Every finding on record at Valley View Manor Nursing Home

Based on observations, record review, and interviews, the facility failed to ensure a clean, comfortable, and homelike environment for two (2) of two (2) resident units (North and South units) and the main front entrance. Specifically, the North and South units had strong urine odors, and unclean walls and floors; and the main front entrance had trash that littered the walkway areas.Findings include: The undated facility policy In-service - Daily Cleaning, documented the objective of a daily cleaning was to ensure cleanliness and safety. Daily cleanings should be performed as follows: trash receptacles should be emptied along with bedside bags, each housekeeper should use good judgement when determining the frequency of trash removal keeping odor control in mind; the housekeep should clean all spots, spills, or scuff marks on vertical surfaces such as walls, doors, and over bed tables; the entire floor must be dry mopped; and the entire floor must be wet mopped, not to forget to mop under the bed, closet floor, behind doors, and the bathroom.The electronic communication from the Administrator documented the facility did not have housekeeping logs and the daily cleaning in-service was the facility housekeeping policy. The Maintenance Logs for both units from 2/13/2026 to 04/03/2026, did not include rooms with scuff marks or rooms in need of painting. Environment observations included:-on 04/01/2026 at approximately 9:45 AM, there was a strong odor of urine in the hallways when entering the units.-on 04/01/2026 at 10:15 AM, the hallway near room [ROOM NUMBER] and the nurse's station had a strong urine odor.-on 04/01/2026 at 10:26 AM, room [ROOM NUMBER] had a strong urine odor.-on 04/01/2026 at approximately 10:30 AM, room [ROOM NUMBER] had peeling paint and the wall behind the bed was in disrepair.-on 04/01/2026 at 10:51 AM, room [ROOM NUMBER] had an unknown spill on the floor.-on 04/01/2026 at 10:55 AM, room [ROOM NUMBER] had food on the floor near the head of the bed with ants on it.-on 04/01/2026 at approximately 11:00 AM, room [ROOM NUMBER] had bed sheets with several rips, and yellow dripping stains down the wall near the side of the bed.-on 04/01/2026 at 11:22 AM, room [ROOM NUMBER] had a strong urine odor.-on 04/01/2026 at 11:31 AM, room [ROOM NUMBER] had black pants, a used towel, and used incontinence briefs on the floor. The resident was not present in the room.-on 04/01/2026 at 2:54 PM and 4:54 PM, room [ROOM NUMBER] had yellow cake like food on the floor near the head of the bed with ants on it. -on 04/02/2026 at 8:11 AM, room [ROOM NUMBER] had yellow cake like food on the floor near the head of the bed with ants on it. -on 04/03/2026 at 8:42 AM, the hallway near rooms [ROOM NUMBERS] had a strong urine odor. During an observation and interview on 04/06/2026 at 1:19 PM, Certified Nurse Aide #5 stated they picked up an extra shift as a housekeeper. The process for cleaning the rooms was to dust high and low, then clean the bathroom. The floors should be mopped every day. They changed the mop three (3) times during cleaning time. They cleaned and tidied the rooms, and then they mopped. Rooms should not have peeling paint or scuff marks, that was not homelike. If they saw things that needed to be fixed, they told Maintenance Worker #6 or wrote it in the maintenance binder at the nurse's station. There should not be any odor of urine in the rooms, hallways, or on the units; that was not home like. The floors were supposed to be mopped daily, so food should not be on the floor for a prolonged period. The aides should help too. Housekeeping staff did not work during the evening. room [ROOM NUMBER] had scuff marks on the walls at various heights from the resident's bed rubbing on the walls. There were black scuff marks along the heater, that was from the resident wheelchair running along the side of the heater. These items should be reported for repair. They were told the whole unit was getting remodeled, so all that should be fixed with the remodel. The scuff marks were not homelike, and made the heater look dirty and undusted. room [ROOM NUMBER] was a room that required extra cleaning, the resident frequently spilled, and staff needed to be mindful of the room's appearance. There was an area above the heater that did not have paint and a noticeable gap in the dry wall. Certified Nurse Aide #5 stated the imperfections should be fixed with the remodel. During an interview on 04/06/2026 at 2:08 PM, the Director of Housekeeping/Maintenance/Laundry stated they did not have enough staff. They previously did, but one changed roles and the other had either called in or no call/ no showed their last few shifts. Housekeeper #8 was the full time laundry person, and Housekeeper #10 was per diem but would pick up shifts. Housekeeper #8 was on vacation, Housekeeper #9 had not come to work, Housekeeper #10 was working their assigned shifts, and Housekeeper #11 changed roles. The Director was covering the laundry and had certified nurse aides pick up extra shifts to help with cleaning. The housekeepers had a room a day to complete an inspection on, this included the walls, curtains, loose screws, or broken/peeling floors. Staff used the maintenance book to document anything that needed to be fixed. It was not homelike for any location to smell of urine. There should not be any scuff marks on the walls or heaters. The South unit was getting remodeled, but they did not know when. The gap above the heater came from the heater being loose or getting bent from the residents hitting it with their wheelchair. The scuff marks came from the outer rim of the wheelchair. They tried to move rooms around to give the residents more room, but the residents did not like the change. room [ROOM NUMBER] was checked and cleaned one to three times per day. It was checked first thing in the morning, after lunch, and before they left for the day. If there was food on the floor from a meal it should be noticed at the room check after that meal, or first thing in the morning. Housekeeping and Maintenance staff were responsible for checking the outside areas and maintenance did the painting. During an interview on 04/06/2026 at 2:29 PM, Maintenance Worker #6 stated there was a maintenance book at the nurse's station for each unit that they reviewed for work orders or things that needed to be fixed. The person reporting the problem put their initials, and they completed the work, noted what they did, and initialed when completed. They did monthly room checks where they checked the call bells were working and the windows opened only so far for elopement risk. They reviewed the rooms then as part of the monthly preventative maintenance checklist. They were responsible for painting. They knew room [ROOM NUMBER]'s closet doors needed paint and that was on their list to get done. Peeling paint was not homelike. They had someone that came and cleaned up outside. 10 NYCRR 415.5(h)(4)

Based on record review and interviews the facility failed to ensure specific services outside the facility when the facility did not employ a qualified professional to furnish the specific service for one (1) of one (1) resident (Resident #22) reviewed. Specifically, Resident #22 was referred to neurology (nervous system specialist), rheumatology (autoimmune diseases, musculoskeletal disorders, and arthritis specialist), pulmonology (lung specialist), and ophthalmology (eye specialist) and the facility did not follow up on these referrals in a timely manner.Findings include: The facility policy Outside Appointments and Consultations, revised 01/2026, documented the facility would ensure all residents received timely, appropriate, and coordinated care when attending outside appointments or consultations. The facility maintained accountability for continuity of care, resident safety, communication, and follow-up in accordance with state and federal regulations. The physician ordered the consultation and scheduled in collaboration with the resident, responsible party, and interdisciplinary team. Prior to the appointment the facility ensured the resident had necessary clinical documentation, medications, and equipment. Additionally, the facility arranged safe transportation with necessary equipment. Upon return from the appointment the consultation documentation was reviewed, new orders were implemented, the physician was notified of significant findings, and the care plan was updated. When an appointment was missed or refused the reason was documented, the physician and responsible party were notified, and the appointment was rescheduled. Resident #22 had diagnoses including rheumatoid arthritis (autoimmune disease), spinal stenosis (narrowing of spinal canal), respiratory failure, chronic dry eye syndrome, and diabetes. The 03/02/2026 Minimum Data Set assessment documented the resident had intact cognition.The 09/18/2024 Comprehensive Care Plan documented the resident had type two diabetes that was poorly controlled with nerve damage. Interventions included medications, labs, and encourage following ordered diet. The resident had chronic pain related to cervical spine pathology and arthritis with interventions including medication. The resident had communication problems with a visual acuity problem and needed new glasses with interventions including a visual exam. The resident had shortness of breath with interventions to assist with posture and encourage resident when short of breath. The resident used oxygen for diagnosis of respiratory failure and chronic obstructive pulmonary disease. The 1/2/2026 neurology report documented no change at today's visit with next appointment scheduled for 1/13/2026 to review the results of the magnetic resonance imaging. During an interview on 04/06/2026 at 10:30 AM, the neurology office receptionist stated the resident had an appointment on 01/13/2026 and did not show up. They rescheduled the appointment for 02/02/2026 and the resident did not show up for that appointment. The resident did not have any scheduled appointments at this time.There was no documented evidence of nursing progress notes addressing the resident's missed neurology appointments. The resident was scheduled for an appointment with pulmonologist (lung specialist) on 01/08/2026.During an interview on 06/06/2026 the staff at the pulmonology office stated the resident missed their appointment 01/08/2026 and was rescheduled for 01/26/2026 and did not show up for that appointment. There was no documented evidence of nursing progress notes addressing the resident's missed pulmonology appointments. The resident was scheduled for an appointment with rheumatology on 01/15/2026.During an interview on 04/06/2026 at 10:19 AM the rheumatology office could not confirm the resident was seen for that appointment or give any current appointment information.The resident was scheduled for an appointment with Retina Vitreous Surgery (eye specialist) on 01/15/2026.During an interview on 04/06/2026 at 10:16 AM, the Retina Vitreous Surgery office stated the resident did not show up for their appointment on 01/15/2026 and had not rescheduled an appointment. They were last seen in December 2024.There was no documented evidence of nursing progress notes addressing the resident's missed Retina Vitreous Surgery appointments. During an interview on 04/01/2026 at 1:06 PM, Resident #22 stated they saw multiple specialists in the community for several different medical conditions. Often the facility cancelled the appointments due to not having the staff to accompany them or forgetting to coordinate transportation. This had been an issue for several months since the scheduler left employment at the facility. During an interview on 04/03/2026 at 1:44 PM, Registered Nurse #16 stated if a resident required medical treatment from a specialist, the physician would put in a medical order. Medical Records scheduled the appointment and transportation. The resident's family was notified of the appointment date and time. Medical Records sent out a schedule of appointments which was put on the daily assignment sheet. Staff was scheduled and took the resident to and from the appointment. There were times when appointments were cancelled because transportation was not set up or transportation was cancelled because of the weather. During an interview on 04/03/2026 at 1:49 PM, Medical Records Staff #20 stated they were responsible for scheduling appointments and transportation to and from outside appointments. When the physician wanted a resident to see a specialist, the nurse brought them a form with the name of the resident and the specialty being recommended. After making the appointment they scheduled transportation. They brought a folder containing the resident's face sheet, medication list, and appointment information to the unit. Every Friday they brought the upcoming list of scheduled appointments to the unit for the nurses to assign staff. They referred to a binder with appointments organized each month and stated they could not confirm if the residents went to the appointments as they did not get any information from the provider following the appointment. During an interview on 04/06/2026 at 9:33 AM, Licensed Practical Nurse Unit Manager #19 stated when the physician wanted a resident to see a specialist they wrote an order for the consult. Once the order was placed, they discussed it with the resident and gave the request for consultation paperwork to Medical Records Staff #20. Medical Records Staff #20 scheduled the appointment and transportation, made a folder that accompanied the resident to the appointment, and placed the appointment on the schedule. On the day of the appointment the time and specialist were written on the assignment sheet. When the resident returned from the appointment, nursing reviewed the exam findings and recommendations, notified the provider of findings and recommendations, and entered a note about the appointment in a progress note. There was never an appointment that was cancelled for lack of staff. They looked in the computer and could not find documentation about the pulmonary appointment that was scheduled for 01/08/2026, the vascular appointment scheduled for 01/12/2026, the neurology appointment scheduled for 01/13/2026, the rheumatology appointment scheduled for 01/15/2026, the retina vitreous appointment scheduled for 1/20/2026, the pulmonary appointment scheduled for 01/26/2026, or the neurology appointment 02/02/2026. They stated Medical Records #20 was able to review the schedule and could see why Resident #22 did not attend those appointments.During an interview on 04/06/2026 at 9:46 AM, Medical Records #20 stated they were able to confirm they scheduled the following appointments and transportation for the resident, however were not able to locate the findings for the 01/08/2026 pulmonary appointment, the 01/12/2026 vascular appointment, the 01/13/2026 neurology appointment, the 01/15/2026 rheumatology appointment, the 01/20/2026 retina vitreous appointment, the 01/26/2026 pulmonary appointment, or the 02/02/2026 neurology appointment. During an interview on 04/06/2026 at 1:38 PM, the Director of Nursing stated it was important for residents to attend outside specialty appointments to get care that the facility physician could not provide. They were just notified by staff that Resident #22 missed several appointments with specialists since December. They stated the facility did not have medical records staff for three months, which was why appointments got missed. Additionally, transportation cancelled appointments in bad weather. When appointments were cancelled for weather, staff should document that in a progress not and did not. 10 New York Codes Rules and Regulations 415.26(e)

Based on observations, record review, and interviews during the facility failed to ensure that residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for one (1) of two (2) residents (Resident #10) reviewed. Specifically, Resident #10 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments or consistent documented evidence of communication with the dialysis center. Findings include: The facility policy Dialysis, revised 7/2008, documented residents that received dialysis received interventions to maintain their highest level of functioning. Every dialysis resident had a comprehensive care plan regarding their need for dialysis and residents going out of the building for hemodialysis will take communication sheets allowing for ease of communication between the facilities.Resident #10 had diagnoses including end stage kidney disease with dependence on dialysis. The 01/05/2026 Minimum Data Set assessment documented the resident was cognitively intact, had end stage kidney disease, required dialysis treatments, and did not reject care.The Comprehensive Care Plan initiated 10/17/2024 documented the resident received dialysis on Monday, Wednesday, and Friday. Interventions included monitoring weights before and after dialysis, monitoring vital signs, and thrill pulsation (a purring vibration felt over a fistula signaling high-flow blood) felt at shunt site under fingers. The 08/02/2023 Physician #15 order documented monitor dialysis fistula site every Monday, Wednesday, and Friday.The 09/24/2024 Physician #15 order documented dialysis three times a week on Monday, Wednesday, and Friday.The dialysis and nursing home handoff communication tool documented the resident attended dialysis on 01/02/2026, 01/05/2026, 01/07/2026, 01/09/2026, 01/12/2026, 01/19/2026, 01/21/2026, 01/22/2026, 01/26/2026, 02/02/2026, 02/06/2026, 02/09/2026, 02/16/2026, 02/18/2026, 02/20/2026, 02/25/2026, 03/06/2026, 03/11/2026, 03/23/2026, 03/25/2026, 03/27/2026, and 4/03/2026. Many of the communication sheets were missing the vital signs, pre dialysis weight, and signature of staff sending the resident to dialysis.Dialysis communication sheets were missing for 01/14/2026, 01/16/2026, 01/28/2026, 01/20/2026, 02/04/2026, 02/11/2026, 02/13/2026, 02/23/2026, 02/27/2026, 03/02/2026, 03/04/2026, 03/09/2026, 03/13/2026, 03/16/2026, 03/18/2026, 03/20/2026, 03/30/2026, and 04/01/2026.During an observation and interview on 04/03/2026 at 9:40 AM, Resident #10 was in their room putting on their coat for dialysis. They stated their vital signs had not been taken yet. During an interview on 04/06/2026 at 8:06 AM, Licensed Practical Nurse # 18 stated they were responsible for oversite of residents including administration of medications and completion of treatments. They had one resident that went to dialysis, Resident #10, and dialysis residents did not require any care prior to attending dialysis. Resident #10 was not sent to dialysis with lunch and returned after 2:30 PM after they had left for the day. They stated the resident required an assessment from a registered nurse upon return. During an interview on 04/06/2026 8:30 AM, the Dialysis Center charge nurse stated many times, the resident was sent to dialysis with the communication book, however there was no form in the book, or the form was missing the vital signs, medications, changes or updates in condition, or weight. Durning an interview on 4/06/2026 1:31 PM, Licensed Practical Nurse Unit Manager #19 stated residents that received dialysis had vital signs and their weight taken prior to dialysis which was documented in a communication book. The book was sent with the resident to dialysis to make sure the resident was stable to receive dialysis. When the resident returned from dialysis the registered nurse completed an assessment which was documented in a nursing progress note and on the Medication Administration Record. The assessment was completed to make sure the resident did not have any complications from the dialysis treatment. The fistula (a connection between artery and vein used for dialysis access) was assessed every shift to ensure it was functioning and documented on the Medication Administration Record. During an interview on 04/06/2026 at 1:59 PM, Licensed Practical Nurse #17 stated they normally worked the day shift, however on 04/03/2026, they worked overtime and picked up the evening shift. When a resident returned from dialysis, they were responsible for reviewing the communication book to see what recommendations dialysis was making and if there were any issues during the treatment. They also notified the registered nurse to complete the assessment to ensure the resident was stable after dialysis and the fistula was patent (intact and functioning). The day shift normally left at 2:30 PM but on 04/03/2026 they took over the unit at 2:45 PM. Resident #10 had already returned from dialysis and was assessed by the registered nurse. They did not document they checked the dialysis site on the Medication Administration Record because it was completed by the day shift nurse. During an interview on 04/06/2026 at 2:05 PM, Registered Nurse #16 stated they were the nurse responsible for preparing Resident #10 for dialysis on 04/03/2026. Prior to sending a resident to dialysis, the resident had their vital signs and weight completed and documented in the communication book to ensure they were appropriate for treatment. When the resident returned from dialysis, they reviewed the communication book from dialysis to see if the resident tolerated treatment. The registered nurse should complete an assessment and document the assessment in a progress note. They did not complete the assessment for Resident #10 on 04/03/2026 as the resident had not returned prior to the end of their shift. They did not check the fistula prior to attending dialysis or when the resident returned because the resident had not returned during their shift. They were not sure where the fistula was located because they had not checked it. During an interview on 04/06/2026 at 1:53 PM, The Director of Nursing stated dialysis residents had their weights and vital signs completed prior to every dialysis session. Information was documented in a communication book and sent with the resident to ensure they were stable to receive the dialysis treatment. When the resident returned from dialysis, vital signs were completed, and a weight was obtained. They recently reviewed the communication book for Resident #10 and there was information that was outdated for months. There were missing pages and blank pages that should have been completed. It was important to follow the dialysis procedure to ensure residents were safe before and after treatment. The assessment after dialysis was often not completed because the resident came back at the change of shift. 10 New York Codes, Rules and Regulations 415.12(k)

Based on observations, record review and interviews, the facility failed to ensure a resident who is fed by enteral means (feeding tube) receives the appropriate treatment and services to prevent complications of enteral feeding for one (1) of one (1) resident (Resident #37) reviewed. Specifically, Resident #37's enteral feeding formula, water flush containers, and tubing were not dated and timed. Findings include: The facility policy Enteral Nutrition, revised 08/2025, did include directions for administering tube feeding and hang life of enteral formulas. Resident #37 had diagnoses including esophageal cancer and gastrostomy (feeding tube) status. The 02/24/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition and required enteral feeding. The Comprehensive Care Plan revised 04/01/2026 documented the resident was at risk for malnutrition related to history of protein calorie malnutrition, schizophrenia, anxiety and depression, history of underweight body mass index, edentulous (having no natural teeth), history of sporadic meal intakes, significant weight loss, increased nutritional needs secondary to cancer diagnoses, low body weight, and low albumin. The resident required a feeding tube for adequate nutrition and hydration, declined scheduled tube feedings at times and other times would push the buttons and stop the tube feeding. Interventions included a regular, pureed consistency, nectar thick liquids diet, may have thin soda and chewing gum; administer tube feeding per physician orders and registered dietitian recommendations; and monitor intakes, weights, labs and skin condition. The 03/31/2026 physician order documented Jevity 1.5 (tube feeding formula) full strength Rate: 75 cubic centimeters per hour x 18 hours twice a day at 2:00 PM and 8:00 AM, continuous. Flush tube with 130 cubic centimeters of water before and after feeding. Administer tube feeding at 2:00 PM and stop at 8:00 AM.During an observation on 04/01/2026 at 12:57 PM, Resident #37 was lying in bed with their tube feeding connected. The formula bottle and flush bags were hung on the pole. The formula bottle was empty with no date, time or staff initials. The flush bag was full and had no date, time or staff initials. The tubing on the bottle and flush bag were not labelled. During an observation on 04/02/2026 at 9:58 AM, the resident was in their wheelchair in the hall. A full bottle of tube feeding formula was hanging on a pole in their room and dated 04/02/2026. The water flush bag was full and hanging on the pole. The flush bag and tubing were not dated or labelled. During an observation on 4/6/2026 at 11:43 AM, the resident's tube feeding formula tubing was connected to the resident and the formula was running at 75 cubic centimeters per hour. The bottle was dated 04/05/2026 and had a volume of 600 milliliters in the bottle. There was no time or staff initials on the bottle. The water flush bag had 500 milliliters in the bag and was dated 04/05/2026. During an interview on 04/06/2026 at 12:03 PM, Registered Nurse #15 stated they were assigned the medication pass for the South Unit. Resident #37 had a tube feeding. The formula bottles were only good for twenty-four (24) hours once opened and should be changed. It was not appropriate for the resident's tube feeding bottle to be dated 04/05/2026. During an interview on 04/06/2026 at 2:25 PM, the Director of Nursing stated tube feeding bottles and tubing should be dated and timed. 10 New York Codes, Rules, Regualtions 415.12(g)(2)

