Every finding on record at Van Duyn Center For Rehabilitation And Nursing

Based on record review, observations, and interviews (iQIES 3066498), the facility failed to promptly identify and intervene for an acute change in a resident's condition for one of three (Resident #1) residents reviewed. Specifically, during the night shift of 06/27/2026, Resident #1 complained of chest pain and requested to go to the hospital three times. Interviews revealed Registered Nurse Supervisor #5 assessed the resident, did not think the resident was having a heart attack and failed to send the resident to the hospital. There was no documented evidence related to the assessment. Licensed Practical Nurse #6, using their personal cell phone, called 911 for the resident on 06/27/2026 at 6:11 AM. The resident was diagnosed with a heart attack and required emergent treatment. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. Findings include: The facility policy Resident Hospital Transfer, revised February 2026, documented any resident requiring transfer to an acute care hospital is assessed promptly, stabilized, and transferred in a safe and timely manner. The facility will ensure appropriate communication with the attending physician, resident representative and receiving hospital. The facility policy Change in Resident Condition, revised February 2026, documented any change in resident's physical condition is promptly assessed, documented and reported to the attending physician and the resident's family/representative. Resident #1 had diagnoses including right side paralysis and weakness secondary to stroke. The 04/09/2026 Minimum Data Set assessment (a resident assessment tool) documented the resident was cognitively intact, did not exhibit any behavioral symptoms, was ambulatory with a cane and was independent with all activities of daily living. The June 2026 Medication Administration Record documented the following: -On 06/27/2026 at 2:32 AM, Licensed Practical Nurse #6 administered as needed Tylenol 1000 milligrams; and at 6:14 AM, Licensed Practical Nurse #6 administered as needed ibuprofen 800 milligrams. There was no documented evidence as to why the resident was medicated with as needed pain medication. The 06/27/2026 Registered Nurse Supervisor #5 progress notes documented the following: -At 3:50 AM, the resident complained that ever since starting the new medication, Neurontin (used to treat nerve pain), they had recurring chest pain and shortness of breath. The on-call medical provider was called with a new order to hold the Neurontin until seen by their primary physician. -At 5:30 AM, the resident complained of chest pain and demanded to go to the hospital. The resident had sharp sternal (breastbone) pain exacerbated with movement and relieved with massage. -At 5:31 AM, per on call provider, send the resident to the Emergency Department. The Emergency Medical Transport Pre-Hospital Care Report documented dispatch was notified on 06/27/2026 at 6:14 AM; Emergency Medical Services was enroute at 6:17 AM; arrived on scene to the resident at 6:32 AM; and the resident arrived at the Emergency Department at 6:47 AM. There was no documented evidence of a registered nurse assessment. There was no documented evidence regarding the delay in calling emergency services, approximately 45 minutes after receiving a medical order to send the resident to the emergency department for complaints of chest pain. The 06/30/2026 Hospital Discharge Summary documented the resident arrived at the hospital with acute crushing substernal chest pain. The electrocardiogram (records the heart's electrical signals) showed the resident was having a heart attack. The resident was treated in the cardiac catheterization lab where they received two stents (tiny, expandable wire mesh tubes placed inside a blocked coronary artery to restore blood flow in the blocked artery). During interview on 07/27/2026 at 11:45 AM, Resident #1 stated back in June, they developed chest pain and had to go to the hospital. They had a heart attack and had two stents placed. Licensed Practical Nurse #6 called 911 for them and they recalled the ambulance took a long time to get there. During an interview on 08/05/2026 at 12:20 PM, Registered Nurse Unit Manager #2 stated when a resident complained of chest pain, they expected a registered nurse to assess the resident from head to toe, obtain vital signs and notify the physician of their findings. The assessment, vital signs and what was done should be documented in a progress note. During an interview on 08/05/2026 at 12:40 PM, Licensed Practical Nurse #6 stated Resident #1 frequently complained of leg pain but never complained of chest pain before the night shift on 06/27/2026. On 06/27/2026 at around 11:00 PM-12:00 AM, a certified nurse aide (unidentified) told them the resident was having chest pain. They went to see the resident who said they wanted to go to the hospital, and the resident was diaphoretic (sweating). They obtained vital signs and notified Registered Nurse Supervisor #5. Registered Nurse Supervisor #5 went in to see the resident and when they came out, they told them the resident did not want to go to the hospital, they were just having heartburn, and they would notify the provider. Licensed Practical Nurse #6 then mentioned to the supervisor that the resident recently started on Neurontin and asked the supervisor if that could be the cause of it. Around 2:30 AM, Licensed Practical Nurse #6 went to check on the resident again who said their chest hurt, the pain was worse and they wanted to go to the hospital. When Registered Nurse Supervisor #5 came back, they again told them the resident did not want to go to the hospital. When Registered Nurse Supervisor #5 left, Licensed Practical Nurse #6 asked the resident again if they wanted to go to the hospital, the resident said they did, and they called Registered Nurse Supervisor #5 and notified them. The nursing supervisor said they did not want to keep calling the on call providers and would call Licensed Practical Nurse #6 back. Around 5:30 AM, Registered Nurse Supervisor #5 said they called emergency medical services but requested no lights and sirens as they did not want to make a scene. The resident got themselves dressed and sat in a chair waiting for the ambulance to come. After about 30 minutes, the ambulance did not arrive, so they called Registered Nurse Supervisor #5 who said they had forgotten to call 911 because they were dealing with a resident fall on another unit. Licensed Practical Nurse #6 stated at 6:11 AM, they called 911 from their personal cell phone and the ambulance arrived 6 minutes later. Resident #1 complained their pain was progressing towards the head by the time the emergency personnel arrived at the facility.During an interview on 08/05/2026 at 1:10 PM Certified Nurse Aide #1 stated on 06/27/2026 Resident #1 complained of chest pain, early in the shift, around 1:00 AM- 2:00 AM. Registered Nurse Supervisor #5 was on the unit at the time when the resident complained of chest pain. During rounds around 4:00 AM-5:00 AM, the resident said they were having chest pain again, and requested they call the supervisor. Licensed Practical Nurse #6 called Registered Nurse Supervisor #5 who said they were in the middle of a resident fall and would be right up to the unit. The resident cleaned themself up, got dressed and sat in the unit lounge to wait for the ambulance. Licensed Practical Nurse #6 had to call paramedics to come, because the resident was waiting and the ambulance had not arrived yet.During a telephone interview on 08/17/2026 at 2:00 PM, Registered Nurse Supervisor # 5 stated they no longer worked at the facility. On 06/27/2026, the resident complained of indigestion, they went to see the resident and checked their vital signs and did an assessment. The resident refused to go to the hospital. They stated the assessment should include checking the resident's vital signs and that is pretty much all you could do and make sure they were moving. They would typically document their assessment in a progress note. They did not know why there was not a progress note about the resident's assessment. They instructed Licensed Practical Nurse #6 to call 911. Registered Nurse Supervisor #5 stated they had to leave for work and would call the surveyor back the next day. The call was terminated and a call back was not received. During an interview on 08/17/2026 at 2:30 PM, the Medical Director stated when a resident complained of chest pain, it would be treated like any other complaint. They referred to the facility's policy and procedure on chest pain to rule out chest pain as cardiac related. The Medical Director refused to answer a question about delaying care when a heart attack is suspected and stated the surveyor knew the answer to the question. During an interview on 08/20/2026 at 9:30 AM, the Director of Nursing (former Assistant Director of Nursing) stated there should be a head-to-toe assessment for chest pain and medical providers should be notified about the data collected. The whole assessment should be documented in the medical record. If the resident wanted to go to the hospital, they should go and the provider should be notified. The responsibility of calling 911 would normally be the nursing supervisor's, but in an emergency the licensed practical nurse could call. No logs were kept for what on-call provider was spoken to but should be in the nurse's progress note.10 NYCRR 415.2

Based on observations, record review, and interviews (iQIES #3110368) the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for one of one main kitchen. Specifically, the facility's food service deliveries were left out of temperature on the loading dock; prepared egg salad was out of temperature; and the dishwasher was not maintained for proper sanitation. Findings include:The facility policy Food Storage and Safety, dated 06/2026, documented perishable food such as meat, poultry, fish, dairy products, fruits, vegetables and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 degrees Fahrenheit and freezer temperatures to keep food frozen solid. Potentially hazardous foods must be maintained at or below 41 degrees Fahrenheit unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees Fahrenheit. Check for proper functioning of the unit at the same time. Refrigerated foods should be stored upon delivery, and careful rotation procedures should be followed. Food Service Delivery The following observations were made on 07/27/2026:- at 5:54 AM, a delivery truck arrived at the loading dock. The garage bay door was opened and there were multiple pallets of food from a previous delivery. The delivery person placed a few boxes on the edge of the dock and left.- at 6:15 AM, facility staff moved the boxes delivered that morning.- at 8:36 AM the pallets inside the loading dock garage area remained in the same area. - at 9:02 AM, two of the three pallets in the loading dock garage area contained mostly refrigerated items. Yogurt on the top of the middle pallet was measured at 55 degrees Fahrenheit (on the middle of the package which was the coldest location) and 67 degrees Fahrenheit (on the outside edge of the package which was the most exposed location). The air temperature on the loading dock was measured at 82 degrees Fahrenheit, and the outside temperature was 75 degrees Fahrenheit. Dietary Delivery Staff #1 stated they did not check the temperature of the delivery dropped off before they started working. They were instructed to put away the items with a blue sticker (cold items) first, then the rest of the delivery. They were not sure how long Time/Temperature Control for Safety food was allowed out of temperature control.During an interview on 07/27/2026 at 9:08 AM, the Director of Dietary stated no one checked the temperature of the deliveries when received. Staff just tried to put them away as soon as possible, frozen items and cold items first. They stated the pallets on the loading dock were delivered around 5:30 AM that morning so they were left out of temperature control for over three and a half hours. They were not sure how long the Time/Temperature Control for Safety foods were out of temperature.The following observations were made on 07/27/2026:-at 9:17 AM, liquid eggs were measured at 46 degrees Fahrenheit and moved to the walk-in cooler. The Director of Dietary voluntarily discarded the 10 cases of yogurt, 3 cases of Greek yogurt, and 1 case of sour cream that were on the top of the pallet. They and Dietary Delivery Staff #1 moved the rest of the pallet to the walk-in cooler.- at 9:45 AM, the second cold pallet had temperatures measured as follows: the juice on the top edge of the pallet was 58 degrees Fahrenheit (warmest location) and on the bottom middle was 46 degrees Fahrenheit (coldest location). Cases of liquid eggs beneath the juice were 49 degrees Fahrenheit. The juice specifications documented the product must remain between 33 and 40 degrees Fahrenheit to stay fresh and safe to drink.- at 10:18 AM, the second pallet was completely moved to the walk-in cooler.- at 10:25 AM, with the Director of Dietary present, the liquid eggs from the first pallet were remeasured at 45.7 degrees Fahrenheit. After having been moved from the loading dock and in the walk-in cooler for 68 minutes, the eggs had only gone down 0.3 degrees Fahrenheit. - at 10:35 AM, the items moved from the second pallet were remeasured with the Director of Dietary present. The liquid eggs were 45-51 degrees Fahrenheit, and the juice was 45-49 degrees Fahrenheit. - at 10:55 AM, Production Manager #4 stated staff did not check the temperature of the deliveries at drop-off or during the stocking process. Checking the delivery's temperature was not a typical procedure because they did not have staff available at that time. - At 11:15 AM, Dietary Staff #5 used juice delivered that morning that was supposed to be discarded by the Director of Dietary. Dietary Staff #5 stated they were not informed about any issues with the juice or deliveries that came in today.During an interview on 07/27/2026 at 2:38 PM, the Director of Dietary #2 stated the deliveries typically arrived around 5:30 AM and staff arrived around 6:00 AM. Production Manager #4 was supposed to check the temperature of the deliveries, but they were late today and that was not done. They should have verified the temperature of the delivery before it was accepted and then again as it was put away to ensure proper temperatures were maintained. Those checks typically were not documented when they were completed. When food was left out of temperature, or if they were not sure it was safe, they were supposed to discard the product, because food left out of temperature could make the residents sick.Egg SaladDuring an observation on 07/27/2026 at 9:39 AM, an 8-inch-deep hotel pan labeled Mixed boiled egg for sandwiches, 07/27/2026 was in the walk-in cooler and measured at 53 degrees Fahrenheit. At 10:18 AM, the egg salad was rechecked and measured at 52 degrees Fahrenheit.During an interview on 07/27/2026 at 10:34 AM, [NAME] #3 stated they made the egg salad and placed it in the walk-in cooler at 8:00 AM that morning. They did not know how long the Time/Temperature Control for Safety foods were allowed out of temperature during necessary preparation.During an interview on 07/27/2026 at 10:35 AM, the egg salad was brought to the attention of the Director of Dietary stated the cooks should know that food cannot remain out of the temperature for more than two hours. They were not sure why the egg salad was made in such a large quantity, and why it was out of temperature because it was made with pre-chilled ingredients.During an interview on 07/27/2026 at 2:38 PM, the Director of Dietary stated staff were supposed to monitor the temperature of the food during production to ensure safe temperatures were maintained and they did not think that was documented.Improper DishwashingThe facility policy Sanitation: 3-Bay Sink and Dish Machine Operation, dated 06/2026, did not document information for a high temperature machine, only instructions for chemical sanitization were included in the policy. The automated, chemical-sanitizing machine was used to sanitize all reusable food-contact items. All items must be sent through the automated dish machine for the sanitizing step.The dish machine Temperature Record (High Temperature Machine) log documented if the wash temperature was less than 150 degrees Fahrenheit, the final rinse temperature was less than 180 degrees Fahrenheit or greater than 190 degrees Fahrenheit, or the test probe results indicated less than 160 degrees Fahrenheit, stop using the machine and notify manager/supervisor. Do not use the dish machine until the manager/supervisor states it can be used again. The log was last completed for lunch on 07/25/2026. 16 of the 25 breakfast temperatures recorded were out of range for the final rinse. 20 of the 25 lunch wash temperatures recorded were below 160 degrees Fahrenheit and 17 of 25 final rinse temperatures were out of range. 12 of 24 dinner wash temperatures recorded were below 160 degrees Fahrenheit and 14 of 24 final rinse temperatures were out of range. During an observation on 07/27/2026 at 11:11 AM, several staff were actively running dishes through the dishwasher. The wash gauge read 145 degrees Fahrenheit (150 degrees Fahrenheit was required); the rinse gauge read 158 degrees Fahrenheit (160 degrees Fahrenheit was required); and the final rinse gauge read 214 degrees Fahrenheit (180 degrees Fahrenheit was required).During an observation and interview on 07/27/2026 at 1:41 PM, several staff were actively running dishes through the dishwasher, the gauges had not changed from the 11:11 AM observation. At the end point of the machine steam or spray was visible beyond the initial wash and rinse area (nearly three quarters of the length of the machine did not show any activity). All staff were asked about the machine temperature checks, but they were not aware of any that had to be completed. Front of the House Manager #6 stated staff were supposed to check the machine temperatures three times daily. They either read the gauges or put a yellow puck through that measured the temperatures. That was demonstrated and the puck documented the highest temperature measured was 156.9 degrees Fahrenheit. Front of the House Manager #6 stated the machine was not working properly. During an interview on 07/27/2026 at 2:38 PM, the Director of Dietary stated the dishwasher was a high temperature machine and should wash at 150 degrees Fahrenheit and have a final rinse at 180 degrees Fahrenheit. They stated they did not check the logs, one of the managers was supposed to, but they did not follow through to see that was done. They were not aware of any issues with the dishwasher this month, and nothing was done for the numerous days it was out of temperature.During an interview on 07/29/2026 at 2:13 PM, the Assistant Administrator stated the dishwasher vendor was in the previous evening. They did not find anything wrong with the machine and the problem was with the puck that checked the machine. The technician replaced the temperature gauge, but the machine was working fine so it was never taken out of service.The dish machine vendor's receipt dated 07/31/2026 documented they were at the facility on 07/27/2026 and 07/31/2026. The technician's notes documented the rinse temperature gauge was reading over 200 degrees Fahrenheit and would never go under 140 degrees Fahrenheit even when the rinse was not on. They verified the machine was spraying rinse water but not much due to the temperature having been so high on the heat exchanger. The Director of Plant Operations told them the heat exchanger was set to 220 degrees Fahrenheit, and they informed them that was too high and above boiling and needed to be below 200 degrees Fahrenheit. They returned on 07/31/2026 and replaced the gauge, but the machine was only getting to 140 degrees Fahrenheit, and the temperature issue was a facility problem.The dish machine vendor's receipt dated 08/04/2026 documented the final rinse probe was not accurate and a fuse was blown. They replaced the probe and the fuse, and the machine was measured at 190 degrees Fahrenheit for the final rinse, and everything was working correctly.During an interview on 08/05/2026 at 3:04 PM, the Director of Plant Operations stated a technician was at the facility on 07/27/2026 and made a few adjustments on the machine. The technician came back the next day and changed the temperature gauge for the final rinse. They checked the machine and measured the final rinse at 190 degrees Fahrenheit, but the gauge read 140, so they had the technician come back out and replaced the gauge a second time and the machine was working properly now.During an interview on 08/07/2026 at 12:35 PM, the Director of Dietary stated the vendor had serviced the dishwasher and it was working appropriately now. The machine was down for about two days, and they used disposable dishware during that time. They did not replace the defective puck, and they were not sure they would because they were using test strips to ensure the dishwasher was reaching the appropriate temperatures.The Dishwasher Test Strips specifications documented they measured up to 160 degrees Fahrenheit.During an interview on 08/07/2026 at 2:13 PM, the Director of Plant Operations stated the gauges were replaced and they measured the temperatures to ensure it was appropriate. They were not aware the test strips were not appropriate for checking the temperature at 180 degrees Fahrenheit. They did not replace the puck but would order one to ensure the gauges remained accurate.10 New York Codes, Rules, and Regulations 415.14(h)

Based on record review and interviews conducted during survey, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 60 residents reviewed. The facility failed to provide oversight, monitoring, and effective communication between staff and practitioners. Specifically, Resident #118 did not have a hematology consultation that was ordered and laboratory tests were completed 14 days after they were ordered. This resulted in actual physical harm for Resident #118 that was not Immediate Jeopardy. Findings include: The facility policy and procedure titled, Continuity of Care, revised 05/2025, documented quality of care was a fundamental principle that applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Nurses were expected to follow valid orders from physicians or other authorized healthcare providers. Hematology Consult Resident #118 was admitted to the facility with diagnoses of unspecified anemia (blood has insufficient red blood cells), atrial fibrillation (irregular heart rhythm), and unspecified anxiety disorder. The [DATE] Minimum Data Set (a resident assessment tool) documented the resident was cognitively intact, was able to make themselves understood, and usually understood others. The progress note dated [DATE] by Nurse Practitioner #1 documented the resident reported seeing a hematologist in the past for anemia. The plan was to add a hematology consult and requested the ward clerk get the resident an appointment for further follow up. On [DATE], the physician order documented hematology consultation for iron deficiency. There was no documented evidence that a hematology appointment was made for the resident. Review of medical visit progress notes by Nurse Practitioner #1 documented: -On [DATE], plan included iron deficiency anemia and documented follow up with hematology. -On [DATE], plan included iron deficiency anemia and documented follow up with hematology. -On [DATE], plan documented the resident had not followed up with hematology yet. -On [DATE], plan included iron deficiency anemia and documented still waiting for appointment with hematology. -On [DATE], plan documented the resident was previously followed as an outpatient by hematology/oncology and an appointment was requested. Nurse Practitioner #1 followed up with the ward clerk and apparently since the resident had not been seen at that practice for quite some time, they needed a new referral, and they were awaiting a new patient appointment. -On [DATE], Nurse Practitioner #1 reordered a hematology consultation for iron deficiency anemia. There was no documented evidence in the medical record regarding the status of the consultation. During an interview on [DATE] at 3:03 PM, Resident #118 stated they had a medical condition and required iron supplements and vitamin B12 injections. They said they had been to the hospital 13 times to figure out why they were losing blood and eventually discovered they were not making enough blood. There was no cancer. Resident #118 was hospitalized in [DATE]. Prior to this hospitalization, Resident #118 stated that it took four weeks for staff to do blood work when they complained of feeling weak. One night when they were feeling really weak they saw Assistant Director of Nursing #2 and told them they did not feel good. They tested their blood in the morning and were told they had to send them to the hospital. The resident stated, I was very sick. The resident was in the hospital for five days and received three units of blood. The resident stated, I could have died. During an interview on [DATE] at 10:32 AM, Family Member #1 stated they were praying the facility was currently doing the bloodwork on time, which should be every two weeks because the resident had anemia and received iron. Prior to the resident's hospitalization on [DATE], they had spoken with Social Worker #1 and Assistant Director of Nursing #2 on separate occasions in the beginning of [DATE] about the bloodwork needing to be done for the resident's diagnosis of anemia and were told they would take care of it. Family Member #1 stated they were very concerned about the resident getting proper care at the facility. During an interview on [DATE] at 5:18 PM, Nurse Practitioner #1 stated they were familiar with Resident #118. The resident had a diagnosis of anxiety and expressed their concerns daily. The resident first started talking about their anemia in February or [DATE]. They ordered a hematology consult after the resident told them they saw a hematologist for their anemia in the past. The ward clerk told them (date unknown) that the hematologist would not see the resident because they owed the provider money. Laboratory Orders The undated facility policy and procedure titled, Request for Diagnostic Services, documented all requests for diagnostic services must be ordered by the resident's attending physician. All orders for diagnostic services must be entered into the resident's medical record and signed by the attending physician. Orders for diagnostic services would be promptly carried out as instructed by the physician's order. Emergency requests must be labeled stat to assure prompt action was taken. The Medical Progress Note dated [DATE] by Nurse Practitioner #1, documented Resident #118 was seen on [DATE], and they would order laboratory tests to check their hemoglobin (a protein in the blood that carries oxygen) level. The Physician Orders report from [DATE] to [DATE], documented: On [DATE] at 1:56 PM, a one-time Laboratory Request Order for a complete blood count (blood test that measures the number and types of cells circulating in your blood) for diagnosis of unspecified anemia. On [DATE] at 3:52 PM, this order was discontinued and documented as the order having been replaced. On [DATE] at 3:52 PM, a one-time Laboratory Request Order for a complete blood count and magnesium level for diagnosis of unspecified anemia. On [DATE] at 7:51 AM, this order was discontinued and documented as the order having been replaced. On [DATE] at 7:51 AM a one-time Laboratory Request Order for a complete blood count and magnesium level for diagnosis of unspecified anemia. On [DATE] at 10:13 AM, the order was discontinued and documented as the order having been replaced. On [DATE] at 10:13 AM, a one-time Laboratory Request Order for a complete blood count and magnesium level for diagnosis of unspecified anemia. There was no documented evidence of laboratory test results for a complete blood count and magnesium level dated [DATE] or [DATE]. The [DATE] Nurse Practitioner #1 progress note documented they saw the resident for evaluation of their pain, chronic obstructive pulmonary disease and their routine 30-day facility follow-up. Diagnoses included iron deficiency anemia with a plan including continue ferrous sulfate (iron supplement) and waiting for appointment with hematology. There was no documentation in the note dated [DATE] by Nurse Practitioner #1 about the status of the laboratory tests for the complete blood count and magnesium. There were no nursing progress notes dated from [DATE] to [DATE]. There were no progress notes dated [DATE] to [DATE]. The progress note dated [DATE] by Nurse Practitioner #1, documented that they saw the resident on [DATE] at the request of nursing to follow-up on the resident's shortness of breath. The resident reported they had some increased shortness of breath with exertion. Plan documented they would have respiratory come and evaluate them. They discussed that the shortness of breath could also be due to other reasons as they did have quite a bit of anxiety. The laboratory results for Resident #118 dated [DATE] at 1:04 PM documented for the complete blood count: the white blood cell count was low, the red blood cell count was low, and hemoglobin was low. It further documented hemoglobin was at 4.6 g/dL, indicated it was a priority and was outside of the normal reference range of 11.7 - 15.5 g/dL. Additionally, hematocrit (measures how much of the blood consists of red blood cells) was low at 15.6 percent, outside of the normal reference range of 35.9 - 46.0 percent. The nursing progress note dated [DATE] at 1:52 PM by Assistant Director of Nursing #2 documented they received a call from the laboratory with critical lab values. Resident #118's hemoglobin level was critically low at 4.5, and white blood count was critically low at 2.2. Upon assessment the resident reported feeling fatigued and generally unwell. An order was obtained to send the resident to the hospital. Notified attending nurse practitioner of the results and received an order to send the resident out (to the hospital) for emergency transfusion. The hospital History and Physical dated [DATE] documented the resident reported a history of chronic anemia and noticed worsening shortness of breath with exertion for the last one to two weeks, suspected their anemia was worse, and requested the provider repeat the laboratory work. Assessment and Plan included acute on chronic anemia (a sudden and rapid decrease in red blood cells) and a transfusion of red blood cells was in progress. The shortness of breath on exertion was likely secondary to symptomatic anemia (occurs when a drop in red blood cells or hemoglobin reduces oxygen delivery to the organs and causes tiredness, weakness, or shortness of breath). The Hospital Discharge summary dated [DATE], documented the resident had a history of chronic anemia requiring multiple transfusions of blood, vitamin B12 shots, and iron infusions in the past. The resident reported to the facility for approximately two weeks that they had been fatigued, experiencing weakness with some leg tenderness, which they recognized as signs that their blood was low. There was no laboratory work done at the facility until just prior to admission to the hospital on [DATE]. The resident was given two units of red blood cells in the Emergency Department and a repeat complete blood count showed correction of the hemoglobin to 7.6 and 23.8 for the hematocrit. The resident was admitted to the inpatient floors for monitoring of acute on chronic anemia. The nursing progress note dated [DATE] at 3:00 PM by Registered Nurse #10 documented the resident was readmitted to the facility from the hospital on [DATE], with diagnosis of pancytopenia (low levels of red and white blood cells and platelets (cells that clot blood). During an interview on [DATE] at 3:03 PM, Resident #118 stated they had a medical condition and required iron supplements and B12 injections. They said they had been to the hospital 13 times to figure out why they were losing blood and eventually discovered they were not making enough blood. Resident #118 was hospitalized in [DATE] for five days and received multiple units of blood. Prior to this hospitalization in [DATE], Resident #118 stated that it took them four weeks for staff to do blood work when they complained of feeling weak. The resident stated, I was very sick. I could have died. During an interview on [DATE] at 10:32 AM, Family Member #1 stated they were praying the facility was currently doing the resident's bloodwork on time, which should be every two weeks because the resident had anemia and received iron. Prior to the resident's hospitalization on [DATE], they spoke with the social worker and Assistant Director of Nursing #2 on separate occasions in the beginning of [DATE] about the bloodwork that needed to be done for the resident's diagnosis of anemia and they were told they would take care of it. Family Member #1 stated they were very concerned about the resident getting the proper care that they needed at the facility. During an interview on [DATE] at 4:53 PM, Assistant Director of Nursing #2 stated they managed the 5th floor unit. Nurse Practitioner #1 saw Resident #118 on [DATE]. Resident #118 had anemia and Nurse Practitioner #1 entered an order in the computer system for a laboratory test to check their hemoglobin levels. For reasons unknown, the phlebotomist (healthcare professional who draws blood and other specimens) did not come into the facility to draw the resident's blood (collect the specimen). There was supposed to be a follow up done to ensure laboratory tests were drawn but they were not made aware and therefore did not follow up. Assistant Director of Nursing #2 stated they were not made aware until it was far later than it should have been. On [DATE], they were notified by the laboratory that the resident's hemoglobin level was critically low. The resident was not feeling well and was sent to the hospital. They stated the first symptom they recalled the resident having was the resident wanting something for asthma and it did not occur to them that the resident was short of breath. That was a few days prior to [DATE]. Assistant Director of Nursing #2 thought it was respiratory related and did not follow up on it. They stated they did not make a connection with the shortness of breath to the anemia until they received the laboratory results on [DATE]. During an interview on [DATE] at 5:18 PM, Nurse Practitioner #1 stated they were extremely familiar with Resident #118. The resident had a diagnosis of anxiety and expressed their concerns daily. The resident first started talking about their anemia in February or [DATE]. They saw the resident on [DATE] and ordered a laboratory test to check the status of the resident's chronic anemia. The specimen for the laboratory test was not drawn, and they did not know why. They explained the process for ordering a laboratory test. Nurse Practitioner #1 entered the order into the electronic medical record system and then the nurse or ward clerk had to enter the order into the laboratory computer system to alert them of the order. The nurse or ward clerk would then print the laboratory requisition for the order(s) from the laboratory computer system and would put the requisition in a binder for the phlebotomist. The phlebotomist came into the facility on Monday, Wednesday, and Friday to collect specimens, or would come if something was ordered urgently. The phlebotomist was supposed to look in the binder for the requisition and then collect the specimen. They were not sure if the order they entered on [DATE] was entered into the laboratory computer system or if the phlebotomist missed the requisition for it. They reviewed the orders and stated it looked like they put the order in for the laboratory test a couple times and it finally got drawn on [DATE]. They stated the ward clerk was responsible for ensuring a laboratory test was ordered in the laboratory computer system and then drawn. They did not know who provided oversight for the process of ordering laboratory tests. The resident was sent to the hospital on [DATE] and had blood transfusions. During an interview on [DATE] at 11:45 AM, Director of Nursing #1 stated if a provider placed an order for a laboratory test independent of the nurse manager, the manager would not know it was in the computer system and needed to be drawn. The laboratory obtained blood specimens on Monday, Wednesday, and Friday. If the test was ordered after 3:00 PM, the laboratory would not be alerted that a specimen needed to be drawn. The Director of Nursing #1 reviewed the orders and stated a complete blood count was ordered on [DATE] at 3:52 PM. This would have been too late to be drawn the next day, Friday. Nurse Practitioner #1 put in another order for a complete blood count on [DATE] at 7:51 AM, a Friday and again the specimen was not drawn because the phlebotomist was in and out of the building relatively quickly. They stated they had experienced issues with the laboratory and there were process improvement plans. If Assistant Director of Nursing #2 was not made aware of the need for the laboratory test, they would not know they had to follow up. During an interview on [DATE] at 12:03 PM, [NAME] Clerk #3 stated they were responsible for reviewing the electronic medical record for laboratory orders. The nurse practitioner entered the order in the electronic medical record system. They checked the system for orders, or the nurse practitioner let them know they entered an order. They stated they periodically checked the system for orders and would enter the order into the laboratory system. An order requisition was printed from the laboratory system and placed in a binder for the phlebotomist to identify the resident and the test needed to be drawn. The phlebotomist comes on Monday, Wednesday, and Friday, usually early around 6:00 AM and leaves the facility around 7:30 AM. During an interview on [DATE] at 12:14 PM, the Medical Director stated they were not very familiar with Resident #118. The surveyor discussed the concerns with the laboratory orders and the outcome to the resident. The Medical Director stated there was a delay in diagnoses due to a lack of collecting the laboratory specimens. They stated there was no harm though because the resident did not have a heart attack or stroke and stated that other than shortness of breath for a couple of weeks, there was no adverse effect from the delay. They stated there should be a system in place to reconcile laboratory orders. If Nurse Practitioner #1 felt the laboratory tests were an emergency, they should have spoken to a nurse about it. During an interview on [DATE] at 12:33 PM, Administrator #1 stated if there was a physician order for a laboratory test, the specimen should be drawn, and the test completed and resulted. 10 New York Codes, Rules, and Regulations 415.12

