had not been notified. The DON and RN #8 both stated they had not been notified. RN #4 stated the areas on the left ischium had deteriorated as now there were two pressure ulcers that were not there before. One pressure ulcer was distal to old scar tissue and measured 1.0 cm x 0.4 cm and the wound bed contained 100% slough and the second pressure ulcer was on the upper part of old scar tissue measuring 4.5 cm x 0.8 cm and the wound bed contained 25% slough and 75% red beefy tissue. RN #4 went to the nursing station and stated to the physician the resident had a new pressure ulcer on his right ankle and the pressure ulcers on the left ischium had reopened. The physician asked if the resident had his heel booties on and the resident needed to be provided with pressure relief. During an interview with the physician on 8/9/018 at 12:05 PM he stated he had not seen the resident's pressure ulcers in over 3 months as they were being managed by the Unit Manager and DON. They would approach him only if they needed treatment orders. He was notified last week the pressure ulcer on the left ischium had healed and he had approved the discontinuation of the wound vac. He stated if a dressing was saturated and not changed as ordered the skin could breakdown, become macerated (softened by moisture) and was at risk of becoming infected. He did not recall changing the resident's treatment from daily to every 3 days and he would want the dressings changed daily especially if there was a lot of drainage. If the resident was not provided with pressure relief such as booties for his feet, a specialty mattress and turning and repositioning, the treatment being applied would not help heal and the skin would eventually breakdown. Heel booties should be in addition to a specialty mattress as an added precaution. He stated the facility had a lot of pressure ulcers and he had reported his concerns to administration. Residents were not getting turned and repositioned as he would see them lying in the same position throughout the day. He stated if a nurse observed any new or worsening skin breakdown he would expect it be reported to him or the Unit Manager immediately to ensure pressure relief interventions and a good treatment was in place. If not repositioned frequently, residents could develop pressure ulcers and it could prevent the healing of existing pressure ulcers. During an interview with CNA #9 on 8/9/2018 at 1:20 PM she stated if she observed any areas on the resident's skin that she was not familiar with or an open area that was not covered she would notify the nurse. She stated she had bathed the resident that morning and she had not noticed any open areas on the resident and that included his feet that she had washed and applied lotion to during care. During a follow up interview with the physician on 8/27/2018 at 10:44 AM he stated if a resident was admitted with a pressure ulcer he would expect treatments to be initiated right away and not wait until an evaluation from the skin team. He would expect that every pressure ulcer be monitored at least weekly as that was the standard. Consistent monitoring ensured pressure ulcers were healing and being treated properly and were not becoming infected, and if any complications were to arise they would be treated timely. During an interview with the Director of Nursing (DON) on 8/27/2018 at 1:00 PM she stated she was part of the wound/skin team and they conducted weekly rounds on residents with pressure ulcers. When a resident was admitted or readmitted the nurse would complete a skin assessment and if any pressure ulcers or other wounds were identified, the physician was notified and treatments would be started immediately. She stated it was not appropriate to wait for treatment orders until the resident was evaluated by the skin team and treatments should be ordered the day the resident was admitted . Treatments should not wait as it places the resident at risk for infection and worsening of the pressure ulcers. She reviewed the orders for Resident #3 and stated the 4/30/2018 admission assessment was incomplete as there was no documentation describing and measuring the wounds and there should be as there was no way to tell the progress of the wound. She stated it was not appropriate to wait until 2 days after admission to initiate treatment orders. She reviewed the resident's skin flow sheets and stated the resident was assessed weekly and she did not know where the assessments were after 5/31/2018 or why there were no assessments of the ankle wounds that required treatment orders on 5/2/2018. She stated there were some assessments missing and she did not know why. During an interview with RN #11 on 8/27/2018 at 4:35 PM he stated his duties included admission assessments and which included assessments of wounds and pressure ulcers. When a resident was admitted to the facility with wounds he would notify the physician for a treatment order the day of admission and would also start a wound/skin flow sheet that included a description of the wound. He did not stage pressure ulcers as that would be done by the skin team when they evaluated them. He did not know when residents were evaluated by skin team after admission, he assumed they looked at them the next day. He would communicate wounds to the skin team by verbal report or documenting on the 24-hour report. He stated he had reviewed the admission assessment he completed on 4/30/2018 for Resident #3 and thought he had obtained treatment orders for the resident's wounds and pressure ulcers. He stated when he looked at the wounds he had removed a gauze dressing and could not recall what he had applied to the areas to keep them covered. During an interview with LPN #12 on 9/4/2018 at 3:45 PM she stated she was the Unit Manager at the time the resident was admitted . Skin assessments were completed by an RN and they would communicate any findings to the physician for treatment orders the day of admission. She recalled the resident had multiple pressure ulcers. 2)Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 7/7/2017 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and he was totally dependent for all activities of daily living (ADLs). The comprehensive care plan (CCP) dated 6/22/2017 documented the resident had a pressure ulcer on the coccyx (bottom portion of spine). It was present on admission, was a Stage III (full thickness skin loss) and measured 7.9 cm (centimeters) x 5.6 cm. Interventions included to provide treatments according to physician orders and monitor effectiveness of treatment plan. The hospital discharge summary dated 6/21/2017 documented the resident had a sacral (lower back) pressure ulcer with no evidence of infection and he had been followed by the wound team in the hospital. A nursing progress note dated 6/21/2017 at 11:00 AM documented the resident was admitted to the facility and he had an air mattress related to decub on buttock. Wound and skin rounds in the morning for assessment and staging, no orders at this time. The 6/21/2017 physician orders documented wound treatment per wound team recommendations. There were no treatments ordered for the resident's identified pressure ulcer. The 6/21/2017 nursing assistant accountability record (care instructions) documented the resident had a pressure ulcer and special instructions included an air mattress, turn and reposition every 2 hours and heels off bed. There was no documented evidence the resident's pressure ulcer was assessed and treated from his admission on 6/21/2017 thru 6/25/2017 when he was readmitted to the hospital. During an interview with the Director of Nursing (DON) on 8/27/2018 at 1:00 PM she stated she was part of the wound/skin team and they conducted weekly rounds on residents with pressure ulcers. When a resident was admitted or readmitted the nurse would complete a skin assessment and if any pressure ulcers or other wounds were identified, the physician was notified and treatments would be started immediately. She stated it was not appropriate to wait for treatment orders until the resident was evaluated by the skin team and treatments should be ordered the day the resident was admitted . The resident would not be evaluated by the skin until the next scheduled wound rounds. Treatments should not wait as it places the resident at risk for infection and worsening of the pressure ulcers. During an interview with the physician on 8/27/2018 at 10:44 AM he stated wound rounds were done weekly and he would expect that every pressure ulcer be monitored at least weekly as that was the standard. Consistent monitoring ensured pressure ulcers were healing and being treated properly and were not becoming infected, and if any complications were to arise they would be treated at that time. During an interview with registered nurse (RN) #10 on 9/18/2018 at 8:55 AM she stated she had worked at the facility as a Unit Manage and she had been responsible for completing skin assessments on newly or readmitted residents. The assessment included measuring pressure ulcers and calling the physician for treatment orders. If the resident was admitted ,[DATE] days prior to skin team rounds they would wait for treatment orders from the skin team evaluation and recommendations. She had been involved with weekly skin rounds with the DON and Director of Dietary and the purpose of monitoring pressure ulcers weekly was to promote healing and ensure interventions were effective. She could not recall any specific information about Resident #2. 3)Resident #1 was originally admitted to the facility on [DATE] with the most recent readmission date of [DATE]. [DIAGNOSES REDACTED]. The 1/23/2018 Minimum Data Set (MDS) assessment documented the resident's cognition was intact and he required extensive assistance for all activities of daily living (ADLs). The comprehensive care plan (CCP) dated 10/2/2017 and updated on 1/28/2018 did not identify the resident had a pressure ulcer. The certified nurse aide (CNA) accountability record (care instructions) included a Roho cushion (used to relieve pressure when sitting) for his wheelchair, frequent repositioning at least every 2 hours and a low air loss mattress (pressure reducing) on bed. Physician orders included: -11/3/2017 to change the wet to dry dressing twice daily (wound location not specified). -11/6/2017 pack wound gently with normal saline gauze and cover with an Allevyn dressing (wound location not specified). -12/11/2018 follow up with the wound clinic for decline in wound. -12/29/2018 apply wound vac (vacuum assisted wound closure) to left buttock wound, apply Duoderm (wound dressing) to left hip Stage II and continue [MEDICATION NAME] (ointment used to debride wounds) to remaining wounds. -2/8/2018 cover sacrum with Duoderm and change every 3 days, apply collegenase to left hip daily, pack left buttock wound with Alginate (an absorbent wound dressing) and cover with dry dressing daily, [MEDICATION NAME] to left buttock/coccyx wound daily and [MEDICATION NAME] to distal left hip wound daily. -3/30/2018 refer resident to wound center. -3/31/2018 obtain wound culture. A dietary progress note dated 11/1/2017 documented the resident had a Stage IV (full thickness tissue loss with exposed muscle, tendon or bone) pressure ulcer (location not documented) and no other measurements until this date, no information available at this time and information was requested to assess if area had improved or worsened. The 1/12/2018 hospital discharge summary documented the resident was admitted to the hospital with [REDACTED]. He was to follow up with the plastic surgeon in 2 weeks. The 1/16/2018 admission assessment documented the resident had a pressure ulcer to the right buttock and two necrotic areas on his left upper thigh. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. The resident had an upcoming appointment with a plastic surgeon for debridement. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. Staff were instructed that he should return to the wound clinic. The 5/2/2018 hospital discharge summary documented the resident had a known history of a Stage IV pressure ulcer on his sacrum that required debridement in 1/2018. The resident was sent to the emergency roiagnom on [DATE] from the wound clinic for worsening pressure ulcers, and he was noted on admission to have a total of 8 sacral and hip ulcers in various stages, draining thick, foul slough. Skin assessments and wound round documentation were requested for the resident on 8/8/2018. The documentation was not received on 8/9/2018 and the documentation was requested again. During an interview with the corporate registered nurse (RN) on 8/9/2018 at 2:30 PM she stated they were unable to locate the pressure ulcer assessments and wound round documentation for the resident. She was aware that he had pressure ulcers that required monitoring and she was sure the assessments were done. She did not know where the documentation was and she would keep looking. During an interview with the DON on 8/27/201/8 at 9:15 AM she stated they were still unable to locate the skin/wound flow sheets for the resident and she did not know where they could have gone. They had looked everywhere and she did not know what happened to them. She was responsible for wound skin rounds and documenting on the flow sheets and she could not recall if the resident was seen on their weekly rounds. During an interview with the physician on 8/27/2018 at 10:44 AM he stated wound rounds were done weekly and he would expect that every pressure ulcer be monitored at least weekly as that was the standard. Consistent monitoring ensured pressure ulcers were healing and being treated properly and were not becoming infected, and if any complications were to arise they would be treated. He was not part of the skin team and they would only come to him when they needed orders. He did not recall any specific information about the resident. During an interview with the Food Service Director #15 on 8/27/2018 at 12:35 PM she stated she had been part of weekly skin rounds and she could not recall ever seeing the resident's pressure ulcers. She would sometimes write down what resident was scheduled on skin rounds that week for her own record keeping, but did not do that consistently. If she did see the resident on wound rounds then she would document a progress note that they were seen and what the dietary recommendations were. She reviewed the 11/1/2017 dietary progress note and stated she did write that progress note and could not recall any specific details regarding the note. During an interview with LPN #5 on 8/27/2018 at 1:40 PM he stated he was familiar with the resident and he had multiple pressure ulcers. He could not recall how many or where they were located. He did not participate in skin rounds and would not know if they were done. Prior to the resident being transferred to the hospital in 4/2018 his pressure ulcers had looked bad and he was in poor shape. During an interview with CNA #16 on 8/27/2018 at 2:45 PM she stated the nursing staff did treatments daily on the resident as he had multiple pressure ulcers. She could not recall the locations as she would just help roll the resident for the nurse to do the treatment. During an interview with LPN #12 on 9/4/2018 at 3:45 PM she stated she had worked as the Unit Manager for the resident's unit. She did not do skin assessments on residents as that was the responsibility of the RN's. She did attend weekly skin rounds on all residents with pressure ulcers. She thought the resident was part of skin rounds but did not remember who was responsible for documenting his assessments on the flow sheet. At times the weekly rounds were not done as there was not enough staff. During an interview with RN #10 on 9/18/2018 at 8:55 AM she stated she had previously worked at the facility as a Unit Manager. Resident #1 had been on her unit while she had worked there and he had multiple, really bad pressure ulcers. He had not been seen on skin rounds as he would be out to [MEDICAL TREATMENT] the day skin rounds took place and she thought the DON had followed up on his wounds. 10NYCRR 415.12(c)(1)