Based on observations, record review, and interviews (Intake #s 2714848 and 2729682) the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for one (1) of three (3) Residents (Resident #3) reviewed. Specifically, Resident #3 had facial hair and shaving was not offered. Findings include: The facility policy Activities of Daily Living, supported, revised 04/2025, documented appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident in accordance with their plan of care, including appropriate support and assistance with hygiene: (bathing, dressing, grooming and oral care).Resident #3 had diagnoses including quadriplegia (paralysis of all four limbs) and depression. The 11/21/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition and was dependent on staff for personal hygiene. The Comprehensive Care Plan revised 02/06/2026 documented the resident required assistance with activities of daily living and functional mobility. The was no documented evidence of the resident's preference for shaving or presence of facial hair. The 03/2026 resident care instructions documented the resident required moderate assistance of one (1) for bathing and stand by assistance for personal hygiene.The following observations of Resident #3 were made:-On 04/01/2026 at 11:29 AM with black facial hair, approximately 1 inch long on the left and right sides of their chin in a beard-like fashion and with a scant amount of black facial hair on their upper lip. Resident #3 stated staff did not offer to shave them, and they preferred to be shaved. -On 04/02/2026 at 10:45 AM in bed with black facial hair on the right and left sides of their chin and upper lip. The resident stated they hoped staff would offer to shave them today.During an interview on 04/03/2026 at 09:53 AM, Certified Nurse Aide #4 stated Resident #3 could verbalize if they would like to be shaved. If the resident asked, the certified nurse aides would shave them. If they observed facial hair, the certified nurse aides would shave the resident provided the resident agreed. They stated there were plenty of staff on the unit to meet the residents' needs.During an interview on 04/06/2026 at 02:07 PM, Licensed Practical Nurse Unit Manager #3 stated activities of daily living for dependent residents included brushing hair, assisting with bathing, and providing oral care and shaving. Resident #3 was cognitive and could make their needs known and should not have to ask to be shaved. The certified nurse aides should offer shaving to the resident. They stated it was undignified for Resident #3 to have facial hair if it was not their preference. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review, the facility failed to ensure resident's right to personal privacy and confidentiality of their personal and medical information for one (1) of one (1) resident (Resident #2) reviewed. Specifically, Resident #2 had a binder located in a holder outside their room, accessible to all, containing staff entries about the resident's personal care. Findings include: The undated facility policy Resident Rights, documented residents had the right to privacy and confidentiality of records. The facility policy Quality of Life – Dignity, revised 08/2025, documented staff should maintain an environment in which confidential clinical information was protected, for example: signs indicating the resident clinical status or care needs should not be openly posted in the resident's room unless specifically requested by the resident or family member. Resident #2 had diagnoses including depression. The 12/27/2025 Minimum Data Set assessment documented the resident had intact cognition; rejected care one (1)- three (3) of seven (7) days; and did not have behavioral symptoms. The Comprehension Care Plan initiated 09/26/2025 and revised 03/06/2026 documented the resident had the potential of accusatory behavior related to attention seeking behaviors. Interventions included staff would document on the log prior to entering and exiting resident room. There was no documented evidence of the location of the log. During an observation on 04/03/2026 at 10:29 AM, there was a white binder with a communication log in a holder on the wall outside Resident #2's room. The binder was located up high and had a STOP sign in red on the outside of the binder. The binder included dates, times, and staff initials of when they entered resident's room. The binder was accessible to anyone who passed by the resident's room. The communication log binder documented multiple daily entries including: -on 03/20/2026 at 3:55 PM, the resident had incontinence care completed. -on 04/03/2026 at 10:30 AM, the resident refused their morning care and needed coffee. -on 04/05/2026 at 11:30 PM, the resident requested as needed pain medication. During an interview on 04/01/2026 at 10:03 AM, Ombudsman #12 stated Resident #2 had a book outside their room that staff used to sign in and out of the resident's room. The binder was in the hallway and accessible to anyone. During an interview on 04/01/2026 at 1:26 PM, Resident #2 stated they had a problem with the book outside their door. They did not know what was in the binder. Staff were supposed to write down what they were doing. They stated they talked to the social worker about the book, the social worker said they would look into it, and nothing came of it. During an interview on 04/06/2026 at 11:30 AM, Certified Nurse Aide #13 stated there was a white binder for Resident #2 they signed when they went in and out of the resident's room. It was used to see how long they were in the resident's room. They stated they also documented things such as if they gave the resident a snack. During an interview on 04/06/2026 at 11:47 AM, Social Worker #14 stated Resident #2 did not have any grievances in the last three (3) months. During an interview on 04/06/2026 at 2:07 PM, Licensed Practical Nurse Unit Manager #3 stated the white binder was used anytime anyone entered and exited the resident's room. They documented anytime care was offered, medications were administered, activities done, and anyone that goes in the room for any purpose. They wrote their name, time, and what they were doing for the resident. The binder was high enough to not be accessible to other residents. They did not think about visitors being able to access the binder. The binder should probably be put behind the nurse's station. They stated Resident #2 had not complained about the binder to them. 10 New York Codes Rules and Regulations 415.3(d)(1)(ii)

Based on record review and interviews during abbreviated survey (NY00317123), the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 3 of 4 residents (Resident #1, #3, and #4) reviewed and for an additional 6 unidentified residents. Specifically, facility investigations did not identify concerns related to: -Resident #2, a cognitively impaired resident, was touched on their breast by Resident #1. Two weeks later, Resident #2 was documented as having Resident #1 rub their genitals against them. There was no documented evidence Resident #2 was assessed timely, no evidence the provider and the resident's family were notified timely and interventions to protect Resident #2 and other vulnerable residents were not implemented timely. - Resident #4, a cognitively impaired resident had their back and buttocks rubbed by Resident #1. - Resident #1 had sexually inappropriate behaviors towards unidentified residents documented in their medical record on 6 occasions (including kissing 2 residents and exposing self and masturbating in front of 4 residents). The 6 residents involved were not identified and there were no corresponding investigations related to the incidents. Findings include: The undated facility policy, Abuse Prevention and Reporting, documented all residents would be kept free from abuse and neglect. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment which resulted in physical harm, pain, or mental anguish. Sexual abuse included, but was not limited to, sexual harassment, or sexual assault. The facility would immediately take steps to ensure resident safety and provide medical attention when necessary. They would secure statements from all parties involved. Social Services would be contacted to interview all parties involved. 1) Resident #2 had diagnoses including Alzheimer's disease. The 12/15/2023 Minimum Data Set assessment documented the resident's cognition was severely impaired. Resident #1 had diagnoses including dementia and sexual dysfunction not due to a substance or known physiological condition. The 5/2/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, exhibited physical behaviors directed towards (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) 1-3 of 7 days which significantly interfered with the resident's care and put others at risk for physical injury, The 1/9/2024 at 9:44 PM Incident Report by Licensed Practical Nurse #4 (Assistant Director of Nursing), documented Resident #1 was seen touching Resident #2's breast around mealtime and Resident #2 appeared unaware of incident and was without injury. Immediate measures taken included redirection which was effective. The physician was notified on 1/10/2024 at 2:10 PM and family notified on 1/11/2024 at 9:24 PM. The 1/9/2024 at 10:11 PM Licensed Practical Nurse #16 progress note documented an aide reported Resident #1 was touching Resident #2's breast outside of clothing during breakfast. The residents were immediately separated, and Resident #2 did not appear aware of incident. Resident #1 was educated about inappropriate behavior and kept to other side of the dining room. There was no documented evidence Resident #2 was assessed immediately following the incident. There was no documented evidence Resident #2's family, and the medical provider were notified of the incident on 1/9/2024. There was no documented evidence Resident #1 was assessed immediately following the incident. There was no documented evidence Resident #1's family, and the medical provider were notified of the incident on 1/9/2024. The 1/22/2024 at 6:05 PM note completed by Licensed Practical Nurse #14 documented Resident #1 was seen rubbing their genitalia on Resident #2. As soon as Resident #1 noticed they were seen, they stopped and headed out of dining room. The 1/22/2024 at 8:30 PM Incident Report recorded on 1/23/2024 at 8:26 PM by Licensed Practical Nurse #8 documented a nurse reported that Resident #1 had Resident #2 touch their genitals. The residents were immediately separated, Resident #1 was placed on 15-minute checks and the incident was reported to the Department of Health. The 1/22/2024 at 8:30 PM Licensed Practical Nurse #8 note documented the nurse reported earlier in the shift, Resident #2 was touching Resident #1's private areas. There was no documented evidence Resident #2 was assessed immediately following the incident. There was no documented evidence Resident's #1 and #2's family or medical provider were notified of the incident on 1/22/2024. 2) Resident #4 had diagnoses including dementia. The 5/1/2023 Minimum Data Set assessment documented the resident's cognition was moderately impaired. Resident #1 had diagnoses including dementia and sexual dysfunction not due to a substance or known physiological condition. The 5/2/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, exhibited physical behaviors directed towards (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) 1-3 of 7 days which significantly interfered with the resident's care and put others at risk for physical injury. The 5/20/2023 at 10:28 PM Licensed Practical Nurse #9 progress note documented it was reported to them Resident #1 had engaged in inappropriate sexual behavior with a resident on the North Unit (grabbing their buttocks with both hands). It was also reported the resident was still on the North side, near the other resident, because attempts to redirect Resident #1 back to the South Unit were in [NAME]. The licensed practical nurse managed to get the resident back on the South Unit at dinnertime when the resident attempted several times to return to the North Unit. At that point they instructed the unit assistant to be 1:1 with the resident to avoid any further behaviors. The 5/20/2023 Incident Report recorded on 5/24/2023 by Registered Nurse #10 documented at 1:20 PM, Resident #1 was observed hugging Resident #4 and rubbing their hand up and down Resident #4's back and buttocks. An assessment was completed and there were no marks on Resident #4. The residents were immediately separated. Resident #1 was also educated to keep their hands to themselves. Resident #1 was redirected and placed on 15-minute checks. The 5/20/2023 nursing schedule did not document Registered Nurse #10 on duty on all 3 shifts the day of the incident. The 5/23/2023 at 11:10 AM Registered Nurse #10 note documented the resident had no recollection of the incident on 5/20/2024 when another resident forcibly hugged them and no indication of psychological harm. 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 5/20/2023. 3) Unidentified Residents The 8/13/2023 at 9:30 PM Registered Nurse #19 progress note documented Resident #1 remained on 30-minute checks throughout shift. There were no issues noted until 9:30 PM when Resident #1 was found with their pants down in the dining room demonstrating inappropriate sexual behavior while another resident was present at a distant table. Resident #1 was encouraged to return their room and would continue 30-minute checks. The 10/30/2023 at 9:29 PM Licensed Practical Nurse #15 progress note documented Resident #1 was in dining room with others present when they pulled their pants down exposing self and was rubbing their genitals. The resident was educated that the behavior was not acceptable. The 1/23/2024 at 10:00 PM Licensed Practical Nurse #8 progress note documented while walking to the nursing station, they observed Resident #1 take their genitalia out of their pants in proximity of a resident. The 1/24/2024 at 7:16 PM Licensed Practical Nurse #1 progress note documented Resident #1 was in the dining room with another resident who was asleep at the next table. Resident #1 changed chairs to be closer to the sleeping resident, pulled their pants down, exposed themself and was touching their genitals. The 7/29/2024 at 3:02 PM former Director of Nursing #20 progress note documented Resident #1 wheeled up to another resident and kissed them on the mouth. Staff immediately intervened and separated residents. There was no documented evidence the facility investigated any of the incidents to identify the other residents present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other residents were impacted by Resident #1's inappropriate behavior. The 10/12/2024 at 3:06 PM Licensed Practical Nurse #4 (Assistant Director of Nursing) progress note documented a housekeeper reported they observed Resident #1 kiss another resident in the dining room. Staff intervened, the residents were easily redirectable and there were no signs of emotional distress. Resident #1 was placed on 15-minute checks for 3 days. The corporate Director of Nursing was updated. The supervisor was contacting family and the provider. The 10/12/2024 at 10:48 PM Registered Nurse Supervisor #7 progress note documented they were notified Resident #1 attempted to kiss another resident in the dining room and the residents were separated. The Director of Nursing and provider were notified. Resident #1 placed on 15-minute checks. No signs and symptoms of distress. The 10/12/2024 Incident report, recorded on 11/7/2024 at 4:34 PM by Licensed Practical Nurse #4 (Assistant Director of Nursing) documented the resident was observed to have kissed a resident of the opposite sex. There was no documented evidence the incident was investigated timely and no documented evidence the residents were assessed on 10/12/2024. During a telephone interview on 11/29/2024 at 9:36 AM, Licensed Practical Nurse #15 stated an incident report was completed when there was something out of the normal that needed to be noted like an injury of unknown origin, resident to resident abuse and elopement. Sexually inappropriate behaviors would also require an incident report. If other residents were exposed to a resident's inappropriate sexual behavior, they needed to be assessed and that was something they could not do as a licensed practical nurse. Sometimes there was a registered nurse on duty who could assess though not always. On 10/30/2023, they did not recall if they completed an incident report however one would have been required. They did not recall who the other residents were present at the time of the behavior. They stated if there was a supervisor in the building on 10/30/2024, they would have notified them and did not recall if they notified. During a telephone interview on 11/29/2024 at 10:23 AM, Licensed Practical Nurse #1 stated the purpose of an incident report was to document falls, resident to resident abuse, as well as any resident-to-resident contact if there was a chance of injury. Sexually inappropriate behaviors also required an incident report and assessment by the registered nurse. They reported incidents to the supervisor and if the supervisor was not a registered nurse, then the Assistant Director of Nursing was notified, and the Assistant Director of Nursing would find a registered nurse to come to the building to assess. Licensed Practical Nurse #1 was responsible to obtain staff statements and notify the provider and family. If residents were exposed to inappropriate sexual behaviors, they would monitor the residents, note any concerns, and speak with them to make sure they were not affected. On 1/24/2024, 15-minute checks were not effective, and the resident continued with sexually inappropriate behaviors during the shift. They did not recall who the other resident was present during the behavior. There should have been an incident report completed and was not sure why one was not completed. On 11/29/2024 at 10:49 AM, Licensed Practical Nurse #8 was not reached in a telephone interview. On 11/29/2024 at 12:51 PM, Registered Nurse #19 was not reached in a telephone interview. On 12/9/2024 at 12:23 PM, Licensed Practical Nurse #9 was not reached in a telephone interview. During a telephone interview on 12/10/2024 at 2:13 PM and on 12/11/2024 at 12:02 PM, Licensed Practical Nurse #4 (Assistant Director of Nursing) stated incident reports were completed at the time of the incident and provider and family notified immediately. If contact was made between two residents, a registered nurse assessment was needed. If residents were exposed to another resident's sexually inappropriate behavior, then a social worker typically followed up. On 1/9/2024, they could not recall why there was no assessment completed for Resident #2 and there should have been an assessment completed. They stated they started the incident report the day after the incident (1/10/2024) because one was not started on 1/9/2024. Staff was trained to start incident reports and they were not sure why one was not started on 1/9/2024. The provider and family were not notified timely for Resident #1 and #2. Licensed Practical Nurse #16 should have updated the care plan per their nursing note for keeping the resident seated at a table with residents of the same sex and they were not aware the care plan was not updated. On 10/12/2024, they were updated while at home by Registered Nurse Supervisor #7 that Resident #1 kissed another resident and they did not recall who the other resident was. They completed the incident report on 11/7/2024 after it was found nobody initiated the paperwork. They believed the incident was investigated timely however the incident paperwork was not. New interventions were put in place on 10/12/2024 at the time of the incident for 15-minute checks. During a telephone interview on 12/11/2024 at 6:59 AM, the facility's Corporate Director of Nursing stated incident reports could be started by all nurses and were necessary so incidents could be investigated to rule out abuse and neglect. However, not all nurses completed incident reports and when the incident was reported to the Director of Nursing, the Director of Nursing was responsible to ensure the incident report was started if one had not. Incident reports should be initiated as soon as possible, and family and providers notified as soon as possible. All incidents required a registered nurse assessment including resident to resident sexual incidents and kissing. If a resident exposed themself in front of others and was masturbating, they expected the other resident would be assessed to ensure they were not touched. The other resident should also be interviewed to determine if they were emotionally alright, and it should be documented. Any staff could observe a resident for signs and symptoms of distress however the registered nurse assessed, and social work followed up. If no registered nurse was in the building at the time of an incident, the Director of Nursing or registered nurse on-call would come into the facility for assessment, or the registered nurse coming on duty the next shift assessed. The Interdisciplinary Team reviewed incidents to ensure current care planned interventions were effective and determined if they needed to change interventions. - On 5/20/2023, they expected an incident report to have been started immediately as well as an assessment by a registered nurse. 5/20/23 was a Monday, Registered Nurse #10 was the covering Director of Nursing (current Director of Nursing was on leave) and was staying locally. They believed Registered Nurse #10 would have come to the facility for assessment and was not sure why the assessment was not documented that day. They were not sure why the incident was documented late. - On 1/9/2024, they expected an assessment by a registered nurse and notifications were not timely. - On 1/22/2024, they expected an assessment by a registered nurse and notifications should have happened at the time of the incident. - On 10/12/2024, the former Director of Nursing was responsible to ensure the incident report was started. When the Administrator noted the incident report was not started on 11/7/2024, they directed Licensed Practical Nurse #4 (Assistant Director of Nursing) to initiate it. - For the incidents where other residents were exposed to the resident's genitalia or to acts of masturbation, there should have been documentation who the other resident(s) were and whether the other resident(s) had any negative effects from the behavior. 10NYCRR 415.4(b)(3)