Based on record review and interviews conducted during survey, the facility failed to obtain physician ordered laboratory tests to meet the needs of its residents for one (1) (Resident # 118) of three (3) residents reviewed. Specifically, the laboratory test ordered for Resident #118 on [DATE] and [DATE] were not completed as ordered. The laboratory test was not completed until it was ordered for a third time on [DATE], which resulted in critical levels requiring hospitalization for a blood transfusion. This resulted in actual physical harm for Resident #118 that was not Immediate Jeopardy. Findings include: Cross-referenced to F656: Develop/Implement Comprehensive Care Plan Cross-referenced to F684: Quality of Care The undated facility policy and procedure titled, Request for Diagnostic Services, documented all requests for diagnostic services must be ordered by the resident's attending physician. All orders for diagnostic services must be entered into the resident's medical record and signed by the attending physician. Orders for diagnostic services would be promptly carried out as instructed by the physician's order. Emergency requests must be labeled stat to assure prompt action was taken. The undated facility policy and procedure titled, Test Results, documented the resident's Attending Physician would be notified of the results of diagnostic tests. Results of laboratory tests would be reported in writing to the resident's Attending Physician. Should the tests results be provided to the facility, the Attending Physician would be promptly notified of the results. The Director of Nursing Services or Charge Nurse receiving the test results would be responsible for notifying the physician of the test results. Signed and dated reports of all diagnostic services would be made a part of the resident's medical record. The facility policy and procedure titled, Continuity of Care, revised 05/2025, documented quality of care was a fundamental principle that applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Nurses were expected to follow valid orders from physicians or other authorized healthcare providers. Resident #118 Resident # 118 was admitted to the facility with diagnoses of unspecified anemia (blood has insufficient red blood cells or hemoglobin and the cause is unknown), atrial fibrillation (irregular heart rhythm) and unspecified anxiety disorder. The Minimum Data Set (a resident assessment tool) dated [DATE], documented the resident had an active diagnosis of anemia, was cognitively intact, was able to make themselves understood, and usually understood others. There was no documented evidence of a comprehensive care plan for the diagnosis of anemia. The Medical Progress Note dated [DATE] by Nurse Practitioner #1, documented Resident #118 was seen on [DATE], and they would order laboratory tests to check their hemoglobin (a protein in the blood that carries oxygen) level. The Physician Orders report from [DATE] to [DATE], documented: On [DATE] at 1:56 PM, a one-time Laboratory Request Order for a complete blood count (blood test that measures the number and types of cells circulating in your blood) for diagnosis of unspecified anemia. On [DATE] at 3:52 PM, this order was discontinued and documented as the order having been replaced. On [DATE] at 3:52 PM, a one-time Laboratory Request Order for a complete blood count and magnesium level for diagnosis of unspecified anemia. On [DATE] at 7:51 AM, this order was discontinued and documented as the order having been replaced. On [DATE] at 7:51 AM a one-time Laboratory Request Order for a complete blood count and magnesium level for diagnosis of unspecified anemia. On [DATE] at 10:13 AM, the order was discontinued and documented as the order having been replaced. On [DATE] at 10:13 AM, a one-time Laboratory Request Order for a complete blood count and magnesium level for diagnosis of unspecified anemia. There was no documented evidence of laboratory test results for a complete blood count and magnesium level dated [DATE] or [DATE]. The [DATE] Nurse Practitioner #1 progress note documented they saw the resident for evaluation of their pain, chronic obstructive pulmonary disease and their routine 30-day facility follow-up. Diagnoses included iron deficiency anemia with a plan including continue ferrous sulfate (iron supplement) and waiting for appointment with hematology. There was no documentation in the note dated [DATE] by Nurse Practitioner #1 about the status of the laboratory tests for the complete blood count and magnesium. There were no nursing progress notes dated from [DATE] to [DATE]. There were no progress notes dated [DATE] to [DATE]. The progress note dated [DATE] by Nurse Practitioner #1, documented that they saw the resident on [DATE] at the request of nursing to follow-up on the resident's shortness of breath. The resident reported they had some increased shortness of breath with exertion. Plan documented they would have respiratory come and evaluate them. They discussed that the shortness of breath could also be due to other reasons as they did have quite a bit of anxiety. The laboratory results for Resident #118 dated [DATE] at 1:04 PM documented for the complete blood count: the white blood cell count was low, the red blood cell count was low, and hemoglobin was low. It further documented hemoglobin was at 4.6 g/dL, indicated it was a priority and was outside of the normal reference range of 11.7 - 15.5 g/dL. Additionally, hematocrit (measures how much of the blood consists of red blood cells) was low at 15.6 percent, outside of the normal reference range of 35.9 - 46.0 percent. The nursing progress note dated [DATE] at 1:52 PM by Assistant Director of Nursing #2 documented they received a call from the laboratory with critical lab values. Resident #118's hemoglobin level was critically low at 4.5, and white blood count was critically low at 2.2. Upon assessment the resident reported feeling fatigued and generally unwell. An order was obtained to send the resident to the hospital. Notified attending nurse practitioner of the results and received an order to send the resident out (to the hospital) for emergency transfusion. The hospital History and Physical dated [DATE] documented the resident reported a history of chronic anemia and noticed worsening shortness of breath with exertion for the last one to two weeks, suspected their anemia was worse, and requested the provider repeat the laboratory work. Assessment and Plan included acute on chronic anemia (a sudden and rapid decrease in red blood cells) and a transfusion of red blood cells was in progress. The shortness of breath on exertion was likely secondary to symptomatic anemia (occurs when a drop in red blood cells or hemoglobin reduces oxygen delivery to the organs and causes tiredness, weakness, or shortness of breath). The Hospital Discharge summary dated [DATE], documented the resident had a history of chronic anemia requiring multiple transfusions of blood, vitamin B12 shots, and iron infusions in the past. The resident reported to the facility for approximately two weeks that they had been fatigued, experiencing weakness with some leg tenderness, which they recognized as signs that their blood was low. There was no laboratory work done at the facility until just prior to admission to the hospital on [DATE]. The resident was given two units of red blood cells in the Emergency Department and a repeat complete blood count showed correction of the hemoglobin to 7.6 and 23.8 for the hematocrit. The resident was admitted to the inpatient floors for monitoring of acute on chronic anemia. The nursing progress note dated [DATE] at 3:00 PM by Registered Nurse #10 documented the resident was readmitted to the facility from the hospital on [DATE], with diagnosis of pancytopenia (low levels of red and white blood cells and platelets (cells that clot blood). During an interview on [DATE] at 3:03 PM, Resident #118 stated they had a medical condition and required iron supplements and B12 injections. They said they had been to the hospital 13 times to figure out why they were losing blood and eventually discovered they were not making enough blood. Resident #118 was hospitalized in [DATE] for five days and received multiple units of blood. Prior to this hospitalization in [DATE], Resident #118 stated that it took them four weeks for staff to do blood work when they complained of feeling weak. The resident stated, I was very sick. I could have died. During an interview on [DATE] at 10:32 AM, Family Member #1 stated they were praying the facility was currently doing the resident's bloodwork on time, which should be every two weeks because the resident had anemia and received iron. Prior to the resident's hospitalization on [DATE], they spoke with the social worker and Assistant Director of Nursing #2 on separate occasions in the beginning of [DATE] about the bloodwork that needed to be done for the resident's diagnosis of anemia and they were told they would take care of it. Family Member #1 stated they were very concerned about the resident getting the proper care that they needed at the facility. During an interview on [DATE] at 4:53 PM, Assistant Director of Nursing #2 stated they managed the 5th floor unit. Nurse Practitioner #1 saw Resident #118 on [DATE]. Resident #118 had anemia and Nurse Practitioner #1 entered an order in the computer system for a laboratory test to check their hemoglobin levels. For reasons unknown, the phlebotomist (healthcare professional who draws blood and other specimens) did not come into the facility to draw the resident's blood (collect the specimen). There was supposed to be a follow up done to ensure laboratory tests were drawn but they were not made aware and therefore did not follow up. Assistant Director of Nursing #2 stated they were not made aware until it was far later than it should have been. On [DATE], they were notified by the laboratory that the resident's hemoglobin level was critically low. The resident was not feeling well and was sent to the hospital. They stated the first symptom they recalled the resident having was the resident wanting something for asthma and it did not occur to them that the resident was short of breath. That was a few days prior to [DATE]. Assistant Director of Nursing #2 thought it was respiratory related and did not follow up on it. They stated they did not make a connection with the shortness of breath to the anemia until they received the laboratory results on [DATE]. During an interview on [DATE] at 5:18 PM, Nurse Practitioner #1 stated they were extremely familiar with Resident #118. The resident had a diagnosis of anxiety and expressed their concerns daily. The resident first started talking about their anemia in February or [DATE]. They saw the resident on [DATE] and ordered a laboratory test to check the status of the resident's chronic anemia. The specimen for the laboratory test was not drawn, and they did not know why. They explained the process for ordering a laboratory test. Nurse Practitioner #1 entered the order into the electronic medical record system and then the nurse or ward clerk had to enter the order into the laboratory computer system to alert them of the order. The nurse or ward clerk would then print the laboratory requisition for the order(s) from the laboratory computer system and would put the requisition in a binder for the phlebotomist. The phlebotomist came into the facility on Monday, Wednesday, and Friday to collect specimens, or would come if something was ordered urgently. The phlebotomist was supposed to look in the binder for the requisition and then collect the specimen. They were not sure if the order they entered on [DATE] was entered into the laboratory computer system or if the phlebotomist missed the requisition for it. They reviewed the orders and stated it looked like they put the order in for the laboratory test a couple times and it finally got drawn on [DATE]. They stated the ward clerk was responsible for ensuring a laboratory test was ordered in the laboratory computer system and then drawn. They did not know who provided oversight for the process of ordering laboratory tests. The resident was sent to the hospital on [DATE] and had blood transfusions. During an interview on [DATE] at 11:45 AM, Director of Nursing #1 stated if a provider placed an order for a laboratory test independent of the nurse manager, the manager would not know it was in the computer system and needed to be drawn. The laboratory obtained blood specimens on Monday, Wednesday, and Friday. If the test was ordered after 3:00 PM, the laboratory would not be alerted that a specimen needed to be drawn. The Director of Nursing #1 reviewed the orders and stated a complete blood count was ordered on [DATE] at 3:52 PM. This would have been too late to be drawn the next day, Friday. Nurse Practitioner #1 put in another order for a complete blood count on [DATE] at 7:51 AM, a Friday and again the specimen was not drawn because the phlebotomist was in and out of the building relatively quickly. They stated they had experienced issues with the laboratory and there were process improvement plans. If Assistant Director of Nursing #2 was not made aware of the need for the laboratory test, they would not know they had to follow up. During an interview on [DATE] at 12:03 PM, [NAME] Clerk #3 stated they were responsible for reviewing the electronic medical record for laboratory orders. The nurse practitioner entered the order in the electronic medical record system. They checked the system for orders, or the nurse practitioner let them know they entered an order. They stated they periodically checked the system for orders and would enter the order into the laboratory system. An order requisition was printed from the laboratory system and placed in a binder for the phlebotomist to identify the resident and the test needed to be drawn. The phlebotomist comes on Monday, Wednesday, and Friday, usually early around 6:00 AM and leaves the facility around 7:30 AM. During an interview on [DATE] at 12:14 PM, the Medical Director stated they were not very familiar with Resident #118. The surveyor discussed the concerns with the laboratory orders and the outcome to the resident. The Medical Director stated there was a delay in diagnoses due to a lack of collecting the laboratory specimens. They stated there was no harm though because the resident did not have a heart attack or stroke and stated that other than shortness of breath for a couple of weeks, there was no adverse effect from the delay. They stated there should be a system in place to reconcile laboratory orders. If Nurse Practitioner #1 felt the laboratory tests were an emergency, they should have spoken to a nurse about it. During an interview on [DATE] at 12:33 PM, Administrator #1 stated if there was a physician order for a laboratory test, the specimen should be drawn, and the test completed and resulted. 10 New York Code of Rules and Regulations 415.20

Based on record review, observation, and interviews conducted during survey, the facility failed to maintain an effective pest control program. Specifically, (a.) on 05/05/2026, a live cockroach was in the kitchen storage room. The kitchen storage room and main kitchen adjacent to the room were visibly soiled and unkept with discarded garbage substances. (b.) on 05/11/2026, ants and a spider were observed alive within the facility's first floor Northern bathroom. This was noted in the main kitchen and on the first floor. Findings include: Cross reference to F-814, Dispose Garbage & Refuse Properly.Policy and procedure titled, Insect and Rodent Control, last revised 05/2025, documented after staff observed a possible insect or rodent and immediately updated the sighting log with specific time and locations, Pest Control Vendor #1 would follow up with deep cleaning of specific areas and applied preventative measure as necessary, and update the sighting log with date of inspection, treatment results and follow up steps. During a tour of the main kitchen on 05/05/2026 between 6:25 AM and 7:17 AM, a live cockroach was observed crawling up the wall of the utility storage room, located adjacent to the automatic dishwasher. During a tour of the facility on 05/11/2026 between 8:00 AM and 11:30 AM, ants and a spider were observed alive within the facility's first floor Northern bathroom (near main entrance and large conference room). Record review of Pest Log/Evidence Log revealed Pest Control Vendor #1 completed weekly service from 01/22/2026 to 04/31/2026 and documented the action taken as 'service.' Cockroaches were logged by facility staff on 03/14/2026 (back of toilet in resident room [ROOM NUMBER]), 03/17/2026 (on wall near elevator-kitchen), 04/09/2026 (5 South Break Room Bathroom), 03/02/2026 (room [ROOM NUMBER]), 04/10/2026 (entrance); and additional kitchen logs on 05/05/2026 (preparation area under slicer), 05/06/2026 (dish room closet), 05/07/2026 (2nd prep station-under), 05/08/2026 (on wall in office), 05/11/2026 (near prep area), 05/13/2026 (silverware sort area-dish room). There was no documented evidence that a sighting log contained treatment results and follow-up steps. Record review of Pest Control Vendor #1 customer service reports from 03/06/2026 through 04/10/2026 documented the service as cockroach/rodent program. All reports documented no sanitation issues that could cause pest problems, no facility preparation issues, no structural concerns that could cause pest problems, no pest activity found during service. Service report dated 03/26/2026 additionally read, 'I only saw 5 to 6 live cockroaches. Did treat let area dry then wash the floors please there's lots of structural issues the floor underneath in the walls there's white in the walls, loose baseboard where these things can hide excess water and food on the ground is not helping the situation but again I treated that entire dish machine. Dish machine treated five live cockroaches lots of dead ones in the electric plan [sic] about five live ones is all I saw. [Pest activity found during service: No; Structural concerns that could cause pest problems: No; Sanitation issues that could cause pest problems: No]' Record review of additional Pest Control Vendor #1 customer service reports revealed the following:Report dated 04/17/2026 documented pest activity found during the service of mice in the exterior area.Report dated 04/24/2026 documented no pest activity found during the service, with additional comment, 'Treated for ants around the entry, doorways and rear door receiving areas now please keep all soiled, utility rooms, clean, and sanitize because there was an outbreak of small flies due to sanitation a week or so ago please clean up on that please clean your drains.'Report dated 05/05/2026 documented no pest activity found during the service, with additional comment 'treated kitchen area in certain locations kitchen bomb was cancelled so I spot treated areas customer wanted. During an interview on 05/05/2026 at 6:35 AM, Food Service Director #2 stated they were in the role for two weeks as an interim because Food Service Director #1 left unexpectedly. They further stated there was a log book for pest sightings and the facility had bombed the kitchen in the past. During an interview on 05/07/2026 at approximately 5:35 PM, Administrator #1 stated the facility had a pest control vendor. During a follow up interview on 05/08/2026 at 1:32 PM, Food Service Director #2 stated there was a staff member responsible for cleaning and organizing the utility storage room but Food Service Director #2 knew it was on their list to be maintained and cleaned out, so after it was pointed out by the surveyor on 05/05/2026, they took it upon themselves to clean the room and get rid of items. During an interview on 05/12/2026 at 5:12 PM, Food Service Director #3 stated they recently began working at the facility and their first day in the kitchen area was the day prior (05/11/2026). 10 New York Codes, Rules, and Regulations 415.29(j)(5)

Based on record review and interviews conducted during survey, the facility failed to ensure timely completion of each resident's quarterly review assessments for 17 of 19 residents (Resident #s 25, 82, 115, 141, 184, 203, 211, 225, 255, 263, 275, 284, 356, 369, 383, 394, and 396) reviewed during the Resident Assessment Facility Task. Specifically, the residents' Quarterly Minimum Data Sets (a resident assessment tool) were not completed within 92 days after the previous Quarterly Minimum Data Set assessment and/or not signed off as completed within 14 days of the assessment start. Findings include:Centers for Medicaid and Medicare Services require the Minimum Data Set Assessments to be completed within 14 days of the assessment start date, quarterly every 92 days, and annually within 366 days of the most recent comprehensive assessment. 1. The Quarterly Minimum Data Set Assessment Reference Date for Resident #396 was 03/24/2026 and signed as completed by the Assessment Coordinator on 04/16/2026, more than 14 days after the start of the assessment. The previous Quarterly Minimum Data Set assessment reference date for Resident #396 was done 12/30/2025, making the 03/24/2026 assessment more than 92 days after the previous assessment. 2. The Quarterly Minimum Data Set Assessment Reference Date for Resident #284 was 04/01/2026 and signed as completed by the Assessment Coordinator on 05/04/2026, more than 14 days after the start of the assessment. The previous Quarterly Minimum Data Set assessment reference date for Resident #284 was done 12/30/2025, making the 04/01/2026 assessment more than 92 days after the previous assessment. 3. The Quarterly Minimum Data Set assessment for Resident #369 was 03/05/2026 and signed as completed 04/08/2026, more than 14 days after the start of the assessment. The previous Minimum Data Set assessment was the annual assessment, which was completed 12/14/2025, making the 04/08/2026 assessment more than the required 92 days after the previous assessment. The previous Quarterly Minimum Data Set assessment for Resident #369 was 08/09/2025, making the 12/14/2025 assessment more than the required 92 days after the previous assessment. During an interview on 05/12/2026 at 11:38 AM, Director of Minimum Data Sets #1 stated Minimum Data Set assessments were scheduled between 84-92 days except for the change in condition assessment or if something needed to be captured in the assessment that was new. There were 14 days to complete the assessment once it was started. When a resident was admitted , the facility had 14 to complete the comprehensive assessment. Director of Minimum Data Sets #1 stated that they did morning rounds three days a week, used email communication and staff input to put the assessment together. At the time that the assessments were late, there had been a lot of turnover in departments and the lack of staff held up the ability to complete the Minimum Data Set assessments in a timely fashion. Activities were one of the departments used as an example. Director of Minimum Data Sets #1 stated they are doing much better now. Corporate staff were already helping with correcting the timing of assessments and there had been a lot of education on it. Director of Minimum Data Sets #1 stated that in October of 2025, they had been following the dates and tracking them for accuracy and things were going well. In February 2026, the dates on the assessments started to be an issue again so they started tracking it again. During an interview on 05/13/2026 at 10:45 AM, Director of Nursing #1 stated they were not aware that there were many residents that had Minimum Data Set assessments that were out of date. Director of Nursing #1 stated that sometimes the information for the assessments was pulled from the medical records, so if the documentation was not in the medical records, it might have delayed the information getting to Director of Minimum Data Sets #1. Director of Nursing #1 acknowledged that there was some staff turnover that could have contributed to the issue as well. During an interview on 05/13/2026 at 11:41 AM, Administrator #1 stated that Director of Nursing #1 handled a lot of the medical and nursing related concerns and the Administrator handled a lot of the day-to-day running of the facility. However, Administrator #1 stated they have gotten involved when they needed to. 10 New York Codes, Rules and Regulations 415.11