Based on observation, record review, and interview during the abbreviated surveys (NY 592 and NY 953) the facility did not ensure all residents were reviewed for accident hazards, supervision and devices for 2 of 3 (Residents #1 and 2) residents reviewed for accidents. Specifically, Resident #1 had two falls with injury; the facility did not initiate fall preventative measures to ensure the resident's safety and did not have a current side rail assessment completed. Resident #2 had three falls in one day, one resulting in injury; the facility did not investigate 2 of the 3 falls to rule out abuse, neglect or mistreatment, did not update the comprehensive care plan (CCP) to ensure the resident's safety, and had only one Accident/Incident form was completed after the resident had 3 separate falls. This resulted in harm that was not immediate jeopardy to Resident #1. Findings include: The undated facility fall policy and procedure documented all residents were to be assessed for fall risk upon admission and quarterly thereafter. General interventions for fall prevention and injury reduction will be implemented for all residents. All residents on the long-term care unit were considered at risk for falls. 1) Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident's cognition was severely impaired. He required extensive assistance for all activities of daily living (ADLs), used a wheel chair for mobility, was incontinent of bowel and did not have any falls in the past 6 months. The side rail assessment dated [DATE] documented the resident required side rails for turning and positioning. There was no further updated documentation regarding side rail assessments, his need for side rails or discontinuation of the side rails since 12/21/2016. The resident certified nurse aide (CNA) Kardex (care instructions) dated 12/16/2016 and provided as current prior to the residents fall, documented the resident required total assistance from staff for all ADLs, he used a mechanical lift for all transfers, he was at risk for falls and used bilateral positioning bars. The comprehensive care plan (CCP) dated 2/6/2018 documented the resident had a potential for falls related to his mental status and impaired mobility. The goal was to decrease the risk of falls and injury by asking for assistance in self-care activities for the next 90 days. Interventions included staff were to assist with transfers, keep items within reach, assess for side rails as enablers, place an anti-skid mat at location and educate for safety. The CCP did not specify what location to place the anti-skid mat and there was no documentation of an updated assessment for the side rails since 12/21/2016. The nursing progress note dated 5/4/2018 at 4:30 AM documented the resident was found on the floor near his dresser, he had a head impact with right side bruising measuring 5 to 6-centimeters and scrapes to his knees. The resident was unable to open his eyes and did not verbalize pain. He was transported to the hospital and the family was notified at 4:50 AM. There was no documented evidence the physician was notified of the resident's fall or transport to the hospital for evaluation. Resident #1 returned from the hospital on [DATE] at 9:30 AM. He was fed by staff and repositioned every 2 hours. There was no documented evidence a re-admission assessment or an RN evaluation was completed upon return from the hospital. His skin tear on his hand or his abrasions to his knees were not addressed and his neurological status was not monitored after sustaining a head injury. The facility investigation dated 5/4/2018 documented Resident #1 was found on the floor at 4:20 AM, he was unable to verbalize what happened and had been positioned properly in the bed at 3:00 AM after being provided incontinence care. The facility statements attached to the investigation documented the fall was unwitnessed. The resident was sent to the hospital for evaluation as he had a head impact with an ecchymotic (bruise) area on the right side and a small skin tear on the left hand. New interventions were to place the resident in the middle of the bed and place the bed in the lowest position. The nursing progress note dated 5/5/2018 at 8:00 PM documented the resident was status [REDACTED]. His treatment was completed per the physician's orders [REDACTED]. The staff would continue to monitor. There was no further documentation of the resident's skin tear on his hand, his abrasions to his knees or if his neurological status had been monitored. The CCP and resident care guide did not document the resident had a fall out of bed on 5/4/2018 and did not document new interventions for fall prevention after the fall. The physician communication book located on the nursing unit to convey information between the nursing staff and physician dated 5/2/2018-6/13/2018 did not document the physician was made aware the resident had a fall, sustained injury or was transported to the hospital. The nursing progress note dated 6/4/2018 documented Resident #1 was found on the floor at 12:10 AM with a laceration on his mid-forehead measuring 5 centimeters (cm) x 2 cm. He was transported to the hospital for evaluation. The facility incident and accident report dated 6/4/2018 at 12:10 AM documented the resident had an unwitnessed fall from his bed and was found on the floor. Staff interviews and statements were obtained, a registered nurse (RN) assessment was completed at the time of the incident and the resident was sent to the hospital for evaluation. The resident sustained [REDACTED]. He returned to the facility at 3:40 AM with 20 stitches to his forehead. The facility investigation documented the plan of care was followed and there was no evidence of abuse, neglect or mistreatment. There was no documented evidence what position the bed was in at the time of the incident to determine if the plan of care was followed. The investigation summary documented new interventions were to be put in place after the incident included fall mats on both sides of the bed. The physicians progress notes dated 6/7/2018 documented Resident #1 fell from his wheel chair the previous weekend and sustained a laceration which required 20 sutures. The resident required a mechanical lift for transfers, he was wheel chair confined. On 6/14/2018 at 9:30 AM Resident #1's room was observed. His bed did not have side rails. He had fall mats located at the end of his bed and on the left side of his bed. His bed was positioned in a normal position from the floor and not at the lowest position. Resident #1 was located behind the nursing station sitting in an activity. His wheel chair had a chair alarm with the cord wrapped around the handle of the wheel chair and it was not connected and did not have a battery. The CCP did not document the resident had a chair alarm. When interviewed on 6/14/2018 at 9:45 CNA #1 stated she was Resident #1's primary care aide for the 7:00 AM -3:00 PM shift. The resident was not alert or oriented, did not maintain any form of eye contact and required total assistance for care. He was transferred using a mechanical lift, he was at high risk for falls and had side rails on his bed previously as he had falls out of bed. The side rails were removed when the facility decided to become side rail free. She stated the resident had been able to help with his turning and positioning prior to the incident and used the enabler bars. He had a recent fall from his bed and sustained a laceration on his forehead and she believed he did have other falls from his bed. His care plan at the time of the fall on 6/4/2018 was updated and fall mats were placed on both sides of his bed for fall prevention and his bed was to be in the lowest position. She stated the resident did have a bed and chair alarm at one time and she was not sure what happened with that. When interviewed on 6/14/2018 at 12:12 PM The Director of Nursing (DON) stated she was not aware of any prior falls for Resident #1 since she had been in the facility. She was made aware the resident had 1 fall on 6/4/2018 at 10:45PM when he fell out of his bed. He sustained a 3-cm laceration on his left forehead. He was sent to the hospital and returned the same day. New interventions were to add a low bed with fall mats. The family was notified of the residents fall at 12:50 AM. The RN completed an assessment and determined the resident required a hospital visit. He was transported at 12:50 AM. The facility met and discussed the incident the following morning as a team and ruled out abuse, neglect or mistreatment as there was no care plan violation. She did not know what the position the bed was in at the time of the incident. Upon the resident's return from the hospital, the facility instituted fall mats and a low bed. She was responsible to complete the facility investigation and rule out abuse, neglect and mistreatment and she felt the investigation was complete and thorough. When interviewed on 6/14/2018 at 1:17 PM CNA #5 stated she was assigned on the 2:00PM - 10:00PM shift and intermittently provided care for Resident #1. She stated she was not present when the resident fell . She stated she thought the resident had other recent falls. When interviewed on 6/15/2018 at CNA #7 assigned on the 4th floor unit on the 10:00PM -6:00AM shift stated Resident #1 required total assist from staff for his care needs. He used a mechanical lift for transfers and for the past year did not move about in the bed. The staff turned and positioned him every 2 hours and if needed. She stated on the night of the incident she was notified by another staff member the resident had fallen out of bed. She stated she was surprised as he did not move when in the bed. Resident #1 did have prior falls mostly out of his wheelchair however, none in the last 6 months. After review of the resident's care guide she stated he did have side rails on his bed to aid in turning and positioning and they were discontinued when the facility went side rail free. She was not sure of the resident's new interventions for fall prevention as she had not provided care for him. She would check the residents care guide every couple of weeks or if she had to provide care. After review of the resident's medical record there was no documented evidence the resident had a fall from his wheel chair in the past year. When re-interviewed on 6/15/2018 at 11: 00 AM, the DON stated she reviewed her files and located an incident report for 5/4/2018 where the resident had a fall from bed. The CCP and the Kardex were reviewed during this interview and she identified the Kardex dated 12/16/16 was the care guide that was in place prior to the incident on 6/4/2018. The new Kardex was undated and reflected new interventions that were put in place on 6/4/2017. She stated she did not know what happened with the resident's bed alarm or chair alarm. She stated the care plan and the resident Kardex were not updated after the incident on 5/4/2018 and no new interventions were initiated. Interventions prior to 6/4/2018 documented on the CCP were bilateral positioning rails for safety which he did not have and there were no interventions for fall prevention until 6/4/2018. Her expectation was the Kardex was to reflect the resident's current plan of care. The resident's side rails were discontinued prior to her starting at the facility in (MONTH) (YEAR). She did not believe the resident was able to turn and position himself and that was the reason for the discontinuation. She was not able to locate an assessment for side rail use. When interviewed on 6/15/2018 at 12:00 PM, The physician for Resident #1 stated he was not notified the resident had a fall on 5/4/2017 or that he had been sent to the hospital. He stated he expected interventions to have been in place for fall prevention after the fall occurred on 5/4/2018 and documented for all the staff to be aware. He stated he was made aware of the residents fall on 6/4/2018 and if fall interventions had been initiated and put in place after the fall on 5/4/2018 they could have prevented the injury from occurring. 2) Resident #2 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident's cognition was modified independence with some difficulty in new situations. She required extensive assistance with all activities of daily living (ADLs) used a wheelchair for mobility, was incontinent of bowel and bladder, and did not have a history of falls. The Fall risk assessment dated [DATE] that was completed during the resident's first admission documented the resident was alert on admission, she had 2 previous falls during the last 90 days, she was confined to a wheel chair and had balancing problems. The assessment documented she was not at risk for falls. The resident was sent to the hospital for unrelated medical issues and was readmitted to the facility on [DATE]. The nursing progress notes dated 5/1/2018 with no time frame, documented the resident was up in the wheel chair and confused. She was being placed in the bed and slid to her knees. The incident was witnessed by a certified nurse aide (CNA) and the resident was returned to bed. The note documented the resident fell twice during the evening shift and sustained ecchymosis (bruising) on her forehead, neurology checks were found to be negative and no acute distress was identified. There was no further nursing documentation regarding the resident's status until 5/3/2018 at 6:00 AM. The physician progress notes [REDACTED]. She had fallen out of bed 3 times in the past 24-hours and fall precautions had been taken. The comprehensive care plan (CCP) dated 5/2/2018 documented Resident #2 had cognitive impairment, her speech was unclear and she had confusion. She had a potential for frequent falls due to her decline in ADL status and she rolled out of bed. The goal was the resident could be on the floor mats due to purposeful movements and she placed herself there. Interventions included staff to assist with transfers, ensure her call bell was within reach, keep environment safe and clutter free and obtain an evaluation for physical therapy (PT). There was no documented evidence that the resident had fallen on 5/1/2018 two times during the evening shift or new interventions for fall prevention were put in place after the falls. The certified nurse aide (CNA) resident's Kardex (care instruction) undated and provided as current for 5/2018 documented Resident #2 was alert, she required extensive assistance from 2 staff with transfers and toileting and her ambulation status was not documented. She required limited assistance of 1 staff for bathing, grooming, hygiene, dressing and locomotion. She was continent of bladder and there was no documentation for fall prevention or safety. The facility Accident/Incident form dated 5/1/2018 at 10:45 PM documented the resident was confused and unable to provide a statement, was found on the floor in a prone position and she sustained a bump on her left forehead. An assessment was completed, her range of motion was in normal limits, she did not have any complaints of pain, the physician was notified and a message was left for the family to contact the facility. The cause was likely due to her confusion and the recommendation was a bed alarm. A fall risk assessment was completed and attached to the facility investigation. The investigation documented there were no signs of abuse, neglect or mistreatment and no care plan violation. The investigation documented a bed alarm was to be initiated for fall prevention. There was no documented evidence if the fall mats were in place at the time of the incident, the bed alarm was initiated or the family was notified of the incidents that occurred on 5/1/2018 during the evening shift. There was no documented evidence the facility investigated the resident's falls during the evening shift until the fall on 5/1/2018 at 10:45 PM. Only one Accident/Incident form was provided for the 3 falls the resident had. When interviewed on 7/5/2018 at 8:53 AM CNA #10 stated she was assigned to the 2:00 -10:30 PM shift and provided care for Resident #2. She stated when the resident was admitted to the facility she required total assistance of 2 staff with her care needs. She checked the residents care guide either every other day or daily. She did remember the resident had a fall during her shift however did not recall when. She did not recall if interventions were put in place after the incident however knew fall mats were added to her bed side at some point after a fall. When interviewed on 7/5/2018 at 9:15 AM licensed practical nurse (LPN) #11 stated she remembered Resident #2 being admitted to the facility, did not recall her prior admission to the facility or if she was at risk for falls. She stated the resident had 1 or 2 falls on 5/1/2018 during her 2:00 PM - 10:30 PM shift and she had fallen again on the following shift before she left the building. She was not responsible for completing an incident/accident report or initiate new interventions as the nursing supervisor was responsible to do that. She did not recall if she provided a statement when the resident had fallen. She did not recall if fall mats were initiated after a fall or when they were placed at the bed side. When interviewed on 7/5/2018 at 9:27 AM registered nurse (RN) Supervisor #12 stated she was assigned to the 3:00 PM - 11:00 PM shift. She stated when a resident had a fall in the facility she was responsible to assess the resident for injury, complete the incident/accident report to determine what happened and if the plan of care was followed. She initiated new interventions for fall prevention and update the residents care plan and Kardex with the new interventions for staff to follow. She did not recall the resident or how many falls occurred during her shift on 5/1/2018. When interviewed on 7/5/2018 at 10:57AM the DON stated any resident who had a change in plane was considered a fall and any resident who was lowered to the floor was to have an incident and accident report completed to rule out abuse, neglect and mistreatment. The supervisor's role was to respond to the fall, assess the resident for injury and initiate an incident and accident report to rule out abuse, neglect and mistreatment. The CCP and the resident Kardex were to be updated after any fall to ensure fall prevention interventions were added to the CCP and Kardex. She expected 3 incident reports to have been completed for the resident's 3 falls on 5/1/2018 and the care plan and Kardex to have been updated with new interventions. She stated that had not occurred for 2 of the 3 incidents. 10 NYCRR 415.12(h)(1)