Based on record review and interviews during abbreviated survey (NY00317123), the facility did not ensure residents were free from abuse and failed to protect residents from further abuse for 2 of 2 residents (Resident #2 and 4) reviewed, and 6 unidentified residents. Specifically, Resident #1 was cognitively impaired with a history of sexually inappropriate behaviors and there were no documented interventions to address the resident's ongoing behaviors or to protect other residents from abuse. Resident #2, a cognitively impaired resident, was touched on their breast by Resident #1. Two weeks later, Resident #2 was documented as being touched inappropriately by Resident #1. There was no documented evidence Resident #2 was assessed timely, no evidence the provider and the resident's family were notified timely and interventions to protect Resident #2 and other vulnerable residents were not effective to prevent recurrence. Resident #4, a cognitively impaired resident had their back and buttocks rubbed by Resident #1. Subsequently, Resident #1 kissed unidentified residents on two occasions, and continued to expose themselves and masturbate in front 6 unidentified residents on multiple occasions and the unidentified residents were not documented as assessed to determine if they had a negative outcome. Findings include: The undated facility policy, Abuse Prevention and Reporting, documented all residents would be kept free from abuse and neglect. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment which resulted in physical harm, pain, or mental anguish. Sexual abuse included, but was not limited to, sexual harassment, or sexual assault. The facility would immediately take steps to ensure resident safety and provide medical attention when necessary. They would secure statements from all parties involved. Social Services would be contacted to interview all parties involved. The facility policy, Resident Supervision 15 Minute/Frequent Checks, revised 3/2021, documented 15 Minute or Frequent Checks was a resident being monitored by a facility staff member to ensure the resident or other residents were safe. Prior to considering a resident for 15 Minute/Frequent Checks, an assessment and plan was to be completed by the Interdisciplinary Team to assess need. Interventions should be developed to recognize, evaluate, and analyze specific behaviors to help identify interventions; identify and develop behavior plans; and address, eliminate or reduce underlying causes of distressed behavior. Medical evaluation was required for any resident determined to be in need of intensive supervision. The Comprehensive Care Plan and certified nurse aide plan would be updated and reviewed at least weekly for appropriateness of 15 Minute/Frequent Checks and possible care plan changes. The certified nurse aide was to document all resident activity, behaviors, etc. This would be completed each shift. Resident #2 had diagnoses including stroke and dementia. The 12/15/2023 Minimum Data Set assessment documented the resident's cognition was severely impaired. Resident #4 had diagnoses including bipolar disorder. The 5/1/2023 Minimum Data Set assessment documented the resident's cognition was moderately impaired. Resident #1: Resident #1 had diagnoses including dementia and sexual dysfunction not due to a substance or known physiological condition. The 5/2/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, exhibited physical behaviors directed towards (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) 1-3 of 7 days which significantly interfered with the resident's care and put others at risk for physical injury, and required supervision for walking in their room and corridor. Resident #1's Comprehensive Care Plan initiated 4/27/2023 documented the resident demonstrated episodes of inappropriate reaching and touching of others, inappropriate comments with sexual overtones, and exposing body parts. Interventions included: 2 staff members for all care; provide support to the resident; and psych evaluation as needed. The resident had the potential to abuse others. Interventions included monitor mood and behavior and provide early interventions; room change or unit change if possible; set limits, and counsel on inappropriate behaviors; if behavior symptoms were unmanageable, call 911 and send the resident to the emergency room for further evaluation. The 4/24/2023 Physician #18 progress note documented the resident was deemed incompetent to make decisions and guardianship was in place. The resident had dementia from a traumatic brain injury and currently had no behaviors. The 5/13/2023 at 12:10 AM note Licensed Practical Nurse #9 progress note documented the resident was reported to have made inappropriate comments towards a unit assistant and stated they should get naked together. The resident was reminded to be appropriate, and staff would continue reminding the resident to not make comments. The 5/20/2023 Incident Report recorded on 5/24/2023 by Registered Nurse #10 documented at 1:20 PM, Resident #1 was observed hugging Resident #4 and rubbing their hand up and down Resident #4's back and buttocks. An assessment was completed and there were no marks on Resident #4. The residents were immediately separated. Resident #1 was also educated to keep their hands to themselves and placed on 15-minute checks. The 5/20/2023 nursing schedule did not document Registered Nurse #10 on duty on all 3 shifts the day of the incident. There was no documented evidence Resident #1's care plan was updated timely and no documented evidence Resident #4 was assessed timely. A 5/23/2023 at 11:16 AM Social Worker #5 progress note documented they spoke with Resident #1 regarding the incident with Resident #4. Resident #1 could not recall the incident. The resident was educated on keeping their hands to themself, as that type of behavior could get them in trouble. The resident was asked to repeat what Social Worker #5 said and if they understood. The resident said they understood. The updated 5/23/2023 comprehensive care plan completed by Registered Nurse #10 documented the resident had altered health maintenance and was an abuser/aggressor. Goals included the resident would stop abusive behavior immediately after staff intervened x 90 days. Interventions included 15-minute checks, cause of the abuse would be ascertained and addressed, residents would be immediately separated, further abusive behaviors would be observed, and the rights of others would be reviewed as needed. The 8/13/2023 at 9:30 PM Registered Nurse #19 progress note documented the resident remained on 30-minute checks throughout the shift. There were no issues noted until 9:30 PM when the resident was found with their pants down in the dining room demonstrating inappropriate sexual behavior while another resident was present at a distant table. The resident was encouraged to return to their room and would continue 30-minute checks. There was no documented evidence the facility investigated the incident to identify the other resident present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other resident was impacted by the behavior. There was no documented evidence the care plan was updated with interventions to prevent recurrence. The 10/30/2023 at 9:29 PM Licensed Practical Nurse #15 progress note documented Resident #1 was in dining room with others present (unidentified). The resident's pants were pulled down to their thighs, exposing themself and they were rubbing their genitals. The resident was educated that the behavior was not acceptable. There was no documented evidence the facility investigated the incident to identify the other residents present at the time and if the other residents were impacted by Resident #1's behavior. There was no documented evidence the care plan was updated with interventions to prevent recurrence of inappropriate sexual behaviors in the dining room. The 10/31/2023 at 10:08 AM Social Worker #5 progress note documented Resident #1 was spoken to about their behavior in the dining room. They were educated that the behavior was not acceptable, and they would not be able to go to the dining room if the behavior continued. The 1/9/2024 at 10:11 PM Licensed Practical Nurse #16 progress note documented an aide reported the resident was touching another resident's breast (Resident #2) outside of their clothing during breakfast and they were immediately separated. Resident #2 did not appear aware of incident. Resident #1 was educated about inappropriate behavior and kept on the other side of the dining room. They discussed with staff to keep the resident at a table to include the same sex, moving forward. The 1/9/2024 Incident Report completed by Licensed Practical Nurse #4 (also the Assistant Director of Nursing) documented at 9:44 PM, the resident was seen touching Resident #2's breast around mealtime and Resident #2 appeared unaware of incident and was without injury. Immediate measures taken included redirection which was effective. The physician was notified on 1/10/24 at 2:10 PM. There was no documented evidence the residents were assessed timely. The Comprehensive Care plan, updated 1/11/2024 documented Resident #1 was to have immediate redirection to private areas during acts/times of sexual behavior, provide redirection as needed away from peers of opposite sex, follow with psychiatry, and medications were to be reviewed. There was no documented evidence the care plan was updated with interventions to keep the resident at the dining room table with the same sex and no documented interventions to protect Resident #2 from further abuse. The 1/22/2024 at 6:05 PM Licensed Practical Nurse #14 progress note documented the resident was seen rubbing their genitalia on Resident #2. As soon as Resident #1 noticed they were seen, they stopped and headed out of the dining room. The 1/22/2024 at 8:30 PM Licensed Practical Nurse #8 progress note documented the nurse reported earlier in the shift, Resident #2 was touching Resident #1's private areas. The 1/22/2024 at 8:30 PM Incident Report, recorded on 1/23/2024 at 8:26 PM by Licensed Practical Nurse #8 documented a nurse reported that Resident #1 had Resident #2 touch their genitals. The residents were immediately separated, and Resident #1 was placed on 15-minute checks. The incident was reported to the Department of Health and the physician and resident representative were notified on 1/24/2024. There was no documented evidence the residents were assessed timely. The Comprehensive Care Plan, updated 1/22/2024 documented new interventions included to approach Resident #1 in a calm consistent manner, for refusals of care, reapproach at another time, monitor changes in mood/behavior and report to provider, provide resident with opportunity to express feelings through 1:1 and group visits, use the resident's name and explain the purpose upon approach, Resident #1's 1/23/2024 updated Comprehensive Care Plan documented 15-minute checks. The 1/23/2024 at 10:00 PM Licensed Practical Nurse #8 progress note documented while walking to the nursing station they observed Resident #1 take their genitalia out of their pants in proximity of a resident (unidentified). They told the resident to pull their pants up and they then walked to their room. There was no documented evidence the facility investigated the incident to identify the other resident present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other resident was impacted by the behavior. There was no documented evidence Resident #1's care plan was updated with interventions to prevent recurrence. The 1/24/2024 at 7:16 PM Licensed Practical Nurse #1 progress note documented Resident #1 was in the dining room with another resident (unidentified) who was asleep at the next table. Resident #1 changed chairs to be closer to the sleeping resident, they pulled their pants down, exposed themself and was touching themself. They told the resident to pull their pants up and instructed aides to move the resident. Resident #1 continued 15-minute checks. There was no documented evidence the facility investigated the incident to identify the other resident present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other resident was impacted by the behavior. There was no documented evidence the care plan was updated with interventions to prevent recurrence. The 1/30/2024 at 11:12 PM Assistant Director of Nursing Licensed Practical Nurse #4 progress note documented the resident was seen by the nurse practitioner (unidentified) to review medications and recent sexual behaviors. There was a new order for Depakote (antiepileptic medication used for behaviors) 125 milligrams twice daily. The 5/24/2024 Medical Director progress note documented nursing notes were reviewed with times of inappropriate sexual behavior documented. The resident's dementia was permanent and progressive. They documented to start Tagamet (gastrointestinal medication, sometimes used for hypersexuality) 200 milligrams twice daily for inappropriate sexual behaviors. The 5/30/2024 at 12:07 PM Licensed Practical Nurse #3 progress note documented the resident was being sexually inappropriate to staff and other residents. No contact was made. The resident was encouraged to keep their hands to themself and not to use language around the opposite sex. The 7/29/2024 at 3:02 PM former Director of Nursing #20 progress note documented the resident wheeled up to another resident of the opposite sex (unidentified) and kissed them on the mouth. Staff immediately intervened and separated the residents. A new order was obtained to increase Tagamet to 400 milligrams twice daily. They would have 15-minute checks daily for 3 days to assist with monitoring the Resident #1's whereabouts and interactions with others. There was no documented evidence of an incident report and no documented evidence the facility determined if the other resident was impacted by the incident. The 7/30/2024 at 7:57 AM Licensed Practical Nurse #23 progress note documented the resident was observed several times standing in the hallway exposing themself and was redirected. The 7/30/2023 at 1:02 PM Licensed Practical Nurse #3 progress note documented the resident continued to be verbally inappropriate asking staff and residents of the opposite sex for sexual favors and they continued 15-minute checks. The 7/30/2024 at 8:49 PM Social Worker #5 progress note documented they spoke with Resident #1 about the incident of kissing another resident (unidentified). The resident did not recall the incident. They were educated to keep their hands to themselves, so they did not get in trouble. Resident #1's 7/30/2024 updated Comprehensive Care Plan documented 15-minute checks for 3 days. The 8/19/2024 updated Comprehensive Care Plan documented interventions included upon completion of meals, Resident #1 would be escorted from the dining room and encouraged to sit in highly visible areas. The 8/26/2024 Nurse Practitioner #22 progress note documented the resident was seen because staff reported despite Tagamet 400 milligrams twice daily, the resident continued with sexual behaviors. The plan included to increase Tagamet to 600 milligrams twice daily. The 9/20/2024 at 12:02 PM Licensed Practical Nurse #3 progress note documented the resident verbalized wanting female residents and staff to perform sexual acts and saying they wanted to do sexual acts to them. No interventions stopped the behavior. The 9/21/2024 physician order documented 15-minute checks every shift for 3 days. The 10/12/2024 at 10:48 PM Registered Nurse Supervisor #7 progress note documented they were notified Resident #1 attempted to kiss another resident (unidentified) in the dining room and the residents were separated. The Director of Nursing and provider were notified. Resident #1 was placed on 15-minute checks. The 10/12/2024 Incident Report, recorded on 11/7/2024 at 4:34 PM by Licensed Practical Nurse #4 (Assistant Director of Nursing) documented the resident was observed to have kissed a resident of the opposite sex. The 10/12/2024 updated Comprehensive Care Plan documented Resident #1 had behavior symptoms. Interventions included 15-minute checks (discontinued on 10/24/2024). The updated 10/17/2024 Comprehensive Care Plan documented Resident #1 would be escorted in and out of the dining room for activities, meals, and supervised at all times while in the dining room area. The resident would be escorted out of the dining room immediately following completion of the meal/activity. The 10/24/2024 at 6:09 PM Registered Nurse #25 progress note documented the resident touched the arm of another resident (unidentified). Both residents assessed with no injury or distress. Resident #1's care plan was updated and orders for 15-minute checks ordered. Placed in physician book for medication review. The 10/24/2024 at 6:11 PM Incident Report completed by Licensed Practical Nurse #4 (Assistant Director of Nursing) documented the resident was observed grabbing another resident's arm (Resident #6). The provider and family were notified on 10/24/2024. The 10/24/2024 at 9:01 AM Social Worker #5 progress note documented they spoke to the resident who had no recollection of inappropriate behaviors the day before. They were re-educated on keeping hands off others. They also contacted the resident's guardian about inappropriate sexual behaviors and to inquire about alternate facilities that could accommodate the resident. The resident likely needed an all-male unit. The 10/24/2024 updated Comprehensive Care Plan documented Resident #1 had behavior symptoms. Interventions included 15-minute checks for 3 days, the resident would not be seated with any residents of the opposite sex during activities or meals. During an interview on 11/26/2024 at 12:03 PM, Resident #5 stated they resided on the resident's unit and the resident had behaviors that made them very uncomfortable, and they were terrified of them. Resident #1 had come to their room door (did not recall date), pulled their pants down exposing their genitals and told Resident #5 look at it. This past Saturday, they were wheeling by Resident #1's open door (bed closest to the doorway) and Resident #1 was naked and masturbating. They reported it to staff and staff closed the resident's door. In the dining room, they had seen the resident approach multiple residents of the opposite sex and try to touch them. They also witnessed the resident kiss another resident although that was a while ago. They stated it seemed like nothing was ever done to prevent the resident from behaving badly. During an interview on 11/26/2024 at 12:55 PM, Certified Nurse Aide #17 stated the resident had a history of touching themself and masturbating in common areas in front of other residents. When the resident displayed the behavior, they were to take them back to their room. The resident was supposed to always be within eyesight of staff. In the dining room in the past, the resident had tried to reach out and grab residents of the opposite sex. Now the resident was brought to the dining room after everyone else was seated and sat with residents of the same sex. They were aware of other instances where the resident was sexually inappropriate with other residents but did not recall the circumstances or what was done as a result. During a telephone interview on 11/29/2024 at 9:36 AM, Licensed Practical Nurse #15 stated residents involved in sexually inappropriate behaviors needed to be assessed. They could not assess residents to determine if there was negative impact as it was not in their scope. They expected a registered nurse to assess. On 10/20/2023, they did not recall who the other residents were in the dining room and did not recall if the other residents were assessed. If there was a supervisor on shift, they would have notified them for an assessment. They did not recall who the supervisor was. They stated the resident was mean and the facility just allowed the behavior. During a telephone interview on 11/29/2024 at 10:23 AM, Licensed Practical Nurse #1 stated when there was an incident, the registered nurse took care of care plan changes. If someone was exposed to a resident's inappropriate sexual behavior, they would monitor the other resident, talk with them to ensure they were alright and note any concerns. When there were instances of resident sexually inappropriate behaviors, the registered nurse should be notified for an assessment. On 1/24/2024, they did not recall who Resident #1 exposed themself to and did not recall if a registered nurse assessed the other resident. Resident #1 continued to have current sexually inappropriate behaviors and 15-minute checks were not effective in preventing recurrence of behaviors. Licensed Practical Nurses #8 and #9 and Registered Nurse #19 were not able to be reached for interviews. During a telephone interview on 12/10/2024 at 2:13 PM and on 12/11/2024 at 12:02 PM, Licensed Practical Nurse #4 (Assistant Director of Nursing) stated incident reports were completed at the time of the incident and the provider and family were notified immediately. If contact was made between two residents a registered nurse assessment was needed. If residents were exposed to another resident's sexually inappropriate behavior, then a social worker typically followed up. On 1/9/2024, they could not recall why there was no assessment completed for Resident #2 and there should have been an assessment completed. They stated they started the incident report the day after the incident (1/10/2024) because one was not started on 1/9/2024. Staff were trained to start incident reports and they were not sure why one was not started on 1/9/2024. The provider and family were not notified timely for Residents #1 and #2. Licensed Practical Nurse #16 should have updated the care plan per their nursing note for keeping the resident seated at a table with residents of the same sex and they were not aware the care plan was not updated. On 10/12/2024, they were updated while at home by Registered Nurse Supervisor #7 that Resident #1 kissed another resident and they did not recall who the other resident was. They completed the incident report on 11/7/2024 after it was found nobody completed the paperwork. They believed the incident was investigated timely and just the incident paperwork was not. New interventions were put in place on 10/12/2024 at the time of the incident for 15-minute checks. During a telephone interview on 12/11/2024 at 6:59 AM, the facility's Corporate Director of Nursing stated incident reports could be started by all nurses and were necessary so incidents could be investigated to rule out abuse and neglect. However, not all nurses completed incident reports and when the incident was reported to the Director of Nursing, the Director of Nursing was responsible to ensure the incident report was started if one had not been. Incident reports should be initiated as soon as possible, and family and providers notified as soon as possible. All incidents required a registered nurse assessment including resident to resident sexual incidents and kissing. If a resident exposed themself in front of others and was masturbating, they expected the other resident would be assessed to ensure they were not touched. The other resident should also be interviewed to determine if they were emotionally alright, and it should be documented. Any staff could observe a resident for signs and symptoms of distress however the registered nurse assessed, and social work followed up. If no registered nurse was in the building at the time of an incident, the Director of Nursing or registered nurse on-call would come into the facility for assessment, or the registered nurse coming on duty the next shift assessed. The Interdisciplinary Team reviewed incidents to ensure current care planned interventions were effective and determined if they needed to change interventions. The Corporate Director of Nursing stated the following about incidents involving Resident #1: - on 5/20/2023, they expected an incident report to have been started immediately as well as an assessment by a registered nurse. Registered Nurse #10 was the covering Director of Nursing and was not sure why the assessment was not documented that day. They were not sure why the incident was documented late. - On 1/9/2024, they expected an assessment by a registered nurse and notifications were not timely. - On 1/22/2024, they expected an assessment by a registered nurse and notifications should have happened at the time of the incident. - On 10/12/2024, the former Director of Nursing was responsible to ensure the incident report was initiated. When the Administrator noted there was no incident report, they directed Licensed Practical Nurse #4 (Assistant Director of Nursing) to initiate it on 11/7/2024. - For the incidents where other residents were exposed to Resident #1's genitalia or to acts of masturbation, there should have been documentation who the other resident(s) were and whether the other resident(s) had any negative effects from the behavior. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews during the abbreviated survey (NY00357986), the facility did not ensure food related equipment functioned in accordance with professional standards for food service safety in the main kitchen. Specifically, the water temperatures of the wash and rinse sinks in the three bay sink system (a 3-step process used to manually wash, rinse, and sanitize dishware) were not hot and less than 110 degrees Fahrenheit. Findings include: The facility policy, Sanitization, revised 5/2024, documented the food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soil by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Sanitizing of utensils should be accomplished by contact with sanitizing solution or immersion for 30 seconds in hot (at least 171 degree Fahrenheit) water. The Pot and Pan Cleaning and Sanitizing Procedures, located on the wall above the three bay sinks documented: - fill wash sink with automatic dispenser or manually by adding hot water and detergent; and - fill rinse sink with hot water and submerge in hot water rinse. The undated facility policy, Lack of Hot Water, documented if the facility experienced a lack of hot water in the kitchen, then the following procedures would be followed: - pots, pans, trays, cooking utensils, and other items required for washing would be washed using the three compartment sink sanitizing method; and - water may be heated on the stove for use in the three compartment sinks and for any other procedure requiring hot water. During an interview on 10/23/2024 at 11:15 AM, the Food Service Director stated they were pouring hot water from a large pot on the stove top into the three bay sinks. They stated the acceptable water temperature range for hot water was 100 degrees Fahrenheit to 120 degrees Fahrenheit. During an observation on 10/23/2024 at 1:24 PM, using a state thermometer the water in the wash sink was temped at 92 degrees Fahrenheit, and the water in the rinse sink was temped at 87 degrees Fahrenheit. Various kitchen items were in these sinks and in the process of being cleaned. During an interview on 10/23/2024 at 1:35 PM, the Food Service Director stated they would temp the water from the stove top and once it hit 150 degrees Fahrenheit it would be poured into the wash sink and the rinse sink. They stated that the soap entering the wash sink would be dispensed through the cold water, and that no cold water would enter the rinse sink. They stated since the loss of hot water occurred on 10/21/2024, they had not been taking temperatures of the three bay sinks and would not consider 92 degrees Fahrenheit and 87 degrees Fahrenheit hot. The Food Service Director verified these temperatures were obtained while a dietary aide was cleaning the various kitchen items used during the lunch meal, and this dietary aide had been reviewing the pot sink instructions posted on the wall. They stated they expected the food service worker to tell them the water in the wash sink and in the rinse sink was not hot. During an interview on 10/25/2024 at 2:02 PM, The Administrator stated they would have expected the food service staff have measured the temperature of the hot water inside the three bay sinks to make sure they were hot. They verified the sanitation policy, last revised 5/2024, had documented hot water was required when manually washing kitchen equipment. 10NYCRR 415.14(h)

Based on record review and interview during the recertification survey conducted 4/29/2024-5/3/2024 the facility did not ensure certified nurse aide performance reviews were completed once every 12 months for 2 of 3 certified nurse aides (certified nurse aides #9 and #10) reviewed. Specifically, certified nurse aides #9 and #10 did not have performance reviews documented at least once every 12 months. Findings included: The facility In-Service Training Program, Nurse Aide, revised October 2017, documented the facility would complete a performance review of certified nurse aides at least once every 12 months. Records would be filed in the employee's personnel file or would be maintained by the department supervisor. During a review of personnel files for certified nurse aides #9 and #10 there was no documented evidence of performance reviews completed at least once every 12 months. During an interview on 5/2/2024 at 10:15 AM, the Corporate Director of Nursing stated the certified nurse aide personnel files containing annual performance reviews were kept in the Human Resources office. If they were not there then, they might be in the storage units kept on the facility's grounds and they would look for them. The current facility Director of Nursing was then included in the interview by the Corporate Director of Nursing. The Director of Nursing stated they had only started in the role at the facility in November 2023 and had not done any annual performance reviews for certified nurse aides and they were unsure of where any previous performance reviews were kept. During a follow-up interview on 5/2/2024 at 10:45 AM, the Corporate Director of Nursing stated they could not find the annual performance reviews for certified nurse aides #9 and #10. 10 NYCRR 415.26 (d) (7)

Based on observation, record review, and interview during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the kitchen ventilation hood was unclean and laden with grease and dust buildup; the floor in the walk-in freezer was unclean with food items under shelving storage; and a section of flooring in front of the main dish machine was in disrepair and had unclean water and food debris. The facility policy Cleaning/sanitation of Kitchen dated 8/2016, documented food service workers and/or cooks were responsible for maintaining a clean environment in the kitchen. All persons were responsible for cleaning up after themselves. The Supervisor Cook, Food Service Manager, diet technician, or dietitian as needed, would ensure this. The Food Service Manager, diet technician, and /or dietitian were responsible party to check on cleaning and maintenance of equipment. The April 2024 weekly cleaning audits documented all areas of the kitchen were signed off as being done. This included sweeping and mopping under the counter, sweeping and mopping under all equipment, and racks in the cooler. No issues were identified on the audits. During observations on 4/29/2024 at 10:00 AM, 4/30/2024 at 10:50 AM, and 5/1/2024 at 11:44 AM the main kitchen hood was unclean, dusty, and grease laden. The hood was over the stove top and ovens. During an interview on 4/29/2024 at 10:00 AM, the Food Service Director stated the hood cleaning vendor came to the facility to clean the hood. They were not sure how often they came in. They stated the kitchen staff did not clean the hood and it should be cleaner. During an observation on 4/29/2024 at 10:05 AM, the section of flooring under the shelving unit within the walk-in freezer on the left side was unclean with food product on the floor. There were single serve ice cream cups, two hamburger buns, and ice buildup under the shelving rack. During observations on 4/29/2024 at 10:13 AM, 4/30/2024 at 10:50 AM, and 5/1/2024 at 11:44 AM there was an approximate 3 inch by 12 inch section of broken flooring in front of the commercial dish machine that had food debris and was holding water. The area under this section was in disrepair and was not smooth and cleanable. During an interview on 4/29/2024 at 10:13 AM, the Food Service Director stated they were not sure how long the floor was broken. Maintenance was made aware. They would like the flooring fixed as it could not be cleaned properly. Dietary staff performed deep cleaning in the kitchen weekly. During an interview on 4/30/2024 at 2:00 PM, the Director of Facilities stated they were aware of the broken section of kitchen flooring and was waiting on a quote to get replacement flooring. The repairing contractor had not sent the quote back. They were not sure how long the flooring had been broken or when the flooring would be replaced. NYCRR10 415.14(h)

Based on observation, interview, and record review during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at appetizing temperatures for 1 of 2 meals sampled (Resident #66). Specifically, food items on 1 of 2 test trays (4/30/2024 lunch meal) were not at acceptable temperatures. Findings include: The facility policy Food Holding Temperatures dated 1/30/2024, documented if temperatures of food were below 140 degrees Fahrenheit, remove them from the steam table and reheat to required minimum preparation temperature of: 165 degrees Fahrenheit - poultry; 150 degrees Fahrenheit - all other meats; 145 degrees Fahrenheit - eggs. The facility policy Temperatures dated 9/2002, documented test trays would be done randomly by the diet technician, registered dietitian, and Food Service Director three days a week and temperature sheets would be kept for sample trays by the diet technician. The policy did not document appropriate food temperatures for meal items when conducting a test tray. During an observation on 4/30/2024 at 11:22 AM, the internal temperatures of lunch food items were measured in the steam table within the main kitchen and included; chicken gravy mix was 190 degrees Fahrenheit, and spinach was 150 degrees Fahrenheit. During an observation on 4/30/2024 at 11:58 AM, the North Unit meal cart left the main kitchen. During an observation on 4/30/2024 at 12:10 PM, a test tray was conducted on a randomly selected North Unit resident's meal tray (Resident #66). A replacement meal tray was requested for the resident. The food was below acceptable palatability ranges. Specifically, the internal temperature of the chicken and gravy mix was measured to be 121 degrees Fahrenheit, and the spinach was measured to be 130 degrees Fahrenheit. During an interview on 4/30/2024 at 12:15 PM, the Food Service Director stated they were surprised foods were measured so low. They wanted foods on resident meal trays to be at least 140 degrees Fahrenheit and they should be warmer for eating. The facility did periodic test trays, and 140 degrees Fahrenheit would be the minimum expected temperature. 10NYCRR 415.14(d)(2)

Based on record review and interview during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with facility assessment for 2 of 2 licensed nurse records (registered nurse #6 and licensed practical nurse #7) reviewed. Specifically, registered nurse #6 and licensed practical nurse #7 did not receive annual competency evaluations to measure their pattern of knowledge, skills, abilities, and other characteristics to perform their work roles successfully as outlined in the 2023 facility assessment and per regulations. Findings include: The Facility Assessment Tool updated 10/2/2023 documented all staff members had or would have yearly competencies, or would receive the facility orientation, including competencies, if employed for less than one year. The facility did not have a policy and procedure for competency evaluations. Nursing personnel records were reviewed for registered nurse #6 and licensed practical nurse #7. Both staff had been employed for over a year and there were no competency evaluations within the last year. During an interview on 5/2/2024 at 10:15 AM the Corporate Director of Nursing stated nursing personnel files were kept in the Human Resources office. They currently did not have a staff educator as the position had been vacant since Fall of 2023. They were planning to transition a Unit Manager into the role of licensed practical nurse/Assistant Director of Nursing to help with staff education. The current Director of Nursing had been performing the staff educator role since January 2024. During a follow-up interview on 5/22024 at 10:45 AM the Corporate Director of Nursing stated they could not find any further documentation on nursing competencies for registered nurse #6 and licensed practical nurse #7. During an interview on 5/3/2024 at 12:11 PM the Administrator stated the current staff educator was the Director of Nursing. They had been hired as the Director of Nursing in November 2023. During survey they promoted a Unit Manager into the role of licensed practical nurse/Assistant Director of Nursing and the plan was to get them involved in staff education, which would include doing annual nursing competencies. 10 NYCRR 415.26(c)(1)(iv)