Based on observations, record review, and interviews conducted during survey, the facility failed to properly store food items according to professional standards for food safety. Specifically, on 05/05/2026, the main kitchen had opened, undated and/or unlabeled food items with no use by date; areas were visibly dirty; one handwashing sink was not maintained; and on 05/12/2026, the automatic dishwasher final rinse temperature was observed at 178 degrees Fahrenheit and was documented as not meeting or exceeding final rinse temperature of 180 degrees Fahrenheit from 05/01/2026 through 05/11/2026. This was observed in the main kitchen and had the potential to negatively impact all residents, staff and visitors who consume facility-prepared food. Findings include:Record review of Vendor #2 Summary of Service dated 03/19/2026 revealed dishwasher machine service was initiated on 03/12/2026 when the facility reported the final rinse was not reaching 180 degrees Fahrenheit. It documented a service on 03/19/2026, where Vendor #2 found an issue with the booster and was submitting a repair estimate. 'Booster should have been replaced when the machine was. The final rinse gauge not working correctly. When I run the temperature gauge through the machine it is showing a plate temperature of 160 degrees which reaches sanitation point. Ordering new final rinse gauge. Install new temperature gauge and verify it is reading the temperature correctly. Currently due to the bad booster heater, the final rinse is only 100 degrees. Luckily the wash and rinse tanks are hot enough to sanitize the dishes. Recommend approving estimate to replace booster heater, water that hot with sanitizer is going to rust the machine.' Record review of Vendor #2 Service invoice dated 03/31/2026 documented service completed on 03/23/2026 and 03/31/2026 that included replacement of a motor, impeller, clamp, vacuum breaker, fuse, gasket, valve and valve solenoid. Technician notes documented that upon arrival to the service call, the facility stated the dishwasher machine was not turning on at all. Vendor #2 found the unit had power but was not doing anything. They determined a loose fuse holder on the relay board, a blown fuse. On 03/23/2026, the unit was only running on one wash pump and two pumps were down; the unit was also leaking out of all three vacuum breaks as well as constantly filling in wash tank. Vendor #2 attempted to drain unit and refill to test all solenoids but drains were clogged completely and unit would not drain. Advised customer it was not recommended to use until repairs were completed and infestation was remediated. On 03/31/2026, Vendor #2 installed all ordered parts and tested unit, and advised the facility the unit needed to be maintained better, with a large amount of trash in the unit causing issues. Record review of Vendor #2 Service invoice dated 03/31/2026 documented technician note of replacing the pump motors and drain bodies; unit was not being maintained with large amounts of debris in the machine. It further read, 'Dishes need to be scraped better. Customer needs to change water after every meal and clean wash and rinse arms daily. None of this is being done. Unit is currently operating correctly. Recommend cleaning.' Record review of May 2026 Dish Machine Temperature Record (High Temperature Machine) revealed: Final rinse temperature below 180 degrees Fahrenheit was logged for Breakfast service on 05/05/2026, 05/08/2026, 05/10/2026, and 05/11/2026. Lunch service on 05/08/2026 and 05/10/2026. Dinner service on 05/01/2026, 05/02/2026, 05/05/2026, 05/07/2026, 05/08/2026, 05/09/2026, and 05/10/2026. During observations on 05/05/2026 between 6:25 AM and 7:17 AM, the following was observed in the Main Kitchen: Walk-in refrigerator (adjacent to dry storage room) contained open, undated items, including one tub of mayonnaise, one tub of Italian dressing, and a sheet rack of bagged liquid eggs (no label). Walk-in freezer (adjacent to dry storage room) contained open, undated items including one package of meat (no label), one box of cucumbers, and one package of sausage patties. Three-compartment sink (adjacent to dry storage room) contained soapy water and food debris. A rag was wrapped tightly around the leftmost sink faucet. Floor was visibly dirty including around three-compartment sink (adjacent to dry storage room) with two shop vacuums present. Two chemical bottles containing liquid sat on a dirty, three-shelf tan cart. Metal preparation cabinet, missing its door, was dirty on the shelves and had items arranged haphazardly. Facility-designated employee handwashing sink located adjacent to the automatic dishwasher had part of an eye washing station attachment to it but did not function. Noted with red grime and a spoon in the sink. During an observation on 05/12/2026 at 5:34 PM in the presence of Food Service Director #3, the automatic dishwasher located within the main kitchen was in use by an employee. The final rinse temperature gauge read 178 degrees Fahrenheit. During an interview on 05/05/2026 at 6:35 AM, Food Service Director #2 stated they were in the role for the last two weeks as an interim because Food Service Director #1 left unexpectedly. During an interview on 05/05/2026 at 7:10 AM, Food Service Director #2 acknowledged the findings and stated that opened items should be dated and labeled. Items that had been opened and not properly labeled or dated would be voluntarily discarded and they would remind the staff as they knew better. During an interview on 05/05/2026 at 7:10 AM, Food Service Director #2 stated they would put a ticket into maintenance or call a vendor if there was something wrong with a piece of equipment. During an interview on 05/07/2026 at approximately 5:35 PM, Administrator #1 stated they had recently invested in repairing the automatic dishwasher when it was down for a short time earlier in the year and would provide vendor records. Administrator #1 stated Food Service Director #2 was serving in an interim role, and that Food Service Director #3 completed onboarding and would be starting on 05/11/2026. During an interview on 05/12/2026 at 5:12 PM, Food Service Director #3 stated they recently began working at the facility and their first day in the kitchen area was the day prior (05/11/2026). They further stated they were observing and seeing what was going on, questioning efficiencies, and working with staff on the importance of proper labeling. During an interview on 05/12/2026 at 10:46 AM, Food Service Staff #5 stated a dietary aide is assigned to unload finished dishware, scrape, sort the silverware, and clean the cart. They stated one of the main tasks for the morning supervisor is to check the automatic dishwasher and before it is used, it is checked to make sure hot water temperatures are where they need to be. If there is a problem, they would report it to maintenance, place a request or call Director of Plant and Operations #1. They further stated that the automatic dishwasher had been down for two to three weeks, and they switched to hand washing until four or five items on the automatic dishwasher was fixed. During an interview on 05/12/2026 at 5:38 PM, Food Service Director #3 stated from what they were seeing, dirty dishes came down from the units and were going through the automatic dishwasher conveyor machine. Supervisors oversaw cooks and the dishwasher, and the final dishwasher temperature should have been 180 degrees Fahrenheit. Food Service Director #3 further stated that the expectation was if something is wrong [if the final temperature is not reaching 180 degrees Fahrenheit], they should let a supervisor know the machine was not getting to temperature. Food Service Director #3 stated they would look into it. During an interview on 05/12/2026 at 5:51 PM, Director of Plant and Operations #1 stated they oversaw security, maintenance and plant operations for all mechanical aspects of the building. They stated domestic hot water was used for the automatic dishwashing machine along with a booster heater. There was a capital investment in the dishwashing machine where they replaced valves, a steam leak repaired, heat coil to dry dishes. Director of Plant and Operations #1 stated they just installed a new final rinse gauge and the lowest temperature they had seen on the final rinse cycle was 177 degrees Fahrenheit. When the surveyor noted the observed final rinse temperature on 05/12/2026 to be 178 degrees Fahrenheit, Director of Plant and Operations #1 stated they would dial up the temperature from the system. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, interviews and record review conducted during survey, the facility failed to maintain a clean and homelike environment. Specifically, on 05/07/2026, Resident #118's recessed light had no light bulb. On 05/05/2026, Resident #27's room walls were dirty, and Resident #126's overbed table had a full, odorous urinal on it. Observations on 05/05/2026 noted sticky floors including Resident #118's room door and floor, the 7th floor nurses station floor, and the 3rd floor common area/core floor. Findings include:Facility housekeeping in-service training, revised 03/2016, documented resident rooms were cleaned to ensure optimum levels of cleanliness and sanitation, prohibit the spread of infection and bacteria and maintain the outward appearance of the facility. Steps in the daily cleaning of a resident room included emptying wastebaskets, cleaning and dusting all horizontal surfaces, cleaning and dusting all vertical surfaces, dust mop the floor, and damp mop the floor. It further documented that the average time for a routine resident room cleaning was 14 minutes. During observations on 05/05/2025 between 6:32 AM and 11:58 AM, the following locations were noted with sticky floors:Hallway outside of Rooms #301, #322, and #640.3rd floor main common/dining room (called Core).room [ROOM NUMBER].Resident #118's room and door.7th floor nurses' station. During an observation on 05/05/2026 at 9:11 AM, a full, odorous urinal was on Resident #126's overbed table. During a Resident Council interview on 05/06/2026 at 10:30 AM, 10 anonymous residents stated the facility was not clean. They stated some of the housekeepers would just change the garbage in their rooms but did not do any other cleaning. They stated the facility was trying to clean better in the Core and hallways, but not so much in the resident rooms. Resident #118:Resident #118 was admitted to the facility with diagnoses of unspecified anemia (low levels of healthy red blood cells and can cause tiredness, weakness, and shortness of breath), atrial fibrillation (irregular and often very rapid heart rhythm) and unspecified anxiety disorder (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks), and other respiratory disorders that were not documented. The Minimum Data Set (a resident assessment tool) dated 02/26/2026, documented the resident was cognitively intact, was able to make themselves understood, and usually understood others. During an interview on 05/07/2026 at 10:32 AM, Resident #118 pointed to the recessed light in the ceiling near their wardrobe and stated they had not had light there since the light bulb was removed from the fixture and was put into the roommate's recessed light fixture. There was no light bulb in the light fixture. Resident #118 also stated there was a light bulb out in the bathroom over the sink and they did not have enough light in the room. During an observation on 05/07/2026 at 10:30 AM, one of two light bulbs above Resident #118's bathroom sink was not working, and the room was dimly lit. During an interview at this time, Resident #118 stated the maintenance department was aware and had not replaced the bulbs. During an interview on 05/12/2026 at 4:53 PM, Assistant Director of Nursing #2 stated Resident #118 had spoken to them about the lighting in the room and they thought the resident wanted the room [NAME]. They stated they tried their best to accommodate the resident and would put in a work order for maintenance. During an interview on 05/05/2026 at 9:25 AM, Housekeeper #1 stated they are responsible for daily cleaning of approximately 20 rooms, which included throwing away trash, cleaning the sink and toilet, refreshing toilet paper, dusting, sweeping and mopping the floors, and making sure the wet floor sign is present. Housekeeper #1 stated if there was a bowel movement in a resident room, the aide would pick it up and then Housekeeper #1 would disinfect and clean the surface with bleach. There are specific rooms that require additional cleaning, wiping down the walls, and removing more trash. During an interview on 05/12/2026 at 5:51 PM, Director of Plant and Operations #1 stated they oversaw security, maintenance, and plant operations for all mechanical aspects of the building systems. Director of Plant and Operations #1 stated maintenance department consists of 13 employees who work from a work order system and fix issues in resident rooms including replacing light bulbs. Any staff member can put a work order in. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observations and interview conducted during survey, the facility failed to ensure the resident call system was maintained in working order and readily accessible to permit residents to summon staff assistance for three of three residents (Resident #86, #353, and #162) reviewed for accessibility of resident call systems and for one resident (Resident #241) identified during observations. Specifically, on 05/06/2026, Resident #86 was observed with a nonfunctioning call light located out of reach on the bedside table and in need of repair. On 05/05/2026 and 05/11/2026, Resident #353 and Resident #162's call bells were observed as not being within reach. This deficient practice placed residents at risk for delayed staff response and urgent care needs. Findings include:Resident #162 was admitted to the facility with diagnoses of encounter for screening for other bacterial diseases, muscle weakness, depression. The Minimum Data Set (a resident assessment tool) dated 02/25/2026, documented that the resident could be understood and could understand others and had intact cognition for daily living decisions. They were dependent on staff with toileting, lower body dressing, putting on/taking off footwear, sitting to lying position, lying to sitting on side of bed, and chair/bed-to-chair transfer. During an observation on 05/05/2026 at 12:58 PM, Resident #162's call bell was out of reach and located hanging on the head of the mattress. Resident #162 raised their arm to press it and was unable to reach the call bell. During an interview on 05/05/2026 at 1:00 PM, Personal Care Aide #1 stated quite a few aides hide the call bell to the top of the bed so the residents cannot get ahold of it when they need assistance. On multiple occasions, Personal Care Aide #1 stated they have come to care for Resident #162 and found the call bell at the top of the bed.Resident #86 was admitted to the facility with diagnoses of unspecified Dementia (a decline in mental ability - such as memory, reasoning, language, and thinking - severe enough to interfere with daily life,) dysphagia, unspecified (difficulty swallowing,) and type 2 diabetes mellitus without complications (a chronic condition where the body cannot properly use or make enough insulin, leading to high blood sugar levels.) The Minimum Data Set, dated [DATE] documented that they were usually understood and usually understood others. They require partial/moderate assistance with self-care including toileting, oral hygiene, showering/bathing self, dressing themselves upper and lower body, putting on/taking off footwear, and personal hygiene.During an observation on 05/06/2026 at 09:27 AM, Resident #86 was observed laying in bed with covers over their head. Call light was observed on the bedside table, not within reach of resident. Call light noted to be in disrepair, with button end of call light missing, rendering call light inoperable.During an observation on 05/07/2026 at 11:22 AM, Resident #86 was noted to be in bed sleeping with the covers over their head. Call light noted to be on the floor, under the bed, out of reach of resident, noted to be repaired with functioning button in place.Resident #353 was admitted to the facility with diagnoses of rheumatoid arthritis (a chronic autoimmune disorder affecting the joints), non-Alzheimer's dementia (cognitive disorders that cause memory loss and impaired thinking not caused by Alzheimer's disease), and heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). They required partial/moderate assistance with toileting and rolling left and right. They required total assistance from staff with showering, upper and lower body dressing, putting on/taking off footwear, sitting to lying, lying to sitting on bed side, and chair/bed-to-chair transfers.During an observation and interview on 05/11/2026 at 3:21 PM, Resident #353's call bell was located at the top of their bed, not near the resident's hands or within sight of the resident. Resident #353 stated they did not know their call bell was above their head in the bed. During an observation and interview on 05/06/2026 at 9:23 AM, Resident #241 was noted to be lying in bed wearing a hospital gown and was covered only by a flat sheet. There were no blankets anywhere near the resident. Resident #241 stated that they had asked for a blanket but were not given one and had cold feet. Their call bell was noted to be hanging from the overbed light and not within reach of the resident.During an interview on 05/12/2026 at 5:51 PM, Director of Plant and Operations #1 stated the Maintenance Department had 13 staff who receive information about issues using a work order system. All staff members can use the system to create a ticket. They further stated maintenance staff can fix problems like call lights.10 New York Codes, Rules, and Regulations 415.29

Based on observation, record review, and interviews conducted during survey, the facility failed to ensure care and services were provided in a manner that promoted dignity and respect for three of eight residents (Resident #207, #230, and #241) reviewed for dignity. Specifically, staff did not intervene to maintain Resident #207's dignity when the resident's hands were visibly soiled with bodily waste and then ate their pudding with their soiled bare hands; Resident #230's dignity was not maintained when staff pulled the resident up by their pants. During observations on 05/06/2026, 05/08/2026, and 05/12/2026, two residents (Resident #76 and #136) were observed being transferred by their arms and pants without the use of a gait belt. Resident #241's dignity was not maintained when staff referred to the resident as a feeder. Additionally, general observations revealed that care and services provided failed to promote dignity and respect. Findings include: Cross reference for F609. The Policy and Procedure titled, Dignity and Respect, revised 01/2026, documented that residents would be provided care that was dignified and in accordance with the residents' rights. The facility would promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of their individuality. The facility maintained a zero-tolerance stance for any violation of the policy. Residents had the right to be treated with dignity, respect, and consideration at all times and had the right to be cared for in a manner that enhanced their quality of life, free from humiliation, harassment, or threats. The facility Staff Member Handbook revised 10/2018 documented except in cases of emergency, cell phones were not to be used during working hours. Staff may use their cell phones in the staff break room or outside the facility before or after their scheduled shifts and during their scheduled break and meals periods only. Failure to follow this rule would result in disciplinary action up to and including termination. Resident #207 was admitted to the facility with diagnoses of unspecified dementia with agitation (a decline in mental ability - such as memory, thinking, or reasoning - that is severe enough to interfere with daily life), gastro-esophageal reflux disease without esophagitis (a chronic condition where stomach acid frequently flows back up into the esophagus), and degeneration of nervous system due to alcohol (a condition where long-term, excessive alcohol consumption causes neuron death and impaired nerve function, resulting in cognitive decline, movement disorders and chronic sensory loss). The Minimum Date Set (a resident assessment tool) dated 03/10/2026, documented the resident had severe cognitive impairment, usually made themselves understood, and usually understood others. During an observation on 05/05/2026 at 7:31 AM, Resident #207 was noted to be walking the hallway in a hospital gown with a blanket hanging over their shoulder wearing an adult brief that appeared to be sagging from incontinence. During an observation on 05/11/2026 at 5:08 PM, Resident #207 was noted with their left hand in the back of their adult brief and holding the outside of their pants in the main dining area, following the drink cart around. Resident #207 was observed to have stool on their fingers. When dinner was served, Resident #207 was observed to be eating their pudding with their bare hands that had not been cleaned. Resident #241 was admitted to the facility with diagnoses of unspecified dementia (a progressive neurological disease characterized by memory loss and behavior issues), adult failure to thrive (inability to maintain healthy weight and self care), and abnormalities of gait and mobility. The Minimum Data Set, dated [DATE] documented Resident #241 was able to be understood, sometimes understood others, and was mildly cognitively impaired. During general unit observations on 05/06/2026 at 9:19 AM, two unnamed staff members were noted to be in Resident #241's room. One staff member asked the other staff member if the resident had received their tray yet and if the resident was a feeder. The staff member responded that Resident #241 was not a feeder, just didn't get breakfast yet. Resident #241 was lying in the bed in front of the staff members, awake, watching the conversation take place. Resident #241's roommate finished their breakfast that they had already received. Breakfast was not served to Resident #241 until 10:10 AM. During an observation and interview on 05/06/2026 at 9:23 AM, Resident #241 was noted to be lying in bed wearing a hospital gown and was covered only by a flat sheet. There were no blankets anywhere near the resident. Resident #241 stated that they had asked for a blanket but were not given one and had cold feet. Their call bell was noted to be hanging from the overbed light and not within reach of the resident. Resident #241's fingernails were crusted underneath with unidentifiable matter. Resident #241 asked the surveyor for a bottle of water and stated that they had been trying for two days to get one stating, It would be nice to have a bottle of water and a few straws next to my bed. Resident #230 was admitted to the facility with diagnoses of schizophrenia (a complex, chronic brain disorder that disrupts a person's ability to interpret reality normally, causing disruptions in thought processes, perceptions, and emotional responsiveness), diabetes mellitus (a disease that affects how the body uses blood glucose (sugar));), and end stage renal disease (when kidneys have lost about 85% to 90% of their function, meaning they are no longer able to filter waste and excess fluids from your blood well enough to keep maintain life). The Minimum Data Set, dated [DATE], documented they could understand others and be understood, and was cognitively intact. During an interview on 05/05/2026 at 8:41 AM, Resident #230 stated last week in the middle of the night they put the call light on for help getting from the bed to the bathroom. The aide told them they were independent and could do it by themselves. Resident #230 told the aide they could not get up alone and needed help. The aide then abruptly rolled them over and pulled them up by their pants and threw them in the wheelchair. Resident #230 stated the above happened many times, especially overnight. When asked if they had reported this to anyone else, Resident #230 said no, the facility would not do anything about it and began to cry. During an interview on 05/12/2026 at 11:40 AM, Registered Nurse #12 stated they spoke with Resident #230, they initiated and closed the investigation (date unknown). The resident had no injury and Certified Nurse Aide #18 was removed from resident #230's assignment and replaced with Certified Nurse Aide #19. During a Resident Council interview held on 05/06/2026 at 10:30 AM, 10 anonymous residents stated that there were certain staff that treated them like children. They stated some staff have yelled or ignored them. Residents stated staff frequently used their phones on all the floors. They stated they should not be using their phones when at work, especially when they were sitting with a resident who was on direct one-to-one supervision. Residents stated staff used their phones when providing care. They stated they use the speakerphone or had video calls when they should not. One resident stated staff would have conversations outside their room while they were waiting for care. They stated they should not have to wait for staff to finish their conversation before receiving care. Residents stated it seemed like staff were at the facility to hang out. They stated that some of the staff were loud and not respectful. Residents stated their packages were often opened before they received them. Residents stated packages were supposed to be opened with them. During an observation on 05/09/2026 at 12:00 PM, a staff member was observed on their cell phone sitting outside a room for a resident on a one-to-one direct supervision. They quickly put their phone away when they noticed the surveyor approaching them. During an observation on 05/09/2026 at 12:35 PM, a staff member was observed at the nurses' desk/station on the 5th floor scrolling through their phone. During an interview on 05/11/2026 at 3:29 PM, [NAME] Clerk #1 stated they checked for packages when they went to gather the mail. They stated sometimes security would bring up packages to the residents or sometimes residents would go down to security and grab it themselves. [NAME] Clerk #1 stated security might open a resident's package to make sure there were no medications or other items residents should not have. [NAME] Clerk #1 stated they opened resident's packages in front of the resident. They stated they must open packages with the resident. During an interview on 05/13/2026 at 11:52 AM, [NAME] Clerk #2 stated they deliver packages to the residents. They stated security opened resident packages in front of the resident, security signed off on it and then delivered the package to the resident. During an interview on 05/13/2026 at 11:19 AM, Security Guard #1 stated when packages were delivered, they held them behind the curtain at the security desk. They stated in some cases, they brought larger packages to the residents, or sometimes the nurses or aides would come down and grab a package for a resident. Security Guard #1 stated they opened and inspected packages right in front of the resident and/or staff and the resident and/or staff would have to sign off on it. They stated if it was something the resident could have, they could take it, but if it was something they should not have, they let Director of Plant and Operations #1 know so they could intervene. They kept an eye out for knives, sharps, razors, blenders, vapes, drugs, and liquor. Security Guard #1 stated if a resident declined having their package searched, they still had to search it. They stated if a resident was adamant about not looking in their package, 9 out of 10 times, it was something they should not have. During an observation on 05/06/2026 at 8:38 AM, Certified Nurse Aide #17 and another unnamed staff member were seen picking up Resident #136 without a gait belt and moving the resident from their wheelchair into a dining chair in the main core dining room on the third floor. The certified nurse aides each wrapped an arm under Resident #136's arm pits and held the back of the resident's pants with their other hand and shifted the resident from chair to chair. During an observation on 05/07/2026 at 12:44 PM, Certified Nurse Aide #5 did not knock on Resident #162's door prior to entering with the lunch tray. During an observation on 05/08/2026 at 12:52 PM, two unnamed staff members were seen moving Resident #76 from their wheelchair to a dining chair without a gait belt, using the resident's arms and waist of their pants. When the resident was in the dining chair, they were observed to be making an unhappy face and rubbing their left hip. The unnamed staff members were overheard asking Resident #76 if they were okay. Resident #76's response was not heard. No further actions were observed to be taken at that time. During an observation on 05/09/2026 at 12:10 PM, therapy staff were observed entering room [ROOM NUMBER] without knocking. During an observation on 05/11/2026 at 3:25 PM, Certified Nurse Aide #3 was observed answering Resident #353's call light without knocking on the door prior to entering the resident's room. During a dinner observation on 05/11/2026 at 5:13 PM in the Unit 4 common area referred to as the core, Resident #345 was observed sitting at a dining table alone in their wheelchair with a urine drainage bag exposed while other residents were seated in the area having their dinner. During an observation on 05/11/2026 at 7:06 PM, Resident #162 was served dinner by Certified Nurse Aide #4 who did not knock on the resident's door prior to entering the room. During an interview on 05/13/2026 at 10:45 AM, Director of Nursing #1 stated they maybe needed to work on the nonverbal cues of residents that staff might be missing. They were trying to teach the staff to look for reasons for resident behavior and not normalize it. Director of Nursing #1 stated they had discussed dignity with the staff before. Director of Nursing #1 cringed when they were told about the conversation held by staff over Resident #241's bed (referring to the resident as a feeder) and acknowledged that more education would need to be done. During an interview on 05/13/2026 at 12:01 PM, Administrator #1 stated packages were delivered to the front desk, security checked them in and held them behind the security desk. They stated if staff from the units did not come down to get the packages, security would deliver the packages. Administrator #1 stated packages were opened with the resident. They stated staff should bring the package up to the resident and open the package with the resident in their room. They stated they were not sure if they had a resident decline their package being opened. For the most part, they were understanding of the process. 10 New York Code Rules and Regulation 415.5(a)