Based on record review, observation, and interview conducted during the extended survey, for 84 residents residing at the facility, including 7 of 7 residents (Residents #3, 9, 16, 18, 19, 20 and 21) reviewed for smoking, the facility failed to implement an effective system to provide an environment free of accident hazards and adequate supervision related to smoking. Specifically, the facility: - Failed to develop and implement a comprehensive smoking policy. - Failed to consistently assess resident ability to smoke unattended and their ability to safely possess and use lighters and matches. - Failed to develop individualized comprehensive care plans to address how the facility would assure safety for the residents who smoked, assure that smoking would not occur in areas not designated for smoking, and communicate resident care plans to responsible staff. - Failed to assure adequate supervision was provided to residents who were not able to smoke safely while unattended or while on oxygen therapy. - Failed to have a system in place to adequately secure smoking materials when not in use. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. Findings include: The facility Smoke Free Environment policy dated 2/17 documented, smoking is forbidden in all indoor and outdoor areas of the facility for residents. All residents, staff members and visitors must observe and comply with the facility's smoking policy. Residents who smoke will be educated about the facility's smoking policy upon admission. Residents identified as being a smoker will be offered a smoking cessation program. Residents who are deemed safe to sign themselves out to go off property to smoke must be assessed by the therapy department first. Assessment includes the resident's ability to follow procedure, rules and transport self to the nearest location that is not on facility property. Residents who refuse to abide by this policy and who represent a danger to themselves or others may be advised to seek placement in another setting. The success of these regulations in promoting a smoke-free environment can be assured if there is recognition by all residents, staff members and visitors that the guidelines must be supplemented by a sense of cooperation and respect for the rights of others. Violations of the smoking policy by residents, staff members and visitors must be reported to the Administrator. 1) Resident #3 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 4/3/2017 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance for locomotion off the unit, did not use tobacco and received oxygen therapy. The comprehensive care plan (CCP) dated 4/13/2017 documented the resident had an alteration in his respiratory system related to [DIAGNOSES REDACTED]. Interventions included education regarding smoking cessation and oxygen as ordered by physician. The certified nurse aide (CNA) care instructions, updated 6/2/2017, documented the resident propelled himself in a wheelchair, needed supervision to go outside, and used 3-4 liters of oxygen via face mask, continuously to maintain oxygen saturation (amount of oxygen carried in the blood) greater than 92%. There was no documentation the resident was a smoker. The CCP updated 6/7/2017 documented the resident transferred with set up for oxygen usage, ambulated 150 feet without assistive device, and was able to self propel his wheelchair. There was no documentation in the resident's record a smoking assessment was completed. On 6/27/2017 at 3:58 PM, the resident was observed by 2 surveyors in his motorized wheelchair in front of the facility, on the sidewalk near the bus stop. The resident was alone. He stood up from his chair, searched in his pockets of his sweatshirt and sat down in his wheelchair facing the facility. An unidentified person, wearing scrubs, walked near the resident, stopped, exchanged words with the resident and proceeded to walk back to the facility. The resident was observed holding an item in his hand, bringing it to his mouth and several puffs of smoke were observed rising above his head. The resident then headed back toward the facility in his wheelchair. Two surveyors walked up behind the resident as he approached the entrance to the facility. The resident was wearing a nasal cannula attached to a portable oxygen tank. The oxygen tank was observed to be on 0 liter flow. The resident was observed entering the facility, going to the elevator, entering the elevator and exiting on the Unit 2 where he proceeded to go directly to his room and did not check-in with staff. On 6/28/2017 at 9:05 AM, the resident was observed entering the elevator on the unit with his oxygen on at 3 liters and the nasal cannula in place. From 9:08 AM to 9:25 AM the resident was observed with 2 other residents and a staff member, outside on the sidewalk smoking. The resident was observed lighting a cigarette and standing up next to the oxygen tank without the nasal cannula on. CNA #39 was interviewed on 6/29/2017 at 9:30 AM. She stated the resident smoked and would go out by himself. He was suppose to sign out and did not always tell someone when he was going out. The secretary downstairs would monitor him. Nurse practitioner (NP) #6 was interviewed on 6/29/2017 at 9:45 AM. She stated the resident should not be smoking with oxygen on, it was dangerous and he could set himself on fire. LPN #5 was interviewed on 6/29/2017 at 9:55 AM. She stated the resident did go outside to smoke and needed reminders to remove his oxygen tank but she usually got to him first. The resident's cigarettes and lighter were kept in the med room but she thought he may have borrowed them from others too. He had a locked drawer in his room and he may have kept them there as well. She stated he was out smoking right now and she usually knew where he was. She would always look out the window to check on him. LPN Unit Manager #7 was interviewed on 6/29/2017 at 10:30 AM and stated the resident was not always compliant with returning his lighter or asking to remove his oxygen tank. He said but my tank is always off. It had been reported to her the other day he was outside smoking and his oxygen tank was on his chair. She stated the resident probably kept the materials on him or locked them in his drawer. Smoking with an oxygen tank was not safe as it was combustible. The attending physician was interviewed on 6/29/2017 at 11:00 AM. He stated the resident should not be smoking with an oxygen tank as it could potentially blow up. 2) Resident #18 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 2/14/2017 Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired and required extensive assistance with moving on and off the unit. The 2/7/2017 Admission Agreement signed by the resident's designated representative had no information pertaining to the facility's smoking policy. The 2/7/2017 nursing assistant accountability records (care instructions) did not document instructions related to the resident's desire or plan to smoke. A 2/9/2017 social history documented the resident used tobacco products. The resident's active comprehensive care plan (CCP), reviewed by the interdisciplinary team on 5/23/2017, documented conflicting information pertaining to the resident's cognition, behaviors and preference to smoke. The resident had been identified as a safe smoker, was interested in quitting, and agreed to reside in a smoke free facility. The resident had impaired memory, disorientation, disregards safety efforts, and had a decrease in cognition. In addition, the CCP documented the resident had good judgment. The CCP documented the resident refused to relinquish smoking materials and staff suspected the resident was smoking in his room as there was a smoke odor and occasional match found in the toilet. The resident had a history of [REDACTED]. The resident had supervised smoking sessions in a designated area at all times. The resident was offered smoking cessation program and refused at the time. Staff were to implement searches as necessary, provide counseling regarding risk of smoking and provide routine counseling/encouragement toward smoking cessation. A 6/1/2017 Smoking Assessment documented as a result of the assessment, the resident did not require a smoking apron. The 6/7/2017 physician orders [REDACTED]. A 6/16/2017 social services progress note documented when the social worker went to meet with the resident, he was in the bathroom and when he came out of the bathroom there was a strong smell of smoke. She asked him if he was smoking and he told the social worker he was not smoking in his room, but he would smoke if no one would bring him outside to smoke. She informed him if he smoked with oxygen he could blow up the building and others around. The social worker noted the resident told her if that was going to happen it would. On 6/28/2017 at 3:35 PM and on 6/29/2017 at 8:47 AM, a lighter was observed on top of the resident's television in his room. On 6/29/2017 at 10:30 AM, a cigarette butt was observed on top of the resident's television and the lighter was no longer present. On 6/28/2017 at 3:35 PM the resident stated he was out of cigarettes but was expecting his family member to bring some in. He smoked two cigarettes per day, and he kept his lighter and cigarettes on top of his television. He did not have a smoking schedule, and was taken outside to smoke when the staff had the time to take him out. During an interview with CNA #35 on 6/29/2017 at 10:44 AM, he stated there were times he heard at shift report the resident had snuck out to go smoke. He had not viewed the resident smoking himself. During an interview with social worker #31 on 6/29/2017 at 11:30 AM, she stated one day she brought the resident outside to smoke and he pulled cigarettes out of his pocket. Staff had not seen the resident smoking in the facility, but they did smell smoke in the room. She did not see the resident with matches, and staff had asked him if he they could hold his lighters. He would state he was waiting for an aide to bring him to smoke. The social worker stated therapy made a determination if a resident could smoke and nursing was responsible for updating the care plan to resident smoking preferences. During an interview with the Director of Nursing (DON) on 6/29/2017 at 12:00 PM, she stated the facility was aware the resident had smoking materials in his possession. The facility believed the resident had smoked in his room as they could smell smoke and had never witnessed the resident doing so. At one point the Administrator had attempted to approach the resident to retrieve smoking materials and the resident had become aggressive. 3) Resident #16 was re-admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 6/9/2017 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, was independent in her wheelchair on and off the unit, and was not a current tobacco user. The 2/11/2017 certified nurse aide (CNA) care instructions had no documentation regarding the resident's smoking preference. A nursing progress note dated 3/25/2017 at 10:00 AM, documented the Director of Nursing (DON) spoke with the resident about an incident with smoking which had occurred the day before. The DON explained the facility's no smoking policy to the resident and stated if the incident happened again, a wanderguard would be placed on the resident. The resident replied she didn't realize she couldn't and wouldn't do it again. The resident asked to be assessed to go outside and a referral was made to therapy for the resident to be assessed. There was no documented evidence in the nursing progress notes the resident had a smoking incident on 3/24/2017. A physician order [REDACTED]. The comprehensive care plan (CCP) was updated 5/30/2017 and documented the resident was considered a safe smoker and demonstrated good judgment and compliance and went outside with supervision. Interventions included to orient the resident to the facility smoking regulation, monitor ongoing smoking for adherence to procedures, supervision with staff and to turn smoking items in to be locked up but refuses. The 6/11/2017 CNA care instructions documented the resident could go outside with staff. There was no documentation related to the resident's plan to smoke. There was no documentation in the resident's record a smoking assessment was completed. LPN Unit Manager #7 was interviewed on 6/29/2017 at 10:30 AM. She stated the resident was a smoker and had to smoke outside with supervision and she could not get down there by herself so someone had to take her out. During an interview with the resident on 6/29/2017 at 11:05 AM, she stated her lighter goes to the nurse after use and she kept her cigarettes in a bag on her wheelchair. There was no sense to keep her lighter in her room as she was not allowed to do that and she had to go outside to smoke with a CNA. During the interview the resident showed the surveyor an unopened cigarette case. The Director of Nursing was interviewed on 6/29/2017 at 5:00 PM. She stated she did not recall an incident involving the resident and smoking from 3/2017. INTERVIEWS During an interview with RN Unit Manager #17 on 6/27/2017 at 9:10 AM, she stated there were 3 residents on the unit who desired to smoke, including Resident #18. During the initial unit tour interview on 6/27/2017 at 10:18 AM, licensed practical nurse (LPN) Unit Manager #7 stated there were 3 residents on the unit who smoked and Resident #16 was one of the 3. Physical therapy would assess the residents to determine smoking safety. Residents who smoked had to do so off the grounds by the bus stop and the materials were usually locked up in the med cabinet and sometimes the residents would not give them up. During an interview 6/28/2017 at 3:30 PM, CNA #3 stated the residents kept smoking materials on their person, even though they had the ability to lock them up in their nightstands. During an interview on 6/29/2017 at 10:20 AM, licensed practical nurse (LPN) #1 stated it was a non-smoking facility, but some residents were secretive about it and tried to hide the fact they were smoking. Residents who were smokers would keep their smoking supplies in their rooms. He knew Resident #18 kept his cigarettes and lighter locked in his nightstand because, he was good about that. During an interview with receptionist #32 on 6/29/2017 at 11:00 AM, she stated she had a list of residents who were able to go outside to smoke off of facility grounds on their own and Resident #3 was not on the list, and a list of residents who required supervision on which Resident #18 was listed. She had a list of residents who were able to go outside to sit alone and Resident #3 was on this list. The receptionist stated all residents who smoked were to go to the side walk, off the grounds, near the bus stop to smoke, I can't see down there to know if they are smoking. During an interview 6/29/2017 at 11:25 AM, RN Unit Manager #17 she stated Residents #9, 18 and 19 who resided on Unit 3 were smokers. All three residents had a safe smoking care plan, and Resident #18 had an additional not safe smoking care plan because they thought he sometimes went in the bathroom to smoke. Resident #9 had family who brought in cigarettes and she hid them, Resident #18 had a family member who brought him cigarettes, and Resident #19 bummed cigarettes off of other people. Nursing liked to keep track of smoking supplies, but the residents did not like to relinquish them. If the supplies were confiscated they were placed in a locked medicine cabinet. There was no set schedule for smoking, and the residents usually went out with staff on their smoke breaks. The social workers had spoken to the residents who smoked, but it never did anything. There was nothing specific in the care plans indicating where residents kept their smoking supplies. Residents signed out from the unit only if family took them out, and the front desk receptionist had a list of the residents who smoked. She was not aware Resident #18 kept his smoking materials on top of his television. During an interview with the Director of Rehabilitation on 6/29/2017 at 11:31 AM. She stated it was outside of physical therapy's scope of practice to complete a smoking assessment. She stated an assessment on the resident's physical function was completed by therapy and she would assess residents on oxygen for ability to maneuver the tank outside by themselves. A referral sheet would be sent for therapy to complete an assessment on ability go outside and the referral did not always specify if the resident wanted to smoke. An out on pass assessment was completed as the grounds were now smoke free and they would have to be off grounds to smoke. Resident #3 had an assessment on 6/2/2017 documenting he was ok to go out. It was nursing's responsibility to update the resident's plan of care based on the assessment. The Administrator was interviewed on 6/29/2017 at 5:15 PM. This had been the first facility she had worked at where there were residents who actively smoked. In 2/2017 she had initiated a new non-smoking policy which would make the facility smoke free. A resident council meeting was held to discuss the smoking policy and letters were sent to all residents and family members. The facility had offered a smoking cessation course by the American Heart Association, all but one smoking resident attended. All smokers were assessed by the therapy department to determine safety to smoke off of the property. If the resident was assessed as not being safe to smoke independently, a care plan was put into place which would require staff to accompany them while smoking. She was not aware of any smoking incidents that may have occurred during 3/2017. The Immediate Jeopardy situation was removed prior to survey exit of 6/30/2017 based on the following corrective actions taken. The facility: - Completed a full house audit to determine what residents desired to smoke, if they had smoking materials in their possession, and immediately removed and securing their smoking materials. - Conducted a Resident Council meeting with identified smokers to discuss safe smoking, including not smoking with oxygen. - Implemented steps to obtain and secure resident smoking materials that included a sign-in, sign-out procedure. - Conducted smoking/out on pass safety assessments of all residents who desired to smoke and care plans and care instructions updated to reflect result of assessments. - Developed and implemented education associated with safe smoking and plan for securing smoking materials that was provided to staff of all disciplines and involved residents. - Developed and implemented a plan to ensure facility grounds remain free of improperly discarded smoking debris. 10NYCRR 415.12