Based on observation, interview, and record review during the recertification survey conducted 4/29/2024 - 5/3/2024, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 2 residents (Resident #39) reviewed. Specifically, Resident #39 did not have their right resting hand splint applied as ordered. Findings include: The facility policy Adaptive Position Equipment dated 8/28/2007 documented the rehabilitation department staff would issue the prescribed equipment. The nursing supervisor would be responsible for ensuring the adaptive equipment would be consistently done on all shifts. It was the responsibility of nursing to investigate or locate the equipment if it became lost or misplaced. Resident #39 had diagnoses including diffuse traumatic brain injury with loss of consciousness and right upper extremity weakness. The 3/26/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required partial to moderate assistance with upper body dressing, supervision or touching assistance with personal hygiene, and had upper and lower extremity functional limitation on one side. The 4/9/2024 comprehensive care plan documented the resident had an alteration in activities of daily living performance related to a diagnosis of traumatic brain injury and the right arm had limitations in the fingers, wrist, and shoulder. Interventions, edited on 4/17/2024, were right hand resting splint, on 4 hours after AM care. A physician order dated 4/17/2024 documented right hand resting splint, on 4 hours after AM care once a day, 8:00 AM. The order was not listed on the medication administration record, the treatment administration record, or the certified nurse aide task documentation for staff to sign for the splint's use. The certified nurse aide care instructions as of 5/2/2024, with a start date of 7/19/2023, documented right hand resting splint, on 4 hours after AM care. The Point of Care Activities of Daily Living Category Report (certified nurse aide documentation) for April 2024 and May 2024 under the area of devices provided choices for cane/crutch, walker, wheelchair, limb prosthesis, and none of the above. It did not reflect a category for the application of splints or braces. There was no documented evidence in nursing progress notes from 4/29/2024-5//3/2024 the resident refused to wear their right hand resting splint. The resident was observed without a right hand resting splint applied: - on 4/30/2024 at 9:22 AM sitting in their bed, dressed. Their right hand, with long fingernails, was contracted. When interviewed and asked if they wore a splint to their right hand, the resident pointed to their nightstand to the right side of their bed. The right hand resting splint was sitting on top of items on the nightstand, out of reach of the resident. - on 5/1/2024 at 10:04 AM the resident was not in their room. The right hand resting splint was sitting on the top of the nightstand. At 10:33 AM at an activity in the South dining room without their right hand resting splint. When interviewed about their right hand resting splint, the resident stated staff did not put it on. An unidentified resident sitting at the table with Resident #39 stated they never saw the splint on Resident #39, and it was supposed to be on for 4 hours each day. - on 5/3/2024 at 9:11 AM sitting in their wheelchair in their room. The right hand resting splint was lying on the bed. The resident stated, Look, not on. During an interview on 5/1/2024 at 10:48 AM certified nurse aide #8 stated the resident did have a splint for their right hand contracture that they thought the resident was supposed to wear during the day. The resident did not like to wear it and would slip it through their hand and hide it under the bed covers. During an interview on 5/1/2024 at 10:53 AM certified nurse aide #11 stated they got the resident out of bed that morning. The resident had a splint because their hand did not stretch out and the splint would prevent it from becoming worse. The resident was supposed to wear it during the day but sometimes the resident would tuck it in their pocket or hide it under the bed if they did not want to wear it. During an interview on 5/1/2024 at 11:05 AM the Director of Therapy stated the resident was supposed to be wearing their right hand splint for up to 4 hours a day due to their right hand contracture and it was to be applied by nursing staff. The resident had the right hand splint order for a long time. The resident was wearing it Monday (4/29/2024) because they went around and checked all the residents who were supposed to be wearing adaptive equipment devices. The resident was currently not being seen by therapy but had been seen on and off in the past, every 3-6 months. During an interview on 5/3/2024 at 11:43 AM licensed practical nurse Unit Manager #12 stated they expected certified nurse aides to follow the order programmed in the Kiosk (the electronic resident chart) so they would know the right hand resting splint was in Resident #39's plan of care. They expected the certified nurse aides to document any refusals by the resident to wear their right hand resting splint and to notify them of the refusals. If staff did report refusals, they would document it and place it on report. 10 NYCRR 415.12 (e) (2)

Based on observation, record review, and interview during the recertification and abbreviated (NY00335434) surveys conducted 4/29/2024-5/3/2024, the facility did not review and revise the comprehensive care plan based on needs of the residents and responses to current interventions for 1 of 4 residents (Resident #47) reviewed. Specifically, Resident #47 had resident-to-resident altercations and their care plans were not reviewed and revised after the incidents to determine if current interventions were effective or if additional interventions were needed. Findings include: The facility policy Resident-to-Resident Altercations revised 12/2016 documented the facility was to make any necessary changes in the care plan approaches to any or all the involved residents. The facility policy Care Plans, Comprehensive Person-Centered revised 3/2023 documented the interdisciplinary team developed and implemented a person-centered care plan for each resident. Care plans were revised as information about the resident's condition changed. The interdisciplinary team would review and update the care plan when there was a significant change in the resident's condition. The facility policy Traumatic Brain Injury dated 5/2024 facility policy documented residents with a known or suspected history of a traumatic brain injury received a thorough assessment by the interdisciplinary team to determine their specific needs and capabilities. Regular interdisciplinary meetings were held to adjust care plans as needed. Resident #47 had diagnoses including traumatic brain injury, irritability, and impulse disorder. The 1/25/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, rarely made self understood or understood others, had inattention and disorganized thinking, had trouble concentrating daily, was short-tempered or easily annoyed most days, had physical and verbal behaviors directed towards others, required supervision or was independent for most activities of daily living, received an antipsychotic and antidepressant, and did not have active discharge planning to return to the community. The comprehensive care plan initiated 8/26/2-21 documented return to community discharge referral: the resident remained at the facility for long term care placement. The resident had not expressed wishes to leave the facility and the resident representative agreed. The 12/7/2023 updated comprehensive care plan documented the resident had aggressor/behavioral symptoms of tensing up and clenching their fist, beating on their chest when agitated, and received psychotropic medications. Interventions included 15-minute checks, 1:1 monitoring for 3 days and assess as needed, attempt to find appropriate environment, attempt to increase activity for helping around the facility, attempt gradual dose reduction of medications, follow up with psychiatrist, initiate non-pharmacological interventions, provide 1:1 activities as needed, talking books or large print material, 1:1 activity visits for stimulation, engage in purposeful activities such as sweeping floors/wiping tables/wiping counters/washing dishes, keep resident in high visibility areas, and redirect. The 3/7/2024 at 8:30 PM incident report completed by registered nurse #18 documented Resident #47 was standing in the North Hallway in front of the unit dining room while Resident #49 was ambulating in the hallway heading in the direction of Resident #47. The residents had a verbal interaction and Resident #47 struck Resident #49 causing Resident #49 to fall to the floor and strike their head. Resident #47 went to their room immediately after being separated from Resident #49. Licensed practical nurse #14's witness statement documented they saw Resident #49 on the ground with Resident #47 standing over them. Licensed practical nurse #14 documented contributing factors to the incident were Resident #47 was known to have extremely violent outbursts and was not being properly supervised. Resident #47 was placed on 15-minute checks all shift for 3 days and the care plan was reviewed. There were no documented evidence Resident #47's care plan was reviewed to determine if interventions for aggressive behaviors remained effective following the 3/7/2024 incident. The 3/13/2024 at 6:44 PM progress note by licensed practical Nurse Manager #12 documented Resident #47's aggressive behavior was reviewed with the medical provider and the provider increased risperidone (antipsychotic) to 2 milligrams twice a day. The risperidone increase was not documented on the care plan. The 3/14/2024 at 11:12 AM social worker #13 progress note documented the facility's goal was to get Resident #47 transferred to a group-like setting. The care plan did not include potential discharge goals to a group setting. The 4/12/2024 at 10:18 PM licensed practical Nurse Manager #12's progress note documented Resident #47 had been seen by neurology in the past for traumatic brain injury and was last seen May 2023. The resident had aggressive intermittent disorder. Neurology notes documented the resident had behaviors for years with psychosis and paranoia. Neurology suggested the resident's behaviors be addressed by psychology. The 4/22/2024 at 4:20 PM incident report completed by licensed practical Nurse Manager #12 documented Residents #47 and #49 were at the nursing station. Resident #49 approached Resident #47 and Resident #49 began shaking their fist at Resident #47. Resident #47 shoved Resident #49 and then grabbed Resident #49's hands to prevent Resident #49 from hitting Resident #47. There were no observed verbal altercations prior to the incident. The residents were immediately separated and there were no injuries to either resident. The incident report documented both residents' care plans were updated, and the residents were placed on 15-minute checks for 3 days. Resident #47s care plan, updated on 4/23/2024, documented an intervention of 15-minute checks for 3 days. The intervention was in place prior to the 4/22/2024 incident. There were no documented evidence Resident #47's care plan was reviewed to determine if interventions for aggressive behaviors remained effective following the 4/22/2024 incident. Resident #47 was observed: - on 4/30/2024 from 10:27 AM until 10:45 AM, sitting in a straight back chair across from the North nursing station, looking up and down the hallway. The resident was not given any form of activity. The resident rose from the chair at 10:45 AM to go to a formal activity occurring on another unit. - on 5/1/2024 from 9:16 AM until 9:49 AM, standing in the unit dining room doorway with no activity or task. The resident walked and entered their room at 9:49 AM. At 10:09 AM, the resident was standing in the dining room doorway. Another resident began knocking on the activities department door located in the unit dining room. Resident #47 began yelling at the resident to stop the banging and became agitated. Staff immediately intervened and told the resident to stop yelling. Resident #47 returned to their room and closed the door. - on 5/1/2024 at 11:44 AM, seated at a table in the unit dining room, other residents were present in the room, and the TV was on. Another resident was continuously yelling out and other residents were telling them to stop yelling. Resident #47 began to get upset, swore, and raised their hands in the air. Staff intervened and asked Resident #47 to not swear. No tasks or independent activities related materials were offered to Resident #47. During an interview on 5/2/2024 at 3:20 PM, licensed practical nurse #14 stated resident specific care was documented in the care plan and care instructions, including behavioral interventions. Staff tried to intervene between Resident #47 and Resident #49 and separate them before the situations escalated. On 3/7/2024, the nurse was down the hall passing medications, the unit assistant made a verbal sound, the nurse turned, and saw Resident #49 going to the floor. The nurse got in front of Resident #47, told the resident to stop and go to their room, and the resident did. On 4/22/2024, the nurse stated they were passing medications, heard Resident #47 make a random noise, turned, and saw Resident #47 attempt to step in front of Resident #49. The residents got into a shoving match and staff were able to intervene prior to either getting injured. The nurse felt Resident #47 was not properly supervised both days of the incident. Interventions for Resident #47 were for staff to give the resident a simple task, a snack or drink, or an electronic tablet. Staff did not provide the resident those things prior to the incidents as it was difficult to know when the resident was going to have an impulsive behavior. During an interview on 5/2/2024 at 3:45 PM, unit assistant #15 stated Resident #47 had previous altercations with other residents, got a weird look on their face, and raised their fist prior to an altercation. On 3/7/24, the unit assistant was handing out bedtime snacks in the hallway, went into another resident's room, exited the room, and saw Resident #49 walking with a walker down the hall in front of the dining room. Resident #49 stated something to Resident #47, they did not hear what was said, Resident #47 drew their fist back and struck Resident #49 in the left cheek. During an interview on 5/3/2024 at 11:45 AM, the Director of Nursing stated a registered nurse initiated a specific care plan topic and any nurse was able to update the care plan once that was done. Each discipline was responsible for their own area in the care plan. The care plan, which incorporated the care instructions, included resident specific interventions. Resident #47's interventions were to watch for triggers and redirect with signs of agitation. Staff supervised both Residents #47 and #49 to prevent injury to another resident. Resident #47 lingered around the nursing station or unit dining room when out of their room and turned into an aggressor when they thought another individual was acting aggressively. There were no new interventions added after the 3/7/2024 incident and there should have been. The facility had busy boxes on the unit that were not added to the care plan interventions. Resident #47 used to have task-related interventions in the care plan that must have dropped off. The 15-minute checks were not new interventions and were only to be done for 3 days after each incident. A medical review was done for Resident #47 after the 3/7/2024 incident and that was not added to the care plan. The care plans were to be reviewed and updated with new interventions after each incident if altercations continued. The facility was also trying to find a more suitable setting for Resident #47 as they were a younger adult with a traumatic brain injury. The facility nursing staff had not had any traumatic brain injury training. During an interview on 5/3/2024 at 12:30 PM, the Administrator stated the expectation was for staff to follow the care plan and new interventions to be implemented with each resident-to-resident altercation. The Administrator expected staff to redirect Resident #47, have them remain around the nursing station for monitoring, and keep them occupied when out of their room. During an interview on 5/3/2024 at 1:11 PM, social worker #13 stated each resident's care plan was reviewed quarterly, annually, and with each significant change. Behavioral interventions were part of the care plan. The care plan was to be updated with each new behavioral intervention. Resident #47's care plan should have been reviewed and updated with each of the incidents and all planned interventions followed by staff. 10NYCRR 415.11(c)(2)(iii)

Based on record review and interviews during the abbreviated survey (NY00308047), the facility did not ensure the development and implementation of an effective transfer or discharge planning process including documentation in the resident's medical record and appropriate communication of information to the receiving health care institution or provider for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 was issued a facility-initiated discharge notice and there was no supporting documentation related to the reasons the facility was unable to meet the resident's needs. There was no care plan related to the discharge, and when discharge plans changed, there was no new plan put in place. Additionally, when the resident was denied readmission to the facility from a hospital stay, they did not provide the hospital with the resident's information and did not contact the hospital for discharge planning. Findings include: The undated facility policy Transfer and Discharge Requirements/Documentation documented: - The facility must permit residents to remain in the facility and not transfer or discharge unless: it was necessary for the resident's welfare and their needs could not be met at the facility; the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident; and the health of other individuals would be endangered. - When the facility discharged the resident under any of the circumstances above, the facility must document the resident's transfer or discharge in the medical record and appropriately communicate the information to the receiving health care institution. - The physician, with the input of the interdisciplinary care team (IDT), will assess the resident's care requirements for the need to be transferred or discharged . - If determined the resident has a need for transfer based on the above criteria, it will be documented in the medical record. The basis for transfer will specify the resident's needs that could not be met and the facility's attempts to meet those needs. - The following information will be provided to the receiving provider: contact information of the resident's practitioner, resident representative's contact, Advance Directives, special instructions for ongoing care, comprehensive care plan goals, discharge summary, and any other documentation as applicable to ensure a safe and effective transition of care. Resident #1 was admitted to the facility with diagnoses including vascular dementia with behavioral disturbance, restlessness, and agitation. The 10/28/2022 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and did not exhibit behavioral symptoms. The section Participation in Assessment and Goal Setting documented the resident participated in the assessment and the resident's overall expectation of being discharged to the community, remaining in the facility, being discharged to another institution, or unknown/uncertain was blank. The comprehensive care plan (CCP) initiated 10/31/2022 and reviewed/revised 11/3/2022 did not include any documentation related to discharge planning. The 12/12/2022 Nursing Home Transfer and Discharge Notice documented the reason for discharge or transfer was the safety of the individuals in the facility was endangered due to the clinical or behavioral status of the resident. There were no other reasons for discharge noted on the form. The effective date was blank. The notice was signed by the Administrator (former) on 12/12/2022. There was no physician signature or resident/representative signature on the form. There was no documented evidence in the resident's medical record related to the basis for the discharge notice. There was no documentation from a medical or psychiatric provider related to the reasons the facility could not meet the resident's needs. The 12/12/2022 at 3:44 PM progress note entered by the Director of Work (DSW) documented the DSW, Administrator, and (former) Director of Nursing (DON) #9 discussed with the resident's relative/HCP (health care proxy, person designated to make health care decisions on behalf of the resident) via telephone, about a 30-day notice. The plan was to have the resident move with their relative in another state. The relative was to arrive to the facility on [DATE] to bring the resident home with them. The relative was to keep staff up to date via email. There was no documented evidence the CCP was updated to reflect a plan for the resident's discharge. There was no documented evidence of resident needs for the anticipated lengthy car trip, no documentation related to medication management, or documentation related to how the resident's needs would be met upon discharge to the setting of their relative's home. The 12/14/2022 at 5:36 PM nursing progress note entered by licensed practical nurse (LPN) #7 documented they spoke to the resident's relative, who expressed fear they would not be able to safely transport the resident to another state. Verbal assurance was given to the relative and the LPN was to call back later that evening as requested. The 12/19/2022 at 2:46 PM progress noted entered by the DSW documented the DSW and Administrator called the resident's relative to follow up about the report from the nurse that the relative was not able to take the resident to their home state. The DSW asked if they were certain, and if they needed to work on another placement. The relative stated they would still like to take the resident and they were worried the resident was not able to sit in a car for the long trip. The relative then stated they could make multiple stops along the way. The DSW sent out the 30-day discharge notice again via certified mail. There was no documented evidence the CCP was updated to reflect the resident's discharge plan. There was no documented evidence of resident needs for the anticipated lengthy car trip, no documentation related to medication management, or documentation related to how the resident's needs would be met upon discharge. The 1/1/2023 at 10:20 AM progress note entered by DON #9 documented the resident was combative and aggressive, police officers and ambulance drivers restrained the resident and transported them to the hospital. The 1/1/23 at 12:01 PM nursing progress note entered by registered nurse (RN) #8 documented they called the hospital for an update. The resident was still in the emergency room waiting for a psychiatric bed/evaluation. The RN was advised the resident was positive for COVID-19. The DON was called, and they stated they spoke to the corporate offices who stated they could not take the resident back due to changes. There was no documented evidence the resident's representative was notified of the resident's discharge to the hospital on 1/1/2023 and no documented evidence of any changes to the discharge plan. The 1/4/2023 at 3:08 PM progress note entered by the DSW documented they faxed a copy of the 30-day notice and progress notes supporting that the team spoke to the resident's relative (HCP) about the notice to the hospital case manager. There was no documented evidence any other information related to the resident's care or discharge plan was sent to the hospital. An email correspondence from the DSW to the resident's HCP dated 1/6/2023 at 11:19 AM documented they had been trying to contact the HCP to discuss the 30-day notice. The DSW noted if the HCP had any questions to please contact them. The email included an attached document that was named only by a series of numbers. The Nursing Home Transfer and Discharge Notice dated 1/6/2023, documented the resident was being discharged to their relative's address in another state. The effective date of the discharge was 2/6/2023 and documented the resident was being discharged for the following reasons: - The transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility. - The safety of the individuals in the facility was endangered due to the clinical or behavioral status of the resident. - The health of individuals in the facility would otherwise be endangered. The notice was signed by DON #9 on 1/6/2023. There was no documented evidence in the resident's medical record related to the basis for the 1/6/2023 discharge notice. There was no documentation from a medical or psychiatric provider related to the reasons the facility could not meet the resident's needs. There was no documented evidence of confirmation of the resident's discharge location or explanation of the effective date (2/6/2023). The 1/6/2023 at 11:24 AM progress noted entered by the DSW documented a 30-day notice of discharge was sent to the resident's relative via certified mail and email, a copy was sent to the Ombudsman, and a copy was also sent to the hospital. The 1/9/2023 at 4:19 PM progress note entered by the Medical Director documented the resident started exhibiting aggressive behaviors immediately after admission. The resident had poor impulse control, was angry, combative, relatively young, and strong. The resident frequently voiced suicidal and homicidal intentions and was found in possession of sharp objects and in their opinion, had the capacity to commit a suicidal or homicidal act. On 1/1/2023, 6 police officers escorted the resident to an ambulance. The resident was admitted to the hospital for psychiatric evaluation. According to hospital records, the resident was receiving multiple IV (intravenous) and IM (intramuscular) medications and the facility could not administer antipsychotic medications parenterally (administering other than oral route). If readmitted , the resident would decompensate very soon, and they were not appropriate for the level of care the facility could provide. The resident should not be sent back to the facility and required a higher level of care, preferably a psychiatric institution. There was no documented evidence in the resident's medical record of any prior evaluation or progress note related to the information as documented in the 1/9/2023 Medical Director note. The 6/23/2023 hospital discharge summary documented the resident was originally evaluated and discharged on [DATE] and was brought back to the hospital after the facility refused to readmit the resident. The resident remained in the hospital pending a safe discharge until 6/23/2023. The hospital case manager was interviewed on 1/10/2023 at 12:15 PM and stated the resident had been cleared medically and psychiatrically and did not require IM medications and was ready to return to the facility on [DATE]. During an interview with the hospital ER Manager on 8/25/2023 at 10:43 AM, they stated after the facility refused to readmit the resident on 1/4/2023 the resident was returned to the hospital. The ER Manager called the facility the following day and their call was not returned. The hospital had no information on the resident at that time and was unaware of the resident's status at the facility. The facility's DSW later sent the resident's chart after another request was made. The facility never contacted the hospital back regarding the resident or for any discharge planning. During a telephone interview with the DSW on 8/29/2023 at 8:09 AM, they stated the facility issued a 30-day discharge notice on 12/12/2022 due to the resident's behaviors and safety issues. There was no psychiatry involvement, and the physician was aware of the resident's behaviors and was adjusting their medications. The DSW was not aware of the specific documentation required in the medical record for a facility-initiated discharge and stated it was an administrative decision to discharge the resident. The DSW was responsible for care plans and was unaware of the reason there was no care plan for the resident's discharge. After the resident's relative was notified on 12/12/2022, a plan was set for the resident to be picked up on 1/14/2023. The DSW was unaware of any further plans related to that discharge date . After the relative expressed concern about the discharge plan, the DSW spoke to them on 12/19/2022 and thought the plan may have changed and was unsure of what changes and there was no documentation. The DSW was unaware of the status of the discharge plan that was in place prior to the resident's hospitalization and attempted to reach the resident's relative on 1/4/2023. The DSW could not recall if they attempted to notify the relative prior to the facility's refusal to readmit the resident. Following the resident's hospitalization , the facility would not take the resident back and the DSW had no further involvement in the resident's discharge planning. The DSW was not involved in the 1/6/2023 30-day discharge notice and was directed by Administration to forward it to the relative, Ombudsman, and hospital on that date. The DSW was unaware of the reason for the updated notice, which was issued after the facility did not readmit the resident. During a telephone interview with the Administrator on 8/29/2023 at 3:18 PM, they stated the resident was issued a 30-day discharge notice on 12/12/2022 due to the resident's unsafe behaviors. The resident could not be managed at the facility, was aggressive, got into fights, and the facility was not the appropriate placement. The Administrator was aware of the requirement for the medical record to reflect the basis for discharge and the supporting documentation that the facility could not provide the needed care. The record did not reflect the needed documentation due to the lack of psychiatric providers available at that time. The Medical Director wrote a statement on 1/9/2023, after the resident's discharge and must have been behind in their notes. When the resident was hospitalized on [DATE] and subsequently not permitted to return to the facility on [DATE], the reason was due to the resident's COVID-positive status and their unsafe behaviors. The Administrator then stated the resident's COVID status was not the overwhelming issue, it was the hospital's lack of planning when they (the hospital) knew of the resident's violent behaviors. The hospital should have made a plan and communicated it to the facility to address the resident's behaviors prior to sending them back. The resident was at risk of harming themselves or others and the facility did not have adequate time to plan for the resident's return. Following the facility's refusal to take the resident back on 1/4/2023, the facility did not hear back from the hospital and expected them to reach out to pursue further discharge planning. 10 NYCRR 415.3(h)(1)(ii)(a)(b)