Based on record review and interviews conducted during the survey, the facility failed to ensure comprehensive person-centered care plans were developed and implemented in accordance with professional standards of practice for two residents (Resident #118 and #248) out of three residents reviewed. Specifically, (a.) Resident #118 received medications for unspecified anemia, iron deficiency, and dry eye syndrome and a care plan was not developed and implemented for the diagnoses; and (b.) Resident #248 was involved in a resident-to-resident physical altercation on 01/20/2026 at 6:50 AM, and a comprehensive care plan for abuse was not developed and implemented. Additionally, Resident #248 had oral surgery on 01/21/2026 and a care plan was not developed and implemented. Findings include: Cross-referenced to F770: Laboratory Services The Policy and Procedure titled, Care Planning/Care Conference Policy, reviewed 02/19/2026, documented the facility utilized a person-centered approach to care planning. The policy ensured that each resident had a comprehensive person-centered care plan with individualized, measurable objectives and timeframes designed to meet the resident's medical, nursing, mental, and psychosocial needs. The comprehensive care plan must include the resident specific applicable services/interventions that were furnished to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being. The care plan would be reviewed and revised as appropriate including any significant change in condition/status and change/update in resident needs, goals, and/or interventions. Each resident's comprehensive care plan would be prepared by the Interdisciplinary Team representing all appropriate health care professionals involved in the resident's care. Resident #118 Resident # 118 was admitted to the facility with diagnoses of unspecified anemia (low levels of healthy red blood cells and can cause tiredness, weakness, and shortness of breath), atrial fibrillation (irregular and often very rapid heart rhythm), and dry eye syndrome of bilateral lacrimal glands (insufficient watery tears are produced by the glands above each eye). The Minimum Data Set (a resident assessment tool) dated 02/26/2026, documented the resident was cognitively intact, was able to make themselves understood, and usually understood others. The resident was assessed to have an active diagnosis of anemia in the last seven days prior to the assessment. There was no documented evidence that a comprehensive person-centered care plan was developed for the diagnoses of anemia, iron deficiency, or dry eye syndrome of bilateral lacrimal glands. The Federally Mandated Visit dated 04/10/2026, by Nurse Practitioner #1, documented that they saw Resident #118 on 04/10/2026. The plan included iron deficiency anemia and documented to continue ferrous sulfate (used to treat/prevent iron deficiency anemia), dry eye and documented to continue artificial tears. Resident #248: Resident #248 was admitted to the facility with diagnoses of encounter for other orthopedic aftercare (fracture of right lower leg), urinary tract infection, and chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs). The Minimum Data Set, dated [DATE], documented that the resident was cognitively intact, was able to make themselves understood, and understood others. The Comprehensive Care Plan for Cognition, Psychosocial, Mood State and Behavior, revised on 02/15/2026, documented the resident had a negative mood state and could easily become agitated and anxious. This was due to their history of past trauma, including sexual assault in the community, and was easily startled. The resident had a tendency to confabulate stories against staff with multiple roommates. Approaches included for Social Work to remain available and reassure the resident they were safe. On 02/15/2026 at 9:33 PM, Resident #248 presented with interpersonal conflict related to shared living arrangements. The resident continued to have verbal disagreements with roommates and demonstrated difficulty interacting with staff at times. Episodes appeared to be related to heightened anxiety and poor tolerance of environmental stressors. The resident remained diagnosed with Post-Traumatic Stress Disorder (a mental health condition that was caused by an extremely stressful or terrifying event), which may contribute to increased reactivity and mistrust in social situations. The resident was assigned two staff members for care. The Resident/Visitor - Incident/Accident Report dated 01/20/2026 at 6:50 AM, documented an unobserved incident. Resident #248 called staff to the room by using the call bell. Resident #248 stated they were sleeping, and someone was touching their back. Resident #248 hit the person in the face, and it was their roommate. The Resident Statement by Resident #248 dated 01/20/2026, documented they hit their roommate in the face because they were startled awake by the roommate touching them on their buttocks. The untimed Nursing Progress Note dated 01/20/2026, by Registered Nurse #13, documented Resident #248 was sleeping in their bed and felt someone touching them on their back. The resident was startled and hit their roommate in the face. The roommate sustained no injuries. Resident #248 was very sorry for hitting their roommate. Registered Nurse #13 reassured Resident #248 that their roommate was not hurt. There was no documented evidence of updated interventions related to the resident-to-resident physical altercation on 01/20/2026 at 6:50 AM within the comprehensive person-centered care plan. The untimed Nursing Progress Note dated 01/21/2026, by Registered Nurse #3, documented Resident #248 returned from a dental procedure with new orders (not documented) that were reviewed with the Nurse Practitioner. Pain medication was given with positive effect. No active bleeding was noted. Soft foods were offered and received for dinner. No further issues were verbalized. Plan of care ongoing. The untimed Nursing Progress Note dated 01/22/2026, by Registered Nurse #3, documented Resident #248 was adjusting well status post dental surgery. Pain well controlled. No active bleeding or acute distress noted. Plan of care ongoing. There was no documented evidence a comprehensive person-centered care plan was developed and implemented for the oral surgery dated 01/21/2026. During an interview on 05/12/2026 at 4:53 PM, Assistant Director of Nursing #2 stated they were responsible for Resident #118's comprehensive care plan and stated there should have been a care plan for all diagnoses that were treated. During an interview on 05/13/2026 at 9:59 AM, Registered Nurse #3 stated they managed the 6th floor unit and were new to the facility. They stated they were responsible for care planning. They were not aware there was no care plan for the resident-to-resident physical altercation on 01/20/2026 and potential for abuse. They interviewed Resident #248, and the resident told them their roommate, who had dementia and wandered to the other side of the room, did not touch their anus. They were aware that Resident #248 had oral surgery on 01/21/2026. They were not sure if a care plan was developed and implemented. They stated they would take care of the care plans. During an interview on 05/13/2026 at 11:45 AM, Director of Nursing #1 stated there should be a care plan for every diagnosis. 10 New York Code of Rules and Regulations 415.11(c)(1)

Based on observations, record review, and interviews conducted during survey, the facility failed to properly dispose of garbage and refuse. Specifically, on 05/05/2026, three garbage receptacles located within the main kitchen had no liners and contained refuse. One of the garbage cans was next to a wall that had dried, liquified spatter covering approximately two square feet of the wall above it. Additionally, dirty garbage lids were observed in the main kitchen storage utility room. This was observed in the Main Kitchen during the initial tour. Findings include: Cross reference to F-925, Maintains Effective Pest Control Program.Policy and procedure titled, Insect and Rodent Control, last revised 05/2025, documented the purpose of pest control was to prevent entry into the facility and reduce the threat of infection and disease; to provide a safe and sanitary environment; and to maintain the appearance of the facility. It further documented, equipment was to be properly cleaned on a daily basis following Centers for Medicare and Medicaid Services policies and procedures. Proper storage of food within the facility. The majority of the prevention of insect and rodent infestation is in the daily cleaning and upkeep of the facility. Policy and procedure titled, Food Storage and Safety, last revised 01/2026, documented that it is the policy of the facility that sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry, and free from contaminants. During a tour of the main kitchen on 05/05/2026 between 6:25 AM and 7:17 AM,Adjacent to the walk-in refrigerator, a yellow, round commercial garbage receptacle was dirty and contained garbage with no liner (bag). It was next to a wall that had dried, liquified spatter covering approximately two square feet of the wall above it.Adjacent to the kitchen utility storage room, there were two round commercial garbage receptacles that were visibly dirty and contained garbage. One can had a liner with food outside of it. The second had no liner. During an interview on 05/05/2026 at 6:35 AM, Food Service Director #2 stated they were in the role for two weeks. They further stated refuse should be in garbage cans with liners. During an observation on 05/08/2026 at 1:30 PM, the main kitchen utility storage room was cleaned and free of debris and grime. Garbage cans were noted with liners. During a follow up interview on 05/08/2026 at 1:32 PM, Food Service Director #2 stated there was a staff member responsible for cleaning and organizing the utility storage room but Food Service Director #2 knew it was on their list to be maintained and cleaned out, so after it was pointed out by the surveyor on 05/05/2026, they took it upon themselves to clean the room and get rid of items. During an interview on 05/12/2026 at 5:12 PM, Food Service Director #3 stated they recently began working at the facility and their first day in the kitchen area was the day prior (05/11/2026). 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and interviews conducted during survey, the facility failed to provide drinks, including water and other liquids, consistent with resident needs and preferences and sufficient to maintain resident hydration for one (Resident # 118) of three residents reviewed. Specifically, the facility failed to ensure Resident #118 received water and ice per their preference to maintain hydration. Findings include: Resident #118 Resident # 118 was admitted to the facility with diagnoses of unspecified anemia (low levels of healthy red blood cells and can cause tiredness, weakness, and shortness of breath), urinary tract infection, and adult failure to thrive (a state of decline that manifests as weight loss, decreased appetite, poor nutrition, and inactivity). The Minimum Data Set (a resident assessment tool) dated 02/26/2026, documented the resident was cognitively intact, was able to make themselves understood, and usually understood others. The Policy and Procedure titled, Nourishment Program Policy and Procedure, dated 10/06/2025, documented it was the policy of the facility to ensure all residents had access to and received appropriate nourishments, snacks, supplements, fortified foods, and hearty snacks to maintain or improve nutritional and hydration status, in compliance with regulatory requirements and individualized care plans. The nourishment pass was defined as the planned delivery of nourishments at designated times between meals, based on resident diet order and care plan. The nourishment pass ensured that residents had consistent opportunities to meet nutritional and hydration needs. Nourishments were passed by the Certified Nurse Aide following delivery to the unit at approximate times of 10:00 AM, 2:00 PM, and HS (hour of sleep, bedtime). The Policy and Procedure titled, Clinical Nutrition, revised 08/2020, documented nutrition and nursing staff determined the hydration needs of all residents and identified those residents at risk for dehydration so that appropriate interventions were implemented. Nursing staff would provide water for residents three times each day in addition to between meal nourishments. The Comprehensive Care Plan for Nutrition, revised 02/25/2026, documented the resident would remain well hydrated as evidenced by no signs/symptoms of dehydration, laboratory test results withing acceptable limits. Approaches (interventions) included thin liquids. During an interview and observation on 05/05/2026 at 3:03 PM, Resident #118 showed the surveyor their water pitcher that was empty and had no lid. Resident #118 stated the lid broke today, and they told their certified nurse aide, who never came back with a new lid. During an interview and observation on 05/06/2026 at 11:15 AM, Resident #118 stated they did not get a new lid for their water pitcher. The pitcher was on the nightstand, had no lid, and was empty. The resident stated they had no water to drink, and staff never filled the pitcher with water last evening/night. They thought about going to the dietary department to get a new lid but were not feeling strong enough. They stated staff did not bring water to them unless they asked for it. Resident #118 stated they liked water and ice. They had to drink the water from the bathroom on several different occasions because staff did not bring water to them. During an interview on 05/07/2026 at 10:32 AM, Resident #118 stated they finally received a lid for their water pitcher after telling staff the State was here, and they would get in trouble if they did not give them a lid. Staff brought a lid but did not bring water/ice. They stated they had to fill their travel cup with bathroom water, which disgusted them. They had to walk down to the kitchenette this morning to get their own water/ice. They stated they had not seen an aide at all this morning. During an interview on 05/11/2026 at 10:14 AM, Certified Nurse Aide #23 stated they were responsible for ensuring residents had water/ice available when rounding and per their care plan, which was typically every two (2) hours. The aide should learn the resident's needs and wants by building rapport, so they were able to anticipate their needs. There was a hydration policy, and they were unsure if there were specific times in the policy that water/ice should be brought to the residents or the specifics of the policy. During an interview on 05/11/2026 at 10:52 AM, Certified Nurse Aide #24 stated they were responsible for ensuring the residents had water and ice available to them. They made rounds on the residents to check the water pitchers. They also checked the water pitchers when they provided care to a resident. Some residents rang their call bell if they needed water and others needed to be encouraged to drink. If they noticed physical symptoms like dry lips, they would encourage the resident to drink water. They were aware of the facility's policy on hydration and stated they should check the resident every two hours for hydration/water, especially for residents who could not make their needs known. During an interview on 05/11/2026 at 10:56 AM, Certified Nurse Aide #25 stated they were responsible for ensuring the residents had water on the bedside table and would ask the resident if they had water. If the resident could not make their needs known, they would ensure the water pitcher was full, ask them if they wanted some water and would encourage them to drink. They looked for physical signs such as dry mouth and urine output (color and odor). They would ensure they mentioned it to the nurse manager if urine odor was strong and they noted a decrease in fluid intake. They documented fluid intake in the electronic medical record system where meal intakes were documented. The policy was for residents to stay hydrated. During an interview on 05/11/2026 at 11:04 AM, Certified Nurse Aide #26 stated they made sure the residents on their assignment had their water pitchers filled with water and ice two times per shift. They were unsure if there were policies and procedures for hydration and just knew the residents should be drinking throughout the day. They documented meal and fluid intake in the electronic medical record. During an interview on 05/11/2026 at 11:14 AM, Licensed Practical Nurse #8 stated when they reported to work in the morning, they made sure the residents had water and ice available. They rounded on the residents to ensure they had water available, sometimes every two hours. If a resident could not make their needs known, for example with aphasia (language disorder that affects ability to speak and understand what others say) they used a picture board to let staff know they were thirsty. They were unsure if there was a hydration policy and did not know what would be in it. During an interview on 05/12/2026 at 4:53 PM, Assistant Director of Nursing #2 stated they managed the 5th floor unit. The certified nurse aides should be bringing water to the residents every shift and supplementally between meals. 10 New York Code of Rules and Regulations 415.14(d)(4)

Based on record reviews and interviews conducted during survey, the facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for one (Resident #412) of three residents reviewed. Specifically, the facility failed to ensure overall systems were established for documentation of all meals by nursing staff and were being maintained according to standards of practice and facility policy when they failed to document breakfast, lunch, and dinner for Resident #412 between the dates of 11/01/2025 through 11/30/2025. Findings include:Resident #412 was admitted to the facility with diagnoses of osteomyelitis of vertebra, lumbar region (a serious infection of the bones in the spine,) acute and subacute infective endocarditis (a life-threatening infection of the heart's inner lining or valves,) and Type 2 Diabetes mellitus, without complications (a disease that affects how the body uses blood glucose (sugar). The Minimum Data Set (a resident assessment tool) dated 11/04/2025 documented that they could make themselves understood and understood others and were cognitively intact. Review of the facility's policy and procedure titled Fine Dining Policy dated 09/2025 stated Nursing staff are required to document meal consumption. A review of Resident #412's Certified Nurse Aide Meal Documentation record for the month of November 2025, did not include documentation of resident meals for the following meals and dates:Breakfast for the dates of 11/04/2025, 11/05/2025, 11/08/2025, 11/12/2025, 11/15/2025,11/18/2025, 11/20/2025, 11/21/2025, 11/22/2025, 11/23/2025, 11/30/2025Lunch for the dates of 11/01/2025, 11/02/2025, 11/03/2025, 11/04/2025, 11/06/2025, 11/07/2025, 11/08/2025, 11/09/2025, 11/10/2025, 11/12/2025, 11/13/2025, 11/14/2025, 11/15/2025, 11/16/2025, 11/19/2025, 11/20/2025, 11/21/2025, 11/22/2025, 11/23/2025, 11/24/2025, 11/25/2025, 11/26/2025, 11/27/2025, 11/30/2025Dinner for the dates of 11/03/2025, 11/04/2025, 11/06/2025, 11/07/2025, 11/11/2025, 11/14/2025, 11/16/2025, 11/17/2025, 11/18/2025, 11/19/2025, 11/22/2025 During an interview on 05/12/2026 at 12:18 PM, Licensed Practical Nurse #3 stated that meals and snacks are documented in the electronic health record. They stated that each shift tracks its own meals and snacks and are expected to be documented for each meal. During an interview on 05/12/2026 at 12:24 PM, Certified Nurse Aide #9 stated all meal intakes were to be documented in their electronic medical record system (charting system on a kiosk) for every one of their residents. 10 New York Codes, Rules, and Regulations 415.14(f)(1)

Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure residents received routine and/or emergency dental services, including assistance in obtaining dental evaluation and treatment for two of three residents (Resident #155 and #162) reviewed. Specifically, (1.) Resident #155 was discovered to have a broken front tooth by family and was not referred to dental services to rule out any potential issues/problems. (2.) On 04/15/2026, Resident #162 was known to be missing upper dentures but their diet was not adjusted to account for this factor until five days later on 04/20/2026, when a dental consult documented to adjust diet as needed. Resident #162's full upper denture impressions were not completed until 05/10/2026. The delay in dental follow-up and denture replacement had the potential to impact the resident's ability to chew, nutritional status, and overall oral health. Findings include: The facility policy titled In-House Dental Services Coordination Process reviewed 06/03/2025, documented the purpose was to ensure timely, coordinated, and documented access to in-house dental care services for residents, enhancing oral health and meeting regulatory standards. Procedure: (1.) Identification and Referral: Licensed staff who identified a resident's need for dental evaluation must report it to the assistant unit manager, unit manager, supervisor, or ward clerk. The patient would then be added to the Dental Service Tracking Sheet located in the O- Drive and a dental consultation sheet would be filled out for the resident. (2.) Scheduling and Confirmation: the on-site clinic staff would review the Dental Services Tracking Sheet regularly and ensure the on-site dental provider had an updated list when at the facility. (3.) Documentation, Communication, Monitoring: After the patient was seen, the clinic staff was responsible for updating the Dental Services Tracking Sheet, providing the consultation sheet to the attending provider for review and signature, and uploading it to the resident's chart. The assistant unit manager/unit manager were responsible for placing a note in the residents' chart with a brief review of the consult, recommendations, and any necessary follow up and ensuring communication with the resident. Resident #162 was admitted to the facility with diagnoses of Encounter for atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hypo-osmolality (concentration of dissolved particles such as sodium, glucose, and urea in the blood or other body fluid is lower than normal) and hyponatremia (a condition where sodium levels in the blood are too low), and depression (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life). The Minimum Data Set (a resident assessment tool) dated 02/25/2026, documented that the resident could be understood, could understand others and had intact cognition for daily living decisions. A lost/missing item report completed for Resident #162 dated 04/15/2026, documented Family Member #1 reported the resident's upper dentures were missing. Dentures were not found. It further documented Resident #162 was seen by the dentist on 04/20/2026 and the process was started for new upper dentures. A dental consult dated 04/20/2026, documented evaluation lost full upper dentures. Adjust diet as needed. There was no documentation that indicated impressions were taken or new dentures were ordered for Resident #162. A nursing progress noted written by Licensed Practical Nurse #4, dated 04/20/2026, documented Resident #162 was seen by the dentist to see if full upper dentures could be made. The dentist was going to get insurance approval then start the process. The resident denied pain. A nutrition progress note written by Diet Technician #2 dated 04/21/2026 at 8:23 AM, documented visited Resident #162 and they reported they lost their upper dentures. Meal plan adjusted to softer food. Resident #162 only wanted ground chicken until dentures were restored. Resident #162's Comprehensive Care Plan for Nutrition dated 03/11/2026 documented the resident was on a regular diet with regular consistency. Interventions included set up, open containers, cut up meat, butter bread. During an interview on 05/05/2026 at 11:05 AM, Resident #162 stated they lost their upper dentures a while ago and a diet technician came to see them who advocated for them to have ground meat. Resident #162 stated breakfast was usually good, but they did not get what they preferred, which was ground meat for lunch and dinner. Resident #162 stated their dentures were supposed to come back 3 weeks ago but never did and is not sure what is going on with their missing dentures but would like them back. During an observation on 05/05/2026 at 1:00 PM, Resident #162 did not have upper dentures in their mouth. The resident was observed to have uncut roast beef for lunch. During an interview on 05/05/2026 at 1:00 PM, Resident #162 stated their upper dentures had been missing for months. They stated they were seen by the dentist 2 weeks ago to make a full upper impression but had not heard anything further. They stated they were on a regular diet but could not chew the uncut roast beef that was served for lunch. During an interview on 05/05/2026 at 1:00 PM, Resident #162' s Personal Care Aide #1 stated the resident's dentures had been missing since they started working with Resident #162 a couple months ago. They stated the food never reflected the meal ticket and the resident's diet was never changed to mechanical soft. During an interview on 05/07/2026 at 3:14 PM, Social Worker #1 stated they received a call from Family Member #1 on 04/14/2026 or 04/15/2026 who informed them that Resident #162's upper dentures were missing. Social Worker #1 went to Resident #162's room to search for the dentures although Resident #162 was asleep at the time. Social Worker #1 stated they found the dentures in the resident's laundry then placed them on the resident's tray table so they would see them when they woke up. Social Worker #1 stated they attempted to wake the resident to inform them that the dentures were found but they would not wake up. The next day Social Worker #1 went to Resident #162's room in the morning to let them know the dentures were found in their room and the resident said they did not see them when they woke up from their nap the previous day. Social Worker #1 stated they filled out a missing items report and notified Registered Nurse #2 who then contacted the dentist. They stated the in-house dentist saw Resident #162 on 04/20/2026. Missing Items reports were filled out and given to Corporate Director of Care Transition who completed the investigation. They stated the process on missing items was to first ask the residents for permission to search their room, call security, try to locate the item then fill out a missing items report if the item could not be found. Social Worker #1 stated if a resident was asleep, they would still search their room. During an interview on 05/08/2026 at 11:27 AM, Diet Technician #1 stated they would see residents if the nurse brought up issues or if there were any changes in conditions. Diet Technician #1 saw Resident #162 on 04/21/2026 and made a recommendation for ground chicken which was documented in a progress note. They stated that when residents were missing dentures, the diet would most likely be changed to ground depending on the resident's chewing ability, although some residents were able to do chopped or softened. Certified nurse aides were responsible for documenting how much residents ate and drank. Diet Technician #1 stated at that time there were no concerns for Resident #162. During an interview on 05/08/2026 at 1:04 PM, Registered Nurse #2 stated Social Worker #1 notified them a couple weeks ago that Resident #162's upper dentures were missing. Registered Nurse #2 stated they assessed Resident #162 to make sure they did not have difficulty chewing or eating. Registered Nurse #2 checked the electronic medical record to see if they documented their assessment and confirmed they did not. They stated they did a quick sweep of the room to look for the dentures but did not see them and put a request in the system for a dental consultation. If items went missing, it was reported to the Social Worker on the floor who followed through with the report. Registered Nurse #2 stated they were waiting to hear back from Resident #162's dental insurance regarding denture coverage. They stated when the dentist came to the facility, Licensed Practical Nurse #2 rounded with the dentist and let them know when anything needed to be done. During an interview on 05/12/2026, at 12:46 PM, Licensed Practical Nurse #6 stated they primarily worked in the clinic on the second floor. Licensed Practical Nurse #6 stated that when Dentist #1 came to the facility, they accompanied Dentist #1 to resident rooms. Licensed Practical Nurse #6 stated Dentist #1 was the only dentist who examined residents for dentures and performed denture-related services. Dentist #2 performed examinations and sent referrals for hygiene appointments. Licensed Practical Nurse #6 stated dental cleanings were typically completed in Rochester, New York, because surrounding areas did not accept geriatric residents and their insurance. Licensed Practical Nurse #6 stated that, previously, the denture process had taken up to four months from start to completion but was unsure of the current timeframe since the facility had hired a new dentist who also came to the facility on weekends if needed. Licensed Practical Nurse #6 stated that on 03/05/2026, Dentist #1 saw Resident #162 for a routine initial examination. Resident #162 had full upper dentures, crowns on teeth numbers 22 through 27, and retained root tips on teeth numbers 21 and 28. No recommendations were made at that time. Licensed Practical Nurse #6 stated that on 04/20/2026, Resident #162 was seen for missing upper dentures. Licensed Practical Nurse #6 stated Dentist #1 had discussed adjusting the resident's diet as needed with the Nurse Manager and Dietician; however, because the resident was not exhibiting any signs of difficulty, no diet changes were made. Licensed Practical Nurse #6 stated Dentist #1 had only come to evaluate the resident at that visit. Licensed Practical Nurse #6 stated that on 05/10/2026, Resident #162 was again seen for missing upper dentures, and impressions were completed at that time. During an interview on 05/12/2026, at 4:00 PM, Dentist #1 stated they had begun working at the facility in March 2026 and had visited the facility several times since then. Dentist #1 stated they were often at the facility checking on residents two to three times per month and planned to work at the facility five to six times per month once the dental clinic room was operational, as the facility was in the process of renovating it. Dentist #1 stated impressions for full upper dentures had been taken for Resident #162 on 05/10/2026 and had been sent to the laboratory. Dentist #1 stated they had discussed with Resident #162 that one additional appointment would be needed for a denture fitting and that the dentures would be completed approximately one week to ten days afterward. Dentist #1 stated they were unsure how Resident #162's dentures had gone missing but stated they would expedite the denture process once the dentures were completed. Dentist #1 stated, if the laboratory work was returned and the visit has not been coordinated, even if they were not scheduled, they would come in to see the resident, even if it was only for that resident. They were hoping the dentures would be completed within two weeks. Typically, it took four to six weeks to complete dentures from beginning to end, but they would try to expedite the process whenever possible. Dentist #1 further stated that if the resident was discharged prior to completion of the dentures, they would continue to follow through to ensure Resident #162 received the dentures and would notify the family. Dentist #1 stated the second visit on 04/20/2026, had been for an examination related to the resident's missing dentures. Dentist #1 stated they were unsure why impressions had not been made during that visit. Resident #155 Resident #155 was admitted to the facility with diagnoses of fracture of sacrum (a break or crack in the large triangular bone at the base of the spine that connects the spinal column to the pelvis), fracture of superior rim of right pubis (a break in the upper front part of your pelvic ring), and dementia (a group of conditions that cause a progressive decline in cognitive abilities). The Minimum Data Set, dated [DATE], documented the resident usually understood others, was usually understood by others, and had severe cognitive impairments. A complaint received by the New York State Department of Health on 03/16/2026 at 3:00 PM, documented family went to visit Resident #155 on 02/17/2026 and noticed they had damaged teeth. Resident #155 had a front tooth cracked in half with exposed roots, visible to the gum, and several cracked teeth in the back. Resident #155 thought they fell but was not sure, and when asked if their teeth were bothering them the resident said yes. Nursing staff were unaware of the broken teeth or what happened. Family met with the Director of Social Work and filed a grievance requesting that an investigation be completed to determine the cause. The facility had not responded to the family's multiple requests for follow-up. The family was still unaware of the outcome of the grievance that was filed on 02/17/2026, or if the resident was seen by the dentist. Family was concerned that the cracked teeth might be related to poor dentation. A Complaint/Grievance Investigation form received 02/17/2026, documented Resident #155's grievance/complaint was: claims resident had a cracked tooth. The corrective action included resident seen by Registered Nurse Unit Manager, no chipped/cracked teeth noted. Family was notified of the results on 03/16/2026. The Grievance Log 2026, documented the date of grievance for Resident #155 was 02/17/2026. The grievance/concern documented resident had a cracked front tooth. The resolution was the resident does not have a cracked tooth. The date the complainant was notified was 03/16/2026. A nursing progress note dated 03/16/2026, written by Registered Nurse #2 documented Resident #155 was alert with some confusion at baseline, but able to make needs known. Resident #155 denied pain or discomfort, Resident #155's oral mucosa was pink and intact. Teeth intact; no sharp edges or cracks noted. Skin intact with no reddened or open areas noted. Plan of care ongoing. An undated Dental Consultation Sheet signed 10/15/2025, documented it was an initial exam for Resident #155. It was documented that the resident had a history of many crowns, which were identified in the picture. There was no documentation to indicate that Resident #155 had chipped, fractured, or root tips. There was no documentation that Resident #155's front left tooth had any issues or concerns. There were no additional dental consultations for Resident #155. A Care Conference Summary note dated 04/21/2026, documented under nursing services, an order was added for Resident #155 to see the dentist. As of 05/08/2026 there was no documented evidence that a new order for a dental consultation was added to Resident #155's physician orders. During an observation on 05/05/2026 at 1:06 PM, Resident #155 opened their mouth and half of their left front tooth was observed to be missing. During an observation on 05/12/2026 at 3:50 PM, a foul smell was noted coming from Resident #155's mouth when observing their teeth. During a telephone interview on 05/06/2026 at 9:50 AM, Family Member #3 stated when they went to visit Resident #155 in mid-February, they discovered that one of the resident's front teeth was chipped. At the time, the resident had stated their teeth kind of hurt and that they had been spitting cracked pieces of their tooth on the floor. Resident #155 told them they had fallen, but the resident had dementia, so they were unsure what happened. Family Member #3 stated they attempted to talk with staff on the floor, but could not locate the unit manager, or the residents' regular Certified Nurse Aide or Licensed Practical Nurse. They stated they met with the Director of Social Work and filed a grievance. They wanted to know what happened to cause the broken tooth and wanted to have Resident #155 seen by the dentist. They stated Resident #155 had still not been seen by the dentist. During an interview on 05/08/2026 at 11:08 AM, Certified Nurse Aide #2 stated they could not remember if Resident #155's tooth was always like that. They stated they were out of work for a couple months, so they were not sure if something happened during that time. During an interview on 05/08/2026 at 11:18 AM, Licensed Practical Nurse #1 stated they were not aware of Resident #155 having a chipped or broken tooth. They stated if they noticed a chipped/broken tooth they would report it to the manager right away. Licensed Practical Nurse #1 reapproached this surveyor at 11:55 AM and stated that Resident #155's tooth had been like that and they just never noticed. During an interview on 05/08/2026 at 11:34 AM, Registered Nurse #2 stated when family complained about Resident #155's teeth being cracked, they assessed the resident, and there were no cracks. They stated Resident #155 did not have any pain or difficulty chewing. They stated family said the resident had a chipped tooth and wanted them seen by dental. They stated they believed they put in a dental consult. They stated dental was at the facility once a month and it took no time to put in a consult. They stated they had written a progress note on 03/16/2026 and there were not sharp edges, cracks, or open areas noted. Registered Nurse #2 went with this surveyor to look at Resident #155's teeth. Registered Nurse #2 looked at the residents' teeth and stated it did not look like that when I assessed them. During an interview on 05/11/2026 at 2:59 PM, Social Worker #1 stated they wrote up a grievance in February for Resident #155. It was about a chipped tooth, not being toileted after meals, and not being up in the morning. Family met with Social Worker #1 and Director of Social Work #1 to file the grievance. Social Worker #1 could not remember if there was a specific tooth that was chipped. They stated family was going to find their own dentist and not use the facility's dentist. During an interview on 05/12/2026 at 12:23 PM, Licensed Practical Nurse #4 stated they were responsible for putting together the list of residents that needed to be seen by the dentist and they did rounds with the dentist when they came in. They stated the facility recently had a new dentist start, so now the facility has 2 dentists. They stated the dentists come to the facility once or twice a month. Licensed Practical Nurse #4 stated residents received an initial dental consult on admission, and then yearly and as needed. They stated the dentist typically checked to see if the resident had any open areas or infections and if further work was needed would refer them out. Licensed Practical Nurse #4 stated when looking at the dental consults, a circle indicated a crown, an x indicated a missing tooth, a fx (fracture) indicated a chipped tooth or half a tooth, and triangles indicated a root tip. Licensed Practical Nurse #4 stated they were responsible for entering any orders given and uploading consults to the electronic medical record after a dental visit. When reviewing Resident #155's electronic medical record, they stated the resident was seen on 10/10/2025 for their initial consult and had not been seen since then. They further stated there were no new orders for dental consult for Resident #155. Licensed Practical Nurse #4 stated the last time a dentist was in was 04/20/2026. When reviewing Resident #155's initial consult, they stated there was no indication that the residents top front teeth were fractured or had root tips. During an interview on 05/12/2026 at 12:00 PM, Registered Nurse #11 stated if a resident had a cracked tooth, they would investigate to see when and how it occurred. They would complete an incident and accident report. They stated they would want to make sure the resident was eating okay, would put in a speech therapy evaluation and occupational therapy evaluation. They stated they would put in the consult and have them seen by the dentist. The stated the consult would indicate if there were any issues/problems after the resident was seen. During an interview on 05/12/2026 at 1:49 PM, Assistant Administrator #1 stated one of the grievances filed for Resident #155 was about their teeth being chipped. They stated the nurse assessed Resident #155 and did not find any cracked teeth. If they had found cracked teeth, they would refer them to the dentist and try to investigate why there was a cracked tooth. During an interview on 05/13/2026 at 10:25 AM, Dentist #2 stated they usually saw patients at bedside, completed an oral screening, charted any teeth missing or broken, or if there was a bridge or crown. A broken tooth or root tip was identified with a blue or red triangle on their consult. They stated they would document if a patient was missing part of their tooth. Dentist #2 stated the facility usually set up a consult if a resident had a filling fall out or a chipped tooth. If there were sharp edges they might be able to smooth them off. If it was not restorable, they would say that in their consult and leave it alone. Dentist #2 stated usually if a patient had a chipped tooth, they would say they wanted a consult and it would be put in. During an interview on 05/13/2026 at 12:01 PM, Administrator #1 stated if a resident had a chipped or broken tooth they would want a Registered Nurse to take a look, the medical provider involved, and a referral made to the dentist. 10 New York Codes, Rules, and Regulations 415.17(a-d)