Based on record review and staff interview conducted during the extended and abbreviated surveys, 84 residents residents residing at the facility, including 7 of 7 residents reviewed for smoking (Residents #3, 9, 16, 18, 19, 20 and 21), the facility did not ensure Administrative staff administered the facility in a manner that enabled the use of resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, administration failed to: - to develop and implement a comprehensive smoking policy; - to consistently assess resident ability to smoke unattended and their ability to safely possess and use lighters and matches; - to develop individualized comprehensive care plans to address how the facility would assure safety for the residents who smoked, assure that smoking would not occur in areas not designated for smoking, and communicate resident care plans to responsible staff; - to assure adequate supervision was provided to residents who were not able to smoke safely while unattended or while on oxygen therapy; and - to have a system in place to adequately secure smoking materials when not in use. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. Findings include: Refer to F323 Free of Accident Hazards/Supervision/Devices During an interview with the Director of Nursing (DON) on 6/29/2017 at 12:00 PM, she stated as of 1/1/2017 the facility wanted to go non-smoking. An outside agency had come in and completed a non-smoking cessation course for the residents. Several residents who wished to smoke still continued to do so. Residents were to give lights and cigarettes to the nurse and she thought there was a policy on this. It was recommended to the Unit Managers to update the certified nurse aide (CNA) care instructions and the comprehensive care plan (CCP) for smoking residents. A letter had been sent notifying families of the new non-smoking policy. The Administrator was aware one of the residents, Resident #18, had his smoking materials in his room prior to survey, as the Administrator went to the resident's room to get the smoking materials and the resident responded physically. When interviewed on 6/29/2017 at 4:50 PM, the DON and the Administrator were asked by the surveyor for a smoking policy prior to the facility becoming smoke free in 2/2017. They stated they would look for one. When interviewed on 6/29/2017 at 5:10 PM, the Administrator stated she had jump drive files (portable data storage devices) from the previous 2 Administrators and was unable to locate a smoking policy prior to the facility becoming smoke free. The Administrator was interviewed on 6/29/2017 at 5:15 PM. She stated this had been the first facility she had worked at where there were residents who actively smoked. In 2/2017 she had initiated a new non-smoking policy which would make the facility smoke free. A resident council meeting was held to discuss the smoking policy and letters were sent to all residents and family members. The facility had offered a smoking cessation course presented by the American Heart Association and all but one smoking resident attended. Any smokers were assessed by the therapy department to determine if they were safe to smoke off of the property. If the resident was assessed as not being safe to smoke independently, a care plan was put into place which would require staff to accompany them while smoking. The facility was unable to provide any additional policies or procedures related to smoking prior to the Immediate Jeopardy on 6/29/2017 at 5:58 PM. The Immediate Jeopardy situation was removed prior to survey exit of 6/30/2017 based on the following corrective actions taken. The facility: - Completed a full house audit to determine which residents desired to smoke, if they had smoking materials in their possession, and immediately removed and secured their smoking materials. - Conducted a Resident Council meeting with identified smokers to discuss safe smoking, including not smoking with oxygen. - Implemented steps to obtain and secure resident smoking materials that included a sign-in, sign-out procedure. - Conducted smoking/out on pass safety assessments of all residents who desired to smoke. Care plans and care instructions were updated to reflect the results of assessments. - Developed and implemented education for staff of all disciplines and involved residents, associated with safe smoking and plans for securing smoking materials. - Developed and implemented a plan to ensure facility grounds remained free of improperly discarded smoking debris. 10NYCRR 415.26

Based on record review, interview, and observation conducted during the recertification and abbreviated surveys (NY 111), it was determined for 1 of 4 residents (Resident #11) reviewed for pressure ulcers, the facility did not ensure necessary treatment and services were provided to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #11 was admitted with a Stage II (partial thickness loss of skin layers) pressure ulcer and experienced actual harm as the wound worsened when the facility did not ensure treatments were completed as ordered and did not ensure nutritional interventions for pressure ulcer healing were implemented timely. The facility: - did not ensure a qualified professional assessed the resident's pressure ulcer when it worsened and when a new pressure ulcer was identified; - did not ensure physician ordered treatments were administered as ordered; - did not ensure weekly complete and thorough assessments of pressure ulcers were done; and - did not ensure nutritional interventions recommended for wound healing were implemented timely. Findings include: Resident #11 had [DIAGNOSES REDACTED]. The registered nurse (RN) admission assessment dated [DATE] documented the resident was admitted with a Stage II pressure ulcer to the coccyx (tailbone). The admission physician's orders [REDACTED]. The comprehensive care plan (CCP), undated, documented the resident had pressure ulcers. Interventions included pressure relieving mattress/chair cushion, repositioning every 2 hours, provide adequate nutrition, and treatments in accordance with physician orders. There was no documentation as to when the undated CCP was initiated. The resident's weekly pressure ulcer/wound flowsheets for the coccyx documented: - on 1/28/2016, a Stage II pressure ulcer/suspected deep tissue injury (DTI) was present that was 3 centimeters (cm) x 1 cm. The appearance was described as a 5 x 5 bruising area with sero drainage; and - on 2/2/2016, the coccyx was unchanged and measured 1.5 cm x 0.4 cm; the wound bed was pink and there was no drainage. - there were no further measurements of the coccyx pressure ulcer until 3/8/2016, when it measured 8 cm x 4 cm x 1 cm. The primary physician's admission history and physical dated 2/3/2016 documented the resident had no bed sores or rashes. The initial registered dietitian's (RD) assessment dated [DATE] at 2:34 PM documented the resident lost 6.9 pounds while in the hospital, his current weight was 162.8 pounds, and his intake was poor to fair. The [MEDICATION NAME] (measure of protein stores) was low at 2.2 grams/deciliter (g/dL-normal range 3.4-5.4 g/dl), and he had a Stage II pressure ulcer. The resident's protein needs were assessed to be increased at 1.3-1.5 grams/kilogram (g/kg) and 60 milliliters (ml) of 2 Cal (dietary supplement) 4 times daily was recommended. There was no documented evidence the 2 Cal was ordered after being recommended by the RD. The physician's orders [REDACTED]. The medical record contained no documented evidence the resident's coccyx pressure ulcer was assessed by a qualified professional when the treatment was changed to Santyl and no documentation of an assessment of the newly identified area on the right buttock. The resident's 2/6/2016 through 2/8/2016 Treatment Administration Record (TAR): - did not document that Santyl was administered to the coccyx as ordered; - did not document the ordered treatment of [REDACTED]. - documented that [MEDICATION NAME] with A&D continued to be administered 3 times daily to the coccyx when the ordered treatment was Santyl. The physician's orders [REDACTED]. The licensed practical nurse (LPN) progress note dated 2/9/2016 at 3:55 PM documented the resident's pressure ulcer treatments had changed. There was no documentation the resident was assessed by a qualified professional on 2/9/2016 when Santyl was changed to [MEDICATION NAME]. The resident's TAR for 2/9/2016 - 2/29/2016 documented: - [MEDICATION NAME] was administered to the black wound bed on the coccyx twice daily; and - [MEDICATION NAME] with A&D was administered to the right buttock twice daily. The dietetic technician's (DT) progress note dated 2/23/2016 at 2:09 PM documented the resident's weight was 156 pounds; he was down 6.8 pounds since admission; and protein needs remained unchanged from the previous assessment. The dietetic technician recommended 2 Cal, 60 ml 4 times daily per the RD's prior recommendation (20 days after it was initially recommended by the RD). The physician order [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, he required extensive assistance with activities of daily living (ADLs), and pressure ulcers were present (one Stage I/observable area of skin alteration, and one Stage II that was present upon admission). The medical record did not document the resident's coccyx pressure ulcer and right buttock wound were assessed by a qualified professional from 2/10/2016 - 3/7/2016. The resident's TAR for 3/1/2016 - 3/17/2016: - documented [MEDICATION NAME] was administered to the black wound bed on the coccyx twice daily; - did not document the ordered treatment of [REDACTED]. - documented that [MEDICATION NAME] with A&D was administered 3 times daily to the coccyx, when the ordered treatment was [MEDICATION NAME]. The RD's progress note dated 3/3/2016 at 12:58 PM documented the resident's weight declined 12% in 1 month; he weighed 143.3 pounds; and protein needs were unchanged from the previous assessment. The 3/5/2016 nurse practitioner (NP) note documented the resident appeared frail and had a sacral (coccyx) wound. The assessment documented it was the initial encounter of the sacral wound. Assessments of the pressure ulcers were not documented by the NP. The LPN note dated 3/8/2016 at 11:10 PM documented the resident's coccyx area remained necrotic (dead tissue). The weekly pressure ulcer/wound flowsheets for the resident documented: - on 3/8/2016, the coccyx pressure ulcer measured 8 cm x 4 cm x 1 cm. The flowsheet did not document that the ulcer had deteriorated. - on 3/15/2016, the coccyx pressure ulcer measured 6.3 cm x 4 cm x 0 cm. - on 3/22/2016, the coccyx pressure ulcer measured 8 cm x 4 cm x 0 cm. On all three dates, the flowsheets did not document: the stage; the status of the wound bed; the drainage; the treatment; or any interventions added. The 3/18/2016 physician's orders [REDACTED]. There was no documentation in the medical record as to why resident's treatments were changed to Santyl. The resident's 3/18/2016 through 3/24/2016 TAR and Medication Administration Record (MAR): - documented that Santyl, to the right and left coccyx, was transcribed onto the MAR and not the TAR, and was not signed as administered; - documented that [MEDICATION NAME] was administered to the black wound bed on the coccyx twice daily, when Santyl was the ordered treatment; and - documented that [MEDICATION NAME] with A&D was administered 3 times daily to the coccyx, when the ordered treatment was Santyl. The Director of Nursing (DON) stated in an interview on 3/22/2016 at 10:54 AM that the unit currently had no RN Manager; the RN Managers from the other units were covering; and she helped out at times. LPN #11 was interviewed on 3/24/2016 at 11:30 AM, and stated first and second checks of the physician order [REDACTED]. She stated there was no verification that the three checks were done other then a check mark next to the TAR order. She stated the process for transcribing an order onto the TAR was the first nurse transcribed it, a second nurse verified it, and both signed the order. She stated the resident's 3/18/2016 order for Santyl was transcribed by the RN Supervisor onto the Medication Administration Record (MAR) and not the TAR, and nobody noticed it. During an observation by the surveyor on 3/24/2016 at 11:30 AM, LPN #14 removed the dressing from the resident's coccyx. The pressure ulcer measured approximately 8 cm x 6 cm, and a foul odor was present. The top third of the ulcer was necrotic, the middle third had yellow slough (dead tissue), and the bottom third had mostly red granulation tissue with a small area of yellow slough toward the bottom left side. LPN #14 cleansed the ulcer with normal saline, applied [MEDICATION NAME] on the necrotic area, applied [MEDICATION NAME] with A&D to the remainder of the ulcer, and covered it with a bordered gauze. LPN #14 stated in an interview on 3/24/2016 at 11:45 AM that the resident's ulcer at admission was small, about nickel size, and it was reddened around the outside of the ulcer. She stated that at one point green drainage was present, and eventually the ulcer got smaller and then grew bigger again. The attending physician stated in a telephone interview on 3/25/2016 at 1:00 PM: - he expected pressure ulcers to be monitored weekly by nursing and that he would be notified when pressure ulcers changed; - he assumed the coccyx pressure ulcer had a significant change when the treatment was changed from [MEDICATION NAME] to Santyl on 2/5/2016; - when [MEDICATION NAME] continued from 2/5/2016 through 2/8/2016, it was not a comparable treatment to Santyl, and did not recall if he was notified that Santyl was not administered as ordered; - when the ulcer was not assessed from 2/3/2016 through 3/8/2016, he did not recall if he was notified; - when the ulcer changed from 1.5 cm x 0.4 cm on 2/2/2016, to 8 cm x 4 cm x 1 cm on 3/8/2016, it was a significant change and he did not recall if he was notified; - when Santyl was ordered on [DATE] and not implemented until 3/24/2016, he did not recall if he was notified; - he usually became aware of dietary recommendations via word of mouth, or by looking in a blue binder on the unit; and - he did not consider it timely when it took 20 days to get the resident's 2 Cal implemented. The DON was interviewed 3/25/2016 at 1:45 PM and stated: - wound rounds occurred weekly on Tuesdays and she was on the team; - the team monitored for ulcer deterioration and notified the physician of changes; - wound round documentation should include measurements, color, what the wound bed looked like, and drainage, and she did not consider the resident's weekly ulcer flowsheets to be complete; - on 2/5/2016, the pressure ulcer worsened and the treatment was changed to Santyl to debride the ulcer. She stated she was not aware that the treatment was not changed and [MEDICATION NAME] was continued from 2/5/2016 through 2/8/2016, and stated that [MEDICATION NAME] was not an equivalent treatment to Santyl; - when the ulcer was not assessed from 2/3/2016 through 3/8/2016, she was not sure why; she recalled being at the facility during that time, she did not think four weeks between assessments was timely, and did not recall if the physician was notified; - on 3/8/2016, the ulcer deteriorated, the treatment at the time was appropriate, and she did not recall if the physician was notified the wound changed; - when Santyl was ordered on [DATE], she stated the wound team did not recommend it and was not sure why it was ordered, and a nursing progress note should have been documented by the nurse that obtained the order; and - on 3/24/2016, she became aware that Santyl was not implemented because the night shift Supervisor reported it to her. She stated the nurse said it was an oversight. The RD was interviewed on 3/25/2016 at 2:00 PM and stated initial nutrition assessments were completed within 14 days of admission and frequently occurred between days 3 and 9. For compromised residents with wounds and low [MEDICATION NAME], the RD stated that interventions should be implemented within four days. She stated that recommending 2 Cal seven days after the resident was admitted was reasonable, and it was not always in the best interest of the resident to jump on things right away. The RD stated the system for communicating recommendations with the physician had changed in the last three weeks. She stated she had to communicate with the nurse Manager about the recommendation and now wrote them directly on to a blank order sheet for the physician to sign. She stated that 20 days for the resident's 2 Cal to be initiated was not timely, and the old system of communicating recommendations may have been to blame for the delay. The dietetic technician was interviewed on 3/25/2016 at 2:00 PM, and stated that upon admission she obtained the resident's diet and food preferences. For a compromised resident with wounds and low [MEDICATION NAME], she stated that interventions should be implemented by the next day. RN Supervisor #6 was interviewed on 3/25/2016 at 2:45 PM, and stated that she did not recall why she obtained an order for [REDACTED]. When asked if she was aware she transcribed Santyl onto the MAR and not the TAR, she stated that nobody had spoken with her and this was the first time she heard about it. She stated she did not discontinue the previous treatment from the TAR at the time she transcribed Santyl, but she should have. 10NYCRR 415.12(c)(1)(2)