Based on record review and interview during the abbreviated survey (NY00308047), the facility did not permit a resident to return to the facility after they were hospitalized for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was sent to the hospital for evaluation for behaviors. The resident was medically cleared, transported back to the facility, and the facility refused to accept the resident. Findings include: The facility policy COVID-19 Mitigation Plan and Prevention and Control last revised 12/2022 documented: - New admissions and readmissions were to be tested on days 1, 3, and 5 except for residents within 30-days of a COVID infection. A negative COVID antigen test was recommended for all new admissions and readmissions prior to admission, unless a COVID test was positive in the last 30 days of admission to the facility. The policy did not address admission or readmission of residents with positive COVID-19 status. Resident #1 was admitted with diagnoses including vascular dementia with behavioral disturbance and restlessness and agitation. The 10/28/2022 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and did not exhibit behavioral symptoms. The 1/1/2023 at 10:20 AM progress note entered by Director of Nursing (DON) #9 documented the resident was combative and aggressive, police officers and ambulance drivers were required to restrain the resident and transport them to the hospital. The 1/1/23 at 12:01 PM nursing progress note entered by registered nurse (RN) #8 documented they called the hospital for an update. The resident was still in the emergency room waiting for a psychiatric bed and evaluation. The RN was advised the resident was positive for COVID-19. The DON was called, and they stated they spoke to the corporate offices who stated they could not take the resident back due to changes. The facility Vacancy Reports for 1/3/2023 and 1/4/2023 documented a total of 19 available beds (2 on the North unit and 17 on the South unit) and no bed holds. The 1/4/2023 at 12:08 AM hospital discharge summary and CPEP (Comprehensive Psychiatric Emergency Program) evaluation documented the resident was transferred from another hospital for evaluation. The resident reportedly had aggressive behaviors at the nursing facility. The resident was noted to be calm and cooperative with no suicidal or homicidal ideations. The resident was evaluated by the nurse practitioner (NP), who recommended they return to the nursing facility and follow up with established providers. The resident was at low risk for violence and did not meet the criteria for involuntary commitment and declined a voluntary hospitalization . The nursing facility staff reported they felt safe with the resident being discharged . Nursing staff at the facility were provided with the number for the crisis hotline and was asked to call 911 and/or bring the resident to the nearest emergency room if they were unsafe, suicidal, or a danger to themselves or others. The 1/4/2023 Emergency Medical Service (EMS) report documented the resident was scheduled for transport from the hospital to the facility and was picked up at 2:45 AM. Upon arrival to the facility at 4:15 AM, the crew transported the resident to the facility lobby. Licensed practical nurse (LPN) #4 was in the lobby and stated the resident could not be brought into the facility due to being COVID positive. The LPN then called DON #9, who stated the facility could not take the resident back due to them having COVID-19. The EMS crew member called the CPEP nurse who completed the resident's discharge. The phones were on speaker, and the DON (on LPN #4's phone) and the CPEP nurse (on the EMS crew's phone) spoke. The DON repeated the resident could not be accepted due to COVID and they were no longer a resident of the facility, as the resident had been evicted. The CPEP nurse stated the facility illegally evicted the resident and the resident was still the facility's responsibility. The DON stated they would go to the facility and arrived approximately 15 minutes later. The DON stated again the resident was not allowed back due to COVID. The EMS crew received directives from their supervisor to return to the hospital with the resident and left the facility at 5:06 AM. The 1/4/23 at 9:24 AM nursing progress note entered by RN #3 documented they spoke to staff at the hospital and the resident tested positive for COVID-19 on 1/1/2023. The resident was sent back from the hospital at 4:00 AM and was returned (to the hospital) due to the COVID diagnosis. During an interview with the Regional DON on 1/5/2023 at 1:00 PM, they stated the resident resided at the facility since 4/2022, and their behaviors escalated after they had COVID-19 (prior diagnosis, 8/2022). The resident had altercations with peers and staff and made threats to them as well. The resident was taken to the hospital on 1/1/2023 after being removed by multiple police officers and tested positive for COVID-19 in the hospital. The resident was then sent to another hospital, and then returned to the facility on [DATE] (actually 1/4/2023) at 4:00 AM without any clearance and was COVID positive status. The facility was not able to accept the resident back due to their COVID status. The resident's representative was given a discharge notice on 12/12/2022 and planned to bring the resident to their home in another state. The representative had since changed their mind and stated they could not manage the resident. The Nursing Home Transfer and Discharge Notice dated 1/6/2023, documented the resident was being discharged to their relative's out of state address, effective 2/6/2023. The resident was being discharged for the following reasons: - The transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility. - The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. - The health of individuals in the facility would otherwise be endangered. The notice was signed by the DON on 1/6/2023. The resident's medical record did not contain any documentation related to the specific needs that could not be met by the facility or any alternative plans made for the resident. The 6/23/2023 hospital discharge summary documented the resident was evaluated and discharged on [DATE], was brought back to the hospital after the facility refused to readmit the resident. The resident remained in the hospital pending a safe discharge until 6/23/2023. During an interview with the hospital emergency room (ER) Manager on 1/6/2023 at 9:14 AM, they stated the resident was sent to the hospital (from another hospital) and was receiving intramuscular (IM, injected into the muscle) medications to calm them. The resident also tested positive for COVID-19. The resident was sent to their hospital for a psychiatric evaluation. The resident has been cleared by medical and psychiatry. A nurse-to-nurse report was completed, and the facility accepted the resident back and the hospital made the transportation arrangements. When the resident got to the facility, they changed their minds and refused to admit the resident saying they could not take them because they were COVID positive. The resident returned to the hospital was currently a social admission. The resident had been calm and was asymptomatic COVID positive. The facility refused to readmit the resident. The hospital case manager was interviewed on 1/10/2023 at 12:15 PM and stated the resident had been cleared medically and psychiatrically and did not require IM medications and was ready to return to the facility on [DATE]. During a follow-up interview with the hospital ER Manager on 8/25/2023 at 10:43 AM, they stated the resident was evaluated by psychiatry at approximately 12:00 AM on 1/4/2023 and was dispositioned for discharge at approximately 1:30 AM. The CPEP nurse at the hospital called the facility and spoke to LPN #4 on 1/4/2023. The LPN was advised the resident was to be transported back that night and the hospital had arranged transportation. The resident was refused admission upon arrival to the facility and brought back to the hospital. During a telephone interview with the DSW on 8/29/2023 at 8:09 AM, they stated the facility issued a 30-day discharge notice on 12/12/2022 due to the resident's behaviors and safety issues. The DSW spoke to the resident's relative, who agreed to pick up the resident on 1/14/2023 at the facility. On 1/4/2023, the DSW sent the 12/12/2022 discharge notice to the case manager at the hospital. The facility could not take the resident back due to their behaviors and placing others at risk. The former DON (#9) and former Administrator were involved in the decision and the DSW was directed to send the notice to the hospital. The DSW was unaware of the status of the discharge plan that was in place prior to the resident's hospitalization and attempted to reach the resident's relative on 1/4/2023. The DSW could not recall if they attempted to notify the relative prior to the facility's refusal to readmit the resident. During a telephone interview with the Administrator on 8/29/2023 at 3:18 PM, they stated the resident was not taken back to the facility on [DATE] due to the hospital's lack of planning and the resident's positive COVID-19 status. The facility could not accept a resident back who was positive for COVID-19, as they were not prepared. It was the Administrator's understanding that current COVID-19 guidelines included a negative COVID-19 test was required prior to admission. The facility did not have the ability or space to provide appropriate isolation. The Administrator was unaware of the census at the time and stated they believed they did not have any available private rooms. The Administrator was not aware that the facility was notified by the hospital on 1/1/2023 of the resident's COVID status and was unaware of any plans that were made as a result. The Administrator was unaware that the facility was notified by the hospital on 1/4/2023 that the resident was to be transported back to the facility prior to their arrival. The Administrator then stated the resident's COVID status was not the overwhelming issue, it was the hospital's lack of planning when they (the hospital) knew of the resident's violent behaviors. The hospital should have made a plan and communicated it to the facility to address the resident's behaviors prior to sending them back. The resident was at risk of harming themselves or others and the facility did not have adequate time to plan for the resident's return. Following the facility's refusal to take the resident back on 1/4/2023, the facility did not hear back from the hospital and expected them to reach to pursue further discharge planning. DON #9 and LPN #4 were no longer employed at the facility and were not available for interview. RN #8 was contacted for an interview and did not return the call prior to the survey exit date. 10NYCRR415.3(h)(4)(iii)

Based on record review and interview during the abbreviated survey (NY00308047), the facility did not notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was issued a 30-day discharge notice, was transferred to the hospital prior to their anticipated discharge date , and the resident's representative was not notified. The facility would not readmit the resident from the hospital and the representative was not notified in writing prior to the facility's refusal to readmit the resident. The facility issued a second 30-day discharge notice after they refused to readmit the resident. Additionally, the discharge notice was not sent to the Ombudsman as required and did not contain the required information. Findings include: The undated facility policy Notice Before Transfer documented before the facility transferred or discharged a resident it was the facility policy to: - Notify the resident and a family member or legal representative of the transfer or discharge and the reasons for the move in writing and in a language, they understand; - Send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman; - Record the reasons in the resident's medical record; - Include in the notice the items mandated by the NYS Department of Health; - Except when otherwise allowed, the notice must be made by the facility at least 30 days before the resident was transferred or discharged ; - The notice may be made in less than 30 days when: the health or safety of individuals in the facility would be endangered; or an immediate transfer or discharge was required by the resident's urgent medical needs. Resident #1 was admitted to the facility with diagnoses including vascular dementia with behavioral disturbance and restlessness and agitation. The 10/28/2022 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and exhibited no behavioral symptoms. The section Participation in Assessment and Goal Setting documented the resident participated in the assessment and the resident's overall expectation of being discharged to the community, remaining in the facility, being discharged to another institution, or unknown/uncertain was blank. The Nursing Home Transfer and Discharge Notice documented the reason for discharge or transfer was the safety of the individuals in the facility was endangered due to the clinical or behavioral status of the resident. There were no other reasons for discharge noted on the form. The date notice given was documented 12/12/2022 and the effective date was blank. The discharge location was the resident's relative's address in another state. The notice was signed by the Administrator (former) on 12/12/2022. There was no physician signature or resident/representative signature on the form. The bottom of the notice had an area to document when the notice was given to the resident or representative, the local Long Term Care Ombudsman Council, and the resident's clinical record and was not completed. The form did not include a local agency or individual to contact the Ombudsman, and the advocacy center contact information was not correct. The 12/12/2022 at 3:44 PM progress note entered by the Director of Work (DSW) documented the DSW, Administrator, and Director of Nursing (DON) #9 discussed with the resident's relative/HCP (health care proxy, person designated to make health care decisions on behalf of the resident) via telephone, about a 30-day notice. The plan was to have the resident move with their relative in another state. The relative was to arrive to the facility on [DATE] to bring the resident home with them. The relative was to keep staff up to date via email. The 1/1/2023 at 10:20 AM progress note entered by DON #9 documented the resident was combative and aggressive, police officers and ambulance drivers were required to restrain the resident and transport them to the hospital. The 1/1/23 at 12:01 PM nursing progress note entered by registered nurse (RN) #8 documented they called the hospital for an update. The resident was still in the emergency room waiting for a psychiatric bed and evaluation. The RN was advised the resident was positive for COVID-19. The DON was called, and they stated they spoke to the corporate offices who stated they could not take the resident back due to changes. There was no documented evidence the resident's representative was notified of the hospital transfer on 1/1/2023 or that the facility would not accept the resident for readmission due to positive COVID-19 status. The 1/4/2023 at 9:24 AM nursing progress note entered by RN #3 documented they spoke to staff at the hospital, the resident tested positive for COVID-19 on 1/1/2023. The resident was sent back from the hospital at 4:00 AM on 1/4/2023 and was returned (to the hospital) due to the COVID diagnosis. The 1/4/2023 at 3:08 PM progress note entered by the DSW documented they faxed a copy of the 30-day notice and progress notes supporting that the team spoke to the resident's relative (HCP) about the notice to the hospital case manager. There was no documented evidence the resident's representative was notified of the hospital discharge on 1/4/2023, the facility would not accept the resident for readmission, or that the resident was sent back to the hospital. The 1/5/23 at 12:24 PM progress note entered by the DSW documented they received a message from the resident's relative stating they needed a call back to let them know what was going on with the resident. The DSW and DON did call them on 1/4/2023 and left a message on their phone as well as message left with another relative to call the facility and also called back this day and left a message. An email correspondence from the DSW to the resident's HCP dated 1/6/2023 at 11:19 AM documented they had been trying to contact the HCP to discuss the 30-day notice. The DSW noted if the HCP had any questions to please contact them. The email included an attached document that was named only by a series of numbers. The Nursing Home Transfer and Discharge Notice dated 1/6/2023, documented the resident was being discharged to the relative's out of state address, effective 2/6/2023. The resident was being discharged for the following reasons: - The transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility. - The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. - The health of individuals in the facility would otherwise be endangered. The notice was signed by DON #9 on 1/6/2023. The bottom of the notice documented it was given to the resident or representative, the local Long Term Care Ombudsman Council, and the resident clinical record on 1/6/2023. The form did not include a local agency or individual to contact the Ombudsman, and the advocacy center contact information was not correct. The 1/6/2023 at 11:24 AM progress noted entered by the DSW documented a 30-day notice of discharge was sent to the resident's relative via certified mail and email, a copy was sent the Ombudsman, and a copy was also sent to the hospital. A certified mail receipt, made out to Resident #1, with the address of the hospital was signed as received (signature illegible). There were no dates noted for when the mail was sent or signed as received. A certified mail receipt, made out to Resident #1's relative/HCP at an out of state address documented the HCP received the mail on 1/25/2023. During a telephone interview with the Ombudsman for the facility's county on 8/24/2023 at 8:58 AM, they stated they did not receive a discharge notice for Resident #1 on or around 12/12/2022. The facility was not sending discharges notices and the Ombudsman had to contact them and request they be sent. During a telephone interview with the DSW on 8/29/2023 at 8:09 AM, they stated the facility issued a 30-day discharge notice on 12/12/2022 due to the resident's behaviors and safety issues. The DSW spoke to the resident's relative, who agreed to pick up the resident on 1/14/2023 at the facility. The DSW emailed the notice to the relative, did not retain a copy of the email, and did not receive the signed notice back. The DSW was uncertain if they sent the notice to the Ombudsman and stated they thought they always sent them. The DSW sent the 12/12/2022 discharge notice to the hospital case manager on 1/4/2023 and stated the DSW and DON #9 attempted to notify the resident's relative that same day. When a resident was sent to the hospital, it was the responsibility of nursing to notify and update the family. The 1/6/2023 discharge notice was completed by DON #9 and the DSW was made aware of the notice. The DSW was not aware of the reason the effective date was 2/6/2023, as the facility had not readmitted the resident from the hospital on 1/4/2023. The DSW was uncertain of the discharge location, which was noted on the form as the relative's address. The facility had not been able to reach the relative and the discharge plan was not finalized. The DSW was unaware of the updated discharge form that required specific contact information for the Ombudsman or the current advocacy center. DON #9 was no longer employed at the facility and was not available for interview. 10NYCRR415(h)(1)(iii)(a-c)

Based on record review and interview conducted during the abbreviated survey (NY 378), the facility failed to provide an environment free of accident hazards as possible and failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed. Specifically, - Resident #1 received [MEDICATION(S)] (anti-anxiety medication) while at the hospital on 7/1/22, and after returning to the facility was noted to be sedated and unsteady and there was no documented evidence of increased supervision to prevent falls. Resident #1 subsequently sustained 3 falls on 7/1/22. - Resident #1's care plan was not was not updated timely following multiple falls with interventions for fall prevention. - On 7/6/22, the resident's plan was updated to include non-weight bearing status and there was no evidence a plan was developed to implement non-weight bearing status. The resident continued to attempt to ambulate and fell , sustaining a second [CONDITION(S)] (right hip). Findings include: The facility Fall Policy and Procedure dated 7/2017 documented the facility strived to provide a safe and secure environment for all residents. The facility was to ensure all residents who sustained a fall would be treated in an appropriate and consistent manner. The following steps were to be completed: - at the time of the fall, the Charge Nurse or designee would take immediate steps to ensure a registered nurse (RN) promptly assessed the resident. If no RN was in house, the RN on call would be notified. - Staff would not move any resident who sustained a fall until a full RN assessment or EMS (emergency medical services) assessment had been completed. -The comprehensive care plan (CCP) was to be updated with interventions to reflect the event. Resident #1 had diagnoses including dementia and diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance of 1 with transfers, bed mobility, and walking in their room, required limited assistance of 1 for walking in the corridor and locomotion on the unit, did not use mobility devices, did not receive anti-anxiety medications in the 7 days prior to the assessment, and received physical therapy (PT) and occupational therapy (OT). The comprehensive care plan (CCP) and care instructions documented: - on 4/25/2022, the resident was at risk for falls and had actual falls in the facility. Interventions included encourage slipper socks, proper fitting footwear with slip resistant soles when out of bed, and slipper socks with non-skid tread while in bed. The resident was encouraged to call for assistance, the bed was to be in the lowest position, the environment was to be kept clean and clutter free. Personal items were to be within reach and the resident was to be monitored. - On 6/10/2022, staff were to encourage the resident to wear slipper socks when out of bed. The 6/30/22 History and Physical documented Resident #1 had multiple falls over the past 12 months with or without injury and was hospitalized with worsening of a right foot wound. An x-ray showed possible [CONDITION(S)] (bone infection) of the right great toe. The 7/1/2022 hospital after visit summary documented Resident #1 was seen for issues with their peripherally inserted central catheter (PICC) line (line for intravenous, IV, access). At 6:19 PM, the resident received [MEDICATION(S)] (anti-anxiety medication) and an oral antibiotic ([MEDICATION(S)]) and was discharged back to the facility. 7/1/22 - Fall #1 The 7/1/2022 at 8:20 PM, licensed practical nurse (LPN) #7's progress note documented Resident #1 returned from the hospital, was unsteady, and placed in bed. At 8:10 PM, the resident was found on the floor with a head injury and a small amount of bleeding from the head. The Supervisor (not identified) was called, first aid was administered, and the physician, family, and Director of Nursing (DON) were notified. The 7/1/2022 Event Form completed by LPN #7 documented Resident #1 was found sitting on the floor in their room and sustained a bump on the head. The resident was drowsy and lethargic. The resident had a recent change in medications and was tripping prior to the fall. There was no further documentation related to the resident's supervision level prior to the 8:10 PM fall and after returning from the hospital where the resident was medicated with [MEDICATION(S)]. 7/1/22 - Fall #2 On 7/1/2022, LPN #7's progress note documented at 8:34 PM, Resident #1 remained unsteady while staff assisted them off of the floor from the previous fall. Resident #1 stood, LPN #7 thought Resident #1 was steady, turned to walk away, and the resident fell again. No new injuries were noted. 7/1/22 - Fall #3 The 7/1/2022 LPN #7's progress note documented at 10:00 PM, Resident #1 was sitting at the nurse's station while the DON was on the phone at the desk. Resident #1 stood up, fell forward, hit their head on the nursing station, falling to the right side and at the same time, hit their head on the floor. Range of motion (ROM) was within normal limits, there was no appearance of pain, and the resident was transported to the hospital. The family and physician were made aware, and the DON was present. The 7/1/2022 DON's progress note at 10:30 PM, documented: - they were called to the facility due to Resident #1's multiple falls, lethargy, and PICC line replacement. - The resident returned from the emergency room around 8:00 PM with by mouth antibiotics instead of a PICC line and while at the hospital, the resident was sedated with 5 milligrams (mg) of [MEDICATION(S)] (anti-psychotic medication) and 2 mg of [MEDICATION(S)]. The resident returned from the hospital with lethargy and as a result, sustained 2 falls in their room, one in which the resident hit their head and sustained a laceration to the right side of the head. ROM was with in normal limits and there was no shortening of the legs. - After the second fall, Resident #1 was placed at the nursing station. The resident remained lethargic and confused, made attempts to stand, leaning forward, and was assisted back to the chair. While the DON was on a phone call, the resident stood up, took a step forward, and had a third fall, hitting their head on the nursing station before falling on the floor. Redness was noted to the right side of the forehead and temporal area. The resident was sent to the hospital for evaluation with a suspected head injury. The Event Form completed by LPN #7 on 7/2/22 documented on 7/1/22, Resident #1 hit their head on the nursing station. The resident had moderate pain and a bump on the forehead. The resident was drowsy with lethargy and had a new onset of sleepiness. The resident was given medications for sedation while at the hospital earlier that shift. The 7/2/2022 RN #3's progress note documented at 10:43 AM, the resident returned from the hospital with a diagnosis of a head injury. The scan of the head was negative and neurological monitoring was initiated. On 8/1/22 at 12:45 PM CNA # 9 stated during an interview: - they were assigned to care for Resident #1 on 7/1/22, the resident went to the hospital before the start of their shift (evening shift, 2:30 PM to 10:30 PM), and while at the hospital, the resident received sedating medication and was unbalanced when they returned to the facility. - LPN #7 helped them put the resident to bed to sleep off the effects of the medication. - The resident had dementia, was at risk for falls, needed supervision with ambulation and transfers, and normally made many attempts to get out of bed by themselves. Interventions included a low bed and the call bell within reach. - The resident's first fall occurred on 7/1/22 and they were notified by the resident's roommate the resident fell . LPN #7 performed an assessment; they obtained vital signs, and LPN #7 assisted them with getting the resident back to bed. No higher ups were in the building at that time and there was no RN Supervisor in the building. - Approximately 45 minutes later, they noticed Resident #1's door was closed. When they opened it, the resident was sitting on the floor. LPN #7 evaluated the resident, there was no RN in the building, and LPN #7 and CNA #9 assisted the resident up and brought the resident to the nursing station. - No new interventions were initiated after either fall on 7/1/22. - After the second fall, CNA #9 went to do care on other residents and when they returned, LPN #7 was on the phone and the resident was still sitting at the desk. Resident #1 self-propelled closer to the nursing station, stood up and fell backwards hitting their head. LPN #7 completed the assessment and got the resident up placing the resident at the end of the nursing desk. - The resident fell again later on, and they did not know when the DON arrived to the facility. On 8/1/2022 at 2:00 PM, LPN #7 stated in an interview: - when a resident fell , they were to notify the medical provider, obtain vital signs, and notify the RN to see if the resident could be assisted off the floor. They were not allowed to assess as a LPN and if there were noted concerns, they would call emergency medical services (EMS). - They did not document any information in the CCP. - Resident #1 was not at risk for falls prior to 7/1/22 and would not be able to use their call bell to call for help. - On 7/1/22, Resident #1 returned from the hospital after 5:00 PM and looked tired and unsteady. EMS and LPN #7 assisted the resident to bed, the bed was in a low position, and the resident was sleeping when they left the room. The hospital discharge paperwork documented the resident had been sedated while at the hospital. They notified the RN on call of this and that was the DON. - Later on 7/1/22, the resident's roommate called LPN #7 to the room and said the resident tried to get out of bed and fell . The resident hit their head. The resident was talking after hitting their head however was lethargic. The resident looked okay, vital signs were stable and themselves and CNA #9 got the resident off the floor. - Once off the floor, the resident attempted to take a few steps and had a second fall. They did not recall calling the DON after the fall and got the resident up as they looked okay. - Between the first and second fall, there was no time to notify the RN and if they did notify the RN, it would be documented in the nursing progress notes. - After the second fall, they got nervous because the resident did not have falls like that before and they told staff to put the resident in the low bed while LPN #9 went to get LPN #12. LPN #12 called the DON and when LPN #9 returned the resident continued to make attempts to get up. CNA #9 stayed with the resident until the resident was brought out to the nursing station. - The DON arrived at the facility sometime between 9:00 PM and 10:00 PM, assessed the resident, and wanted the resident sent to the hospital. There were no documented nursing progress notes on 7/3/2022 to 7/4/2022. On 7/4/2022, the CCP was updated and documented the resident was to transfer with stand pivot assist with a wheeled walker and cues with extensive assistance of one staff. Non-weight bearing status The 7/5/2022 PT progress note documented at 1:17 PM, upon standing, Resident #1 required increased assistance and had difficulty taking 2 steps forward without facial apprehension. Limping indicated the resident was unable to bear weight. The resident was put back into bed, inspection did not reveal [CONDITION(S)] (redness) or bruising and the resident had tenderness on the right hip with palpation (pressing the surface) and they were unable to determine pain type. A stop and watch form (notification form) was filled out. On 8/1/2022 at 3:00 PM, PT #11 stated during an interview, they did not receive notification from nursing about Resident #1's falls on 7/1/2022. On 7/5/2022, they saw the resident for a previously planned visit due to an issue with their toe. While working with the resident on 7/5/2022, the resident was unable to bear weight. They assessed ROM and Resident #1 had signs of pain upon palpation. They completed a stop and watch form and notified nursing. The 7/5/2022 DON's progress note documented at 2:22 PM, therapy came to them with a stop and watch form that noted Resident #1 was limping. An x-ray was ordered and obtained and results showed an acute fracture. The physician was notified and a referral to orthopedics was to be made. The 7/5/2022 x-ray report documented Resident #1 had an acute fracture of the right hip. On 7/6/2022, the PT progress note documented at 7:59 AM, they recommended non-weight bearing status until seen by orthopedics. The CCP or care instructions were not revised to include the resident was to be maintained on non-weight bearing status and there was no documentation of a plan to implement non-weight bearing status. On 7/6/2022 RN #3's progress note documented at 3:23 PM, orthopedics was notified, and the earliest appointment was 7/20/22. On 7/6/2022, RN #3's progress note documented at 4:37 PM, PT notified them the resident reported they fell in the room. Upon arrival they observed the resident in a chair with another PT staff present. A 1-centimeter (cm) abrasion on the left knee was noted and the resident reported they fell when they got out of bed. A dressing was applied, and the resident was transferred to the wheelchair maintaining non-weight bearing status and brought to a high visibility area. The resident denied pain and vital signs were stable. The physician and family were notified. On 7/7/2022, LPN #7's progress note documented at 5:09 PM, Resident #1 continued to be restless, bothered the roommate, and continued to stand despite staff redirection. On 7/7/2022, LPN #7's progress note documented at 9:50 PM, Resident #1 was found on the floor in their room, on their left side, in between the beds. No injury was noted. Pain was noted related to the previous right [CONDITION(S)] as evidenced by facial grimacing, anxiousness, and crying. The physician was notified, and [MEDICATION(S)] (narcotic pain reliever) was ordered to be given every 6 hours as needed for complaints of pain. 1:1 observation was documented as a fall precaution. The family and DON were notified. The DON was in to perform an assessment. The facility was unable to provide documentation 1:1 was provided as documented in the 7/7/22 LPN #7's progress note. The 7/7/2022 physician's orders documented orders for, [MEDICATION(S)] 1 tablet 5/325 every 6 hours as needed. The 7/2022 Medication Administration Record (MAR) documented the resident received [MEDICATION(S)] on 7/7/22 at 9:52 PM and 7/8/22 at 8:00 AM. On 7/8/2022 RN #3's progress note documented at 6:18 PM, Resident #1 was sitting in the wheelchair across from the nursing station. PT observed the resident stand from the wheelchair and walked up the hallway to assist the resident. Resident #1 stumbled fell on the left side striking their head on the medication cart before staff were able to intervene. The resident complained of left hip pain and ROM was not within normal limits. The physician was notified, and the resident was sent to the hospital for evaluation of the left hip. At 4:00 PM, the facility was notified by the hospital the resident sustained a fracture of the left hip and was being transported to a out of area hospital. The resident did not return to the facility after the 7/8/2022 discharge. The CCP was revised on 7/25/2022 by the DON and documented: - on 7/1/2022, Resident #1 was sent the hospital. - On 7/1/2022, the resident had a fall. Interventions included to send the resident to the hospital a second time. - On 7/1/2022, the resident had a third fall and interventions included to keep the resident in high visibility areas. On 8/1/2022 at 2:40 PM, RN #3 stated in an interview: - all CCPs were completed by RNs and when an incident occurred, the RNs should document on the CCP. - LPNs were not allowed to assess residents however they could evaluate for injuries. Prior to getting a resident off the floor, the RN must be notified. - The CCP should be updated after all falls. - They did not believe they were scheduled to work on 7/3/22 or 7/4/22 but when they worked they attempted to keep the resident near them however there was no formal 1:1 supervision in place for the resident. - They did not recall if they worked on 7/5/22 when the resident was found unable to bear weight but they were aware the physician was notified, a x-ray was ordered, and non-weight bearing status was in place. - They would not have updated the CCP as they were a new RN and were not sure how to do that. - They were not aware of any specific monitoring in place after the resident's falls. The 8/1/2022 at 3:20 PM the DON stated during an interview: - when a fall occurred, LPNs were to call the RN on call before assisting the resident off the floor. An assessment as to be completed via the telephone and if there were no injuries, ROM issues, or pain, the RN would instruct the LPN to get the resident off the floor. The RN would also instruct the LPN on what new interventions would be put into place. The RN would observe the resident the following morning and document in a progress note. - The CCPs were completed by the RNs however the LPNs could input new interventions. - On 7/1/22, Resident #1 returned to the facility from the hospital at approximately 8:00 PM. While at the hospital, the resident received [MEDICATION(S)]. The resident had a fall and they thought LPN #7 notified them of that fall. They recalled the resident had a head laceration, the resident's ROM was with normal limits, and the DON instructed LPN #7 to initiate neurological checks and assist the resident off the floor and monitor for any changes. - No new interventions for fall prevention were added to the CCP until after the resident had their second fall and they were not sure of the date the CCP was updated. - They arrived at the facility at about 9:00 PM on 7/1/22, after the resident fell the second time. They completed an assessment and documented one note for all 3 falls. - While the DON was at the facility, Resident #1 had a third fall. Resident #1 attempted to get up and fell . - They received phone calls from LPN #7 on 7/1/2022 at 8:14 PM, 9:04 PM and 9:20 PM according to their phone's call log but had no documentation what was discussed during those calls. - They were not able to provide documentation of 1:1 supervision after reporting 1:1 was conducted after the resident fell . - On 7/5/2022, PT notified them the resident was unable to bear weight. They performed an assessment. The resident had pain and an x-ray was ordered. They did not know if the assessment was documented and did not recall if the CCP was reviewed or revised. The X-ray was completed at the facility. - On 7/6/2022, the resident's CCP was revised to include the resident was non-weight bearing status. - On 7/8/2022, while assisting another resident, they heard a commotion. They observed Resident #1 on the floor. RN #3 completed an assessment, 911 was called and the resident was sent to the hospital and diagnosed with a left [CONDITION(S)]. In a follow-up interview on 8/4/22 at 11:18 AM, the DON stated the resident was not placed on 1:1 supervision at any time. After the resident's second fall on 7/1/22, the resident was moved to near the nursing station and the staff were present to observe the resident there. On 8/1/2022 at 4:15 PM, the Administrator stated in an interview, when a resident fell , the RN should be immediately notified, an investigation be completed and documentation in the nursing progress notes regardless of if an injury occurred. If a resident sustained a head injury, the RN assessment should be completed immediately in person, and the CCP should be updated with new interventions to prevent further falls. PT should be informed of the fall. If the resident was unable to bear weight, there should be documentation on the CCP at the time of discovery, documentation of the resident's condition and CCP intervention initiated. When the resident had a fall on 7/7/22 and 7/8/22, staff were expected to complete an assessment, document the assessments, and review and revise the CCP with new fall interventions. On 8/1/2022 at 11:40 PM the physician stated during an interview, on 7/1/2022 Resident #1 had falls with sedation due to [MEDICATION(S)]. LPNs could not assess the resident after a fall. All residents should be assessed by a RN at the time of the fall. If a RN was not in the facility, then EMS should be notified before getting a resident off the floor. Staff could not prevent falls however CCP interventions should be in place for falls and reviewed and revised after each fall to prevent falls from reoccurring. They were not aware CCP interventions for fall prevention were not in place after the falls from 7/1/2022 to 7/8/2022. They stated increased supervision may have presented the resident from falling. 10NYCRR 415.12(h)(1)