Based on observation, record review, and interviews conducted during survey, the facility failed to ensure that its medication error rate did not exceed 5 percent for two (Resident #230 and #245) of five residents observed during medication administration with 33 observations. This resulted in a medication error rate of 6.06 percent.Findings include:The facility's policy and procedure titled Self-Administration of Medications reviewed 01/2026, documented in order to maintain residents high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team (or equivalent) has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted monthly or when there is a significant change in condition.The facility's policy and procedure titled Storage of Medications reviewed 01/2026, documented certain medications or package types, such as Intravenous (IV) solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency.Resident #230 was admitted to the facility with diagnosis of Schizophrenia (a complex, chronic brain disorder that disrupts a person's ability to interpret reality normally, causing disruptions in thought processes, perceptions, and emotional responsiveness); diabetes mellitus (a disease that affects how the body uses blood glucose (sugar));); and end stage renal disease (when kidneys have lost about 85% to 90% of their function, meaning they are no longer able to filter waste and excess fluids from your blood well enough to maintain life). The Minimum Data Set (a resident assessment tool) dated 09/15/2025, documented they could understand others and be understood, and were cognitively intact. The Medication Administration Record for Resident #230 documented give fluticasone 50 micrograms one nasal spray to each nostril daily. Apply hydrocortisone cream topical to left heel two times per day.The Comprehensive Care Plan for Resident #230 did not include care plan for self-medication administration. There were no physician's orders for Resident #230 to self-administer medication.During an observation on 05/07/2026 at 10:30 AM, Licensed Practical Nurse #5 handed Resident #230 a bottle of fluticasone 50 micrograms nasal spray to self-administer while they walked to the other side of bed with their back turned to resident. Licensed Practical Nurse #5 asked Resident #230 if they wanted assistance applying ordered hydrocortisone topical cream to left heel. The hydrocortisone topical cream was left with the resident unopened at the bedside.Resident #245 was admitted to the facility with diagnosis of chronic obstructive pulmonary disease (a progressive lung disease that causes obstructed airflow from the lungs, making it difficult to breathe), hypertension (high blood pressure), and anxiety disorder (persistent, excessive fear or worry that interferes with daily life). The Minimum Data Set, dated [DATE], documented they could understand others and be understood, and were cognitively intact. The Medication Administration Record for Resident #245 documented administer artificial tears eye drops one drop to both eyes daily.During an observation on 5/07/2026 at 10:10 AM, Licensed Practical Nurse #5 noted a bottle of artificial tears eye drops with conflicting open and expiration dates. There were dates of 03/25/2026 on the box for the eye drops, a date of 03/19/2026 on the actual bottle of eye drops and an expiration date of 09/27/illegible written on the box for the eye drops. Licensed Practical Nurse #5 stated due to the discrepancies they would throw out the bottle of eye drops and replace it with a new one from the medication room. Licensed Practical Nurse #5 administered eye drops from the bottle with the date discrepancies to Resident #245. Licensed Practical Nurse #5 later explained they forgot and then replaced the bottle of eye drops.During an interview on 05/07/2026 at 11:31 AM, Director of Nursing #1 stated they had seven residents that self-administer medication. Director of Nursing #1 provided a list of those seven residents. Resident #230 was not on the list of residents that had been approved to self-administer medications. Director of Nursing #1 stated if a resident wishes to self-administer medication they are evaluated by the interdisciplinary team; an assessment is completed by a registered nurse for capability of self-administering medication. If it is determined the resident can self-administer medications, a physician's order is obtained and placed on the resident's medication administration record. The care plan is also updated so the resident can self-administer medication.Director of Nursing #1 stated when nurses are administering medications the process includes identifying the resident, introducing themselves to the resident and explaining what medications are about to be given. The medication nurse completes the five rights of medication administration that include the right resident, right mediation, right dose, right route, time and ensure the medication is administered and consumed. 10 New York Codes, Rules, and Regulations 415.12(m)(1)

Based on observations, record review, and interviews conducted during survey, the facility failed to ensure ongoing provision of programs to support residents in their choices of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for two (Resident #3 and #243) of two residents reviewed. Specifically, Resident #3 and Resident #243 both required the use of a mechanical lift to get out of bed, and were not provided with meaningful, accommodating activities to maintain their highest quality of life. Findings include: The Policy and Procedure titled, Activities/Therapeutic Recreation Program Policy revised 01/2026, documented, It is the policy of Van Duyn Center for Rehabilitation and Nursing (VDC) to provide a structured and individualized program of activities and therapeutic recreation that meets the interests and enhances the quality of life the residents residing at the facility. Van Duyn Center aims to ensure that each resident has the opportunity to engage in meaningful activities designed to promote physical, mental, and psychosocial well-being, in accordance with their comprehensive care plan, preferences, and abilities. PROCEDURE: 2. Program Development and Staff Leading: 1. Include a variety of individualized and group options. 2. Create, design, and organize activity programs tailored to resident needs, wishes, feedback, and preferences. 3. Schedule programs to accommodate resident availability and Preferences. 4. Coordinate with community groups or vendors, as necessary. 5. Programs can be led by recreation leader, director, assistant director, music therapist, or art therapist. 3. Participation and Documentation: 1. Encourage resident participation, but honor resident's right to refuse attendance. 2. Document refusals, preferences, and participation. 3. Gather feedback regarding refusals and preferences. 4. Assist residents with transfers to programs, if appropriate / applicable. Resident #3 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that causes obstructed airflow from the lungs, making it difficult to breathe); diabetes mellitus (a disease that affects how the body uses blood glucose (sugar)); and peripheral vascular disease (a slow, progressive circulation disorder characterized by the narrowing, blockage, or spasms of blood vessels outside the heart and brain). The Minimum Data Set (a resident assessment tool) dated 11/25/2025, documented the resident was cognitively intact, made themselves understood, and understood others. During an observation on 05/06/2026 at 9:53 AM, Resident #3 was observed lying in bed with their head underneath the covers. Resident #3 stated they were awake, and shared they are blind, but they listen to the Price is Right. They stated they could hear very well. Resident #3 stated the facility does not have adaptive equipment, devices, or special programs for them. They also stated they do not remember the last time they were out of bed. However, they would like to get out of bed for sunshine and to socialize. Record review of Activities for Resident #3 documented their last activity was a 1:1 visitation on 12/25/2025. Resident #243 was admitted to the facility with diagnoses of heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen); dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and complete loss of vision. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, made themselves understood, and understood other. During an observation on 05/05/2026 at 12:52 PM, Resident #243 was observed awake in bed and did not respond to any questions. Resident #243 did not attend the group activity and was still wearing a hospital gown. Record review of Activities for Resident #243 documented their last activity was a 1:1 visitation on 02/10/2026. During an observation on 05/07/2026 at 11:03AM, there was a BINGO game with nineteen residents in attendance with Activities Aide #1. Resident #3 and Resident #243 were not present, and both were observed in their bed still wearing a hospital gown. During an interview on 05/07/2026 at 11:30AM, Activities Aide #1 stated when residents do not get out of bed, the Activities Team does one-to-one activities at the bedside. Activities Aide #1 was unable to provide recent documentation of one-to-one activities for Resident #3 and Resident #243. They stated the last documented activity for Resident #3 was 12/25/2025 and for Resident #243, the last documentation for activity was 02/10/2026. During an interview on 05/07/2026 at 12:55 PM, Certified Nurse Aide #22 stated Resident #3 does not get out of bed because it is too painful as she is frail with bony prominences. During an interview on 05/07/2026 at 1:00 PM, Physical Therapist #1 stated Resident #3 no longer received therapy services. The nursing staff can make referrals at any time necessary. Physical therapy will also provide reclining geriatric chairs and cushions for comfort for residents when out of bed. During an observation on 05/08/2026 at 10:30 AM, Residents #3 and #243 were both out of bed and sitting in the common area near the nurses' station in front of television. Resident #3 enjoys listening to television although they are unable to see. Resident #3 stated they were very happy to be out of bed and socializing with other residents. They denied any pain or discomfort. Resident #243 was awake and pleasant with no signs of discomfort. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on record review and interviews conducted during survey, the facility failed to ensure each resident's person-centered, comprehensive care plan was reviewed and revised timely for two (Resident #379 and Resident #162) out of 60 residents reviewed for care plan revisions. Specifically (a), Resident #379's care plan for psychotropic drugs was not revised when the medication Risperidone (an antipsychotic medication) was reduced from 0.25 milligrams twice daily to once daily on 01/07/2026, nor was the care plan revised when this medication was discontinued for the resident on 03/26/2026; (b) Resident #162's nutrition care plan was not revised when the resident lost their upper denture, requested ground meat instead of a regular consistency meal due to difficulty chewing their food. Findings include: Cross Referenced: F790 Routine/Emergency Dental Services The facility policy titled Care Planning/Care Conference Policy, last revised 01/27/2026, documented that it was the policy of the facility to utilize a person-centered approach to care planning. The interdisciplinary team worked in conjunction with the resident and resident's family/surrogate/designated representative, as appropriate, to provide an individualized comprehensive resident assessment and care planning process in order to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Additionally, the purpose of this policy was to ensure the resident care and treatment planning process was timely, systematic, and comprehensive, incorporated interdisciplinary input, and provided meaningful opportunities for resident and resident family/surrogate/designated representative participation. The policy further ensured that each resident had a comprehensive, person-centered care plan with individualized, measurable objectives and timeframes designed to meet the resident's medical, nursing, mental, and psychosocial needs. Resident #379 Resident #379 was admitted to the facility with diagnoses of unspecified dementia (a decline in mental abilities - such as memory, thinking, and reasoning - that is severe enough to interfere with daily life,) hypothyroidism, (a condition where the thyroid gland does not produce enough thyroid hormones,) and essential (primary) hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 03/10/2026, documented that they could make themselves understood and sometimes understood others. A review of Resident #379's care plan titled Psychotropic Drugs, last updated 05/01/2026, documented resident was at risk for potential side effects from psychotropic medications, and had a Black Box Warning for the medication Risperidone. A review of Resident #379's physician orders documented a reduction in the dose of Risperidone 0.25 milligrams from twice daily to once daily on 01/07/2026, and discontinuation of Risperidone 0.25 milligrams on 03/25/2026. There is no documented evidence that the care plan was updated related to the changes in Risperidone dosage and discontinuation. During an interview on 05/07/2026 at 12:42 PM, Registered Nurse #5 stated that whoever took the order to decrease and discontinue the medication should have updated the care plan. They stated when the order was given/written by the physician, the nursing staff should update the family and the care plan. If these steps were missed at the time the order was given, it should have been updated when the care plan was reviewed on 05/01/2026. Resident #162 Resident #162 was admitted to the facility with diagnoses of encounter for atrial fibrillation (an irregular, often rapid heart rate that commonly caused poor blood flow), hypo-osmolality (a decrease in the measured particle concentrations of the fluid in the body) and hyponatremia (a condition where sodium levels in the blood were too low), and depression (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impaired daily life). The Minimum Data Set, dated [DATE], documented the resident could be understood, could understand others and had intact cognition for daily living decisions. Resident #162's comprehensive care plan for nutrition dated 03/11/2026, documented the resident remained on a regular diet with regular consistency. Interventions included setup assistance, opening containers, cutting meat, and buttering bread. A nutrition progress note dated 04/21/2026 documented Diet Technician #1 visited Resident #162 after the resident reported missing their upper denture. The note documented the meal plan was adjusted to softer foods and the resident requested ground chicken until dentures were restored. There was no documented evidence of interventions on the care plan regarding altered food texture or mechanical soft consistency after Resident #162 reported their upper denture was missing and that they were having difficulty chewing their food, or that the resident had been seen by the dentist due to the missing denture. During an interview on 05/05/2026 at 11:05 AM, Resident #162 stated they had lost their upper denture a while ago and had been requesting ground meat for meals. They stated breakfast was usually acceptable; however, lunch and dinner meals were not consistently provided in a texture they could chew. During an observation and interview on 05/05/2026 at 1:00 PM, Resident #162 was observed without their upper denture and was served uncut roast beef for lunch. They stated they could not chew the roast beef. During an interview on 05/05/2026 at 1:00 PM, Personal Care Aide #1 stated Resident #162's dentures were missing for several months. Personal Care Aide #1 stated the resident's diet had not been changed to a mechanical soft diet. During an interview on 05/08/2026 at 11:27 AM, Diet Technician #1 stated residents missing dentures would most likely have their diets changed to ground consistency depending on their chewing ability. Diet Technician #1 confirmed they had recommended ground chicken for Resident #162 on 04/21/2026. During an interview on 05/08/2026 at 1:04 PM, Registered Nurse #2 stated Social Worker #1 had informed them Resident #162's dentures were missing several weeks earlier. Registered Nurse #2 stated they assessed the resident for difficulty chewing or eating but confirmed there was no documentation of the assessment in the electronic medical record. During an interview on 05/12/2026 at 12:46 PM, Licensed Practical Nurse #6 stated no diet changes were made because Resident #162 was not exhibiting signs of difficulty chewing food at that time. During an interview on 05/13/2026 at 10:30 AM, Director of Nursing #1 stated care plans were a guide for resident care. Any registered nurse could update the care plan. 10 New York Code of Rules and Regulations 483.21 (b)(2)(iii)

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse. Specifically, Resident #230 reported to a Registered Nurse Supervisor an allegation of abuse, stating that Certified Nurse Aide #18 abruptly rolled them over and pulled them up by their pants and threw them in their wheelchair. Findings include:Cross reference to F550, Resident Rights/Exercise of Rights.The facility policy titled, Prevention of Abuse, Neglect, Exploitation, Mistreatment and Misappropriation, last revised 02/27/2026, documented it is the policy of the facility to ensure that residents are free from abuse, neglect, exploitation, mistreatment, and misappropriation of property to prioritize the emotional, physical, and psychological well-being of all residents in accordance with federal and state guidance to through the following: Facility shall ensure that all staff are educated on the prevention, identification, and reporting of abuse, neglect, involuntary seclusion, exploitation, mistreatment, and misappropriation of property. Additionally documented under definitions, in pertinent part: mistreatment was defined as the inappropriate treatment or exploitation of a resident and neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services necessary to a resident to avoid physical harm, pain, mental anguish or emotional distress. Documented under education was that all employees shall receive education upon hire and at least annually, abuse prevention: recognizing signs of burnout, frustration, and stress, appropriate interventions for caring for behavioral residents. During an interview on 05/05/2026 at 8:41 AM, Resident #230 stated last week in the middle of the night they put the call light on for help getting from the bed to the bathroom. Certified Nurse Aide #18 told them they were independent and could do it by themselves. Resident #230 told Certified Nurse Aide #18 they could not get up alone and needed help. The aide then abruptly rolled them over and pulled them up by their pants and threw them in the wheelchair. Resident #230 stated the above happened many times, especially overnight. When asked if they had reported this to anyone else, Resident #230 said no, the facility would not do anything about it and began to cry. During an interview on 05/12/2026 at 11:40 AM, Registered Nurse #12 stated they spoke with Resident #230, they initiated and closed the investigation (date unknown). The resident had no injury and Certified Nurse Aide #18 was removed from resident #230's assignment and replaced with Certified Nurse Aide #19. There was no documented evidence that a Facility-Reported Incident involving Resident #230 was submitted to the New York State Department of Health between 03/01/2026 and 05/12/2026. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on observation, record review, and interview conducted during survey, the facility failed to ensure restraint use was monitored and implemented in accordance with a physician order and resident needs for one of one resident reviewed for restraints (Resident #13). Specifically, Resident #13 was observed wearing a physician-ordered harness seatbelt during mealtimes that was not released as required. Findings include: Resident # 13 was admitted to the facility with diagnoses of contracture (permanent shortening of muscles, tendons, ligaments or joints that limited range of motion), anoxic brain damage (brain damage caused from brain not receiving oxygen), Cerebral Palsy (neurological disorder that effects body movement). The Minimum Data Set (a resident assessment tool) dated 04/07/2026 documented Resident #13 had severe cognitive impairment, incontinent of bowel and bladder, and dependent for activities of daily living. The Restraint Minimization policy dated 04/04/2020 (revision date of 06/02/2025) documented procedure included the restraint must be released for all meals. The Interdisciplinary Care Plan Team will review restraint usage and evaluate appropriateness for each resident as their care plan is due, quarterly at a minimum. The Activities for Daily Living Comprehensive Care Plan dated 03/03/2026 documented impaired physical mobility related to cerebral palsy, restricted joint movement and stiffness, contracture (unspecified joint). Resident #13 required total assistance with all activities of daily living. The Physical Restraint Care Plan dated 04/12/2026 documented a harness seat belt while in chair for fall safety. Documented interventions included restraint will be reviewed quarterly and as needed for possible reduction and least restrictive device, responsible party to be educated on the risks/benefits of restraint. Monitor for changes in behavior, decrease in activities of daily living status, and skin breakdown. Provide opportunities for social interactions, release every two hours for activities of daily living, activities, meals and hygiene. The At Risk for Falls Comprehensive Care Plan was reviewed dated 01/12/2026; interventions included harness seat belt when in chair. The Restraint Physician's Order dated 08/19/2021 documented harness seat belt, release every two hours. The Care Conference Summary dated 04/14/2026 documented annual conference held, it lacked documented evidence of restraint review or responsible party notification. The Restraint Use assessment dated [DATE] documented a restraint in use, self-releasing seat belt. Release restraint every two hours. Restraints needed to control behavioral symptoms (rocking, kicking, sliding). Use of physical restraint is supported by seizure disorder and anoxic brain disorder. Restraint would be utilized when in wheelchair to prevent falls and enhance safety. Review of the medical record lacked documented evidence of reassessment of the physical restraint quarterly. The Restraint Use Assessments were completed 06/11/2024 and 5/04/2026. On 05/05/2026 12:16 PM Certified Nurse Aide #7 was observed feeding Resident #13. The resident was seated upright in their wheelchair and was noted to be wearing a harness vest restraint. The restraint was snug, fitting to the resident's chest and secured in the back of the wheelchair. Certified Nurse Aide #7 confirmed it was secured; per Certified Nurse Aide #7 the restraint had to be on while the resident was in their chair. They confirmed they did not release the restraint while the resident was eating lunch. During an interview on 05/07/2026 at 11:40 AM with Registered Nurse #6, they stated Resident # 13 was nonverbal and wore a harness seatbelt when out of bed and in their chair. They stated the certified nurse aides release the restraint every two hours. The restraint assessment was done quarterly by the registered nurse for the assigned unit. The restraint was released every two hours; the staff did not remove the harness they would just loosen it. There was no specific time it needed to be released for. During meals, the aides need to release it. The regular aide was familiar with Resident #13 and knew to release the restraint during meals. Certified Nurse Aide #7 was helping feed the resident and was not as familiar. 10 New York Codes, Rules, and Regulations 415.4(a)(2-7)