Based on record review, observation, and interview conducted during the standard survey, it was determined for 1 of 21 sampled residents (Residents #1), facility did not provide the necessary care and services to attain or maintain the highest practicable physical well being. Specifically, Resident #1 was administered [MEDICATION NAME] 3 times a day, instead of 3 times a week subsequently resulting in abnormal lab values requiring intravenous (IV) fluids, and developed [MEDICAL CONDITION] at the IV site requiring antibiotic treatment. This resulted in actual harm for Resident #1 that is not immediate jeopardy. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The comprehensive care plan (CCP) dated 7/9/2013 documented the resident urinated "frequently on the floor." The plan included to toilet the resident around routine daily functions and as needed, and to monitor for signs and symptoms of an infection. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nursing notes documented the resident was sent to the hospital on [DATE] following a fall, and was readmitted to the facility on [DATE]. The hospital's transfer summary dated 9/24/2013 documented the resident fell at the nursing home on 9/21/2013 and sustained a fractured right hip, which was surgically repaired. The resident had no [MEDICAL CONDITION] (swelling) and medications would be continued including [MEDICATION NAME] 20 mg 3 times daily before meals. A medication list attached to the transfer summary documented "HOME" medications, "No new orders/changes" and was checked to "continue" by the facility's nurse practitioner (NP) on 9/24/2013. The readmission orders [REDACTED]. The resident's CCP dated 9/24/2013 documented to toilet per policy and as needed. The resident's 10/2013 MAR indicated [REDACTED]. The resident's laboratory test results, dated 10/1/2013, documented: - BUN (blood urea nitrogen, measure of kidney function and hydration status) was high at 34 mg/dl (milligrams per deciliter, normal = 7-18 mg/dl, - sodium (measure of hydration status) was slightly high at 146 mEq/L (miliequivelents per Liter), normal = 136-145 mEq/L, and - creatinine (measure of kidney function) was elevated 1.51 mg/dl, normal=0.80-1.30 mg/dl. The laboratory documented the results were faxed to the resident's physician along with past results for comparison. The Minimum Data Set (MDS) assessment signed as completed on 10/4/2013, documented the resident's cognition was severely impaired. The resident required extensive assistance with most activities of daily living (ADLs). A registered dietitian's (RD) progress note dated 10/4/2013 documented the resident was at the lower end of his recommended weight range at 140.6 pound. The CCP dated 10/9/2013 documented the resident was a increased hydration risk, was to consume sufficient fluids, and have acceptable blood pressure, hydration laboratory test results, and weight. Staff were to monitor for [MEDICAL CONDITION], and elevate the residents legs. The CCP documented the resident had a history of [REDACTED]. The CCP dated 10/11/2013 by the registered nurse (RN) Manager documented a goal for the resident to have less incontinent episodes through next review and to record the resident's meal and liquid intake for each meal. A licensed practical nurse (LPN) progress note documented on 10/11/2013 at 10:08 PM, the resident urinated in the hallway, twice that shift, after being toileted. The physician's orders [REDACTED]. The orders documented the resident was to receive [MEDICATION NAME] 20 mg 3 times daily and had a "stop date" of 11/17/2013. Nursing progress notes documented: - on 10/21/2013 at 8:48 PM, staff anticipated the resident's needs, he was at times fed by staff, and he urinated in the dining room; - on 10/22/2013 at 12:07 PM, the resident continued to urinate in hall after being toileted; - on 10/24/2013 at 6:36 PM, the resident continued to "void in hall"; and - on 11/2/2013 at 5:16 PM, the resident continued to urinate on the floor. There was no documentation in the resident's medical record in 10/2013 the resident had [MEDICAL CONDITION]. There was no documented evidence following 10/11/2013 in the medical record the resident's CCP was reassessed to address his frequent urination. An RD note dated 11/4/2013, documented the resident weighed 127.1 pounds which was below his goal weight range of 140 - 150 pounds and was indicative of excessive, unplanned significant weight loss within 30 and 90 days. The note recorded the resident was at increased nutrition and hydration risk. Nursing progress notes documented: - on 11/7/2013 at 6:14 PM, the resident continued to void in the hall after being toileted; - on 11/9/2013 at 5:48 PM, the resident continued to be on a toileting scheduled but continued to be incontinent and required 1:1 assistance at meal time; - on 11/10/2013 at 10:04 AM, the resident was fed by staff; - on 11/11/013 at 5:07 PM, the resident pulled out his private parts in the dining room and hallway, staff then toileted the resident; and - on 11/12/2013 at 6:38 PM, the resident had an incontinence episode in the dining room and the hall and the toileting schedule was followed. There was no documentation in the resident's medical record in 11/2013 the resident had [MEDICAL CONDITION]. There was no documented evidence the resident's CCP was reassessed to address his frequent urination. The resident's 11/2013 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A nursing progress note dated 11/16/2013 documented the resident's family called twice concerned about the resident's [MEDICATION NAME] order. The note recorded the resident's attending physician was notified. The physician's orders [REDACTED]. laboratory results dated [DATE] documented the resident's: - BUN was elevated at at 149 mg/dl; - sodium was elevated at 159 mEq/L; - chloride was elevated at 123 mEq/L (normal=98-107 mEq/L); and - creatinine was elevated at 5.25 mg/dl. The physician's orders [REDACTED]. Nursing progress notes documented: - on 11/17/2013 at 3:01 PM, an IV was started in the resident's left elbow pit; - on 11/17/2013 at 8:57 PM, the resident pulled the tubing out of the port, and the Supervisor re-attached the tubing; - on 11/18/2013 at 12:14 PM, the resident's IV site was bleeding and the solution was not infusing. The IV was restarted in the resident's left forearm and the arm was wrapped with Kling (gauze wrap); and - on 11/18/2013 at 6:04 PM, the resident urinated on the floor despite being toileted every 2 hours. laboratory results dated [DATE] documented the resident's: - BUN was elevated at 116 mg/dl, creatinine was elevated at 3.09 mg/dl; - sodium was elevated at 160 mEq/L; and - chloride was elevated at 128 mEq/L. The attending physician documented in a progress note on 11/19/2013, that he made a "mistake" as the [MEDICATION NAME] was given to the resident 3 times a day instead of decreased to once a day. The physician contacted the daughter to "apologize." The resident had a significant elevation in his BUN, creatinine and [MEDICAL CONDITION]. The resident's IV was continued, and the [MEDICATION NAME] was discontinued. The physician's orders [REDACTED]. The laboratory results dated [DATE] documented the resident's: - BUN was elevated at 36 mg/dl; - creatinine was slightly elevated at 1.33 mg/dl; - sodium was elevated at 156 mEq/L; and - chloride was elevated at 125 mEq/L. The physician's orders [REDACTED]. The nursing progress notes documented: - on 11/21/2013 at 3:26 PM, the IV was restarted over the left forearm, no redness or swelling seen over the site; - on 11/21/2013 at 9:01 PM, the resident pulled out the IV at 6:30 PM, and it was restarted in the left forearm; - on 11/22/2013 at 4:27 PM, the resident's IV was infusing well. Upon check of the insertion site, it was somewhat inflamed, his left hand was puffy and he complained of pain in his hand and wrist when palpated. The physician was notified and ordered the IV's discontinued and to encourage oral fluids; - on 11/24/2013 at 4 PM, the resident's left wrist was reddened, [MEDICAL CONDITION] and warm to touch. The physician was notified and ordered Keflex (antibiotic) 500 mg by mouth every 8 hours for 1 week; - on 11/25/2013 at 2:42 AM, the resident's left wrist was [MEDICAL CONDITION] and warm to touch; and - on 11/28/2013 at 9:21 AM, the resident continued on antibiotic for [MEDICAL CONDITION] of left hand. The hand was slightly warm to touch, and slightly pink in color. During an interview with the registered nurse (RN) Manager on 1/9/2014 between 11:30 AM and 12:10 PM, he stated that when the resident was readmitted from the hospital following the [MEDICAL CONDITION] he was responsible to review the resident's orders and contact the physician. He stated the resident previously resided on another unit within the facility and he was not familiar with the resident's medications or records. He stated he did not review the resident's previous orders/medications when he was readmitted . He stated the discharging doctor from the hospital was the same as the facility's attending physician so he contacted the physician by phone when the resident returned to the nursing facility to clarify the medication orders. If the physician was the same physician as the discharging hospital physician, he would ask overall if there were any changes to the orders. He would not read through each of the orders/medications to the physician over the phone. He stated that the resident's daughter was concerned about the [MEDICATION NAME] and that was when laboratory work was ordered. He stated the resident had occasions where he would grab his groin and have increased urination. He said he knew the resident had some incontinence/urination "behaviors" on his previous unit so he had not thought anything of it, and did not reassess the resident's CCP. He stated they started him on a toileting plan and there were no other changes made to the CCP to address the urination. The plan was to bring the resident to the bathroom when he started to make those movements. During an interview with the Director of Social Services on 1/9/2014 at 12:20 PM, she stated the resident looked perkier now than he had a couple months prior, and that the resident went up and down for awhile. She said he was not alert and oriented. During an interview with the resident's daughter on 1/9/2014 at 12:35 PM, she stated that the resident had a decreased appetite, increased lethargy, difficulty standing, and decreased talking. She stated she asked to see the resident's medications and she became aware the resident was receiving [MEDICATION NAME] 3 times a day. The doctor was notified and labs were order. The doctor then ordered an IV as the resident was "severely dehydrated." During an interview with the attending physician on 1/9/2014 at 12:44 PM, he stated when the resident was in the hospital, he received [MEDICATION NAME] 3 times a day. When the resident returned to the facility, the [MEDICATION NAME] 3 times a day continued. His daughter noticed changes in the resident's energy and mood and spoke with the nurse on the unit. At that time, the daughter became aware the resident was receiving the [MEDICATION NAME] 3 times a day, not 3 times a week. The physician stated he then ordered laboratory tests that showed an elevated creatinine and BUN, and the resident was dehydrated. The physician spoke to the daughter and IV fluids were given. The physician stated, it was a mistake, and the resident should have been receiving [MEDICATION NAME] 3 times a week, not 3 times a day. He approved the resident's medical orders upon return from the hospital, and continued to reorder them, and it was an oversight. He stated, the resident was under his care, he approved the medicine, and [MEDICATION NAME] 3 times a day was too much for a nursing home resident. During an interview with the Director of Nursing (DON) on 1/9/2014 at 12:50 PM, she stated that the doctor did not intend for [MEDICATION NAME] to be given in that way. She stated when a resident came into the facility, the discharge orders were sent with the resident and an RN transcribed what was on the discharge order to the physician's orders [REDACTED]. On 1/9/2014 at 2:10 PM, the DON stated in an interview, it was not a transcription error on the part of nursing it was a "forced error" as the doctor wrote the order. She stated if she was administering medications she might not have questioned the order if the resident had [MEDICAL CONDITION] or [MEDICAL CONDITION] as diagnoses. She stated if the resident's daughter did not review his medications, the facility would not have found the error. The daughter told the RN and the RN told the DON on 11/18/2013. The doctor said he did not intend that to be the order. She did not look at the issue as a medication error. The RN Manager, who was present, stated the resident was new to him and he did not review the resident's medical record prior to the date he arrived on his unit. The resident had swelling post-op which was not unusual and lethargy and pain, which was also not unusual for a post-op patient. The DON stated the facility would not review the resident's prior medical record after a hospital readmission as that was a new admission, and for a new or different reason. The DON said if a resident was admitted on an off shift, the RN was to review the admission orders [REDACTED]. 10NYCRR 415.12

Based on observation, record review, and interview conducted during the standard survey, it was determined for 1 of 21 sampled residents (Resident #1), the physician did not review the resident's total program of care, including medications at each visit, prior to signing the physician's orders. Specifically for Resident #1 the physician did not review the ordered medications for accuracy after the resident was readmitted from the hospital, and the resident received [MEDICATION NAME] 3 times a day instead of 3 times a week, resulting in abnormal lab values requiring intravenous (IV) fluids, and the development of [MEDICAL CONDITION] at the IV site requiring antibiotic treatment. This resulted in actual harm for Resident #1 that is not immediate jeopardy. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission physician's orders dated 4/2/3013 documented the resident was to receive [MEDICATION NAME] (a fluid pill) 3 times a week, on Monday, Wednesday and Friday. The comprehensive care plan (CCP), dated 4/10/2013, documented the resident had dementia, was not able to voice his needs, and staff were to anticipate his needs. The resident was incontinent of bladder, was to have intake and output monitoring, staff were to encourage fluids, and lab work was to be done as ordered. The resident had a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired. The resident required extensive assistance with most activities of daily living (ADLs) and was frequently incontinent of bladder. Nursing progress notes documented the resident was hospitalized from [DATE] to 9/24/2013 following a fall at the nursing facility. The hospital discharge summary dictated on 9/24/2013 at 10:48 AM, documented the resident had a fall at the nursing home and was admitted to the hospital for a right [MEDICAL CONDITION] that was surgically repaired during admission in the hospital. The laboratory studies done on 9/24/2013 documented the resident's BUN (blood urea nitrogen, measure of kidney function and hydration status) was slightly elevated at 20 mg/dl (milligrams per deciliter), normal = 7-18 mg/dl, sodium (measure of hydration status) was normal at 142 mEq/L (milequivelents per liter), normal = 136-145 mEq/L, and creatinine (measure of kidney function) was normal at 1.28 mg/dl, normal = 0.80-1.30 mg/dl. During the hospitalization , the resident received [MEDICATION NAME] 3 times a day and was discharged with a recommendation for [MEDICATION NAME], 20 milligrams 3 times a day. The resident's readmission orders [REDACTED]. The 10/20/2013 physician's orders were not signed by the attending physician and were signed by a nurse in the "Nurse Review" section. The orders documented the resident was to receive [MEDICATION NAME], 20 mg 3 times daily and there was a "stop date" of 11/17/2013. The nursing progress note dated 11/16/2013, documented the family called twice related to a concern about the resident's [MEDICATION NAME] order and nursing notified the attending physician. The physician's orders dated 11/16/2013 documented to hold the [MEDICATION NAME] until further notice and do blood work on 11/17/2013. laboratory results dated [DATE] documented the resident's BUN was elevated at 149 mg/dl, sodium was elevated at 159 mEq/L, chloride was elevated at 123 mEq/L, normal = 98-107 mEq/L, and creatinine was elevated at 5.25 mg/dl. The physician's orders, dated 11/17/2013 documented the [MEDICATION NAME] was to be discontinued and intravenous (IV) fluids were to be initiated of 1/2 normal saline at 100 cubic centimeters (cc) per hour until 11/19/2013. The resident was to have a basic metabolic panel (BMP, blood work) checked on 11/19/2013 and 11/22/2013. laboratory results dated [DATE] documented the resident's BUN was elevated at 116 mg/dl, creatinine was elevated at 3.09 mg/dl, sodium was elevated at 160 mEq/L, and chloride was 128 mEq/L. The physician's orders dated 11/19/2013 documented to continue the resident's IV of 1/2 normal saline at 100 cc per hour through 11/21/2013 and obtain a CBC (complete blood count, blood work) and BMP on 11/21/2013. The resident's attending physician documented in a progress note on 11/19/2013, that he made a "mistake" as the [MEDICATION NAME] was given to the resident 3 times a day instead of being decreased to once a day. The physician contacted the resident's daughter to "apologize." The physician documented the resident had a significant elevation in his BUN, creatinine and [MEDICAL CONDITION]. The resident's IV was continued, and the [MEDICATION NAME] was discontinued. During an interview with the registered nurse (RN) Manager on 1/9/2013 between 11:30 AM and 12:10 PM, he stated that the discharging doctor from the hospital may be the same admitting physician to the nursing facility. He stated that he would contact the doctor by phone when the resident returned to the nursing facility to clarify medication orders until the physician was able to come in to the facility. If the physician was the same physician as the discharging physician, he would ask overall if there were any changes to the orders. He would not read through each of the orders/medications to the physician over the phone. He would then fax the orders to the pharmacy. When the physician came in he would sign the paper orders. During an interview with the attending physician on 1/9/2014 at 12:44 PM, he stated when the resident was in the hospital, he received [MEDICATION NAME] 3 times a day. When the resident returned to the facility, the [MEDICATION NAME] 3 times a day continued. The resident's daughter noticed changes in the resident's energy and mood and spoke with the nurse on the unit. At that time, the daughter became aware the resident was receiving the [MEDICATION NAME] 3 times a day which was not his previous order. The physician stated at that time, he ordered labs and the labs showed an elevated creatinine and BUN, and the resident was dehydrated. The physician spoke to the daughter and IV fluids were given. The physician stated, it was an error, the resident should have been receiving [MEDICATION NAME] 3 times a week and not 3 times a day when he returned from the hospital. He stated he approved the resident's medical orders upon return from the hospital, and continued to reorder them, and it was an oversight. He did and was responsible for reviewing the resident's medication orders. He stated, the resident was under his care, he approved the medicine, and [MEDICATION NAME] 3 times a day was too much for a nursing home resident. During an interview with the Director of Nursing (DON) on 1/9/2014 at 12:50 PM, she stated the physician did not intend for the [MEDICATION NAME] to be given in that way. She stated when a resident was admitted , the discharge orders were sent with the resident and an RN transcribed them onto the physician's order form. The physician signed for the medications prior to admission and the nursing staff did not have to call the physician when a resident arrived at the facility, as they would follow the discharge summary. She stated a nurse would call the physician if they had medication questions. On 1/9/2014 at 2:10 PM, the DON stated in an interview, it was not a transcription error on the part of nursing it was a "forced error" as the physician wrote the order. She stated if the resident's daughter did not review the medications, the facility would not have found the error. The DON said the physician said he did not intend that to be the order. 10NYCRR 415.15(b)(2)iii