Based on record review and interview conducted during the abbreviated survey (NY 378), the facility failed to ensure all allegations of abuse, neglect, or mistreatment were thoroughly investigated for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 had multiple falls and was found with a fracture and there was no documentation investigations were completed to rule out abuse, neglect, or mistreatment, to determine whether current interventions for fall prevention were appropriate, and to determine whether care plan changes were needed. Findings include: The facility policy Accident/Incident Investigation and Reporting revised 7/2017 documented all accident or incidents involving residents shall be investigated and reported to the Administrator. The Supervisor /Charge Nurse shall promptly initiate and document an investigation of the accident or incident. The following shall be included on the report: the dates, the names and witnesses of the event, and any corrective actions taken. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan (CCP) and care guide (care instructions) documented: - on 4/25/22, the resident was at risk for falls and had actual falls in the facility. Interventions included proper fitting footwear with slip resistant soles when out of bed, and slipper socks with nonskid tread while in bed. The resident was to be encouraged to call for assistance, the bed was to be maintained in the lowest position, and the environment was to be kept clean and clutter free. Personal items were to be within reach and the resident was to be monitored. - On 6/10/2022, staff were to encourage the resident to wear slipper socks when out of bed. On 7/5/2022, the PT progress note documented at 1:17 PM, the resident was observed lying in bed. Upon standing, the resident required increased assistance and had difficulty taking 2 steps forward without facial apprehension. Limping indicated the resident was unable to bear weight. The resident was put back in bed, and inspection did not reveal [CONDITION(S)] (redness) or bruising. The resident did have tenderness on the right hip with palpation (feeling the area with hands) and was unable to determine pain type. A stop and watch form (notification form) was completed. On 7/5/2022, registered nurse (RN) #2's progress note documented at 2:22 PM, PT came to them with a stop and watch form that documented Resident #1 was observed limping, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The results showed Resident #1 had an acute fracture. The physician was notified and a referral to orthopedics was to be made. The 7/5/2022 x-ray report documented Resident #1 the resident had an acute fracture of the right hip. There was no documentation an Event Form (incident report) was completed to determine the cause of the fracture, to rule out abuse, neglect, or mistreatment, and to determine if care plan changes were needed. On 7/6/2022, a PT progress note documented at 7:59 AM, they recommended the resident be non-weight bearing until seen by orthopedics. There was no documented evidence the CCP was revised to include the resident was to be maintained on non- weight bearing status. On 7/6/2022, RN #3's progress note documented at 4:37 PM, PT notified them the resident reported they had just fallen in their room. Upon arrival they observed the resident in a chair with another PT staff present. A 1-centimeter (cm) abrasion on the left knee was noted and the resident reported they fell when they got out of bed. A dressing was applied, and the resident was transferred to the wheelchair maintaining non-weight bearing status and brought to a high visibility area. There was no documentation an Event Form (incident report) was completed to determine the cause of the fall, to rule out abuse, neglect, or mistreatment, and to determine if care plan changes were indicated. On 7/7/2022 LPN #7's progress note documented at 9:50 PM Resident #1 was found on the floor in their room, in between the beds, on their left side. No injury was noted. Pain was noted related to the previous right hip fracture as evidenced by facial grimacing, anxiousness and crying. The physician was notified, and [MEDICATION(S)] (narcotic pain medication) was ordered to be given every 6 hours as needed for complaints of pain. 1:1 observation was documented as a fall precaution. There was no documentation an Event Form (incident report) was completed to determine the cause of the fall, to rule out abuse, neglect, or mistreatment, and to determine if care plan changes were indicated. On 7/8/2022 RN #3's progress note documented at 6:18 PM Resident #1 was sitting in a wheelchair across from the nursing station. PT observed the resident stand from the wheelchair and walked up the hallway to assist the resident. Resident #1 stumbled and fell on their left side striking their head on the medication cart before staff were able to intervene. The resident complained of left hip pain and range of motions (ROM) was not within normal limits. The physician was notified, and the resident was sent to the hospital for evaluation of the left hip. At 4:00 PM, the facility was notified by the hospital the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation an Event Form (incident report) was completed to determine the cause of the fall, to rule out abuse, neglect, or mistreatment, and to determine if care plan changes were indicated. The resident did not return to the facility after the 7/8/2022 discharge. The CCP was revised on 7/25/2022 by the Director of Nursing (DON) and documented: - On 7/1/2022, Resident #1 was sent to the hospital. - On 7/1/2022, the resident had a fall. Interventions included to send the resident to the hospital a second time. - On 7/1/2022, the resident had a third fall and interventions included to keep the resident in high visibility areas. On 8/1/2022 at 2:00 PM, LPN #7 stated during an interview when a resident fell , they were to notify the medical provider and a RN. They would not document any information in the CCP. If a resident had a fall, they completed an Event Form and notified the RN to see if the resident could be moved off the floor. On 8/1/2022 at 2:40 PM RN #3 stated during an interview, all CCPs were completed by RNs, and the LPNs completed Event Reports. When an incident occurred, the RNs documented the falls on the CCP. They did not recall if they worked on 7/5/2022 when the resident was found unable to bear weight. They were aware the physician was notified, and an x-ray was ordered and non-weight bearing was in place. They would not have updated the CCP as they were a new RN and were not sure how to do that. When the resident fell , an Event Form should have been completed. On 8/1/2022 at 3:20 PM, the Director of Nursing (DON) stated during an interview, when a fall occurred in the facility the LPN was supposed to call the RN on call before assisting the resident off the floor so an assessment could be completed via telephone. If there were no injuries, ROM issues, or pain, the RN would instruct the LPN to get the resident off the floor and the RN would instruct the LPN on what new interventions to put in place. CCPs were completed by RNs however the LPN could add new interventions. The nurse on duty at the time of the fall was responsible for completing an Event Report. The DON was unable to provide an Event Report for the 7/7/22 incident. On 7/8/2022 while assisting another resident, they heard a commotion and observed Resident #1 on the floor. They did not complete an Event Report for that fall. On 8/1/2022 at 4:15 PM the Administrator stated during an interview, following falls, an investigation should be completed and the CCP updated with new interventions. 10NYCRR 415.4(b)(1)(ii)

Based on record review and interview during the abbreviated survey (NY 687) conducted on [DATE], the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 10 residents reviewed (Resident #3). Specifically, Resident #3 had a decline in condition and when their condition worsened, there was no documented evidence of timely reassessment, physician notification and transfer to the hospital. This resulted in actual harm to Resident #3 who expired shortly after arrival to the hospital. Findings include: The facility policy Change in Resident Condition dated ,d+[DATE] documents: - Upon determining a change in the resident's condition has occurred, the nurse should notify the DON (Director of Nursing)/Assistant DON (ADON). - A change in condition may include: a significant change in the resident's medical status, a reaction to a medication, and a need to transfer the resident to the hospital. - The supervisor or nurse will notify the physician and family. - The nurse or supervisor will record in the resident's medical record information relative to changes in the resident's medical or mental condition. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance of two people for bed mobility and dressing, was dependent on two staff for transfers and toileting, and required extensive assistance from one person for hygiene. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - on [DATE], full code (initiate cardio pulmonary resuscitation, CPR, chest compressions in the event the heart stopped). - On [DATE], a renewal order was written for [MEDICATION(S)] (blood pressure medication), 10 milligrams (mg) daily at 8 AM, hold for systolic blood pressure less than 100 (the top number of a blood pressure reading). The ,d+[DATE] Medication Administration Record (MAR) and nursing progress notes documented: - On [DATE], licensed practical nurse (LPN) #10 held [MEDICATION(S)] for a BP of ,d+[DATE]. - On [DATE], registered nurse (RN) # 17 held [MEDICATION(S)] for a BP of ,d+[DATE]. - On [DATE] at 9:41 AM, RN #17 noted the resident was alert and at baseline. Blood pressure was ,d+[DATE] and [MEDICATION(S)] was held related to BP below parameters per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - On [DATE], RN #17 held [MEDICATION(S)] for a BP of ,d+[DATE]. - On [DATE] at 10 AM, RN #17 documented the resident's BP was ,d+[DATE] and blood pressure medication ([MEDICATION(S)]) was held. The BP was rechecked at 9:30 AM, was ,d+[DATE], and the plan was to monitor. - On [DATE] at 2:37 PM, RN #17 noted the resident was alert and sitting up in the wheelchair in the dining room. BP was ,d+[DATE]. - On [DATE], LPN #10 administered [MEDICATION(S)] at 8:00 AM and recorded the resident's BP as ,d+[DATE]. The Vital Signs Report documented on [DATE] at 11:54 PM, BP was ,d+[DATE], pulse was 118 (triggered for out of range). There were no nursing progress notes in the resident's medical record on [DATE]. LPN #10 stated in an interview on [DATE] at 12:49 PM, they worked the day and evening shifts on [DATE]. LPN #10 reviewed the ,d+[DATE] MAR and stated they administered [MEDICATION(S)] on [DATE] at 8 AM when the resident's systolic BP was below 100 and the medication should not have been administered. LPN #10 did not notify a Supervisor or the physician and was unaware an error had been made. LPN #10 held the [MEDICATION(S)] on [DATE] due to low BP and could not recall if the physician was notified at that time. The physician should be notified and document in medical record if a medication was held, if there was an error, and if a medication was given outside ordered parameters. On the evening of [DATE], the resident appeared at baseline, took their medications with no issues, responded to staff, ate dinner, and the certified nurse aides (CNA) did not report any concerns. The [DATE], RN #9's progress notes and the Vital Signs Record documented: - at 1:26 AM, the resident had decreased responsiveness, looked up when their name was called, withdrew from pain, spontaneously opened their eyes, and blinked. The resident's skin was ashen, warm, and dry, breathing was easy and regular, and skin was tenting. The resident had one episode of emesis (vomiting) that had clear liquid with [MEDICATION(S)]. The on-call physician was called and intravenous (IV) fluid was started, blood work was drawn for a complete metabolic panel (CMP), complete blood count (CBC), and the resident was straight catheterized for a urine specimen. The samples were sent to the hospital laboratory. The [DATE] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)], 0.9% [MEDICATION(S)] solution 75 milliliters per hour (ml/hr), IV. - Urinalysis, urine culture, stat (immediately). - CMP, CBC with differential stat. - Oxygen at 2 liters (L) per minute via nasal cannula continuous. The [DATE], RN #9's progress notes and the Vital Signs Record documented: - At 3:03 AM, the resident had more emesis. There was no documented evidence medical was notified of the resident's additional emesis. - At 5:55 AM, BP was ,d+[DATE], pulse was 118 (triggered for out of range). There was no documentation medical was notified when the resident's BP remained low. - At 6:36 AM, the resident had a third episode of emesis, BP was slightly better, the resident was less responsive, opening eyes, not blinking and not responding to voice. Physician #12 was contacted and a new order was received to send the resident to the emergency room . The [DATE] emergency medical services (EMS) Prehospital Care Report (PCR) documented they were called at 7:24 AM and the resident was found unresponsive, with shallow breathing. The nurse at the facility reported the resident had been in this condition since 3:30 AM and EMS was called due to emesis two times that morning, the respiratory rate was rapid, and the last BP obtained was ,d+[DATE]. The nurse gave no other information to EMS aside from the fact the resident had strokes in the past and was a full code status. The resident's eyes were non-reactive, vital signs showed hypotensive with tachycardia (abnormal fast heartbeat). An IV was established, 18 gauge, and the resident was given fluids bolus with IV wide open. The resident was placed on high concentration oxygen (,d+[DATE] liters). At 7:29 AM, the resident's BP was ,d+[DATE], pulse was 110. The [DATE] hospital emergency department record documented: - The resident arrived at 7:49 AM; was unresponsive, short of breath, and with low blood pressure at least since 1:30 AM according to facility records. - The resident presented in critical condition, unstable, ineffective respirations, and hypotensive. - At 7:50 AM, the resident's BP was ,d+[DATE], oxygen saturation was 71%, and respirations were 30. - The resident had a fixed gaze up to the right, was unresponsive, and extremities were cool to the touch. - The resident expired at 10:47 AM following unsuccessful CPR efforts. During a telephone interview with CNA #20 on [DATE] at 3:45 PM, the CNA stated: - They were assigned to the resident on the night shift from [DATE] through [DATE]. Shortly after the beginning of the shift (after 10:30 PM), the CNA noted the resident did not appear well, had vomited a large amount of brown emesis, had an elevated heart rate and low BP - The CNA could not locate RN #9 and went to get LPN #14, who obtained vital signs and instructed CNA #20 to get RN #9 immediately. - RN #9 responded, called the physician and returned to do a draw blood. - The CNA took the blood sample to the hospital laboratory around 12 AM and then continued to check on the resident, who remained unresponsive. - When the CNA returned for incontinence care around 3 AM, the resident had another episode of vomiting a large amount. CNA #20 stated a concern that the resident should go to the emergency room , as they were full code and did not look well at all. - RN #9 declined and stated the physician had been notified, ordered treatments were in progress, and there was nothing more to do. - When RN #15 arrived at the facility in the morning, the CNA asked RN #15 to see the resident. - RN #15 saw the resident and emergency medical services (EMS) was called shortly after. During a telephone interview on [DATE] at 4:13 PM, LPN #14 stated while working the night shift on [DATE], CNA #20 reported concerns with Resident #3, who had low oxygen level, was unresponsive, had vomited, had labored breathing, and did not look good. LPN #14 obtained the resident's vital signs, could not recall what they were, but noted the BP was out of normal range and the resident had a rapid pulse. RN #9 arrived, and the LPN encouraged the RN to call 911 to send the resident to the hospital. The RN declined and said the physician would be notified. An order was received for fluids which was started. LPN #14 reported being very concerned about the resident and given the resident's full code status, thought they should have been sent to the hospital. The resident had facial drooping, weakness, was non-responsive, and vomited food particulate and bile. LPN #14 stated they returned to work on the other unit for the remainder of the night shift. When another nurse (RN #15) entered the building in the morning, the CNAs reported their concerns and the resident was sent to the hospital. During a telephone interview with CNA #16 on [DATE] at 11:59 AM, the CNA stated on the [DATE] on the night shift, CNA #16 assisted CNA #20 with Resident #3 for rounds. Upon entering the room, they found the resident with labored breathing. CNA #20 went to get RN #9 and CNA #16 called out to hurry. CNA #16 knew the resident was full code status. The resident had vomited a large amount. RN #9 called the physician and IV fluids and oxygen were started, CNA #20 ran the blood and urine samples to the hospital laboratory. CNA #16 stated their concerns to RN #9 several times that shift because of their knowledge of the resident's baseline, unresponsive status, and being a full code. RN #9 replied they would wait for laboratory results and would call the physician back. LPN #10 was interviewed on [DATE] at 12:49 PM and reported on [DATE] when they arrived for the day shift (near 7:00 AM), the resident was still in the facility. An IV had been started, the resident was unresponsive, had a blank stare, and one side of their mouth was drooping. During a telephone interview with RN #15 on [DATE] at 3:05 PM, the RN stated upon arrival to the facility on [DATE] at approximately 6:,d+[DATE]:00 AM, CNA #20 asked the RN to look at Resident #3. The RN took one look at the resident and told RN #9 to call the physician. The resident had a drooping right lip and was unresponsive with a blank stare. RN #9 reported IV fluids and oxygen had been started and did not state how long the resident had been in that condition. During a telephone interview with RN #9 on [DATE] at 3:16 PM, the RN stated: - On [DATE] before 12:00 AM, the resident had a large emesis, the RN and CNA #20 assisted the resident. The resident also had a low blood pressure and the off-hours medical number was called and orders were received for fluids and to obtain blood and urine samples. The RN stated at that point, the resident should have been sent to the emergency room due to being a full code status and not looking well and was unresponsive. The on-call physician did not authorize the resident to be sent out despite the RN's request. The RN could not recall if this was documented. - Around 3:00 AM, the resident vomited a very large amount and the RN was concerned the resident had a GI bleed, based on the color, consistency, and odor of the emesis. RN #9 stated the emesis was dark in color and had shreds of mucous. The RN called the off-hours medical number again and awaited a call back. The RN stated orders were needed to send someone to the hospital but if a resident's condition was very serious, the RN could call 911 without a medical order. The RN stated the resident was in very bad condition at that point and she thought she called 911 at that time. - After reviewing the timeline of events on [DATE], RN #9 stated they recalled they did not call 911 at 3:00 AM, and they started administering medications to other residents at around 3:00 AM or 4:00 AM and was awaiting a call back from medical. - Around 6:00 AM, it was reported the resident's blood pressure was rechecked, it had improved, and the RN continued the medication pass. - When RN #15 arrived for the day shift, RN #9 requested they look at the resident. RN #9 stated the resident was still not responsive and RN #9 called attending physician #12, who ordered the resident be sent to the hospital. - RN #9 called the ambulance and reported the resident's low blood pressure, and unresponsive status. - RN #9 did not see any facial drooping. - RN #9 stated the resident should have been sent to the hospital at 3:30 AM but they were waiting for a return call from medical at that time. The RN stated while waiting for the return call, the resident was holding and RN #9 stated they went back to do the medication pass. During a telephone interview with paramedic #19 on [DATE] at 2:30 PM, the paramedic stated: - upon arrival to the facility, the resident was found unresponsive and an IV was in place. - On arrival, the resident's BP was ,d+[DATE], which was critically low. - The paramedic stated concern that the nurse reported the BP was ,d+[DATE] at 3 to 3:30 AM, which was critically low and EMS should have been called at that point. Paramedic #19 stated it was unclear why there was no call until 7:30 AM, the resident was full code status, and the outcome may have been different if the resident received emergency treatment sooner. During a telephone interview with physician #12 on [DATE] at 12:46 PM, the physician stated: - Calls from the facility were not tracked, and the expectation was for nursing staff to document in the resident record when the physician was notified and what was happening with the resident. - If the [MEDICATION(S)] was held for 3 days due to ordered parameters, the physician expected to be notified. The physician may have ordered another medication or treatment, and may have reviewed current medications. - The [MEDICATION(S)] should not have been administered on [DATE] when the resident's BP was low for the last 3 days. The physician was not notified of this and should have been, as it was a medication error in addition to the low BP for 4 days. Had the physician been notified, the resident's status could have been reviewed, new orders may have been provided such as fluids or monitoring. Administering the [MEDICATION(S)] after the resident had been running low BP for 4 days could have caused the resident's BP to drop even further an the physician was not made aware of that. The Assistant Director of Nursing (ADON) stated during a telephone interview on [DATE] at 12:30 PM, the ADON was covering the role of DON, and was not aware of a medication error for Resident #3. The ADON stated they were not made aware of the resident's declining condition the night/early morning of [DATE]. The ADON expected monitoring and documentation in the resident's record of all calls to the physician or after hours medical coverage. The ADON stated the attending physician (physician #12) was able to be contacted at any time, day or night, if another provider was not able to be reached. The ADON stated nursing staff could call 911 of there was an emergent situation. 10NYCRR 415.12