Based on record review and interviews during a survey, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #1) reviewed. Specifically, from 12/15/2025-01/30/2026 Resident #1 had acute medical complaints including urinary symptoms. Urinalysis reports on 12/19/2025 and 01/01/2026 were not adequately addressed by nursing and medical; the resident was treated multiple times with a cephalosporin (antibiotic) without obtaining a urine culture and sensitivity; and a urology consult was not reviewed. The resident continued with frequent complaints of not feeling well and was hospitalized on [DATE] and admitted to the intensive care unit for urosepsis (life threatening response to a urinary tract infection) and metabolic acidosis (acid build up in the blood). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.Findings include: The facility policy Physician Visits, revised 05/2025, documented the attending physician performed relevant tasks at the time of each visit that included a review of the resident's total program of care and appropriate documentation. The undated facility policy [Laboratory] Diagnostics Results and Reporting Overview, documented the laboratory results were seamlessly integrated with all other relevant clinical information in a patient's electronic medical record, making it easier to provide patients with the best possible care. The provider or authorized representative had the responsibility of interpreting the result in the context of the patient's clinical condition and taking appropriate action. The facility policy Outside Consults Policy, revised 04/2025, documented the Unit Manager/ Charge Nurse documented confirmation in the electronic medical record of follow up appointments and any recommendations. The Unit Manager reviewed recommendations with the resident's provider. Resident #1 had diagnoses including chronic kidney disease, diabetes, and a history of urinary tract infections. The 11/27/2025 Minimum Data Set assessment (a resident assessment tool) documented the resident was cognitively intact, was independent with activities of daily living, and was always continent of urine. The 12/15/2025 Registered Nurse Unit Manager #6 progress note documented the resident had acute dysuria (painful urination) and new/increased incontinence, urgency, and frequency. An order for urinalysis and urine culture was obtained from Nurse Practitioner #5. The 12/15/2025 Nurse Practitioner #5 progress noted documented the resident was seen per nursing request for follow up of dysuria. The resident reported increased frequency of urination as well as some incontinence due to urgency. The plan was to have nursing send a urine for evaluation of a possible urinary tract infection. The 12/18/2025 Nurse Practitioner #5 progress note documented the resident was seen for follow up of urine results. Nursing sent a urine sample but for some reason the laboratory did not run it. The resident reported their symptoms improved a bit so for now they would hold off on sending another sample and continue to monitor. The 12/19/2025 urinalysis laboratory report documented a urine specimen was collected 12/17/2025 at 1:15 PM, received by the lab on 12/19/2025 at 2:04 AM, and reported to the facility on [DATE] at 11:48 AM. The test was not performed because a suitable specimen was not received. Please resubmit order with yellow top urinalysis transport tube. The 12/19/2025 Registered Nurse #15 progress note documented the resident's temperature was 101.9 degrees Fahrenheit. There was no documented evidence of the unsuitable urine specimen or plans to obtain a new specimen. The 12/20/2025 Registered Nurse #14 progress note documented the resident was diaphoretic (sweaty), appeared lethargic, complained of decreased appetite, did not eat dinner, complained of upper back pain, and abdominal pain with pressure. Medical Director/Attending Physician #4 was notified, and an order was given for Tylenol for pain. The 12/22/2025 Medical Director/ Attending Physician #4 progress note documented the resident was seen for a federally mandated 30-day follow up visit which included a review of the medical record including any recent consultations and diagnostic results, discussions with staff about current medical status and review of their orders. The resident had a fever several days ago with a negative work up. The resident still felt under the weather. The genitourinary assessment documented no dysuria, urinary urgency and frequency was normal. The laboratory test results reviewed included a respiratory viral panel that was negative. There was no documented evidence the physician was aware the 12/17/2025 urinalysis was not performed due to an unsuitable specimen. The 12/23/2025 Nurse Practitioner #5 progress note documented the resident was seen at the request of nursing for follow up of nausea and vomiting. The resident reported not feeling well again today. A medication was ordered for the nausea. There was no documented evidence Nurse Practitioner #5 was aware the 12/17/2025 urinalysis was not performed due to an unsuitable specimen. The 12/25/2025 Registered Nurse #21 progress note documented the resident had complaints of body aches. They had a temperature of 101.0 degrees Fahrenheit. Orders for Rocephin (cephalosporin antibiotic) 1 gram intramuscular for one dose, Motrin 800 milligrams, and follow up with the nurse practitioner in the morning were obtained. The 12/26/2026 Nurse Practitioner #5 progress note documented the resident was seen for follow up on nausea and now reported a cough. The resident was swabbed several times over the past few weeks, and all had been negative. It was difficult to determine if the symptoms were real as the resident often reported vague symptoms. The resident reported they had not been eating or drinking. An order for a liter of intravenous saline was ordered as well as laboratory blood work that included a complete blood count and a comprehensive metabolic panel for further follow up. There was no documented evidence Nurse Practitioner #5 reordered a urinalysis when the 12/17/2025 urinalysis was not performed due to an unsuitable specimen. The 12/26/2025 Registered Nurse Unit Manager #6 progress note documented the resident was not feeling well and did not have an appetite. Stat (immediate) blood work and intravenous fluids were ordered. The 12/26/2025 complete blood count laboratory report documented an elevated white blood cell count, elevated absolute neutrophils, elevated absolute monocytes, zero absolute eosinophils, elevated neutrophils, and low lymphocytes (indications of infection). The 12/27/2026 Registered Nurse Supervisor #7 progress note documented the resident reported they still did not feel good. The 12/28/2025 Registered Nurse Unit Manager #6 progress note documented an order for urinalysis and culture was obtained. The 12/29/2025 Registered Nurse Unit Manager #6 progress note documented the resident was seen by the attending Nurse Practitioner this morning. Rocephin 1 gram daily for 5 days was ordered. The resident had new urinary incontinence, and a urinalysis and culture were ordered. The 12/30/2025 Nurse Practitioner #5 progress note documented the resident was seen for follow up of the laboratory results. The resident had not been feeling well for almost a week now. The resident had several viral respiratory panels which all come back negative. The resident developed nausea and vomiting and was given medication for that. The resident also had some intravenous fluids and blood work was ordered. The 12/26/2025 laboratory tests were reviewed and did show an elevated white blood cell count with no clear source of infection. One gram of Rocephin intramuscularly was ordered. Nursing would send a urine to evaluate for urinary tract infection. Blood work would be rechecked at the end of the week. A chest x-ray was ordered though they felt this was a gastrointestinal issue rather than a respiratory one. The physical exam did not include a genitourinary assessment. The 12/31/2025 Registered Nurse #15 progress note documented the Nurse Practitioner saw the resident this morning. The resident had increased lethargy with complaints of nausea and constipation; abdomen was tender to palpation. An order for 1-liter intravenous fluid, and abdominal x-ray, labs on Friday was obtained. The 12/31/2025 Nurse Practitioner #5 progress note documented the resident was seen for follow up of the chest x-ray results and abdominal pain. The resident continued to not feel well. The resident continued with gastrointestinal issues. An abdominal x-ray was ordered and another liter of intravenous fluids for continued poor intake. The 01/01/2026 Registered Nurse Assistant Director of Nursing #3 progress note documented a urine culture was pending. The resident had a decreased appetite and was incontinent of urine which was not their baseline. A Nurse Practitioner was notified. The 12/30/2025 urinalysis and urine culture report documented the specimen was collected on 12/30/2025 at 3:30 PM, received on 12/31/2025 at 5:31 AM, and reported 01/01/2026 at 9:57 AM. The report documented the specimen contained trace blood, trace protein, 2+ leukocyte esterase, 40-60 white blood cells (indicating infection) and 6-10 squamous epithelial cells (indicated an unclean specimen) and a urine culture was recommended. The urine culture documented less than 10,000 CFU (colony forming units)/milliliter of single gram-negative organism (bacteria) isolated and no further testing would be performed. If clinically indicated, recollection using a method to minimize contamination, with prompt transfer to urine culture transport tube was recommended. The 01/02/2026 Nurse Practitioner #5 progress note documented the resident was seen for follow up of abdominal pain. The abdominal x-ray showed significant fecal matter and a superimposed ileus (slow down or stoppage of movement in the bowel). The resident had not been eating well due to not feeling well. Medications were ordered for constipation. There was no documented evidence the urinalysis report from 01/01/2026 was reviewed. The 01/14/2026 Nurse Practitioner #5 progress note documented the resident was seen for follow up on nausea. Nursing reported that the resident complained they did not feel well today. They had off-and-on stomach issues over the last few weeks. A different medication was ordered for nausea. The physical exam did not include a genitourinary assessment. There was no documented evidence that the urinalysis report from 01/01/2026 was reviewed. The 01/15/2026 Nurse Practitioner #5 progress note documented the resident was seen for follow up on cough and nasal congestion. The resident continued to not feel well. They had new or different complaints pretty much every day for the past couple of weeks. Yesterday, they were nauseous. They ordered a chest x-ray and laboratory orders for a complete blood count and a comprehensive metabolic panel. There was no documented evidence the urinalysis report from 01/01/2026 was reviewed. The 01/16/2026 Registered Nurse Supervisor #7 progress note documented the resident stated they did not feel well and had a temperature of 101.5 degrees Fahrenheit. The resident was pale, had audible wheezing and a productive cough. Orders were received and implemented for Tylenol, breathing treatments, steroid therapy and intravenous fluids. The 01/16/2026 Nurse Practitioner #5 Progress note documented the resident was seen for follow up on abnormal laboratory results. The laboratory results were reviewed. The resident did not have a white blood cell count so it did not seem like they had an active infection. The white blood cell count on 01/15/2026 was 10.5 (reference range 3.8-10.8). They thought the resident was slightly dehydrated as they had not had great oral intake over the past couple of days. Intravenous fluids were ordered. There was no documented evidence that the urinalysis report from 01/01/2026 was reviewed. The 01/17/2026 Registered Nurse #16 progress note documented the resident had a temperature of 102 degrees Fahrenheit, heart rate was elevated at 102, respirations were elevated at 24 and shallow. An order for a one-time Rocephin (antibiotic) one (1) gram dose was obtained from Nurse Practitioner #5. The 01/19/2026 Registered Nurse #17 progress note documented the resident was lethargic, had slowed speech, and delayed responses. The 01/19/2026 Registered Nurse Unit Manager #6 progress note documented the resident reported they did not feel well. The attending nurse practitioner was notified and ordered Rocephin one (1) gram daily for 4 days. The 01/20/2026 Nurse Practitioner #5 progress note documented the resident was seen for follow up on fever. The resident did not feel well over the weekend and was lethargic. When vital signs were obtained, the resident had a fever of 102 degrees Fahrenheit and on call was contacted and the resident was given one gram of Rocephin. Today the resident reported they still did not feel well. Viral illness was ruled out several times. Chest x-rays were all negative. It was unclear what was going on with the resident at this time, but they were obviously sick. The plan was to give Rocephin one gram daily for 4 more days and laboratory tests on Wednesday (01/21/2026). The 01/20/2026 Urology Consult progress notes documented the resident had a cystoscopy (visualization of the urinary system using a thin, lighted camera tube) for gross hematuria (blood in urine) and urge incontinence. The cystoscopy was normal. The plan was for vaginal estrogen nightly for atrophy and concerns for recurrent urinary tract infections. The 01/20/2026 Registered Nurse Supervisor #7 progress note of consultation review documented the resident had a urology appointment with a normal cystoscopy and start vaginal estrogen nightly using finger application. There was no documented evidence that a nurse practitioner or physician was made aware of the urology procedure or the medication recommendation. There was no documented evidence that a Nurse Practitioner/Physician reviewed the details of the urology appointment or the recommendation to start vaginal estrogen cream nightly for recurrent urinary tract infections. The 01/21/2026 Registered Nurse Supervisor #7 progress note documented the resident was tired throughout the shift and refused to get out of bed, they had a poor appetite and episodes of emesis (vomiting). A nurse practitioner was notified. The resident remained on Rocephin for increased white blood cell count. The 01/21/2026 Medical Director/ Attending Physician #4 progress note documented the resident was seen for a federally mandated 60 day follow up visit which included review of the medical record including any recent consultations and diagnostic results, discussion with staff about their current medical status and review of orders. The genitourinary assessment documented frequency and urgency were normal. Blood work from 01/21/2026 was reviewed. There was no documented evidence the urinalysis report from 01/01/2026 or the 01/20/2026 urology visit details were reviewed The 01/22/2026 Registered Nurse Supervisor #7 progress note documented the resident remained in bed and reported not feeling well. The 01/22/2026 Nurse Practitioner #5 progress note documented the resident was seen for follow up on nausea and vomiting. The resident had not been feeling well over the past week or so. The laboratory results did not show anything specific, and they had ruled out viral respiratory illness. The resident now reported nausea and vomiting. A change in medication for nausea was ordered. The physical exam did not include a genitourinary assessment. There was no documented evidence the urinalysis report from 01/01/2026 or the 01/20/2026 urology visit details were reviewed The 01/29/2026 Nurse Practitioner #5 progress note documented the resident was seen for follow up of influenza A and multiple falls. The resident was found to have influenza A last week and was treated with Tamiflu. Today, again, the resident was reporting feeling worse and was quite lethargic. The resident's lung sounds were poor. A chest x-ray and recheck of a complete blood count and comprehensive metabolic panel was ordered. The physical exam did not include a genitourinary assessment. There was no documented evidence the urinalysis report from 01/01/2026 or the 01/20/2026 urology visit details were reviewed The 01/30/2026 Nurse Practitioner #5 progress note documented the resident was seen for follow up on their chest x-ray which showed clear lungs. The resident reported feeling a bit better today. It was discussed with the resident to get out of bed and go to breakfast as they had been in bed for the past week. The physical exam did not include a genitourinary assessment. The 01/30/2026 Registered Nurse Supervisor #7 documented the resident had an unresponsive episode, had pale skin, and was diaphoretic with labored breathing. A physician was notified and a new order to send to the hospital for further evaluation was obtained. The 01/30/2026 Hospital emergency room physician progress notes documented an unidentified resident came in for a reported psychiatric evaluation. However, on presentation the patient was tachycardic (elevated heart rate) and tachypneic (elevated respirations) and ill-appearing. The resident was non-verbal and could not provide any further history, so it was very limited. On physical exam the resident was ill-appearing and toxic-appearing. The resident was admitted to the intensive care unit in critical condition for severe sepsis (systemic infection), metabolic acidosis (acid build up in the blood), likely starvation ketosis (the body breaks down fat for energy when there is not enough blood sugar). The Hospital History and Physical documented the resident was critically ill with a serious or life-threatening alteration in organ system function or was at high risk for deterioration of vital organ system dysfunction. The principal problems were acute metabolic and septic encephalopathy (brain dysfunction caused by body-wide illness), severe sepsis due to urinary tract infection, metabolic acidosis, hyperkalemia (high potassium level) of 8.1 (normal 3.5-5.0), and acute kidney injury superimposed on chronic kidney disease. The urine culture showed a resistance to cephalosporin (Rocephin) antibiotics. The 02/06/2026 Hospital Discharge Summary documented the resident completed seven (7) days of intravenous antibiotics for sepsis and bacteremia secondary to a urinary tract infection. During an interview on 02/26/2026 at 11:36 AM, Licensed Practical Nurse #10 stated Resident #1 was very sick prior to their hospitalization on 01/30/2026. The resident had urinary incontinence, was too sick to complain, was only verbal to a minimum, was weak, and did not get out of bed. During a telephone interview on 02/26/2026 at 11:53 AM, Registered Nurse Unit Manager #6 stated Resident #1 was sick prior to hospitalization. They did a lot of blood work and the resident's white blood cell counts were high. The resident needed intravenous fluids and antibiotics. There was a problem with the 12/2025 urine specimen and Nurse Practitioner #5 said they did not need it. A urine culture and sensitivity was needed to determine the right antibiotic. A urinary tract infection could get worse if not treated. Resident #1 was hospitalized with a urinary tract infection on 01/30/2026 after they became unresponsive. During an interview on 02/26/2026 at 12:33 PM, Registered Nurse Supervisor #7 stated Resident #1 was very ill for a couple of weeks prior to their hospitalization for a urinary tract infection with sepsis. They did not remember if a urine specimen was collected. They ran a lot of tests on the resident because they did not know why they were sick. During a telephone interview on 02/26/2026 1:03 PM, Nurse Practitioner #5 stated if a resident had a urinary tract infection, they expected to see symptoms such as burning with urination, frequency, suprapubic tenderness, and new urinary incontinence. If a urinary tract infection was not identified, it could get worse. If a resident was symptomatic with fevers or chills and the urinalysis showed increased leukocytes and white blood cells, they would start antibiotic treatment even before a urine culture resulted. If a urine culture showed resistance to cephalosporins, Rocephin would not be an appropriate treatment. Resident #1 ended up being hospitalized for urosepsis from a urinary tract infection. The resident had been sick for several weeks prior to the hospitalization. They were not sure if they ordered a urine specimen or not, but they were ordered too frequently, and infections were treated that did not need to be. They assumed the resident's hospitalization could have been prevented but the resident presented differently. During a telephone interview on 02/26/2026 at 2:35 PM, the Medical Director/ Attending Physician #4 stated they were responsible for overseeing the resident's medical care. If a resident had new onset urinary incontinence, decreased intake, abdominal pain, nausea/ vomiting, they would order tests to look for acute illness. They would have done a physical exam, reviewed their history, looked at the current medication list and ordered a complete blood count, comprehensive metabolic panel, urinalysis and culture. These symptoms could indicate constipation, urinary tract infection, bowel obstruction, sepsis, or pyelonephritis (kidney infection). Results of the tests ordered should be reviewed by the provider as soon as they come in. The provider who ordered diagnostic tests was responsible for reviewing the results. If an infection was identified, an antibiotic should have been ordered at that time. During a follow up telephone interview on 03/04/2026 at 11:01 AM, Nurse Practitioner #5 stated if they reviewed the results of a urinalysis, it would be documented in their progress notes. Resident #1 was sick for a long time, they did not suspect urinary tract infection, but urinalysis could rule out or conclude infection. They eventually ordered a urinalysis but was not suspicious of a urinary tract infection. The resident had a cystoscopy on 01/20/2025, and they thought the office would have done a urine test prior to the procedure. The resident should not have an invasive procedure like that if they were sick. They were not sure how the urinary tract infection diagnosis was missed, but the resident never complained of urinary symptoms. They believed the invasive procedure (cystoscopy) 10 days prior to hospitalization when the resident was already not feeling well was the cause of the urinary tract infection that led to hospitalization. The resident was complicated because of mental illness and frequently reported vague sick complaints with negative work ups. The resident did not bounce back this time, then got the flu, so they thought that was why they were sick. During a follow up telephone interview on 03/04/2026 at 11:34 AM, Medical Director/Attending Physician #4 stated after reviewing the urine results from 01/01/2026 for Resident #1, the urinalysis was suspicious for infection and should have been correlated with symptoms. They would have treated this empirically with an antibiotic. If any lab work was ordered, it was ordered for a reason, and the ordering provider was responsible for reviewing the results. The resident was very sick when they were hospitalized on [DATE]. If the nurse practitioner could not determine the source of infection, they expected they would send them to the hospital, especially if they were not responding to the ordered treatment. There was no question, the resident had a very serious illness on the most recent hospitalization with significant acidosis, urosepsis, acute kidney injury, and was severely dehydrated. During a follow-up interview on 03/04/2026 at 12:02 PM, Medical Director/Attending Physician #4 stated they looked at the resident's record and found a urology consult and the resident had a cystoscopy on 01/20/2026 for gross hematuria. The urology office must have done urine testing prior to that procedure, as the resident had to be healthy to undergo the procedure so more than likely the infection came after the cystoscopy. During a follow-up telephone interview on 03/04/2026 at 2:10 PM, Nurse Practitioner #5 stated they usually followed a specialist's recommendation for a medication. If they reviewed a consultation sheet they would initial and date it. It was documented in a note if it was reviewed. The resident was not on vaginal estrogen as recommended after the procedure to help with atrophy and current urinary tract infections. They were on an oral medication, so this was likely a pharmacy recommendation. During a follow-up telephone interview on 03/04/2026 at 2:23 PM, Medical Director/Attending Physician #4 stated there was documentation Registered Nurse Supervisor #7 reviewed the urology consultation paperwork. It did not document a discussion with the provider. They did not see the vaginal estrogen was ordered as recommended but the resident was on a similar oral medication for a long time. The indication was to build up the vaginal mucosa and therefore the resident may have less urinary tract infections. The specialist recommendations were normally followed unless there was a reason not to. Theoretically, the vaginal cream was used instead of the pill because there was less risk for stroke. They saw the resident on 01/21/2026 but the urology consultation was likely not uploaded yet at that time. 10 New York Codes, Rules, Regulations 415.15(b)(1)(i)(ii)

Based on record review and interview during the survey the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1's care plan documented the resident was to have no male caregivers. During the night shift (11:00 PM-7:00 AM) on 02/03/2026, male Certified Nurse Aide #2 was assigned to provide 1:1 supervision for Resident #1. On 02/04/2026 at 7:00 AM Certified Nurse Aide #2 was witnessed by Certified Nurse Aide #1 abusing Resident #1. The facility's failure to ensure comprehensive care plans were implemented resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 418 residents in the facility at risk for the likelihood of serious physical and psychological harm, serious injury, serious impairment, or death. Refer to: F 600 Findings include:The facility policy Care Planning/Care Conference Policy, revised 01/27/2026, documented the facility utilized a person-centered approach to care planning. The interdisciplinary team worked in conjunction with the resident and resident's family/designated representative, as appropriate to provide an individualized comprehensive resident assessment and care planning process to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility policy Dignity and Respect, revised 01/2026, documented residents have the right to be cared for in a manner that enhances their quality of life, free from humiliation, harassment or threats. Residents also have the right to be free from physical, mental and verbal abuse and be treated with dignity, respect and consideration at all times. Resident #1 had diagnoses including traumatic brain injury and anxiety. The 01/22/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, had verbal and behavior symptoms directed toward others, required moderate assistance or was dependent for most activities of daily living. The 01/23/2026 Comprehensive Care Plan documented the resident had behaviors related to their traumatic brain injury with cognitive deficits that included verbal aggression and physical aggression towards staff. Interventions included two (2) caregivers for care, no male caregivers, and 1:1 during the night shift due to falls at night. The undated care instructions documented two (2) staff for all care and no male caregivers. The 02/01/2026, 02/09/2026, and 02/12/2026 certified nurse aide assignment sheet documented male Certified Nurse Aide #14 was assigned to Resident #1 during the 7:00 AM-3:00 PM shifts. The 02/03/2026 certified nurse aide assignment sheet documented Certified Nurse Aide #4 (male) was assigned to Resident #1 as their 1:1 for the night shift on 11:00 PM-7:00 AM. The 02/04/2026 Incident Report and witness statements documented on 02/04/2026 at 7:00 AM, Certified Nurse Aide #1 and Certified Nurse Aide #2 were providing care to Resident #1 care on the last rounds of the nightshift when Resident #1 became combative. Certified Nurse Aide #1 interlocked their hands with the resident to de-escalate the situation and Resident #1 spit at Certified Nurse Aide #2. Certified Nurse Aide #2 was witnessed pushing Resident #1's face down with their hand. During an interview on 02/24/2026 at 10:37 AM, Assistant Director of Nursing stated Resident #1 appeared more agitated and aggressive towards males, which their spouse agreed was true. The care plan was updated to include no male caregivers. This information was documented on the special information on the care card, which certified nurse aides had access to. During a follow up interview on 02/25/2026 at 11:19 AM, Assistant Director of Nursing #5 stated they did not know male caregivers were assigned to the resident. Care plans should be followed as they instructed staff how to care for the residents. During an interview on 02/24/2026 at 2:56 PM, Certified Nurse Aide #1 stated they were assisting Certified Nurse Aide #2, who was assigned 1:1 for Resident #1 on the nightshift. Resident #1 became combative during care and spit into Certified Nurse Aide #2's face. Certified Nurse Aide #2 forcefully pushed Resident #1's face into the pillow causing scratches over the resident's face and neck. During an interview on 02/24/2026 at 3:09 PM, Licensed Practical Nurse #3 stated they asked Licensed Practical Nurse Assistant Unit Manager #11 why the resident had a male 1:1 on 02/04/2026 as they were not to have male caregivers. They stated Licensed Practical Nurse Unit Manager #11 checked Resident #1's care plan and confirmed the resident was not supposed to have male caregivers. During an interview on 02/24/2026 at 3:22 PM, Licensed Practical Nurse Unit Manager #11 stated there was a previous incident where the resident was using foul, offensive language toward male Certified Nurse Aide #14. They stated after this they made the resident no male caregivers. The overnight nurse or licensed practical nurse team leader on the floor was responsible for assigning the 1:1 for the resident. During a telephone interview on 02/25/2026 at 10:46 AM, Registered Nurse Supervisor #8 stated the unit assignments were planned out, but they usually let the floor staff decide what certified nurse aide did the 1:1 for the shift. They were unaware Resident #1 was not to have male caregivers. They heard Resident #1 had negative interactions with male caregivers, they triggered the resident, and they became agitated. They stated care plans should be followed to ensure residents' needs were met. During an interview on 02/25/2026 at 12:53 PM, the Director of Nursing stated the care card directed care and all staff, certified nurse aides, the licensed practical nurses and the Registered Nurse Supervisor, were supposed to look at it at the beginning of their shift prior to care. The certified nurse aide assigned to the resident for the shift, the certified nurse aide assigned to be the resident's 1:1, and the licensed practical nurse should have all seen Resident #1 was not to have male caregivers. The licensed practical nurse or an advanced certified nurse aide were the ones who made the floor assignments. They were unsure who made the assignments for the night shift on 02/03/2026. They stated the assignment of Certified Nurse Aide #2 as the 1:1 was not a care plan violation as the 1:1 was for falls, not care. The resident had a female certified nurse aide assigned for their care. When male Certified Nurse Aide #2 was assisting Certified Nurse Aide #1, they were only buckling the resident's brief which was not considered providing care. During an interview on 02/26/2026 at 10:25 AM, Nurse Practitioner #9 stated Resident #1 was care planned to have no male caregivers and should not have had a 1:1 who was male. Male caregivers triggered the resident since the resident was admitted to the facility. They were confused as to why a male certified nurse aide was involved. It was important to follow the residents' care plan to ensure their safety. During an interview on 02/26/2026 at 10:41 AM, the Medical Director stated they heard that Resident #1 was not supposed to have male caregivers. If the care plan documented a resident was to not have male caregivers, they should not have male caregivers. 10 New York Codes, Rules and Regulations 415.11(c)(1)The facility performed the following steps to lift the Immediate Jeopardy for F656 issued 02/27/2026 at 5:15 PM:- As of 02/27/2026, Resident #1's care plan was reviewed to ensure all interventions, including the no-male caregivers was clearly documented and communicated to all staff. - As of 02/28/2026, 100% of in-house staff were educated on adhering to care plans, residents who required no male care and where it was documented, and reviewing care cards for their assignment prior to starting care with the care card acknowledgement sign off. - As of 02/28/2026, an immediate review had been completed to identify individuals with the specific need for no male care.- Unit assignment sheets were verified to have the no male caregiver residents clearly identified as compared against the master list provided by the facility. - On the evening of 03/01/2026 they reached 85% of their total staff educated for adhering to care plans residents who required no male care and where it was documented and reviewing care cards for their assignment prior to starting care with the care card acknowledgement sign off. - On 03/02/2026 Staff education list was reviewed and verified against the post-test and staff listing with no discrepancies. - Staff assignments were verified against the no male caregiver list to ensure no residents who were care planned to not have male care were given care by male staff with no discrepancies. - Care Card acknowledgement sign-off sheets were verified against the staff assignment sheets to verify they were being completed. - On 03/02/2026 Staff education was verified on site; Multiple certified nurse aides, licensed nursing staff, and Unit Managers were interviewed with concerns noted regarding retention related to review the resident care cards and signing off they had done so. - On 03/02/2026, the care card acknowledgement sheet for 7 North 11 PM to 7 AM shift was blank and not signed by staff. - On 03/02/2026, the care plans of the residents identified to not want male care were reviewed to ensure the information was clearly documented on the care plan and care card. Two residents identified did not have the information on their care card or care plan. - On 03/03/2026 the Administrator provided a plan to re-educate the staff regarding reviewing the care card prior to their shift, an audit for ensuring the designation for no male was clearly identified on the care plan and signing the care card acknowledgement sheet process. - On 03/04/2026 they reached 91% of their total staff for re-education. - On 03/04/2026 Staff education was verified on site; Multiple certified nurse aides and licensed nursing staff were interviewed with no concerns noted. The Administrator was notified the Immediate Jeopardy was lifted on 03/04/2026 at 12:58 PM.