Based on record review and interview conducted during the extended survey, it was determined for 1 of 13 residents (Resident #2), reviewed for physician services, the facility did not ensure the physician reviewed the resident ' s total program including medications and treatments, and signed and dated orders. Specifically, Resident #2 order to flush the nephrostomy tube as needed, did not document the parameters to be followed, and was not reviewed or signed by the Physician or Nurse Practitioner. This resulted in no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Findings include: Resident #2 had [DIAGNOSES REDACTED]. The hospital Transfer Summary Report [REDACTED]. The summary did not document care specific to the nephrostomy tubes. A physician order dated 2/28/2014 documented the resident's nephrostomy tubes were no to be irrigated, and if the tubes stopped draining to notify the resident's urologist. The licensed practical nurse (LPN) progress note dated 3/13/2014 at 1:03 PM, documented urology was notified the resident had strands of hematuria (blood in urine) draining from the nephrostomy tubes. The note had documented that per the nurse at the urologist office if the urine did not look like ketchup do not treat and the nurse would let the urologist know. The LPN note dated 3/13/2014 at 1:57 PM documented the NP, after consulting with the urologist, ordered the resident's nephrostomy tubes could be gently irrigated with with "100 cc" of normal saline solution as needed for occlusion or large clots. A nurse practitioner (NP) telephone order, written by a licensed practical nurse (LPN), dated 3/13/2014 documented if the resident ' s nephrostomy tube had large clots or became occluded the nephrostomy tubes may be irrigated gently with 10 cubic centimeters (cc) of normal saline as needed. The order was not signed by the physician or NP. The order did not document how often the nephrostomy tube was to be flushed, who was to flush the tubes or when resident's physician should be notified. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact, required extensive assistance with most activities of daily living (ADLs) and the resident had nephrostomy tubes. During an interview with the resident ' s attending physician on 3/18/2014 at 1:15 PM he stated the resident was a very complicated case and he expected nursing would be monitoring the resident ' s nephrostomy tubes for blood and notify him. He stated if there was blood or occlusion in the resident ' s nephrostomy tubes the urologist would most likely be notified or the resident sent to the hospital for evaluation. He stated he was not aware there was an order to flush the resident's nephrostomy tube as needed. During an interview with the licensed practical nurse on 3/18/2014 at 1:40 PM, she stated she notified the urologist office regarding strands of blood that were in the resident ' s nephrostomy drainage. She stated she then notified had the NP regarding her conversation with the urologist office, and she had received a verbal order from the NP to flush the resident ' s nephrostomy tubes if clots were noted or the tubes became occluded. During an interview with the registered nurse (RN) Unit Manager on 3/18/2014 at 1:50 PM she stated she was not aware there was a NP order to flush the resident's nephrostomy tubes as needed. During an interview on 3/18/2014 at 3:20 PM, with the NP, who gave the order for irrigation of the resident's nephrostomy tubes, she stated the order should have contained parameters regarding flushing the residents nephrostomy tubes. She said the order should direct every 8 hours as needed or every 12 hours as needed, and it was a concern the order did not document a time frame as to how often the resident ' s nephrostomy tubes should be flushed. During an interview with the Director of Nursing (DON) on 3/18/2014 at 2:48 PM, she stated she was not familiar with the order to flush the resident ' s nephrostomy tubes. She said the order was not specific and did not tell her anything. She stated for the nursing staff to flush nephrostomy tubes they would need to be educated and signed off on the procedure. She was unsure if the nursing staff were educated regarding flushing of nephrostomy tubes and she would have to do some research regarding education and whether or not the licensed practical nurse can flush nephrostomy tubes. During an interview with the urologist on 3/18/2014 at 3:40 PM, he stated that he could not directly recall the conversation regarding the resident's nephrostomy tubes. He stated the intention of the flush was to keep the urine flowing, and if the resident ' s nephrostomy tube did not flush easily the resident should be transported to the hospital. 10NYCRR 415.15(b)(1)(i)(ii)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility failed to ensure policies and procedures were implemented that prohibited mistreatment, abuse and neglect of residents for 2 of 23 sampled residents (Residents #6 and 9). Specifically, for Resident #6, the facility failed to implement their policy when they did not ensure a thorough and accurate investigation was completed, when the care plan was not followed, to determine if abuse/neglect occurred. For Resident #9, the facility failed to implement their policy when they did not thoroughly investigate an incident of alleged physical abuse. This resulted in no actual harm with the potential for serious harm to resident health and safety that was Immediate Jeopardy and Substandard Quality of Care for Residents #6 and 9. Findings include: The facility's undated policy "Abuse/Neglect/Mistreatment of [REDACTED]. - "The term neglect shall mean failure to provide timely, consistent, safe, adequate and appropriate services, treatment and care." - All staff will be made aware of events and occurrences that can constitute or contribute to abuse as well as the signs and symptoms that can identify a person had been abused. - On knowledge or reporting of any allegation of abuse, neglect, mistreatment or misappropriation, an investigation will be conducted and the State Department of Health will be notified of the occurrence and the follow-up being conducted. - Any individual who has been the victim of abuse or has reported an incident of abuse will be protected during the investigation of the allegation. The investigation will be conducted in a confidential manner to protect both the individual and the reported. 1) Resident #9 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated December 8, 2011, documented the resident's cognition was intact. The MDS recorded the resident transferred with extensive assistance of 2 persons. Her balance was recorded as unsteady, and she was able to stabilize herself with "human assistance." The comprehensive care plan (CCP) and the CNA accountability record (used to direct care), dated December 20, 2011, documented the resident transferred with the assistance of 1 person, a gait belt (transfer belt) and a rolling walker. The nursing progress note, dated December 25, 2011, documented the resident stated "the nurse's aide did this to me. She squeezed me. She squeezed me." The resident stated she had pain under her breasts and when she coughed. The note documented "last evening" 2 staff members assisted the resident to sit the resident further back in her wheelchair. The resident's skin was assessed and there was no redness or bruising. The note recorded the resident's daughter was notified. The daughter stated the resident had pain and told her she hurt her ribs "yesterday." The "Incident Details" form (incident report) dated December 25, 2011, completed by registered nurse (RN) #1, documented the resident was alert and "well" oriented. The report recorded the resident had an incident, while being transferred, on December 24, 2011 at 5 PM. The staff involved were RN #2 and a certified nurse aide (CNA) #8. The report documented the resident said she had pain under her breasts, when she coughed, and she stated the nurse aide "did this to me. She squeezed me. She squeezed me." The resident's daughter stated the resident had pain "today" and "relayed to them" she (the resident) "hurt her ribs yesterday." The report recorded the corrective action taken by the facility was reviewing transfer technique with CNA #8 involved, and medicating the resident with Tylenol. RN #2's statement dated December 25, 2011 documented, on December 24, 2011, the resident was sitting on the edge of her wheelchair yelling for help. RN #2 documented she called for CNA #8 to help her, they tried to lift the resident, by holding onto her arms and legs, "but it did not work." CNA #8 then told the resident to put her arms around her (the CNA's) neck and CNA #8 "held/supported" her by holding her (the resident) on her sides. "She coached the resident to stand" while RN #2 put the wheelchair under the resident. CNA #8's statement dated December 25, 2011 documented the RN #2 called CNA #8 to help with the resident. CNA #8 recorded they tried to do a 2 person lift "but it did not work." The statement documented CNA #8 "locked" the resident's legs with her's, had the resident put her arms around her (the CNA's) neck, on the count of 3 the resident stood, and RN #2 pushed the wheelchair under the resident. The incident report dated December 25, 2011 was not signed as reviewed by the Administrator, the Director of Nursing (DON), or the Medical Director. There was no documented determination if the resident's CCP had been followed, or if abuse/neglect had occurred. The nursing notes documented the resident complained of rib pain and was medicated with Tylenol on: - December 25, 2011, at 9:13 PM, and 12 AM; and - December 26, 2011 at 5:38 AM. The nursing noted dated December 26, 2011 documented the resident's left rib pain was of sudden onset related to a traumatic event, was sharp and intermittent. The note recorded the physician was notified. The chest x-ray report dated December 26, 2011 documented there were no fractures. The physician progress notes [REDACTED]." The resident had some difficulty breathing. The physician documented the resident had some pain in the lower portion of her ribs, and he felt her shortness of breath was due to pain. The physician documented an x-ray had been done and "did not show any fracture so it is more contusion" (bruising). In an interview with the Administrator on January 17, 2012 at 4:30 PM he stated he was not aware of signing the investigation, and said someone may have decided it was a care issue. The Administrator stated the Director of Nursing (DON) reviewed investigations every morning. The DON stated during an interview on January 19, 2012 at 10:42 AM, the investigation for the resident's incident on December 24, 2011, contained statements from CNA #8 and RN #2 describing what happened. She stated, after the statements were obtained, there was no further follow up. During an interview with the resident on January 19, 2012 at 11:20 AM, she stated she remembered the incident on December 24, 2011. She stated CNA #8 squeezed her "so hard", and the "nurse just" stood there and held the chair. The resident stated she felt as if her ribs were broken and she could not breathe. She stated she was "afraid of the nurse." The Director of Physical Therapy (PT) stated the resident transferred with 1 assist, a rolling walker, and a gait belt (transfer belt). The PT Director stated he had not heard of an incident where the resident was "squeezed" during a transfer. He stated the gait belt would not be placed over the resident's ribs. In summary the facility failed to implement their policy and procedures to protect residents from abuse and neglect when they: - did not initiate an investigation at the time of the incident; - did not determine if the care plan was followed to determine if abuse or neglect occurred; - did not implement measures to protect the resident, after the incident occurred, until the investigation was complete; and - did not document the specifics of the "review of transferring" with CNA #8, or re-educate RN #2 regarding transferring and following resident's care plans to prevent reoccurrence. 2) Resident #6 had [DIAGNOSES REDACTED]. The Nursing Assistant Accountability Record (used to provide care), dated December 19, 2011, documented the resident transferred with the assistance of 2 persons and a gait belt (transfer belt) at all times. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, and required extensive assistance of 2 persons for transferring. The resident's functional range of motion was within normal limits, and she was able to stabilize herself, during transfers, with "human assistance." On January 12, 2012, between 3:36 PM and 3:42 PM, the surveyor observed three attempts, by the certified nurse aide (CNA) #1 and the registered nurse (RN), to transfer the resident from the wheelchair to the bed: - At 3:36 PM, CNA #1 placed the sling of the sit to stand lift (a mobile lift that allows for patient transfers from a seated position to a seated position) around the resident's chest. As CNA #1 raised the lift, the resident did not bear weight on her legs. The sling moved up directly under the resident's arms. The resident raised her arms and did not rise from the wheel chair, as the sling came up over her head. - At 3:40 PM, CNA #1 placed the sling around the resident's chest. As CNA #1 raised the lift, the resident did not bear weight on her legs. The sling moved up directly under the resident's arms, and she did not rise from the wheelchair. The resident raised her arms and the sling came up over her head. CNA #1 then told the RN the resident needed assistance of 2 for transferring. The RN stated the sling was not applied right. - At 3:42 PM, CNA #1 placed the sling around the resident's chest. As CNA #1 raised the lift, the resident did not bear weight on her legs. The resident's buttocks rose slightly above the wheelchair. As CNA #1 started to move the lift towards the resident's bed, the RN pulled up on the back of the resident's pants and lifted her onto the bed. The RN stated during an interview on January 17, 2012 at 12:28 PM, that the resident's transfer "wasn't the best." The RN said after the transfer she checked the resident's transfer status on the Nursing Assistant Accountability Record. She said the resident should have been transferred with the assistance of 2 persons, not with the sit to stand lift. The RN stated she did not know why CNA #1 transferred the resident with the sit to stand lift. She said she talked to CNA #1 about the resident's transfer after she checked the accountability record. The RN stated she did not notify anyone the resident's CCP was not followed or start an investigation. During an interview with the Director of Physical Therapy, on January 17, 2012 at 12:44 PM, he stated the resident transferred with the assistance of 1 person and a gait belt. He said the resident should not have been transferred with a sit to stand lift. During an interview, on January 17, 2012 at 2 PM, the RN stated she verbally counseled CNA #1 about the technique she used to transfer the resident. The RN stated she did not document the counseling. CNA #1 was interviewed on January 17, 2012 at approximately 2:25 PM, and stated she transferred the resident with a sit to stand lift because "someone told me to." CNA #1 stated the sling to the sit to stand lift was in the resident's room, and she did not remember who told her to use the lift. The Director of Nursing (DON) stated during an interview on January 17, 2012 at 3 PM, she was not aware the resident's CCP was not followed during a transfer. She stated she would expect the RN Supervisor to correct the CNA, she would not expect the RN to document this unless the resident was injured. During an interview with the DON on January 19, 2012 at 10:40 AM, she stated there was no investigation regarding the resident's CCP not being followed, while being transferred, on January 12, 2012. In summary, the facility failed to implement their policy and procedures to protect residents from abuse and neglect when they did not investigate an incident, where the resident's care plan was not followed, to determine if abuse or neglect occurred, and to protect the resident from further occurrences. 10NYCRR 415.4(b)