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 4 of 16 sampled residents (Residents #2, 3, 6 and 7), the facility did not provide the necessary care and services to attain or maintain the highest practicable well-being. Specifically, the facility did not address or follow up when the podiatrist identified Resident #6's wound on the right toe, and the area worsened. Additionally, Resident #6's heels were not assessed or monitored by nursing staff; and the compression wraps were applied incorrectly. For Residents #2 and 3, skin impairment was not monitored, assessed or treated as planned. For Resident #7, there was no documented evidence the resident's intermittent loose stools were assessed or treated as planned. Findings include: 1) Resident #6 had [DIAGNOSES REDACTED]. RIGHT TOE CONCERNS: A physician order [REDACTED]. The ultrasound diagnostic report dated the same day documented the resident's right lower extremity had normal venous (blood) flow. The comprehensive care plan (CCP) dated 6/12/2015 documented the resident was at risk for skin breakdown and pressure ulcers related to decreased mobility and incontinence. Interventions included a systematic skin inspection weekly by licensed staff, using a lift sheet to move resident in bed, and reporting any signs of skin breakdown. The August 2015 treatment administration record (TAR) documented the resident had weekly skin checks on 8/3, 8/10, 8/17, 8/24 and 8/31. The medical record did not document any skin impairments observed on the weekly skin inspection. A physician order [REDACTED]. A podiatry consult dated 8/13/2015 documented the resident had no [MEDICAL CONDITION] and he had an ulceration on the tip of the right hallux (big toe) that measured 0.5 centimeters (cm) in diameter. The podiatrist documented the plan was to consult with staff; start on a topical antibiotic; and suggested a foot rest on the wheel chair's right side to prevent the resident from pushing wheelchair with his foot. The handwritten initials of the physician assistant (PA) with a date of 8/28/2015 was on the documented podiatry consult. There was no documented evidence in the medical record the podiatrist's recommendations were followed or discussed with the physician. There was no further documentation in the medical record regarding the ulcer to the resident's right big toe. There was no documented evidence in the medical record the PA assessed the resident's toe or initiated a treatment after he initialed the consult. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired, he required extensive assistance with activities of daily living (ADLs) except for eating, and he did not have any unhealed pressure ulcers. A quarterly nutritional assessment dated [DATE] documented the resident's skin was intact. A physician progress notes [REDACTED]. The progress note did not include skin impairments. The resident was observed on 9/16/2015 at 5:45 PM, sitting in his wheelchair, near the nursing station, with a bedside table in front of him. There were no leg rests on the wheelchair and he was wearing non slip socks on both feet. The resident's right heel was on the footbar of the bedside table, and the left foot was on the floor. During a wound observation with licensed practical nurse (LPN) #6 on 9/17/2015 at 10:05 AM, the resident had a wound on the tip of his right big toe measuring approximately 1 cm in diameter. The wound bed was covered with dark, dead tissue and a small area on the upper aspect of the wound contained yellowish moist tissue. The surrounding skin was red and scaly. The resident's entire right big toe was red and swollen. The LPN stated she did not see the wound on the toe before and she would report it to the Unit Manager. During an interview with the Director of Nursing (DON) on 9/17/2015 at 10:15 AM, she stated she looked at the resident's heels on 9/14/2015. She stated she did not inspect the rest of the foot and did not observe any other areas of concern. During an interview with the LPN Unit Manager on 9/17/2015 at 10:25 AM, she stated the treatment or medication LPN was responsible for doing weekly skin checks. The LPN initialed the TAR to document it was done, and if skin impairments were observed, the LPN wrote a progress note and notified either the DON, the physician, or herself. During an interview with the physician assistant (PA) on 9/17/2015 at 11:15 AM, he stated the resident was being treated for [REDACTED]. The PA reviewed the podiatrist consult from 8/13/2015 with the surveyor. He stated he initialed the consult to indicate it was reviewed. He stated he did not order the topical antibiotic or the foot rest. He also stated the resident had a scabbed area on the tip of his right toe that was firm and not open, and he did not order a treatment for [REDACTED]. The resident was observed on 9/17/2015 from 11:30 AM to 12:30 PM. He wore non slip socks on his feet and used his feet to propel his wheelchair; there were no foot rests on the wheelchair. He then sat near the nurses station with the bedside table in front of him. His feet were on the floor and the resident's right toes pressed up against the footbar of the bedside table. The resident was observed on 9/17/2015 at 4:45 PM. He propelled his wheelchair in the hall with his non slip sock covered feet. He approached the surveyor and asked if she wanted to look at his toe again. He stated it was very sore. The resident was observed on 9/18/2015 at 7:50 AM, sitting by the nursing station with the bedside table in front of him. The resident was wearing non slip socks and both feet were on the floor. The right toe was approximately less than 1 inch away from the footbar on the bedside table. During an interview with the podiatrist on 9/18/2015 at 9:35 AM, he stated the ulcer on the resident's right toe was pressure related and the resident used his toe to propel his wheelchair. He stated his intention for ordering the topical antibiotic and the leg rest was to prevent pressure and worsening of the area. During an interview with the LPN Unit Manager on 9/18/2015 at 10:50 AM, she stated the process for podiatry consults was: the nurse rounded with the podiatrist; he gave recommendations; the nurse called the physician with the recommendations and obtained an order. She stated she did not know why the recommendations were not followed. She also stated the DON and the PA observed the resident's toe yesterday and she did not see any new orders. The DON was interviewed again on 9/18/2015 at 11:15 AM. She stated she looked at the resident's right toe yesterday with the PA and they agreed the ulcer on the tip of the right toe was related to friction and not pressure. She stated she did not document her assessment in the progress notes and she did not know why the recommendations from the podiatrist were not followed. She stated she read the podiatrist consult yesterday and the area was now bigger than 0.5 cm. She stated it was approximately 1 cm and no treatment was ordered. She stated when the podiatrist identified the area a registered nurse (RN) should have assessed the toe, documented the assessment, and notified the physician. The medical record was reviewed on 9/18/2015 at 11:30 AM and did not document an assessment of the resident's right toe or treatment orders. The resident was observed on 9/18/2015 at 11:50 AM, in the hallway waving his hand to summon the physician. The resident had his right foot on a wheelchair foot rest and he removed his right sock. His right toe was red and swollen; the ulcer on the tip of the toe was observed and unchanged from the day before. During a skin observation with the physician on 9/18/2015 at 12 PM, the physician observed the tip of the resident's right toe. The physician asked the LPN Unit Manager if the resident was having any pressure applied to the area and the LPN responded she was not sure and thought the resident might bump his foot on the bar of the bedside table. The physician stated he thought the ulcer was an abrasion caused from rubbing his toe on something. He stated if the podiatrist assessed the area and made recommendations, he would follow them as that was the podiatrist's area of expertise. He would expect the nursing staff to call him with the podiatrist's recommendations and he would give an order for [REDACTED].>HEEL CONCERNS: The January 2015 treatment administration record (TAR) did not contain any treatments for the resident's heels. The February 2015 TAR documented the resident had a weekly skin check done on February 2, 9, 16 and 23. The medical record did not document any skin impairments observed during the skin checks. The TAR documented on 2/27/2015 [MEDICATION NAME] (hydrating) cream was to be applied to both heels twice a day. A physician order [REDACTED]. The medical record did not document an assessment of the resident's heels or rationale for the treatment. The comprehensive care plan (CCP) dated 3/2015, documented the resident was at risk for skin breakdown and pressure ulcers related to decreased mobility and incontinence. Interventions included a systematic skin inspection weekly by licensed staff, using a lift sheet to move the resident in bed, and reporting any signs of skin breakdown. The CCP did not include any interventions for the resident's feet/heels. A physician order [REDACTED]. The order documented to cleanse the area on the left heel with normal saline, apply Santyl ointment (chemical debridement; removes dead tissue from open wounds) and apply a dry sterile dressing daily and as needed. The medical record did not document an assessment of the resident's heels or rationale for the change in treatment. A physician order [REDACTED]. The medical record did not document monitoring or an assessment of the resident's heels, or rationale for the change in treatment. The April 2015 TAR documented to cleanse both heel open areas with normal saline and apply Hydrogel and dry dressing twice a day. An annual nutritional assessment dated [DATE] documented the resident's skin was intact. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired, required extensive assistance with activities of daily living (ADLs) except for eating, and he did not have any unhealed pressure ulcers. The MDS documented he had open [MEDICAL CONDITION] on the foot that required application of dressings and ointments/medications. The May 2015 TAR documented to cleanse both heel wounds with normal saline, apply Hydrogel and dry dressing twice daily. The treatment was signed for twice daily from 5/1/2015 - 5/31/2015. There was no documented assessment or monitoring of the heel wounds in the medical record. The comprehensive care plan (CCP) dated 6/12/2015, documented the resident was at risk for skin breakdown and pressure ulcers related to decreased mobility and incontinence. Interventions included a systematic skin inspection weekly by licensed staff, using a lift sheet to move the resident in bed, and reporting any signs of skin breakdown. The CCP did not include interventions for the resident's feet/heels. A physician order [REDACTED]. The medical record did not document monitoring or an assessment of the resident's heels, or rationale for the change in treatment. A physician order [REDACTED]. The medical record did not document an assessment of the area on the right heel, rationale for stopping the treatment on 6/19/2015, or rationale for restarting the treatment. The July 2015 TAR documented the Duoderm treatment for [REDACTED]. The medical record did not document monitoring or an assessment of the resident's heels that required treatment. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident did not have any unhealed pressure ulcers and he had open [MEDICAL CONDITION] on the foot and required application of dressings and ointments/medications. A quarterly nutritional assessment dated [DATE], documented the resident's skin was intact. The August 2015 TAR documented the Duoderm treatment for [REDACTED]. The medical record did not document monitoring or an assessment of the resident's heels that required treatment. The September 2015 TAR documented Duoderm was applied to both of the resident's heels and changed every 3 days. A physician progress notes [REDACTED]. The progress note did not document concerns with the heels or the treatment provided. During an interview with the licensed practical nurse (LPN) Unit Manager on 9/16/2015 at 11:35 AM, she stated there were no residents on the unit with pressure ulcers. The resident was observed on 9/16/2015 at 5:45 PM, sitting in his wheelchair, near the nursing station, with a bedside table in front of him. There were no leg rests on the wheelchair and he was wearing non slip socks on both feet. The resident's right heel was on the footbar of the bedside table, and the left foot was on the floor. The Director of Nursing (DON) was interviewed on 9/17/2015 at 10 AM, she stated she did not monitor the resident's heels weekly as the areas were not pressure areas. She stated she looked at his heels on 9/14/2015 and the resident had some slits from dry skin on his heels. She stated she did not document her assessment of the heels in the medical record and did not remember the last time she assessed the resident's heels prior to 9/14/2015. During a wound observation with licensed practical nurse (LPN) #6 on 9/17/2015 at 10:05 AM, the resident was observed with a boarder foam dressing in place on both heels. The LPN removed the boarder foam dressings and stated the resident should have had Duoderm on the heels. The resident's heels were observed. The left heel was slightly red with some dry scaly skin and no open areas; the right heel had a small pinpoint discolored area with intact skin. The LPN stated the treatment was scheduled for the 3 PM - 11 PM shift, she did the treatment once before, and he had a larger scabbed area on the right heel that has healed. During an interview with the LPN Unit Manager on 9/17/2015 at 10:25 AM, she stated the areas on his heels were open areas and he had them for months. She stated the treatments were changed throughout the past couple of months as the nursing staff thought the areas were worsening. She stated she did not do treatments on residents and was unable to recall the last time she observed the resident's heels. She stated when the physician was notified of a change in condition, and treatments were changed, a progress note should have been written by nursing. During an interview with the physician assistant (PA) on 9/17/2015 at 11:15 AM, he stated he never looked at the resident's heels. The following resident was observed on 9/17/2015 from 11:30 AM to 12:30 PM in his wheel chair. He wore non slip socks, the wheel chair did not have foot rests, and his feet were on the floor. The resident was observed on 9/18/2015 at 7:50 AM sitting by the nursing station with the bedside table in front of him. The resident was wearing non skin socks on his feet and both feet were on the floor. The LPN Unit Manager was interviewed again 9/18/2015 at 10:50 AM, she stated the CCP should have included interventions to address the resident's heels. She also stated there should have been documentation and monitoring of the areas in the progress notes. The DON was interviewed on 9/18/2015 at 11:15 AM, she stated she was told the resident only had dry cracks on his heels. She stated Santyl and Hydrogel were used to treat wounds and would not be applied to dry intact skin. She stated the resident did not have pressure areas on his heels so pressure relief was not needed. She stated if the areas on his heels where pressure related dietary would be involved to add supplements to his diet. The physician was interviewed on 9/18/2015 at 12:30 PM. He stated if the resident required treatment to his heels, he expected monitoring and documentation to be in the chart. He stated when a treatment was not working the nursing staff called him for a change in treatment. He did not recall assessing the resident's heels. He stated he would normally order Santyl for wounds with necrotic (dead) tissue and Hydrogel for wounds that needed moisture. He stated Duoderm was used as a treatment for [REDACTED]. He stated if he ordered a Duoderm dressing he would not expect it to be substituted with a boarder foam dressing. The facilities undated Pressure Ulcer policy documented a pressure ulcer was a localized injury to the skin or underlying tissue as a result of pressure or pressure in combination with shearing and/or friction. The policy documented the following was done for residents with pressure ulcers: - a complete head-to-toe assessment was completed by licensed staff on designated shower days and if an alteration in skin integrity was found it was documented in the appropriate places (skin tracker, progress note); - dietary was notified and nutritional status was assessed; - the CCP included individualized interventions for skin issues identified; - monitoring and assessing healing/deterioration was done weekly on skin rounds; and - the physician generated a monthly progress note detailing the status of all pressure ulcers. COMPRESSION WRAPS IMPROPERLY APPLIED: A physician order [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired, he did not have any behaviors, did not reject care and required extensive assistance with personal hygiene and dressing. Physician orders [REDACTED]. The comprehensive care plan (CCP) dated 9/7/2015, documented the resident required assistance with activities of daily living (ADLs) and he had difficulty making himself understood. Interventions included to provide a quiet, non hurried environment and report any deterioration in the resident's physical status to the physician. The CCP did not include interventions for [MEDICAL CONDITION] to his lower extremities. During a wound observation on 9/17/2015 at 10 AM ,the resident was observed with the ace wrap to the left leg. The ace wrap started just above the ankle extending up to his knee and did not cover his foot. The resident had pitting (skin indents when pressed) [MEDICAL CONDITION] in the foot with minimal [MEDICAL CONDITION] to the ankle. During a wound observation with the physician on 9/18/2015 at 12 PM, the resident was observed with the ace wrap to the right leg. The ace wrap started at the ankle extending up to his knee and did not cover his foot. The resident had [MEDICAL CONDITION] in the foot. During an interview with the physician on 9/18/2015 at 12:30 PM, he stated the ace wraps were ordered for compression to decrease the [MEDICAL CONDITION] in his legs. He stated the resident had [MEDICAL CONDITION] in both feet which did not extend past his ankles and the ace wraps were not effective unless they were wrapped from his toes up to his knees. During an interview with the licensed practical nurse (LPN) Unit Manager on 9/18/2015 at 1 PM, she stated the resident used ace wraps for the [MEDICAL CONDITION] in his legs and they should be wrapped from his toes up to his knees. 2) Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severe cognitive impairment and required limited to extensive assistance with activities of daily living (ADLs). The resident was frequently incontinent of bowel and bladder. Nurse practitioner (NP) progress notes dated 2/13/2015 through 4/9/2015, documented periodic concerns with gastrointestinal upset, and the resident was being treated with medications for nausea and vomiting. The progress note did not document any concerns with the resident's bowel status. On 5/4/2015 a nursing progress note documented the resident was incontinent of a large soft bowel movement. On 5/6/2015 a nursing progress note documented the resident had loose stools 4 times on the day shift and the physician was updated. On 5/6/2015 the physician documented the resident was being seen for diarrhea, and the staff reported the resident was having at least 2 loose/watery stools per day for months. The physician documented it was the first he had been told, and staff stated it was a usual occurrence and had increased recently. The physician documented he would obtain a stool culture ( to detect bacterial growth) and an O and P (ova and parasite - a test to detect parasites and eggs in the intestines). On 5/6/2015 an order was written for a stool culture and ova and parasites. No laboratory results were documented in 5/2015 for a stool culture. The test for ova and parasites was negative. There was no documentation in the nursing progress notes or in the physician progress notes [REDACTED]. During an interview with the physician assistant (PA) on 9/17/2015 at 12:40 PM, he reviewed the resident record and stated he was unable to locate the results of a stool culture as ordered on [DATE], and there was no documentation the order was discontinued. Nursing progress notes documented the resident had loose stools, 1 to 4 times a day, in May 2015 on 5/7, 5/8, 5/9, 5/10, 5/13, 5/14, 5/15, 5/16, 5/18, 5/19, 5/20, 5/21, 5/23, 5/24, 5/25, and 5/26/2015. On 5/10/2015, the resident's stool was documented as a large, loose stool foul odor greenish color, and on 5/14 and 5/21/2015 the resident's loose stool was documented as having a foul odor. In June 2015, nursing progress notes documented the resident had loose stools on 6/3, 6/5, 6/8, 6/11, 6/12, and 6/18/2015. On 6/18/2015, an NP progress note documented the resident was seen for diarrhea. As a result, Banatrol (anti-diarrhea) packets 3 times per day were to be ordered. Physician orders [REDACTED]. Nursing progress notes from 6/19/2015 through 7/19/2015, documented the resident had loose stools one or more times a day on 19 of 31 days. On 7/13/2015, a nursing progress note documented the resident's loose stools were foul smelling. On 8/3/2015, the nursing progress note documented the resident had loose stools. A nursing progress note documented the resident was admitted to the hospital on [DATE] for dehydration and a urinary tract infection. A nursing progress note dated 8/17/2015, documented the resident was readmitted to the facility. The readmission physician orders [REDACTED].>A PA progress note dated 8/25/2015, documented the resident was being evaluated for dehydration as the resident was not eating or drinking. The PA documented the resident had no nausea, vomiting, or diarrhea. On 8/25/2015, a nursing progress note documented the resident had a large loose bowel movement. On 8/26/2015, a nursing progress note documented the resident had loose stools running down her legs. A physician's orders [REDACTED]. There was no documentation in the physician or nursing progress notes regarding the addition of the [MEDICATION NAME]. The certified nurse aide (CNA) report, for 8/27/2015 through 9/18/2015, documented the resident had loose stools on 8/30, 8/31, 9/4, 9/5, 9/7, 9/8, 9/10, 9/14, 9/16 and 9/18/2015. There were no nursing or physician progress notes [REDACTED]. The Medication Administration Record [REDACTED]. During an interview with CNA #2 on 9/18/2015 at 10:10 AM, she stated when the resident had loose stools, she documented it in the Kiosk and did not necessarily inform the nurse. During an interview with the licensed practical nurse (LPN) Manager on 9/18/2015 at 11:15 AM, she stated the CNA bowel report was printed daily and documented when the resident had his/her last bowel movement. If a resident was having a problem with loose stools, the CNAs were to report it to the nurse. The LPN Manager reviewed the resident's record and was unable to determine why the stool sample ordered in May, was not done. She stated she was not aware the resident continued to have a problem with loose stools. During an interview with the physician involved with the resident's care (who ordered the stool culture in 5/6/2015), on 9/18/2015 between 11:45 AM and 12:40 PM, he stated he did not follow up on the stool culture as he was informed the resident was no longer having a problem. He stated if he was told now the resident had diarrhea, it was no longer considered an independent occurrence, and needed to be looked at. He would now consider obtaining a gastrointestinal (GI) consult. The physician stated he should have been told about the ongoing problem. 3) Resident #2 had [DIAGNOSES REDACTED]. The nursing progress note dated 6/3/2015 at 4:30 PM, documented the resident had moisture related excoriation to the perineal and groin, the physician was notified and an order was in place. The nursing progress note dated 6/15/2015 for 7 AM - 3 PM, documented the resident continued to have loose stools twice during the shift. The nursing progress note dated 6/21/2015 for 7 AM - 3 PM, documented the resident had loose stools twice during the shift. The nursing progress note dated 6/22/2015 at 12 PM, documented the resident's physician was updated about the loose stools. The physician's progress note dated 6/25/2015, documented the resident was incontinent of urine and bowel. No skin impairments were documented. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired. She required extensive assistance of one person for toilet use, transferring, personal hygiene, and walking; she was frequently incontinent of urine and bowel. The MDS documented the resident had moisture associated skin damage (MASD) and skin treatments included a pressure reducing device for the bed and applications of ointments/medications. The nursing progress note dated 7/3/2015 for 11 PM - 7 AM, documented the resident's peri area, groins, and coccyx were red and excoriated and a message was left for the physician. The nursing progress note dated 7/4/2015, documented a treatment remained in place for the resident's red coccyx and peri area. The resident's care card (care instructions) dated 7/17/2015, documented the resident was incontinent of bowel and bladder, wore incontinence briefs, and required assistance of one for toilet use. The comprehensive care plan (CCP) dated 7/17/2015, documented the resident was at risk for skin breakdown. Interventions included a weekly skin inspection, reporting signs of skin breakdown, using a moisture barrier product, and updating the physician. The physician's progress note dated 7/20/2015, documented the resident had a peri area rash and was improving with treatment. The physician's orders [REDACTED]. The nursing progress note dated 8/6/2015 for 3 PM - 11 PM, documented the resident had an excoriated buttock and was awaiting an order from the physician. The physician's progress note dated 8/7/2015, documented the resident was re-evaluated for a rash on the peri area which was clearing and to continue the treatment with normal saline washes and [MEDICATION NAME] cream until resolved. The note documented the resident was on a [MEDICAL CONDITION] medication and had chronic loose bowel movements. The plan was to add an as needed dose of [MEDICATION NAME] (medication used to treat and control diarrhea) to the regimen for the loose bowel movements and re-evaluate in 2 weeks. The physician's orders [REDACTED]. The physician's progress note dated 8/18/2015, documented the resident had mild excoriation and redness in the peri area which was being treated and improving. The Medication Administration Record [REDACTED]. There was no documentation of the resident's status prior to or after administration. The nursing progress note dated 9/15/2015, documented the resident had 3 loose stools on the 3-11 PM shift. There was no documentation in the nursing notes from 8/6/2015 to 9/15/2015. The September 2015 MAR indicated [REDACTED]. The [MEDICATION NAME] was administered during September. During an observation on 9/17/2015 at 9:05 AM, the certified nurse aide (CNA) # 4 walked the resident from the dining room to the bathroom in the resident's room. The resident was incontinent of urine and loose stool. Her groin and buttocks were very red. CNA #4 stated the resident often had loose stools. During an interview on 9/18/2015 at 12:30 PM, the registered nurse (RN) Manager stated when a rash developed it was documented in the nursing progress notes and the physician was called for a treatment order. She expected the staff to document on it the first few days and if it worsened. She stated if the rash was not improving, the doctor should be notified. She stated the resident's rash was not resolved and it was caused by chronic diarrhea which was a side effect from her [MEDICAL CONDITION] medication. She stated the resident's order for [MEDICATION NAME] was ongoing as she had chronic redness and excoriation from the diarrhea. She was unaware the resident had an order for [REDACTED].