Based on record review and interviews during the abbreviated survey the facility failed to ensure residents were free from abuse for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1's head was forcefully pushed backward by Certified Nurse Aide #2 during care resulting in scratches and redness to Resident #1's face. The facility's failure to protect residents from abuse resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 418 residents in the facility at risk for the likelihood of serious injury, serious harm, serious impairment, or death.Findings include: The facility policy Prevention of Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Policy, revised 02/2026, documented residents were to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of property to prioritize the emotional, physical, and psychological well-being of all residents in accordance with federal and state guidance. The willful infliction of injury, involuntary seclusion, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse applies to all residents, regardless of mental or physical condition. Physical Abuse was the use of physical force that may result in bodily injury, physical pain, or impairment.Resident #1 had diagnoses including traumatic brain injury and anxiety. The 01/22/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, had verbal and behavioral symptoms directed toward others, and was dependent or required moderate assistance for activities of daily living. The Comprehensive Care Plan revised 02/13/2026 documented the resident had behaviors related to their traumatic brain injury with cognitive deficits including verbal aggression and physical aggression towards staff. Interventions included two (2) caregivers for care, no male care givers; and 1:1 during the night shift due to falls at night. The 02/04/2026 facility Incident Report completed by Registered Nurse Investigator #11 documented on 02/04/2026 at 7:00 AM, Certified Nurse Aide #1 and Certified Nurse Aide #2 (male) were providing care to Resident #1 during the last rounds of the nightshift. Resident #1 became combative during their incontinence brief change. Certified Nurse Aide #1 interlocked their hands with the resident to de-escalate the situation and Resident #1 spit at Certified Nurse Aide #2. Certified Nurse Aide #2 was witnessed by Certified Nurse Aide #1 pushing Resident #1's face down with their hand. Certified Nurse Aide #1 instructed Certified Nurse Aide #2 to leave the room. Licensed Practical Nurse #3 came to the room due to hearing screaming. Resident #1 told Licensed Practical Nurse #3 the certified nurse aide was yelling at them, disrespecting them, and scratched their face twice. Certified Nurse Aide #1 reported the incident to Registered Nurse/Assistant Director of Nursing #5 (time of report was not documented). Registered Nurse/Assistant Director of Nursing #5 assessed Resident #1 who had an abrasion below their right eye and on the right cheek, redness to the tip of their nose, redness to the left eyebrow and below the left eye, two (2) abrasions above the lip on the right and a scratch from the bottom right lip extending to the chin. The resident was assessed for emotional distress and appeared to be agitated. The resident was assessed by the Medical Director on 02/06/2026. The 02/04/2026 timecard for Certified Nurse Aide #2 documented they clocked out at 7:10 AM. There was no documented evidence Certified Nurse Aide #2 left the premises at 7:10 AM. During an interview on 02/19/26 at 10:35 AM, Certified Nurse Aide #1 stated on 02/04/2026 at around 6:50 AM, they went to see who the 1:1 for Resident #1 was on the over the night shift. Certified Nurse Aide #2 asked them for assistance with changing Resident #1. Resident #1 was lying naked across their bed and stated they did not want to be touched. They told Certified Nurse Aide #2 they should reapproach the resident later, but Certified Nurse Aide #2 wanted to proceed due to time constraints. Certified Nurse Aide #1 stated Resident #1 allowed them to roll them but when they went to pull the resident's brief up, the resident started swinging. They asked the resident to stop, and the resident stated they did not want the certified nurse aides touching them. Resident #1 spat in Certified Nurse Aide #2's face. Certified Nurse Aide #2 put their hand on the resident's face and pushed it aggressively. Resident #1 became red in the face and more agitated after having their face pushed. They stated they pushed Certified Nurse Aide #2 away from the resident and told them to leave. They did not know where Certified Nurse Aide #2 went after they left the room. During a follow up interview on 02/24/2026 at 2:56 PM, they stated the resident had lacerations and scratches all over their face and neck. They stated they knew a resident could not be held down like that and it was abuse. They had informed both Licensed Practical Nurse #3 and Registered Nurse/Assistant Director of Nursing #5. During an interview on 02/24/2026 at 3:09 PM, Licensed Practical Nurse #3 stated on the morning of 02/04/2026, they heard someone scream just before the night shift change and determined it was Resident #1. As they got to the resident's room, Resident #1 stated the [expletive] scratched them in the face. There was redness and scratches on the resident's face. The resident was very agitated, used foul language, and stated they were disrespected by staff. Licensed Practical Nurse #3 stated they informed Licensed Practical Nurse Assistant Unit Manager #4 of the incident when they came in for their shift sometime after 7:00 AM that morning. During an interview on 02/24/2026 at 3:22 PM, Licensed Practical Nurse Assistant Unit Manager #4 stated they were informed around 7:30 AM on 02/04/2026 there were some problems overnight with Resident #1 and Certified Nurse Aide #2, but they were not informed abuse occurred. They were informed by Registered Nurse/Assistant Director of Nursing #5 Resident #1 had red marks and an open area to the side of their mouth. As soon as an allegation was made, the staff member should be put on suspension pending the investigation. Licensed Practical Nurse Assistant Unit Manager #4 stated Certified Nurse Aide #2 was not in the facility when they arrived for work, but they would have been removed immediately if they had known. During a phone interview on 02/25/2026 at 9:49 AM, Certified Nurse Aide #2 stated on 02/04/2026 around 6:50 AM, they were providing care to Resident #1 with another certified nurse aide. Resident #1 was swinging their arms around. They stated they did not push the resident's face or hurt them in any way. They did not know where the marks on the resident's face came from. They stated no one told them to leave the facility; they left because their shift was over. During an interview on 02/25/2026 at 11:19 AM, Registered Nurse/Assistant Director of Nursing #5 stated around 11:30 AM to 12:00 PM, Certified Nurse Aide #1 informed them that Resident #1 spit in Certified Nurse Aide #2's face and Certified Nurse Aide #2 held Resident #1's face down with their hand while the resident was swinging. Certified Nurse Aide #1 told Certified Nurse Aide #2 to get out of the room. Certified Nurse Aide #1 stayed with the resident to calm them down. During an interview on 02/25/2026 at 1:23 PM, the Administrator stated Certified Nurse Aide #2 left the unit and had clocked out on the time clock at 7:10 AM on 02/04/2026. Generally, after a staff member clocks out at the time clock, they leave the building. They believed Certified Nurse Aide #2 left the building after clocking out, but they could not say for sure.During a phone interview on 02/26/2026 at 10:25 AM, Nurse Practitioner #9 stated if there was alleged abuse, they should assess the resident to ensure they were okay. They were notified the next day Resident #1 had complained they were assaulted by a certified nurse aide on the night shift. The resident had abrasions. If there was an allegation of abuse, the employee should be pulled off the floor and off the premises until the investigation was completed. If there were no witnesses to where Certified Nurse Aide #2 went after they clocked out, they could not ensure the certified nurse aide left the building. During a phone interview on 02/26/2026 at 10:41 AM, the Medical Director stated if there was alleged abuse by staff against a resident, the staff member should be notified they were being investigated and kept away from the residents until it was determined there was no risk. Medical staff should be notified of the allegation and of any injuries. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)____________________________________________________The facility performed the following steps to lift the Immediate Jeopardy for F600 issued 02/27/2026 at 5:15 PM:- As of 02/27/2026, Resident #1 had a head-to-toe assessment and psychosocial evaluation to ensure no further harm occurred. - As of 02/25/2026, the facility policy for abuse was revised to include that failure to follow a resident's care plan can place residents at risk for abuse and employees who were alleged of abuse were to have an immediate escort from the facility by security and placed on administrative leave pending completion of the investigation.- Certified Nurse Aide #2's employment was terminated on 02/19/2026 - As of 02/28/2026, 100% of in-house staff were educated on the abuse prevention policy, reporting abuse within appropriate timeframes, and the importance of following the care plan. - As of 02/28/2026, an immediate review had been completed to identify individuals with the specific need for no male care and current staff assignments were evaluated to match residents based on care plan and needs.- On the evening of 03/01/2026 they reached 85% of their total staff educated on abuse prevention policy, reporting abuse within appropriate timeframes, and the importance of following the care plan. - On 03/02/2026 Staff education list was reviewed and verified against the post-test and staff listing with no discrepancies. - Staff education was verified on site on 03/02/2026; Multiple certified nurse aides, licensed nursing staff, security, and housekeeping were interviewed regarding abuse and reporting abuse with no concerns noted. The Administrator was notified the Immediate Jeopardy was lifted retroactively to 03/01/2026 on 03/04/2026 at 12:58 PM.

Based on record review and interviews conducted during the survey, the facility failed to ensure residents were free from abuse for one (1) of three (3) residents reviewed (Resident #1). Specifically, Resident #1 had a history of verbal behaviors of using racial slurs directed at others and had multiple physical behaviors directed toward others, including the following:-on 09/10/2025 Resident #1 threw coffee at staff, hitting another resident. -on 09/30/2025, Resident #1 hit Resident #3 in the face. -on 11/10/2025, Resident #1 refused medications and started swinging at staff. -on 12/24/2025, Resident #1 threw a glass vase at staff. -on 12/25/2025, Resident #1 hit Resident #2 in the head with a wheelchair leg rest. There was no documented evidence effective/adequate interventions were put into place after each incident to protect residents from potential abuse by Resident #1. The facility's failure to protect residents from abuse resulted in potential for harm that is Immediate Jeopardy and Substandard Quality of Care and placed all 456 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death.Findings include:The facility policy Care Planning/Care Conference revised 05/20/2025, documented the comprehensive care plan should describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences and how the facility would assist in meeting needs and preferences. Care plans were to be updated/initiated at the time of any change in the resident's status, needs, goals and/or interventions. Care plans were to be reviewed and revised as appropriate upon readmission, quarterly, annually and with any significant change. The facility policy Prevention of Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property, revised 05/2025, documented it was the policy of the facility to assure that all staff was familiar with the prevention of abuse, neglect, involuntary seclusion and misappropriation of property. The facility would investigate and report all allegations of abusive conduct. The facility would prevent further abuse of the allegedly abused residents while the investigation was in progress. In addition to orientation, all employees shall be in-serviced annually regarding the appropriate interventions for dealing with aggressive residents. Resident #1 had diagnoses including Alzheimer's disease and bipolar disorder (extreme shifts in mood) with psychotic (disconnection with reality) features. The 10/02/2025 Minimum Data Set (a resident assessment tool) documented the resident's cognition was moderately impaired and they had no behavioral symptoms during the assessment period. There was no documented evidence of a behavioral care plan prior to 12/25/2025. The 09/10/2025 at 2:20 PM Registered Nurse Supervisor #7 progress note documented staff reported the resident threw coffee on staff, hitting another resident seated at the table. They tried to talk to the resident about throwing the coffee, the resident did not want to continue speaking about their behavior and they used excessive profanity toward staff and residents. Medical staff were notified with a new order for labs and a valproic acid (Depakote, anticonvulsant medication used as a mood stabilizer) level. There was no documented evidence of an incident report for the 09/10/2025 behavior of throwing coffee; no documented evidence of a root cause analysis for the resident's behaviors to determine appropriate interventions; and no documented evidence the resident's care plan was reviewed/updated regarding behavioral symptoms. The 09/11/2025 laboratory report documented the valproic acid level was low at 19.6 micrograms per milliliter (normal range 50-100 micrograms per milliliter, indicating the drug concentration in the blood was low and the medication dose may require an adjustment).The 09/30/2025 at 5:45 PM Incident Report completed by Registered Nurse #2 documented that on 09/30/2025, Resident #1 had a negative interaction with Resident #3. The 10/01/2025 Investigative Summary completed by the Director of Investigations and attached to the 09/30/2025 Incident Report documented Resident #3 attempted to remove food from Resident #1's plate and Resident #1 hit Resident #3's cheek resulting in light redness. Corrective action was Resident #3 was encouraged to remain seated during meals. There was no documented evidence Resident #1's care plan was reviewed/updated regarding them hitting Resident #3 or interventions to avoid recurrence. Nursing progress notes from 11/05/2025 to 11/10/2025 documented Resident #1 was refusing medications including Depakote, using racial slurs, and was physically aggressive towards staff. The 12/23/2025 at 6:15 PM Investigative Summary completed by Registered Nurse Investigator #3 documented Resident #1 was attempting to clean up the table during mealtime when they were punched in the mouth by Resident #2. Resident #1 sustained a loose lower front tooth. Interventions were put into place for Resident #2 including 1:1 supervision, initiation of Depakote and a psychiatric consult. On 12/23/2025, Resident #1's care plan was updated with the potential to be abused. The 12/24/2025 at 12:03 PM Licensed Practical Nurse Assistant Manager #4 progress note documented Resident #1 attempted to throw a glass vase at staff and used racial slurs. Resident #1 was redirected to their room. The provider saw the resident and the provider would review Depakote orders and change the dose. The resident was now calm. The 12/24/2025 Nurse Practitioner #4 note documented they followed up with Resident #1 after they were punched in the mouth. One (1) loose tooth was noted. The plan was to refer the resident to dental and increase the Depakote dose.There was no documented evidence of a physician or practitioner order to increase Depakote. The 12/25/2025 Incident Report and nursing note completed by Registered Nurse Supervisor #6 documented Resident #1 hit Resident #2 in the head with a wheelchair leg as Resident #2 ambulated down the hallway with their 1:1 staff. Resident #2 sustained redness to their forehead and neurological checks were normal. Medical was aware and the care plan was in place and ongoing. Four (4) wheelchair legs were found in Resident #1's room and were removed. The 12/25/2025 at 9:12 PM, Licensed Practical Nurse #1 progress note documented Resident #1 hit Resident #2 in the forehead with a wheelchair leg rest from their wheelchair. When they asked Resident #1 why they hit Resident #2, the resident stated they wanted Resident #2 to pay for the teeth they knocked loose, and every time they saw Resident #2, they were going to kick their ass. On 12/25/2025, Resident #1's comprehensive care plan was updated with potential to abuse others. One (1) intervention was added to include redirect the resident. The 12/29/2025 physician order documented Resident #1's Depakote was increased to 500 milligrams twice daily.During an interview on 01/08/2026 at 2:28 PM, Certified Nurse Aide #9 stated Resident #1 had issues with larger females, if they thought they were someone from their past, or if they suspected staff were sleeping with their spouse. The resident could be violent and recently threw a vase. Resident #1 liked to clean up tables when residents were finished eating and was doing so at the table they sat at with Resident #2, who punched Resident #1 in the mouth. They believed Resident #1 recalled the incident from 12/23/2025 because when they were walking with Resident #2, Resident #1 exited their room and struck Resident #2 with a wheelchair leg rest. They intervened and separated the residents. They were not sure what was being done about Resident #1's behavior. They knew they needed to monitor Resident #1 and keep them away from certain residents but did not recall a specific behavior plan. During an interview on 01/09/2026 at 11:26 AM, Licensed Practical Nurse Assistant Manager #4 stated Resident #1ad dementia and had a good memory. The resident could be verbal at times and was not usually physically aggressive. When a provider wanted a medication ordered, the provider usually told them verbally, however, providers could enter their own orders in the resident's record. On 12/24/2025, they were with Resident #1 when Nurse Practitioner #5 evaluated the resident and said they would review the record. After the 12/24/2025 incident with the vase, the resident was brought back to their room, they denied the incident at first and then stated they were sorry. They stated they could not implement or edit care plans and could not perform assessments. As Licensed Practical Nurse Assistant Manager #4 reviewed the record, they stated Resident #1 had no care plan for behaviors prior to 01/09/2026. The registered nurse would have been responsible to implement a behavior care plan. During an interview on 01/09/2026 at 3:39 PM, Licensed Practical Nurse #1 stated Resident #1 had some cognitive impairment and seemed to remember things although acted like they did not remember. The resident had behaviors and that was why they were on the dementia unit. The resident had an incident on 12/23/2025 with Resident #2. Resident #1 started clearing plates at the table, Resident #2 became agitated and punched Resident #1. Resident #1 was known to hold resentment and said Resident #2 was going to pay for their dental bill. On 12/25/2025, they were passing medications and saw Resident #1 hit Resident #2 with the wheelchair leg. No changes were made to Resident #1's care plan and staff on the unit continued to monitor Resident #1. The unit currently did not have a manager. Resident #1 had no further incidents since 12/25/2025. During an interview on 01/09/2025 at 12:17 PM, Registered Nurse Supervisor #7 stated they believed the care plan got updated immediately after a resident displayed behavioral concerns and any registered nurse could update the care plan. On 09/10/2025, the resident directed the thrown coffee at staff, and it consequently hit a resident nearby. The other resident had no injury. They believed an Incident Report was required though not sure if they filled one out. The care plan should have been updated, and they were not sure why they did not update it. During an interview on 01/12/2026 at 10:06 AM, Registered Nurse #2 stated on 09/30/2025, they believed they updated the resident's care plan. When they looked back at the care plan in the electronic record, they did not see any updates during that time. They should have put a behavior care plan in place after the incident and was not sure why they did not. They were not aware of any resident behaviors prior to 09/30/2025. They stated they would expect the resident's care plan to be updated on 12/25/2025 after Resident #1 hit Resident #2 with a wheelchair leg rest and it was not done timely. During an interview on 01/12/2026 at 11:00 AM, Quality Assurance Registered Nurse #8 stated they updated care plans, sometimes daily or based on team meetings and did so for the whole building. The care plan should be updated for any identified changes or when they found something during an audit. A resident-to-resident altercation required a care plan update. If they were aware of an altercation during a team meeting, they would update the plan, otherwise the nurse manager would update it. On 12/25/2025, the supervisor should have updated the care plan after the incident. On 01/12/2026, Registered Nurse Supervisor #6 was unable to be reached for an interview.During an interview on 01/12/2026 at 2:05 PM, the Medical Director stated they expected all residents with behaviors to have a care plan. They were not aware of the resident's incidents when they occurred, however, could see in the record that a provider was notified each time.During an interview on 01/12/2026 at 4:47 PM, Nurse Practitioner #5 stated they were notified of the recent incidents involving Resident #1 throwing a glass vase at staff and hitting Resident #2 with a wheelchair leg rest. They felt these were isolated incidents. They saw Resident #1 on 12/24/2025 after the incident with Resident #2. Resident #1 was very upset, wanted to know who was going to pay their dental bill and they were able to calm the resident down. They were reviewing the resident's medications to see if they needed adjusting and documented to increase Depakote however did not increase Depakote until 12/29/2025 because they wanted to discuss with the team first. When they did change the Depakote dose, it was more for the resident's increased paranoia due to dementia, not their bipolar depression. There was no therapeutic level for Depakote unless the medication was taken for seizures, not for behaviors. They did Depakote levels for the resident to monitor for toxicity. If Depakote was at a non-therapeutic level, it would not cause an increase in behaviors. They did not have an opinion about care planned interventions and stated that was up to nursing. During an interview on 01/13/2026 at 12:30 PM and 5:10 PM, the Director of Nursing stated when there was an incident between residents, the residents were separated, the supervisor notified, the registered nurse assessed, and the Director of Nursing or the Administrator were notified. The registered nurse that assessed the resident was responsible to review/revise the care plan and they expected the care plan reviewed/revised within the shift. The Interdisciplinary Team did a thorough review into root cause analysis and determined if a resident should be on 1:1 supervision based on previous aggressive incidents and if interventions were not immediately working. On 09/10/2025, the incident with the coffee was incidental, the coffee was cold, and the other involved resident was not injured. Resident #1 had labs done on 09/15/2025 and the provider documented they were reviewed; the resident was at baseline and to continue to monitor. They expected the care plan to be updated if the behavior continued and current interventions did not work. If the resident returned to baseline and did not continue to need interventions, then they would not expect new interventions to be added. On 09/30/2025, when the resident punched Resident #3 in the face, based on the investigation, Resident #3 attempted to take Resident #1's food. There was redness noted to Resident #3's cheek, no pain and both did not recall the incident. Resident #3's care plan was updated to encourage to be seated at meals. They did not see any interventions added to Resident #1's care plan. They believed Resident #1 reacted because Resident #3 invaded their personal space. Staff knew how to care for Resident #1, but it would have been helpful to have the care plan updated after this incident and the care plan was not updated. The facility protected other residents from Resident #1 after the incident by notifying the medical provider and reviewing the incident the next day. Pain was ruled out as a contributing factor at the time of the incident. On 10/01/2025, Nurse Practitioner #5 saw Resident #1 nd documented the resident was at baseline and that gave the facility a level of comfort and safety for other residents. After the 12/23/2025 incident with Resident #2, Resident #2 was put on 1:1 related to several prior incidents and history of aggression. They believed Resident #2 had a friend of the opposite sex seated at the table and that is what triggered them to punch Resident #1 in the mouth. Resident #1's care plan was updated on 12/23/2025 with potential to be abused and that was helpful. On 12/24/2025, when Resident #1 threw a vase at staff, they typically did not do an incident report for something like this. The resident was seen by Nurse Practitioner #5 and noted no increased behaviors. If the resident was easily redirectable and the behavior was corrected after the 12/24/2025 incident, then they would not have expected the care plan be updated. On 12/25/2025, 1:1 supervision was not considered for Resident #1 because looking back at the previous incident on 12/23/2025, Resident #2 was the aggressor, and they were more concerned that Resident #2 would retaliate. The care plan was not updated after because Resident #1 was easily redirectable and that was appropriate. The facility protected other residents from Resident #1 by having Resident #1 seen by the nurse practitioner who documented the resident's behavior returned to baseline. After being hit by Resident #2, Resident #1 was upset and had a lucid moment of Resident #2 hitting them and had since returned to baseline. The facility reported incidents to New York State Department of Health following F609 regulation related to abuse. The 09/30/2025 incident was not reported because there was no injury, no pain and no mental anguish noted. During an interview on 01/14/2026 at 12:40 PM, the Administrator stated they learned about incidents by attending morning report, reading records, and attending the wellness committee. If there was an incident report for resident-to-resident abuse, they were involved. Incidents were communicated to them by the nursing supervisor or by the Director of Nursing. They were somewhat familiar with Resident #1 and knew they had behaviors. They were aware of all the incidents with Resident #1. Staff knew how to manage the resident through the care plan. Medical was on top of Resident #1's care and made medication changes. In response to the 09/10/2025, 09/30/2025 and 12/25/2025 incidents, the Administrator stated the resident went from October to November without behaviors, the resident attempted to throw a vase and was not sure if it hit staff. They did not have a role in updating the care plan and that was the responsibility of nursing. There were a lot of long-term staff on the unit that were very familiar with the resident. Those long-term staff reported to newer staff verbally through report and knew what redirect meant in the care plan. The staff were to try non-pharmacological interventions first. They were not sure if the resident was seen by psych services after the incidents. After the 09/30/2025 incident, they looked at the dining room, the ambiance, added more supervision with aides, nursing and therapeutic technicians. The 09/30/2025 incident, the paperwork was not perfect, however, since implementing dining room changes, behaviors for all residents had been better. 10 NYCRR 415.4(b)(1)(i)____________________________________________________________________________Immediate Jeopardy was identified and the facility Administrator notified on 01/14/2026 at 4:09 PM. Immediate Jeopardy was removed on 01/15/2026 at 5:30 PM prior to survey exit based on the following corrective actions: -On 01/13/2026 Resident #1 was assessed by social work, medical, nursing, and a psych referral ordered. Pharmacy reviewed the resident's medications.-Resident #1's care plan was revised and included 1:1 monitoring. The plan would be reviewed and revised as needed. -On 01/14/2026, a complete hazard sweep was completed to ensure no objects could be used as weapons. -Staff communication included a shift report indicating the resident's supervision level. -All residents with a resident-resident encounter within the last 90 days had their care plans reviewed and revised as necessary with appropriate interventions in place. -As of 01/15/2026 at 12:20 PM, 96.5% of the facility staff had received education. -Understanding and retention of education for staff was verified by interviews. Staff were able to report content of education and confirmed the day they received the education.