Based on observation, staff interview, and record review conducted during the extended recertification survey and abbreviated survey (complaint #NY 607), it was determined for 5 of 23 sampled residents (Residents #10, 11, 13, 21 and 23), 5 of 5 residents in the expanded sample (Residents #24, 25, 26, 27 and 28), and 1 of 6 employee files reviewed (RN #1), the facility failed to: - ensure all alleged violations involving mistreatment or abuse were reported to the New York State Department of Health (NYSDOH); - ensure all alleged violations were thoroughly investigated; - ensure interventions were implemented to prevent further injuries; and - protect the residents from further abuse while investigating the allegations. Specifically, for Resident #23, who alleged physical abuse by a staff member, the facility failed to: -protect the resident from further abuse during the investigation; -implement measures to prevent further incidents; -ensure a thorough investigation was completed following the incident; -ensure an incident of alleged abuse reported to administration; and -ensure the incident was reported to the NYSDOH. Residents #10, 11, 13, 21, 24, 25, 26, 27 and 28, the facility failed to: - initiate timely and thorough investigations to determine if abuse/neglect occurred; - complete all abuse/neglect investigations within 5 days; - report instances of alleged abuse/neglect immediately to the appropriate authorities within the facility and to the New York State Health Department as required by law; and - take all measures necessary to prevent and protect the resident from further instances of abuse/neglect. For RN #1, who had access to and provided care to residents, the facility did not have a valid RN license on file to ensure there were no findings concerning abuse, neglect, mistreatment of [REDACTED]. This resulted in no actual harm with potential for serious harm to resident health and safety that was Immediate Jeopardy and Substandard Quality of Care. Findings include: 1) Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Social Service progress note dated January 11, 2012 documented the resident was alert and oriented to person, place and time. On January 17, 2012 at 10:15 AM the resident approached a surveyor and asked if she could report "something." The resident stated to the surveyor, that on January 15, 2012 at approximately 6 PM, she had requested help with toileting and certified nurse aide (CNA) #10 was rude and abrupt with her. The resident stated "the CNA grabbed my right arm and twisted it, called me a name and would not help me off the toilet." The resident also stated she reported it immediately to a registered nurse (RN #1) and the nurse practitioner (NP). The resident said no report had been done, she was afraid and CNA #10 still came in her room. The resident stated "she is afraid of CNA #10 because she's aggressive." The nursing assistant accountability record (used to direct care) dated January 11, 2012 documented the resident needed the assistance of 2 persons, a gait belt and a rolling walker for transferring to the wheelchair and toilet. The resident's statement dated January 15, 2012, was recorded and unsigned. The statement documented on January 15, 2012, at 4 PM, the resident had her call light on, for over an hour, and no one came to her room. The resident walked with her walker to the nurse's station and told the nurse she had to go to the bathroom. CNA #10 brought a wheelchair and "abruptly" said "come on get in it", took the resident to the bathroom and told her to call when she was done. The statement recorded the resident asked for a washcloth and towel when she finished, CNA #10 told her she did not need one, and in a "real nasty" tone of voice asked the resident if she was ready. CNA #10 told the resident "don't you dare pull it" referring to the call light. The statement recorded the resident pulled the call light and CNA #10 grabbed the resident's wrist, turned it and called the resident an expletive. When the resident stated she could yell, CNA #10 stated she could yell louder. An unsigned and undated entry on the back of the resident's statement noted the resident's family came to the facility after the incident and discussed the resident's past behaviors (at home). There was an additional undated unsigned entry noting, there was no bruising, pulses positive, full range of motion and baseline fine motor skills. CNA #10's written statement dated January 15, 2012 documented after assisting the resident to the bathroom, CNA #10 asked the resident to turn off the call light because she (the CNA) had not left the room. CNA #10 recorded the resident refused, so she tried to turn off the call light. CNA #10 documented the resident pushed her hand away and told her she was in big trouble. CNA #10 reported this to the nurse. RN #1 was interviewed on January 17, 2012, at 11 AM and stated the RN charge nurse called her to see the resident on January 15, 2012, as she was the supervisor that evening. She said the resident complained staff were rough with her, and hurt her wrist. The resident told her no one answered her call bell, so she went to the nurse's station and that was where the incident occurred. RN #1 stated she started a report and put some of the information on the 24 hour nursing report. She said she put the report in the nursing office with a note to save for her, she did not complete an investigation, and did not work on January 16, 2012. RN #1 stated she was going to finish the investigation but had not had time yet. She said she told CNA #10 not to go into the resident's room alone to have another CNA accompanied her. RN #1 stated she did not document this and she did not reassign CNA #10. RN #1 said she did not report the incident of alleged abuse to the Administrator, the Director of Nursing (DON), or the New York State Department of Health (NYSDOH). The 24 hour nursing report dated January 15, 2012 documented the resident complained of staff. In an interview with the DON and the Administrator on January 17, 2012 at 11:50 AM they stated they were not aware of the incident of alleged abuse until the DON saw the statements, that morning, on a table in the nursing office, with a note to save for RN #1. They said RN #1 did not report the incident to them. On January 17, 2012 at 4:40 PM the nurse practitioner, who had been called by the resident, was interviewed. The nurse practitioner stated "she reports any problems to the RN Supervisor, and that she had called RN #1 to report the incident; she also stated she would expect the RN Supervisor to fill out an incident report and do an investigation. When asked if alleged abuse had been called into NYSDOH she stated "I don't know." The nursing notes from January 11, 2012 to January 17, 2012 were reviewed by a surveyor and showed no documentation of the incident. In summary, the facility: - failed to conduct a thorough investigation following the incident of alleged abuse in a timely manner; - failed to protect the resident from further abuse while the investigation was conducted; - failed to implement measures to prevent further incidents; - failed to report the incident of alleged abuse to administration, and to the NYSDOH. 2) Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. The comprehensive care plan (CCP), dated November 4, 2011, documented the resident was at risk for falls due to dementia, was non-ambulatory due to contractures of the lower extremities, and was unable to use a call bell. The planned interventions included: maintain proper body alignment in bed and chair using pillows as needed; check the resident's skin every shift; keep within vision, and provide close supervision when out of bed. The goal was for the resident to be free from falls and injuries through the next review. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was rarely understood, and had severely impaired decision making skills. The MDS recorded the resident was totally dependent and needed assistance of two persons for mobility, transferring, dressing, eating, toileting, and personal hygiene. Registered nurse (RN) #3 was interviewed on January 17, 2012 at 11:30 AM. She stated the resident could not use the assist siderails to turn and position herself because she had contractures, and was not able to move her arms or hands. A nursing progress note dated December 11, 2011 documented the son asked at 4:55 PM how the resident sustained [REDACTED]. The note recorded the bruise measured 1.8 centimeters (cm) long with a bump underneath. A statement dated December 12, 2011, by the certified nurse aide (CNA) providing care to the resident on December 10 and 11, 2011, documented she, and another CNA, observed the resident's bruise on December 10, 2011 at 10 AM, during morning care. The CNA documented she reported the bruise to RN #2 at that time. An incident report dated December 11, 2011 documented RN #2 assessed the bruise, on the resident's forehead, on December 11, 2011 at 4:58 PM. The report documented the bruise was not new, as it was greenish-yellow with no bluish-purple discoloration. The assessment completion date was listed as December 22, 2011 (11 days after the date of the injury). The corrective action listed on the report was "follow plan of care." The report: - did not determine how the injury of unknown origin occurred; - determine whether the care plan was followed; - did not include statements from all staff involved in the resident's care prior to the discovery of the bruise of unknown origin; - did not address why an incident report was not initiated when the bruise was found; and - did not complete the investigation within 5 days to determine if abuse/neglect occurred. A RN note dated December 18, 2011 at 10:53 AM, documented the resident had a small bruise, on the right wrist, which the son believed was caused by staff banging the right side of the resident's chair into the elevator. The note recorded staff was requested to be more careful when transporting the resident. An incident report, dated December 18, 2011, documented an RN assessed the bruise on the resident's arm. The report documented the resident's son alleged staff backing the resident into the elevator caused the injury, and also documented there were no witnesses. The assessment completion date was listed as December 22, 2011. The corrective actions taken were "staff to take more care with transport." No statements were obtained from the son or staff. The report did not determine: - whether the comprehensive care plan was followed; - include statements from all staff involved in the resident's care, including the staff alleged to have caused the injury during transport; and - determine if there was reasonable cause to suspect if abuse/neglect occurred and report this to the New York State Health Department within 24 hours as required by law; and The Director of Nursing (DON) was interviewed on January 17, 2012 at 12:55 PM. When asked for the facility's investigations on the 2 incidents, she stated she could not find these investigations in her files. She said she saw the bruise on the resident's wrist, and felt it was very small, and difficult to notice. 3) On January 12, 2012 at 10:55 AM, registered nurse (RN) #1 stated in an interview she performed weekly wound rounds on all the resident units, worked as the RN Supervisor, and on that day was working as the RN on Unit 3. Review of RN #1's personnel file revealed the RN license the facility had on file was valid through June 30, 2011. There was no documented evidence of a current license. On January 19, 2012 at 1 PM, the Director of Human Resources stated in an interview he did not have a current RN license on file for RN #1. During the interview, he verified RN#1's license on the New York State Department of Education's website and provided a copy to the surveyor. In summary the facility failed to have a valid RN license on file for RN #1. 10NYCRR 415.4 (b)(1)(ii)

Based on observation, record review, and staff interview conducted during the extended recertification survey and abbreviated survey (complaint #NY 607), it was determined for 7 of 23 sampled residents, (Residents #6, 9 10, 11, 13, 21, 23) and 5 of 5 residents, (Residents #24, 25, 26, 27 and 28), in the extended survey sample the facility's administration failed to administer the facility in a manner that protected the health and safety of its residents, in accordance with accepted professional standards. Specifically, the facility failed to have a system in place to: - ensure all incidents or allegations of abuse/neglect and injuries of unknown origin were thoroughly investigated; - ensure interventions were implemented to prevent further injuries; - ensure residents were protected from the potential for further abuse while an investigation was pending; and - ensure all alleged violations involving abuse, neglect, or mistreatment were reported to the New York State Department of Health (NYSDOH). This resulted in no actual harm with the potential for serious harm to resident health and safety that was Immediate Jeopardy and Substandard Quality of Care for Residents #6, 9, 10, 11, 13, 21, 23, 24, 25, 26, 27 and 28. Findings include: The Administrator was interviewed at 4:30 PM on January 17, 2012. He stated: - he was not aware of a problem with the completion and accuracy of abuse/neglect investigations, or investigations of injuries of unknown origin; - he was not aware measures were not implemented to protect residents and prevent abuse/neglect; - he expected to be notified (at home if he was not at the facility) when there was an allegation of abuse, or injury, and "any incident that required increased monitoring or vigilance"; - he was not aware of the Quality Assurance Committee completing any audits on the accuracy of investigations/incident reporting, during the past year; - he was not aware of the alleged abuse related to Resident #23 on January 15, 2012, until informed by the survey team on this date (January 17, 2012), and stated he should have been contacted at the time the investigation was initiated; and - he did not recall signing the incident report dated December 25, 2011 pertaining to the alleged abuse related to Resident #9. The Director of Nursing (DON) was interviewed on January 17, 2012 at 3 PM and stated: - if there was an alleged incident and a resident was not injured, there may not be an incident report or an investigation; - she was not aware of the alleged abuse that occurred on January 15, 2012, until she arrived at the facility on this date (January 17, 2012). She said her expectation was the RN Supervisor should have notified her and the Administrator, so they could have decided whether to remove the alleged perpetrator to protect the resident during the investigation; - she was not aware Resident #6 had been transferred, from the wheelchair to the bed, inappropriately on January 12, 2012; and - she said she was unable to locate the original incident report related to the alleged abuse of Resident #9 documented on December 25, 2011, and later provided a copy of the report, with no evidence the report had been reviewed by the DON or the Administrator. Review of incident reports for Residents #10, 11, 13, 21, 25, 26, 27 and 28 from October 2011 through January 17, 2012 revealed the Administrator and the DON signed the reports as complete, with no documented evidence the incidents were thoroughly investigated. For Residents #6, 9, 23 and 24, investigations were not initiated in a timely manner. During the above interviews with the Administrator and the DON, there was no evidence the Administrator or the DON had considered reporting these incidents of alleged abuse to the NYSDOH. In summary, the administration failed to administer the facility in a manner that protected the health and safety of its residents, in accordance with accepted professional standards, as they failed to thoroughly investigate alleged violations involving abuse/neglect and injuries of unknown origin, protect residents during the investigative process, and report the alleged abuse to the NYSDOH as required. For further details refer to tags: F 224 Residents have the right to be free from abuse and neglect; F 225 Investigate/Report Allegations/Protect Residents. 10NYCRR 415.26(a)