Based on observation, record review, and interviews conducted during the standard survey, it was determined for 5 of 6 residents reviewed for weight/nutrition (Residents #4, 6, 7, 8, and 14), the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, - For Resident #4 who was admitted to the facility with a low [MEDICATION NAME] and surgical wound, the resident was not reassessed timely by clinical nutrition staff when she developed a Stage II (partial thickness loss of skin layers) pressure ulcer, the Stage II pressure ulcer progressed to an unstageable pressure ulcer (depth unknown), and when the resident had a significant weight loss. - For Resident #6 who was admitted with a surgical wound, the resident was not reassessed by clinical nutrition staff and changes were not made to the plan of care to promote adequate intake when: the resident's [MEDICATION NAME] decreased, she ate poorly, a significant weight loss was exhibited, and when the surgical wound progressed and tunneling was observed. - Resident #7 lost 13 pounds from March 2014 to April 2014 and was not reassessed timely by clinical nutrition staff. - Resident #8 had a history of [REDACTED]. - Resident #14 had a significant, unplanned weight loss that was documented afterward as a planned weight loss. The weight loss was not ordered by the physician, was not care planned, and a weight goal was not specified. This resulted in actual harm of significant weight loss, worsening [MEDICATION NAME] levels, and worsening wounds for Residents #4 and 6 and no actual harm with potential for more then minimal harm that is not immediate jeopardy for Residents #7, 8, and 14. Findings include: 1) Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The weekly skin assessment form dated 7/29/2014 documented the resident was admitted with a 35.5 centimeter (cm) x 5.5 cm x 4 cm surgical, abdominal wound. The physician's orders [REDACTED].A.C. (vacuum assisted closure) treatments to the abdominal, surgical wound. A serum [MEDICATION NAME] level (measure of protein stores), dated 7/31/2014, documented the resident had a low [MEDICATION NAME] of 2.0 g/dl (grams per deciliter) (normal 3.5-5.1 g/dl). The Minimum Data Set (MDS) assessment, dated 8/5/2014, documented the resident had moderately impaired cognition, required extensive assistance with most activities of daily living (ADLs), and was on a mechanically altered diet. The registered dietitian's (RD) assessment dated [DATE], documented the resident weighed 284 pounds and consumed 42% of meals. The RD assessed the resident's nutritional needs based on an adjusted body weight of 165 pounds as the resident was obese and assessed needs to be 1924-2124 calories and 113-150g (grams) protein per day. The RD documented the resident was at nutritional risk related to poor intake, low [MEDICATION NAME], and a surgical wound. The RD documented no planned snacks or supplements would be provided as a "gradual weight loss would be beneficial to resident." The RD did not document the calories or protein provided to the resident in the meal plan; did not document the calories or protein consumed by the resident when she ate 42% of foods provided, and did not document how the resident was being provided with her assessed calorie and protein needs when snacks or supplements were not provided. The comprehensive care plan (CCP), dated 8/8/2014, documented the resident was at risk for weight loss, left greater than 25% of meals uneaten, had increased nutritional needs secondary to surgical wound healing, and had increased protein needs secondary to depletion of [MEDICATION NAME]. A weekly skin assessment flow sheet, dated 8/11/2014, documented the abdominal surgical wound measured 35.5 cm x 5.5 cm x 4 cm deep. A serum [MEDICATION NAME] level, dated 8/14/2014, documented a low reading of 1.8 g/dl (normal=3.5-5.1 g/dl). The weight record documented the resident weighed 270 pounds on 8/13/2014 (12.8 pound loss in 1 week). There was no documented evidence the resident was reassessed by the RD when her [MEDICATION NAME] decreased and she lost 12.8 pounds in 1 week. During a meal observation, on 8/19/2014 at 12:15 PM, the resident stated to the surveyor, she did not like the food that was served at the facility. The resident ate none of her turkey, stuffing, or vegetable, and requested yogurt of which she ate 50%. During an observation, on 8/19/2014 at 5:20 PM, the resident stated she did not want the pasta salad and pepperoni that had been served, wanted to go back to her room, and requested chicken noodle soup from an unidentified certified nurse aide (CNA). The resident was returned to her room and transferred back into bed. At 5:45 PM, the resident received a bowl of chicken noodle soup, the head of her bed was not elevated, and she was not able to reach her soup. At 6 PM, the resident was observed lying flat in her bed, was not eating her soup, and stated to the surveyor she was hungry. At 6:05 PM, the resident turned her call light on, and the registered nurse (RN) Manager came in at 6:10 PM, and stated she would get some help to move the resident and left the room. The resident was repositioned in bed, her soup was reheated, and she ate her soup at 6:15 PM. The resident's abdominal surgical wound was observed on 8/20/2014 at 10:52 AM in the presence of the attending physician and licensed practical nurse (LPN) #6. The top 50% of the tissue surrounding the wound was reddened and there was a less than 1 centimeter (cm) round area of white necrotic tissue in the middle of the wound. The physician stated in an interview at that time, he had not previously observed tunneling in the wound. He used a sterile swab and probed under the umbilical area to a depth of approximately 1 cm. When the swab was removed, white drainage was observed on the swab and stick, and there was an odor from the wound. The weight record documented the resident weighed 261.4 pounds on 8/20/2014 (23 pound/8% loss in less than 1 month). There was no documented evidence the RD reassessed the resident's significant weight loss, low and decreased [MEDICATION NAME] levels, wound progression, and/or intake. During an interview with the registered nurse (RN) Manager, on 8/21/2014 at 11:05 AM, she stated the RD received a verbal report from nursing when residents lost weight. The RN Manager stated she was not sure who would have notified the RD of the resident's weight loss as it was not documented. She stated she did not notify the RD of the resident's weight loss. The RN Manager stated it was not unusual for the resident to refuse meals and she liked chicken noodle soup a lot. During an interview with the Director of Nursing (DON), on 8/21/2014 at 11:20 AM, she stated the physician and RD were responsible for monitoring weight loss, protein needs of residents, and labs. She stated the nursing staff obtained weights and reported them to the RD weekly. During an interview with the RD on 8/21/2014 at 12:11 PM, she stated she had not evaluated the resident's nutritional needs since her admission and was not aware the resident lost weight, had a decreased [MEDICATION NAME] level, and there was tunneling in her wound. The RD stated if she had known, she would have reviewed the resident's intake at meals, recommended supplements, and provided foods higher in protein. She stated the resident had not expressed any food preferences to her and she was not aware of the resident's refusal of foods. She stated she had not seen the resident eat and did not review food preferences with the resident on admission as the resident's family was present and she spoke to them. The RD stated she should have received a nutrition referral regarding the resident's weight loss, labs, and wound, and had not. She stated it may have been because she was on vacation and there was no coverage for her during that time. During an interview with the attending physician, on 8/21/2014 at 1 PM, he stated the resident was a very picky eater, refused milk products, the RD reviewed the resident's food preferences with her, a protein supplement had been ordered, and her weight loss was favorable due to a prior history of obesity. 2) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The 6/12/2014 laboratory report documented the resident's [MEDICATION NAME] was low at 2.6 g/dl (grams per deciliter), normal=3.5-5.1 g/dl. The 6/13/2014 registered dietitian's (RD) nutrition assessment documented the resident weighed 122 pounds and was on a no concentrated sweets (NCS), pureed consistency diet. The RD assessed the resident's protein needs increased to 66-72 g (grams) per day and calorie needs increased to 1535-1737 calories per day. The resident was consuming 64% at meals; received Prosource twice daily for surgical wound healing; had a low [MEDICATION NAME], and the plan was to follow-up with the resident on 9/11/2014. A 6/18/2014 weekly skin assessment flow sheet documented the resident was found to have a Stage II (partial thickness loss of skin layers) pressure ulcer on the right heel that measured 4 centimeters (cm) long X 8 cm and was described as a dark blister. A nursing progress note dated 6/18/2014 documented a dietary referral was sent. There was no documented evidence a nutrition reassessment was completed following the 6/18/14 referral. The weight record documented the resident weighed 112.2 pounds on 6/25/2014 (10 pound/8% loss in less than 1 month). There was no documented evidence the resident was reassessed by the RD when she lost weight and developed a Stage II pressure ulcer. The Minimum Data Set (MDS) assessment, dated 07/05/2014, documented the resident had severely impaired cognition, required extensive assistance with most activities of daily living (ADLs) and was on a therapeutic, mechanically altered diet, weighed 118 pounds, and did not have a significant weight loss. The weight record documented the resident weighed 117.6 pounds on 07/07/2014. A 7/8/2014 weekly skin assessment flow sheet documented the pressure ulcer on the right heel was now unstageable, measured at 4.0 cm X 6.5 cm with 80% thick black eschar (necrotic tissue) and serous drainage. Weekly skin assessment flow sheets dated 7/14/2014 and 7/21/2014 documented the resident continued with an unstageable pressure ulcer on the right heel. The laboratory report documented the resident's [MEDICATION NAME] was decreased to 1.8 g/dl on 7/15/2014. The comprehensive care plan (CCP), dated 07/21/2014, documented the resident was at risk for skin breakdown and alteration in nutritional/hydration status, weight loss potential, left greater than 25% of meals uneaten, and had increased nutritional needs secondary to wound healing. The weight record documented 106.8 pounds on 07/22/2014 and 105.2 pounds on 07/24/2014. There was no documented evidence the RD reassessed the resident when the pressure ulcer was unstageable and the resident lost weight. The Intake and Output Chart Detail Record documented the resident's average intake for 07/2014 was 46% of meals. The weight record documented the resident weighed 109.2 pounds on 08/01/2014 and 102.6 pounds on 08/04/2014. The weight record documented 106 pounds on 08/06/2014 and 106.6 pounds on 08/13/2014. The 8/19/2014 weekly skin assessment flow sheet documented the resident continued with an unstageable pressure ulcer on the right heel that was 80% eschar. On 8/19/2014 at 1:03 PM, the resident was observed in the dining room being fed by an unidentified licensed practical nurse (LPN). The resident received pureed foods and a Mighty Shake (supplement). During a meal observation on 8/19/2014 at 5:50 PM, the resident was served her supper tray. The tray consisted of pureed pasta salad, 1 ounce of cheese, pureed bread, 1/2 cup vegetables, 1/2 cup applesauce, vegetable soup and 6 ounces of Mighty Shake. The pureed bread was watery and runny and covered 75% of the plate. The pureed pasta salad covered 25% of the plate. The resident was being fed by an unidentified LPN standing next to her wheelchair. The resident coughed after being given a mouthful of pureed salad. The unidentified LPN brought a chair over and sat down. At 6:10 PM, the LPN continued to feed Resident #4, who consumed 1/2 of her bread, 1/2 of the pasta salad, all of the applesauce and 1/2 of the mighty shake. The weight record documented 108 pounds on 08/20/2014. The Intake and Output Chart Detail Record documented the resident's average intake for 08/2014 was 55% of meals. The resident's Meal Pattern printed on 8/21/2014 documented the resident received 6 ounces of Mighty Shakes at lunch and supper. There was no start date documented for the Mighty Shakes. There was no documentation in the resident's medical record regarding Mighty Shakes being initiated for the resident. During an interview with the RD, on 08/21/2014 at 11:46 AM, she stated she was not aware of the dietary referral for the Stage II pressure ulcer which was sent 06/18/2014. She stated the resident was on Prosource at that time and she would not have changed the resident's nutrition needs for the Stage II pressure ulcer as she assessed the resident as needing 1.2-1.3 g of protein per kilogram of body weight on 06/13/2014. She stated a nutrition reassessment was not done when the resident's pressure ulcer progressed from a Stage II to an unstageable pressure ulcer as she was not notified. The RD stated if she had been notified a reassessment would have been done. The RD stated the resident was started on Mighty Shakes twice a day on 7/22/2014, according to the documentation in the kitchen. She stated the Food Service Director sometimes changed residents' plans of care and the Mighty Shakes must have been added by the Food Service Director. 3) Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. The 1/31/2014 registered dietitian's (RD) assessment documented the resident weighed 109 pounds, received 2 Cal HN (supplement), 120 cc (cubic centimeters) twice a day, and consumed 43% at meals. The resident's weight was stable for the past 5 months. The plan included continuing with the 2 Cal HN with medication passes and alternative meals when the resident's intake was poor. The 4/16/2014 RD assessment documented the resident weighed 112 pounds, ate 37% of meals, and received "multiple supplements." The RD documented the resident was to receive fortified cereal at breakfast, soft Sandwich, fortified mashed potatoes at lunch and supper, Mighty Shake (supplement) as a morning snack, and to continue with plan of care. The weight record documented the resident weighed: - 106.5 pounds on 5/1/2014; - 106 pounds on 5/2/2014; - 104.6 pounds on 6/4/2014; and - 101.6 pounds on 7/1/2014. The 7/4/2014 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, weighed 102 pounds, needed set-up and supervision assistance at meals, and did not have a significant weight loss. The RD 7/18/2014 assessment documented the resident's weight was 101.6 pounds, she consumed 40% of meals, and received multiple supplements including 2 Cal HN at medication passes. The RD documented the plan was to provide ice cream in the afternoon and before bed and to continue to monitor weekly weights. The weight record contained no further weights for 7/2014 after the one documented as obtained on 7/1/2014. The comprehensive care plan (CCP) updated on 7/15/2014 documented the resident's goal weight was 109-115 pounds, and the resident was at nutritional risk related to poor intake. The plan included diet and supplements as ordered and alternatives if she did not eat the meal provided. The weight record documented the resident weighed 102 pounds on 8/2/2014 and 100.4 pounds on 8/9/2014. The 8/6/2014 physician's orders [REDACTED]. The 8/19/2014 RD progress note documented the resident lost 8 pounds in the past 3 months (7%) and consumed 46% of meals. The plan included changing the morning and afternoon snacks to Magic Cup to provide an additional 580 calories and 18 g protein. The Intake and Output Chart Detail Report documented between 8/1/2014-8/20/2014, the resident consumed an average of 36.2% at meals. On 8/19/2014 the resident was observed eating lunch at 12:40 PM. The resident received fortified mashed potatoes, squash, pureed stuffing, and an egg salad sandwich. The resident's meal ticket listed pureed turkey. She never received the turkey. The resident's sandwich was wrapped in a wax paper package, staff did not open the sandwich for the resident, and the resident was observed attempting to unwrap the sandwich. The resident stopped trying to open the sandwich, ripped a piece of her napkin, and put it into her coffee. At 12:55 PM, the resident had not eaten anything and took 1 sip of water. She continued to rip the napkin. No staff interacted with the resident from 12:40 PM to 12:55 PM. At 12:58 PM, another resident placed their hand in the resident's food and at 1:05 PM, the resident was provided with a replacement meal. The replacement meal was also missing the pureed turkey. When the replacement meal was placed in front of the resident she stated "I don't eat it. I don't eat it." At 1:10 PM, the resident's sandwich remained wrapped up and she had not eaten any food. She drank 1/2 milk and 1/2 water. At 1:16 PM, the licensed practical nurse (LPN) asked the resident if she was all done, the resident said yes and she asked her to drink. The Intake and Output Chart Detail Report documented the resident consumed 40% of the lunch meal and drank 240 cc (cubic centimeters) of fluid on 8/19/2014. The resident was observed on 8/19/2014 at 5:30 PM, eating supper. She received pureed pasta salad, soup, bread, applesauce, tea, water, and milk. The meal ticket listed fortified potatoes. The resident did not receive the potatoes. The resident fed herself pasta salad using a soup spoon. At 5:45 PM, the resident pushed the plate away. She ate some of the pasta salad, no soup or bread, no applesauce, and did not drink the milk or water. No staff approached the resident since she was served at 5:30 PM. At 5:54 PM, the resident remained in the same position, had not been approached by staff, and she had not eaten or drank anything more. The Intake and Output Chart Detail Report documented the resident consumed 25% of supper and drank 240 cc fluid on 8/19/2014. On 8/20/2014 at 10:55 AM, the resident was asleep in bed with a milkshake on her windowsill. The surveyor picked up the milkshake and nothing had been drank from the carton. At 11:30 AM, the resident and the milkshake remained in the same position. On 8/21/2014 at 10:45 AM, certified nurse aide (CNA) #3 stated in an interview, the resident needed set-up at meals only. She stated the resident should be encouraged and not fed by staff. She stated she received a sandwich at every meal and she needed staff to open the sandwich for her. The RD was interviewed on 8/21/2014 at 11 AM and stated she recommended weekly weights for the resident in 7/2014 and she could not find that they were done. She stated the resident needed assistance setting up the tray and opening packages and she would expect staff provide this assistance. She stated she was unaware the resident did not receive all items on the meal ticket this week. She stated the resident received supplements and fortified foods related to weight loss and she would expected them to be provided. On 8/21/2014 at 11:10 AM, the LPN Manager (LPN #7) stated in an interview, the resident needed a lot of encouragement at meals and also needed staff to fully set-up her meal tray which included opening cartons and sandwiches. She stated she considered the resident a "fair eater." The 8/21/2014 Meal Pattern documented the resident was to receive 8 ounces of whole milk with meals, fortified cereal with breakfast, fortified potatoes with lunch and supper, an egg salad sandwich at lunch, a Mighty Shake and Magic Cup in the morning, a Magic Cup in the afternoon. 4) Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. The 11/5/2013 registered dietitian (RD) assessment documented the resident weighed 172 pounds, was 162% of ideal body weight, consumed 55% of meals, received fortified mashed potatoes at lunch and pudding in the evening, and the goals included preventing further weight gain. The resident was not on a planned weight change program. The comprehensive care plan (CCP), last updated on 1/27/2014, documented the resident was at nutritional risk related to medical [DIAGNOSES REDACTED]. The goal was for the resident to maintain a body weight of 174-180 pounds and the approaches included provide the ordered diet and monitor intake. The 2/4/2014 RD assessment documented the resident weighed 177 pounds and was not on a planned weight change program. The resident consumed 80% at meals and the plan was to discontinue fortified foods and monitor weights monthly. The weight record documented the resident weighed 163.6 pounds on 3/1/2014. This was a 13.4 pound/7.5% loss in 1 month. There was no documented evidence a re-weight was completed. There was no documentation a RD reassessment was completed. The weight record documented the resident weighed 179.2 pounds, 174.8 pounds, and 176 pounds on 4/3, 4/7, and 4/8/2014. There was no documented evidence the weight fluctuations were addressed by the RD. The weight record documented the resident weighed 161.4 pounds on 5/1/2014; 158.6 pounds on 5/16/2014; 165.4 pounds on 6/3/2014, and 163 pounds on 7/2/2014. The 7/11/2014 RD assessment documented the resident weighed 165 pounds and consumed 72% of meals. The RD documented the resident's weight was down from 183 pounds one year ago and gradual weight loss had been planned and was beneficial. The assessment also documented the resident was not on a planned weight change program. The 8/8/2014 physician's progress note did not document the resident was on a planned weight change program. The resident was observed on 8/19/2014 at 1:03 PM. She fed herself in the dining room. She had a scoop dish and the raised portion of the dish faced away from the resident. When the resident scooped her food, the food fell off the front (low portion) of the scoop dish. The resident received turkey, squash and stuffing. The squash was in a bowl placed inside the scoop dish. The resident ate almost all of the food provided. The RD was interviewed on 8/21/2014 at 11 AM and stated the resident's weight loss was not a physician ordered program but it was beneficial for her as she was at a more healthy weight now. She stated the current goal was to maintain body weight. 10NYCRR 415.12(i)(1)