Based on observation, record review, and staff interview conducted during the extended recertification survey and abbreviated survey (complaint #NY 607), it was determined for 7 of 23 sampled residents, (Residents #6, 9 10, 11, 13, 21, 23) and 5 of 5 residents, (Residents #24, 25, 26, 27 and 28), in the extended survey sample, the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with potential to cause serious harm to the health and safety of residents related to abuse/neglect, mistreatment and injuries of unknown origin. Specifically, the QA Committee failed to monitor the reporting, investigation and prevention components of their abuse prohibition protocol. This resulted in Immediate Jeopardy to resident's health and safety for residents with reported incidents of abuse, neglect, mistreatment and/or injuries of unknown origin. Findings include: 1) Resident #23 alleged she was abused by a staff member on January 15, 2012. The RN did not immediately implement measures to protect the resident, did not notify administration, and did not complete an investigation according to the facility policy and procedures. When the administrator was interviewed on January 17, 2012 at 4:30 PM, he stated neither he or the DON were made aware of the incident in a timely manner in order to implement measures to protect the resident. 2) Resident #9 reported to facility staff that a certified nurse aide (CNA) was rough with her during care on December 24, 2011. During interviews with nursing staff, including the Director of Nursing (DON) and the Administrator on January 17, 2012 between 2:30 PM and 4:30 PM, they were unable to provide a complete investigation of the incident. 3) Resident #6 was observed by a surveyor on January 12, 2012, being transferred with a stand lift , which was not according to the resident's plan of care. This incident was witnessed by a registered nurse (RN) who reported to the surveyor, the plan of care was not followed. As of January 17, 2012, the DON stated in an interview at 2:30 PM, she was unaware of the incident and there was no evidence an investigation had been initiated. 4) Resident #21 had 2 incidences of injuries of unknown origin in December 2011. There was no documentation the incidents were thoroughly investigated to rule out abuse/neglect. 5) Residents #10, 11, 13, 24, 25, 26, 27 and 28 experienced injuries of unknown origin between October 2011 and January 15, 2012 that were not thoroughly investigated to rule out abuse/neglect. The administrator, who is a member of the QA Committee, was interviewed on January 17, 2012, at 4:30 PM. He stated the last meeting was December 14, 2011 and meetings occur monthly. Topics covered included falls, pressure ulcers, and restraints. He said the accuracy and completion of abuse investigations was not formally reviewed by the committee. He stated incident investigations were not always completed timely and stated staff were retrained by the Inservice Coordinator as a result of this concern. The Director of Nursing (DON) was interviewed on January 17, 2012 at 6:40 PM. She stated she was aware there was a problem with the completion and thoroughness of abuse investigations. She stated there was nothing wrong with the policy, the problem was making sure the staff completed the investigations correctly. In summary, the facility failed to provide a QA program that monitored the reporting, investigation and prevention components of their abuse prohibition protocol that had the potential to cause serious harm to the health and safety of residents. For further details refer to tags: F 224 Residents have the right to be free from abuse and neglect; F 225 Investigate/Report Allegations/Protect Residents. 10NYCRR 415.27

Based on observations, staff interviews, and record reviews conducted during the standard survey, and the abbreviated survey (complaint #NY 607), it was determined for 4 of 23 sampled residents, (Residents #5, 8, 13, and 24), the facility did not provide adequate supervision and assistance to prevent accidents. For Resident #8, who experienced multiple falls and a fractured elbow, and Residents #13, and 24, who experienced multiple falls, the facility did not evaluate the effectiveness of planned interventions, or implement appropriate interventions to prevent further falls. For Resident #5 there were no interventions developed, after the resident experienced a burn from a hot liquid, to prevent reoccurrence. For Resident #24 there were no interventions developed to prevent choking, after the resident experienced a choking episode. This resulted in actual harm (a fractured elbow) for Resident #8, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #5, 13, and 24. Findings include: 1) Resident #8 had [DIAGNOSES REDACTED]. The "Incident Details" (incident report) August 7, 2011 documented the resident had an unwitnessed fall from bed. The resident's "Fall Risk Assessment" form dated August 10, 2011 documented the resident had a history of [REDACTED]. The Resident Restrictive Device assessment dated [DATE], documented the resident had impaired balance while standing, and had fallen within the past 30 days. The assessment documented "restrictive devices attempted to date" were a bed alarm and a chair alarm. The comprehensive care plan (CCP) dated August 10, 2011, documented the resident had the potential for falls related to a history of frequent falls, weakness, confusion, dementia, and peripheral neuropathy. The CCP recorded the resident had 6 falls, without injuries, from May 11, 2011 through August 10, 2011. The goal was for the resident to be free from "falls-injuries" through January 31, 2012. The planned interventions included: - a clip chair and bed alarm as needed; - assist with toileting every 2 hours; - provide supervision when she was out of bed; - keep call bell within reach at all times; and - frequently reinforce to ask for assistance with any transfer. An incident report dated August 21, 2011 documented the resident was found on the floor. The report documented the bed alarm was found on the side of the resident's mattress. The corrective action was for staff to monitor the location of the alarms, whether the resident was in the bed or in a wheelchair, and keep the call bell within reach of the resident at all times. The report did not document an evaluation of the effectiveness of planned interventions. The incident report dated August 29, 2011 documented the resident had an unwitnessed fall from the toilet. The report did not document a review or revision of the resident's CCP. The Nursing Assistant Accountability Record (used to direct care) dated September 21, 2011 documented the resident was incontinent of bowel and bladder, and needed assistance. The record did not specify what assistance was needed, or to assist the resident with toileting every 2 hours. The record noted the resident had no safety awareness and needed the assistance of 1 person and a walker to ambulate. The CCP dated September 21, 2011 documented the resident's falls on August 21, and 29, 2011. There was no evaluation of the planned interventions, for fall prevention, related to the resident's unwitnessed falls. The CCP documented a plan for the resident to "walk to each meal and sit in a stationary chair during the meal." A nursing progress note dated November 16, 2011, documented the resident was found sitting on the floor of her bathroom. The progress note documented the resident stated she was walking from her bed to the bathroom, got tired, and sat on the floor. The incident report dated November 16, 2011 documented the resident was found sitting on the floor of her bathroom. "She said she was walking from her bed to the bathroom but got tired and sat down on the floor. She crawled halfway to her bathroom door where she was found by staff." The report documented the resident had a clip alarm "but she took it off" and it was in her bed sounding. The Incident Log dated November 16, 2011, documented the resident was found on the floor. The log recorded the resident's fall was reviewed and physical therapy and occupational therapy were in place. The log recorded therapies would be continued to increase the resident's strength, and continue planned interventions. A nursing progress note dated November 17, 2011, documented the resident wanted to go to the bathroom, and she was "discouraged" from doing so independently. A second nursing progress note on this date, documented the resident "transferred" herself to the bathroom, The resident was reminded to ask for help and wait for assistance. The progress note documented the resident had poor safety awareness. The nursing progress note dated November 21, 2011 documented the resident was observed by a certified nurse aide (CNA) ambulating in the hall carrying her clip alarm. When redirected the resident sat on the floor. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively severely impaired. The MDS documented the resident had a history of [REDACTED]. The resident's balance was unsteady, and she was able to stabilize with "human assistance." The MDS recorded the resident was frequently incontinent of bladder, occasionally incontinent of bowel, and was not on a toileting program. A nursing note, dated November 25, 2011, documented the resident was found sitting on the floor of her bathroom. The resident stated she attempted to transfer to the toilet, lost her balance, and sat on the floor. The progress note documented the resident insisted she did not fall, and did not hit her head. The note did not evaluate the effectiveness of planned interventions, or a rationale for not implementing new interventions to prevent falls. The nursing progress note dated November 30, 2011, documented the resident was discussed in the Interdisciplinary Team Coordination, care planning meeting. The note recorded the resident's CCP and physician orders [REDACTED]. There was no rationale recorded regarding continuing with the current plan, and not implementing a change in planned interventions. The Nursing Assistant Accountability Record (used to direct care) dated November 30, 2011, documented the resident had frequent falls, increased confusion, and no safety awareness. The record instructed the resident had a clip bed and chair alarm and used a Barca lounger (type of recliner) to socialize and be around others. The resident was incontinent of bowel/bladder and needed assistance. The record did not specify what assistance was needed or to assist the resident with toileting every 2 hours. The record noted the resident had no safety awareness and needed the assistance of 1 person and a walker to ambulate. The CCP dated December 1, 2011 documented the resident's 2 unwitnessed incidents, (November 16, and 25, 2011), and the 2 occasions (November 17, and 21, 2011), where she was found ambulating independently. A nursing progress note, dated December 14, 2011, documented the resident's bed and clip alarms were going off and staff went to check on her. The resident was in the bathroom trying to sit on the toilet, "however" she missed the toilet and sat on the floor. "Per the CNA who witnessed" the fall she was unable to prevent the resident from falling. There was no documented evidence the CCP was reviewed or revised. The nursing progress note dated January 4, 2012, documented that on January 3, 2012, a CNA came out of another resident's room and "saw" the resident lying on the floor in the corridor, with clip chair alarm going off. The resident complained of pain in her left elbow, and her left elbow was swollen. The note recorded an x-ray of the left arm was done and showed a fractured elbow. The Incident Log dated January 3, 2012, documented the resident was found on the floor. The log noted an occupational therapy evaluation on January 5, 2012. The nursing notes dated January 8, 2012 documented the resident was found in the bathroom, did not call for help and took off the clip alarm. The CCP dated January 12, 2012 documented the resident's 2 falls (December 24, and January 3, 2011), and that she ambulated independently to the bathroom. The planned intervention was for the resident to see an orthopedic surgeon, and use a splint to her lower left arm. During an interview on January 11, 2012 at 10 AM, the registered nurse (RN) #3 Clinical Care coordinator, stated the resident had fallen and fractured a "part of her elbow." In an interview on January 17, 2012, at 11:30 AM the DON stated the Clinical Care Coordinators update CCP's with any new nursing problem. She said she did not know if the resident's CCP had been reviewed or revised after her falls. During an interview with the Clinical Care Coordinator RN #3 on January 17, 2012 at 11:50 AM, she stated the changes in the CCP, after each fall, included the bed and chair alarms, and a chair in the hall. She stated she would have to check the resident's chart to see if she experienced multiple falls. In an interview with the Director of Rehabilitation on January 17, 2012, at 2 PM he stated the fall committee looks at falls after morning report and documents on the fall log. In an interview with the DON on January 19, 2012, at 1:15 PM, she stated she had not yet been able to review and revise the resident's CCP due to her other responsibilities. In summary the resident experienced harm, a fractured elbow, when the facility did not review and revise the CCP, in a timely manner, after the resident experienced multiple falls, to evaluate the effectiveness of planned interventions and implement changes to prevent further falls. 2) Resident #5 had [DIAGNOSES REDACTED]. Physicians orders dated October 7, 2011 documented an order for [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely impaired cognitively and needed assist with all activities of daily living including eating. An incident report dated November 29, 2011 documented the resident reached for another resident's coffee and spilled it on herself. An incident report follow up dated November 30, 2011 documented the resident had a significant decline in mental status, should not be left alone with hot beverages. The report instructed, hot beverages should not be poured, without staff seated at the table ready to assist the resident with the meal. The comprehensive care plan (CCP) printed January 11, 2012 did not document the resident's burn; a treatment for [REDACTED]. The nursing assistant accountability record (used to direct care) dated January 11, 2012 had no planned interventions to prevent further burns. In an interview, on January 17, 2012 at 10 AM, the certified nurse aide (CNA) stated resident always grabbed at items that were on the table during meals. Resident's tray menu ticket dated January 17, 2012 did not document precautions for staff to follow when serving the resident hot beverages. In summary, after the resident experienced a burn, the facility did not implement interventions to prevent further burns. 3) Resident #24's [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated September 8, 2011 documented the resident was at risk for falls and required assistance with transfers. The CCP recorded the resident was confused due to dementia and had long and short term memory impairment. The planned interventions included bed and chair alarms for safety. A nursing progress note dated October 14, 2011 documented the resident fell . An Incident Report dated October 16, 2011 documented the resident was found on the floor next to her bed. The Incident Report Follow-up dated October 17, 2011 documented the resident had confusion, and did not remember to call for assistance to get up. The corrective action was to use bed and chair clip alarms. The nurse's note dated October 26, 2011 documented the resident was found on the floor with no injuries noted. There was no documented evidence the CCP was evaluated for the effectiveness of planned interventions. The nurse's note dated November 16, 2011 documented the resident was found on the floor near her bed with no injuries noted. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognitive level was severely impaired and the resident needed assist of 2 for transfers. Nursing note dated November 26, 2011 documented the resident was found on the floor with no injuries noted. The nurse's note dated December 6, 2011 documented the resident had an episode of choking while eating in the main dining room. The note recorded the resident swallowed "very small pieces of vegetable and corn, Heimlich maneuver administered and resident brought up a small piece of corn and pieces of vegetables." The resident lungs were clear with no coughing or congestion noted. The resident's CCP dated December 7, 2011 had no documentation regarding the choking incident or planned interventions to prevent the resident from choking again. The Nursing Assistant Accountability Record (used to direct care) dated December 9, 2011, documented the resident was on a regular consistency diet. Review of accident and incident reports for December 2011 revealed no documented evidence a report was filed following the resident's choking episode. Nursing notes dated December 13, 16, 18, 22 and 25, 2011 documented the resident had been found on the floor. There was no documented evidence in the resident's medical record the CCP was reviewed for the effectiveness of planned interventions to prevent falls. The nursing notes dated January 4, and 11, 2012 documented the resident was found on the floor. The nursing note dated January 17, 2012 documented the resident had a 17 centimeter (cm ) x 6.5 cm bruise on her left knee from a fall on January 15, 2012. There was no documentation of a fall on January 15, 2012 in the resident's medical record. In an interview on January 18, 2012 at 1:25 PM, the certified nurse aide (CNA) stated the resident falls frequently, usually due to having to go to the bathroom. During an interview with registered nurse (RN) #2 on January 19, 2012 at 2 PM, she stated she had now changed the resident's toileting schedule to every 2 hours, "hopefully to prevent her from falling too much" and had a swallow evaluation ordered for her. The director of nursing (DON) was interviewed on January 19, 2012 at 1:30 PM, and stated she did not have an incident report regarding the resident's choking episode on December 6, 2011. She said she was not aware of the incident but felt there should have been an investigation. In an interview on January 19, 2012 at 2:50 PM, the RN who wrote the progress note when the resident choked, stated she did not document the incident on the 24 hour nursing report. She said she did not call the Supervisor when the incident occurred, and told her at the end of the shift. She stated she did not have a role in completing incident reports at the facility. On January 19, 2012 at 4:20 PM, the RN Supervisor who worked the evening the resident choked was interviewed. She stated she "vaguely" remembered the incident and thought she was told by the RN prior to the end of the shift. She said she did not document anything in the medical record and did not expect to be called at the time of the incident. She said the RN on the unit could "handle it" herself. She stated the unit RN would complete the incident report. In summary the facility did not re-evaluate the resident's CCP for effectiveness, and implement new interventions to ensure the resident's safety, after the resident experienced multiple falls and an episode of choking. 10NYCRR 415.12 (h)(1) & (2)