Based on record review and interviews during the abbreviated survey the facility failed to provide adequate supervision to prevent accidents for one (1) of three (3) residents (Resident #2) reviewed for elopement. Specifically, Resident #2 who was cognitively intact and had a history of suicidal ideations, opioid dependence, and mental health disorders, eloped from the facility on 02/24/2025 at an unknown time. Resident #2 was allegedly last seen by facility staff on 02/24/2025 at 2:00 PM and the resident's absence was not discovered until 5:45 PM. The resident was contacted via telephone by law enforcement on 02/25/2025 at 12:11 AM after the facility called emergency services to report the resident missing on 02/24/2025 at 11:16 PM. The resident would not disclose their location to law enforcement and did not return to the facility. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #2 and placed all residents identified at risk of elopement and/or leaving the facility against medical advice at risk for the likelihood of serious injury, serious harm, serious impairment, or death. Findings include:The revised 05/2011 facility policy Discharge Against Medical Advice Policy revised 05/2011 documented the facility must provide for the safest discharge possible under all circumstances. This included educating the resident/responsible party on the risks and potential consequences of the decision to leave the facility. As soon as it was apparent that a resident or family member was considering a discharge against medical advice, a discussion was initiated immediately with the resident/responsible party and interdisciplinary team to identify the motivation for the desire to leave the facility against medical advice and to attempt to resolve concerns to the extent possible. This included the failure to comply with the out on pass care plan, observation of removing personal possessions from the resident room, or verbalization of leaving [against medical advice]. Notification of the intent to leave the facility [against medical advice] made to Administrator/On-Call Administrator, Attending Physician/On-Call Physician, Nursing Administration, Social Work, and Responsible party. The resident/responsible party would be counseled regarding the possible complications of the discharge intentions such as threat to physical and/or social well-being, including concerns relating to: transfer ability, positioning, toileting needs, food and fluids, invasive or external medical devices and/or treatments, medical diagnosis/conditions that could exacerbate or require interventions, possible difficulty arranging for home care or follow up services, need to make immediate arrangements for necessary medication or equipment. Such counseling would be documented in the medical record, including the resident reaction to such. This counseling of the resident/responsible party would include the Attending Physician as soon as possible. After every effort was made to counsel the resident of the risks associated with discharge [against medical advice], the resident would be required to sign the Discharge Against Medical Advice form. If the resident refused to sign the form, the discussion would be documented on the form and signed by at least two (2) witnesses. Documentation in nurse's notes and social work progress notes would reflect the circumstances surrounding the resident's decision to discharge against medical advice, and outline the information provided to the resident to assist in the decision-making process. A physician order would be obtained for Discharge [against medical advice] The 08/01/2022 facility policy and procedure Code White/Elopement Search Policy & Procedure documented elopement was defined as the incident in which a resident successfully leaves the building unnoticed and unsupervised and enters into harm's way. Any staff that cannot account for a resident would notify the charge nurse who would notify the supervisor immediately. The nursing supervisor would inform the operator to make an announcement. Operator would announce Name of Resident, please return to unit. This would be repeated three (3) times. If the resident did not respond in a reasonable period of time not to exceed 20 minutes, the charge nurse would call the operator and security, they would announce Code [NAME] Name of Resident, was wanted on unit. This would be repeated three (3) times. Administration would be notified immediately of code white (if non-business hours, the nursing supervisor would notify Administrator and Assistant Administrator). Administrator or designee would set up command post in Administrative Conference Room or [Activity Room]. This announcement would be an indication for staff that all residents were to return to their rooms and for unit staff to begin head count of all residents. The nursing supervisor would attempt to reach the resident's contact to determine if the resident went out of the building with a family member. All department head staff would be notified by an administration staff member in the event the incident occurs during non-business hours with intent of assisting with search efforts. A photograph of all residents with [wander alert device] are available under the Adventure Club tab on the [electronic medical record] dashboard. Department supervisor or director or their designee would initiate a search of their areas utilizing their unit/department search checklists. As each nursing unit and department search was completed the department supervisor or director or their designee shall provide the search checklist to Administrator at designated command post. Department supervisor or director or their designee would await further instruction from command center at this time. After checklists are complete, the assigned team, under the direction of the nursing supervisor, would search all rooms on the floor to verify the resident was not accounted for on unit/floor. If the resident has not been found, the Administrator or Assistant Administrator would determine when the appropriate outside agencies would be notified. No staff would be allowed to leave until the resident was found or approved by the Administrator. Unit Manager/Charge Nurse would complete a detailed nursing narrative note (must be completed on the same shift that the resident was found) in [the electronic medical record]. Unit Manager/Charge Nurse completed an Incident Report form in [the electronic medical record]. Record review of the aforementioned 08/01/2022 facility policy and procedure, Code White/Elopement Search Policy & Procedure, revealed there was no timeframe on when to call 911 or involve emergency services if the resident was not found. Instead, the policy documented, the Administrator or Assistant Administrator would determine when the appropriate outside agencies would be notified, and did not specify what was meant by outside agencies. Resident #2 had diagnoses including cocaine dependence, opioid dependence, other psychoactive substance abuse with psychoactive substance-induced mood disorder, suicidal ideations, personal history of suicidal behavior, noncompliance with medical treatment and regimen, anxiety disorder, and acute respiratory failure. The 03/26/2025 Minimum Data Set (a resident assessment tool)documented the resident was discharged on 02/25/2025 to home/community. A subsequent Minimum Data Set submitted 06/09/2025 documented the resident discharged on 02/24/2025 to home/community. The basic care plan initiated on 02/18/2025 documented a discharge care plan. Interventions included establishing a predischarge plan with the resident/family/caregivers and evaluate progress and revise the plan. There was no documented evidence the basic care plan initiated 02/18/2025 included supervision or elopement prevention interventions related to the resident's medical history The 02/2025 nursing care instructions documented Resident #2 was alert and forgetful at times and required three (3) liters of oxygen via nasal cannula at all times. There was no documentation of the resident's mobility status. The 02/19/2025 at 10:00 AM Three (3)-Day Meeting template completed by Social Worker #2, documented the goals were to complete short-term rehabilitation and possibly discharge to an assisted living facility. It documented Resident #2 wanted assisted living facility placement since they did not have informal support and no family/friend support. It further documented that Resident #2 was homeless and living in hotel/motel housing prior to admission. It documented Resident #2 had mental health diagnoses, was on substance use disorder medications, and was dependent on supplemental oxygen. An Elopement Risk Assessment completed 2/17/2025 at 2:30 PM by Registered Nurse #30 documented a score of zero (0), The resident was not independently mobile with or without assistive devices. During an interview on 12/09/2025 at 11:18 AM, Registered Nurse #30 stated they completed resident Against Medical Advice and Elopement risk assessments upon resident admission. They stated they did not recall the specific resident, as they saw so many people, but would spend 10 to 15 minutes with a resident upon admission. Registered Nurse #30 further stated that they assessed a resident's mobility based on what devices the transport agency provided to the resident for a chair transfer. If a resident scored more than five (5) for either the Against Medical Advice or Elopement assessment, they would be given a wander alert device. Registered Nurse #30 reviewed the assessments in the electronic medical record during the interview and stated Resident #2 scored more than five (5) for the Against Medical Advice risk assessment, but a wander alert device was not placed on the resident. Registered Nurse #30 stated the resident had suicidal ideations. During an interview on 12/18/2025 at 12:39 PM, Physical Therapist #35 stated Resident #2 was unsteady with mobility and had a gait deviation due to right eye blindness. On admission, they were a minimal assist where they performed 75 percent of the movement on their own. When they discharged from the facility, they were contact guard assist due to the blindness and steadiness. Physical Therapist #35 stated Resident #2 could ambulate 60 feet with a rest after each 60-foot section. They were dependent on three (3) liters of oxygen. Physical Therapist #35 further stated that Resident #2 tended to rush the movements with poor regard for safety. Cognitive deficits were also noted when teaching and showing them about mobility. They could maybe walk 100 feet but would be physically exhausted. They were unsteady to the point of falling; they would fall into the walls. There was depth perception concern due to the right eye blindness. The 02/19/2025 History and Physical progress note by Physician #3 documented that before being admitted to the facility, Resident #2 was seen at a hospital for diarrhea, fatigue, shortness of breath, and toxicology screening at the hospital completed on 02/12/2025 detected cocaine. Diagnoses included opioid dependence. Past medical history documented depression with history of psychotic features and history of suicidal ideation, epilepsy, hypothyroidism, chronic pain, nicotine dependence, chronic obstructive pulmonary disease, history of gastrointestinal bleed, cocaine use disorder, amphetamine use disorder, tetrahydrocannabinol (main psychoactive compound in cannabis) dependence, alcohol use disorder, cluster B personality traits (dramatic, emotional, erratic, and impulsive behaviors, characterized by unstable relationships, attention-seeking, grandiosity, or a disregard for others. Key traits include intense mood swings, impulsivity, difficulty with emotional control, frequent conflict, and challenges with self-image and stable connections, often leading to risky behaviors or rule-breaking), opioid use disorder, chronic abdominal pain, migraine, drug-induced constipation, retinal vein occlusion of the right eye, atherosclerotic cardiovascular disease (condition caused by plaque buildup in artery walls, narrowing them and restricting blood flow to vital organs), post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event, characterized by intrusive memories; avoidance of reminders; negative changes in mood and thinking such as guilt, detachment, loss of interest; and hyperarousal of being jumpy, irritable, tense), and cataract of an eye. It further documented Resident #2 was of low weight, had lived alone, and was not mobile in their home due to weakness. It further documented Physician #3 discussed the case with the resident's occupational therapist who reported Resident #2 had poor safety awareness. Record review of the 02/2025 physician orders revealed no documented evidence for Resident #2 to leave the building or to be out-on-pass. Day of Elopement, 02/24/2025: The 02/24/2025 Eating/Fluid report documented the last meal consumption for Resident #2 was breakfast on 02/24/2025. The 02/2025 Medication Administration Record documented Registered Nurse #12 administered Gabapentin (a prescription anticonvulsant medication used primarily for nerve pain and to control certain types of seizures in epilepsy by calming overexcited nerve signals in the brain) to Resident #2 on 02/24/2025 at 2:00 PM. During an interview on 12/22/2025 at 1:32 PM, Resident #2 stated they did not feel welcome at the facility. The staff picked on them and did not provide care assistance when needed. They stated they told someone on the seventh floor they were leaving and the staff member responded saying, yeah, whatever. Resident #2 stated that on 02/24/2025, they packed their bags, used a wheelchair with oxygen to get to the lobby, and then walked out the front entrance with their bags in hand. Resident #2 stated no one at the facility attempted to stop them, ask where they were going, or request that they sign out when they left. They walked off property but had to leave their supplemental oxygen behind because it was too heavy to carry. Resident #2 stated a stranger who was driving had stopped to give them a ride. Resident #2 stated they had difficulty breathing when they were picked up. They did not return to their last known address and instead remained at Friend #28's house. The 02/24/2025 Incident Report - Employee Statement by Licensed Practical Nurse #14 documented they had last seen Resident #2 days before. The resident stated they did not have any clothes, so Licensed Practical Nurse #14 brought them clothes. They went straight to the resident's room on 02/24/2025 at 2:45 PM but did not find Resident #2. The roommate, who was of sound mind, stated Resident #2 would visit friends on other floors. It documented Licensed Practical Nurse #14 checked back around 3:4 PM [sic], then again at 5:45 PM. They called the supervisor. Two (2) all calls were done and a Code White. They documented they had not seen Resident #2 during the shift. At the time of the incident, they searched other floors, went to the first floor and spoke with security, involved floor certified nurse aides and supervisors. They notified Registered Nurse #26 and Nurse #40. During a telephone interview on 12/10/2025 at 2:02 PM, Licensed Practical Nurse #14 stated they recalled Resident #2 based on bringing clothes in for them. They came in a bit early for their shift on 02/24/2025 to bring the clothes to Resident #2. When they got there, the resident was not in the room. The roommate told them Resident #2 was visiting friends in the building. They returned to Resident #2's room later in the evening, and Resident #2 was still not back. They overhead paged and did a Code White. They searched down to the basement. They did not find Resident #2 and reported it to their supervisor. The 02/2025 Medication Administration Record documented the medications scheduled for 02/24/2025 at 5:00 PM to 10:00 PM and 7:00 PM to 11:00 PM were documented as Out of Building. Centers for Medicare and Medicaid Services documents in State Operations Manual Appendix PP, revision 232 issued 07/23/2025, that residents with a history of substance use disorder may be at increased risk for leaving the facility without notification and should be assessed for the risks and care plan interventions should be implemented to ensure the safety of all residents. Facilities are responsible for identifying and assessing a resident's risk for leaving the facility without notification to staff and developing interventions to address this risk. A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. The 02/24/2025 at 11:16 PM Onondaga County 911 audio file, documented Resident #2 walked/snuck out of the building on foot sometime on the evening shift. The caller stated they were Registered Nurse #8. Resident #2 had mental or health concerns that included anxiety, depression, opioid dependence, and suicidal behaviors and ideations. They did not know when the resident left the building as they were third party to the information and just coming into work for the night shift. Based on information gathered during the aforementioned telephone interview on 12/10/2025 at 2:02 PM with Licensed Practical Nurse #14, review of the aforementioned 02/24/2025 Incident Report - Employee Statement by Licensed Practical Nurse #14, and review of the aforementioned 02/24/2025 at 11:16 PM, Onondaga County 911 audio file, the Code [NAME] search did not locate Resident #2 within the facility, and the facility delayed calling emergency services. Onondaga County 911 was called five (5) hours and 31 minutes after Code [NAME] was initiated. During this time, the facility did not know of Resident #2's whereabouts. The 02/24/2025 at 11:21 PM, Onondaga Sheriff's Report, documented there was a missing person investigation that was later amended to a status check. They spoke with Licensed Practical Nurse #25 who stated they were the nursing supervisor, and they were made aware that Resident #2 was missing from [the facility]. Resident #2 had been missing since the 02/24/2025 evening check. The resident had a visitor around 11:00 AM that day and had mentioned they wanted to go back to their apartment. They stated Resident #2 was free to leave when they pleased. Although they were free to come and go, Resident #2 had never left the facility. Resident #2 was contacted by Police via telephone and would not provide their location but stated they would return to the facility on [DATE]. Day After Elopement, 02/25/2025: The 02/25/2025 at 5:41 AM progress note by Registered Nurse #8 documented Police were called to complete a wellness check and found Resident #2 at their home. It documented Police stated Resident #2 was an adult, was not a missing person, and they could make their own decisions. It documented Resident #2 decided not to return to the facility. During an interview on 12/22/2025 at 1:32 PM, Resident #2 stated the facility contacted them a day or so after they left (making it on/about 02/25/2025) and had a staff member meet them at Friend #28's house. Resident #2 stated they did not know they signed an Against Medical Advice document and were instead told they had to sign the papers the staff member brought. Resident #2 further stated the documents were not explained to Resident #2. The facility document Discharge Against Medical Advice documented Resident #2's name, dated 02/24/2025 at 2:30 PM. The document was signed by Resident #2, witnessed by Director of Social Work #17, and dated 02/25/2025. The discharge location was Friend #28's house with contact information. The reason for leaving Against Medical Advice was documented as resident did not want to stay at [Facility]. The 02/25/2025 at 02:25 PM progress note by Director of Social Work #17 documented they went to meet with the resident on this date to complete Against Medical Advice paperwork. The resident was able to sign paperwork on this date. Director of Social Work #17 asked the resident if they had any questions or concerns at this time which they did not. Resident had information to call the facility if needed and access to local hospital information. [Adult Protective Services] call was made. Director of Social Work #17 would continue to follow. There was no documented evidence that Resident #2 was counseled regarding the possible complications of the discharge intentions such as threat to physical and/or social well-being, or the need to make immediate arrangements for necessary medication or equipment when leaving the facility against medical advice. There was no documented evidence a physician was made aware that Resident #2 left the facility Against Medical Advice. Review of Residents Leaving [Facility] sign out sheet, dated 02/08/2025 to 02/28/2025, did not have documented evidence that Resident #2 signed out against medical advice, out on pass, or discharged . Record review revealed the facility informed Police that Resident #2 was free to leave despite no documentation of discharge, counseling, or physician notification. Interviews:During an interview on 12/16/2025 at 1:37 PM, Nurse Practitioner #37 stated Resident #2 was previously on their service, but the last note they wrote for them was on 02/24/2025. They stated they believed the resident was transferred to another unit, because they were still in the provider system, but not on their service. Resident #2 did not have the best decision-making skills. Based on the substance use disorder and behaviors, Resident #2 was at risk for leaving the facility. They should not be alone. Resident #2 would have been safe in terms of mobility, as they got around with their wheelchair. They would expect to be notified if a resident left against medical advice, and they were not notified. They would have to put in a discharge note and discharge the resident from the system. Resident #2 was still in the provider system and not a discharged resident. Nurse Practitioner #37 stated they would expect to be notified if a resident eloped from the facility, and they were not notified that Resident #2 left the facility in any way. Nurse Practitioner #37 stated they received notifications from the facility Monday through Friday at any time of day or night, but there was a weekend on call team also. During an interview on 12/16/2025 at 12:44 PM, Director of Social Work #17 stated they did not recall Resident #2, and Social Worker #29 was assigned to that resident. They did not recall any information that was not documented in the electronic medical record. They vaguely recalled going to Friend #28's house, meeting Resident #2 on the porch, and it being cold. Director of Social Work #17 could not recall why the documentation was dated 02/25/2025, why they went to the resident after they left on 02/24/2025. They stated there was a need to get the paperwork done, and they did what they had to do to get it done. Director of Social Work #17 stated once a resident says they want to leave against medical advice, there would be an interdisciplinary team discussion. Director of Social Work #17 further stated the team would need to figure out why the resident wanted to leave, and the facility should know when a resident leaves. During an interview on 12/09/2025 at 11:52 AM, Social Worker #29 stated there was nothing in the medical record to know what happened with Resident #2. They stated that they would have expected a note in the electronic medical record that documented the resident physically left with whomever and when they left. Resident #2 was at high risk, and of serious concern if they just left. They were homeless and had substance use disorder. During an interview on 12/09/2025 at 12:10 PM, Licensed Practical Nurse #31 stated that if the resident discharged against medical advice, physician orders would be discontinued. During an interview on 12/10/2025 at 3:21 PM, Security Guard #38 stated if a resident came to the desk trying to leave and asking to leave against medical advice, they would call the nursing supervisor to help with the resident. During a telephone interview on 12/16/2025 at 11:53 AM, Registered Nurse #12 stated the 2:00 PM administration time listed on the 02/24/2025 Medication Administration Record was the scheduled time of the medication. They had an hour before and an hour after that time to administer the medication. They did not recall a resident requesting to leave against medical advice or leaving the facility during their shift; and that was something they would have recalled. They further stated a resident with suicidal ideations and substance use disorder would not be someone that would be able to leave the building alone and would be a resident who would need continuous care and observation. During a telephone interview on 12/31/2025 at 01:31 PM, Onondaga County Sheriff Deputy #36 stated they went to the facility on the evening of 02/24/2025 for a missing resident. They went to Resident #2's room. Resident #2 left behind their wallet and identification. Deputy #36 stated they worked on the case for most of the night and made contact via telephone with Resident #2 between 3:00 and 4:00 AM on 02/25/2025. Resident #2 stated they were at a friend's house, but did not provide the actual location. Sheriff Deputy #36 reminded Resident #2 their wallet and identification were at the facility. Resident #2 stated they would return to the facility to collect their belongings. During a telephone interview on 12/16/2025 at 3:52 PM, Registered Nurse #8 stated Resident #2 was supposed to be in the facility when they got to work on 02/24/2025, but were not there. They contacted Director of Nursing #1, who told them to call emergency services for a wellness check. Registered Nurse #8 stated they thought Resident #2 was out on pass. They thought the resident left the facility with someone. Registered Nurse #8 further stated they got information about the resident by reading the 24-hour report in the electronic medical record. They could not recall who notified them that the resident was not in the building. Registered Nurse #8 stated Police came to the facility, informed them the resident went out, did not return and they were concerned about the resident's safety. During an interview on 12/10/2025 at 12:06 PM, Director of Nursing #2 stated Resident #2 was discharged from the system on 02/24/2025 at 2:10 PM. They stated Resident #2 departed the facility with a friend that did not enter the building to check in. They did not know how they left. The time and date that a resident is discharged from the system indicated the resident was no longer in the building. The discharge time was determined by Assistant Administrator #1 and then, by reviewing the camera footage. Director of Nursing #2 stated Resident #2 independently moved around in the building. Director of Nursing #2 further stated the elopement assessment was done on admission, and the information was obtained on a nurse-to-nurse report, which might not be how the resident actually moved. The assessments were done quarterly. Director of Nursing #2 stated an assessment would not be completed for elopement once a resident was identified as being not mobile. Director of Nursing #2 stated if Resident #2's assessment information was carried over from the against medical advice assessment to the elopement assessment, Resident #2 probably would have triggered as an elopement risk. Director of Nursing #2 stated they did not know what time Resident #2 signed the against medical advice paperwork. Director of Nursing #2 stated the facility would complete follow up calls on residents that leave against medical advice to make sure the residents were safe. Director of Nursing #2 stated Resident #2 independently walked out of the building and was cognitively intact. Director of Nursing #2 further stated the facility made sure Resident #2 was safe at home at 11:00 PM on 02/24/2025. They stated Resident #2 did not leave undetected on 02/24/2025, that the front desk watched them leave but could not provide the exact time. Director of Nursing #2 stated they thought the resident departed out of the front door with the overhang but could not recall for sure. They stated they could not make someone sign out against medical advice if they did not want to. Director of Nursing #2 stated, Resident #2 was able to walk out the front door without their oxygen without concern. During an interview on 12/10/2025 at 3:11 PM, Administrator #1 stated they were not involved in Resident #2's discharge. Administrator #1 stated Resident #2's discharge was investigated by the facility, and that they would have to review the investigation to know the outcome. Administrator #1 stated Resident #2 was not an elopement risk but was at risk for leaving against medical advice. Administrator #1 stated staff could document on a resident at any time, such as if a resident was seen while in the building, staff could document after the fact. Administrator #1 stated it would be appropriate as documentation was just the vehicle. The facility was notified of the Immediate Jeopardy on 12/18/2025 at 3:19 PM, signed by Administrator #1 at 3:45 PM. Record review of the Facility Immediacy Removal Plan, version 01, submitted on 12/18/2025 at 4:24 PM revealed the facility's plan to remove the immediacy relied on already-completed risk assessments for elopements based on Minimum Data Set information that could be up to three (3) months old. There was no documented evidence that the facility would review current data points based on current resident conditions. Record review of the Facility Immediacy Removal Plan, version 02, submitted on 12/18/2025 at 6:30 PM revealed the facility did not specify what would happen next procedurally when a resident could not be located after calling a Code White. Additionally, the facility's plan to remove the immediacy relied on only elopement risk assessments. There was no documented evidence that other risk factors such as against medical advice risk assessments would be considered. The Facility Immediacy Removal Plan did not address how adequate supervision would be accurately determined for all residents in the facility, to then determine the subset of those residents at risk for elopement or at risk for leaving the facility against medical advice, including cognitively intact residents with substance use disorders. During an interview on 12/18/2025 at 7:19 PM, Administrator #1 reviewed what was meant by Against Medical Advice, what the Elopement and Against Medical Advice risk assessments for Resident #2 were documented as. Administrator #1 reviewed that Resident #2's elopement risk score was documented as zero (0), requiring no care plan interventions, and that the Facility Immediacy Removal Plan only described elopement. When asked where a section of proposed immediacy removal plan that addressed how the facility would ensure adequate supervision for all residents, Administrator #1 stated they were only looking at it from the elopement perspective. Administrator #1 stated they would add a new line about a resident change of condition that would prompt a new Against Medical Advice and Elopement risk assessments. Administrator #1 stated law enforcement would be promptly called when a resident could not be found after issuing a Code White, that the policy would be revised, and all staff would be educated on the change. Facility Immediacy Removal Plan, version 03, submitted on 12/18/2025 at 7:54 PM was approved. The Immediate Jeopardy was lifted effective 12/19/2025. The facility's immediacy removal actions included the following:All residents in the facility had their elopement risk assessment completed within three (3) months in accordance with the Minimum Data Set and had interventions in place in accordance with the assessed risk.All residents assessed as an elopement risk that triggered the requirement for use of a Wanderguard bracelets had their bracelet in place. Residents with Wanderguard bracelets were placed on the Adventure Club list, which contains their picture indicating their elopement risk. This was within the electronic medical records and available to staff. If the resident required 1:1 supervision, that supervision was provided (two (2) residents) identified.Exit doors were inspected, locked, and alarmed. Their functionality was confirmed

Based on record review and interviews conducted during a survey, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) of three (3) residents (Resident #11) reviewed. Specifically, on 11/25/2025, Resident #11's respiratory complaints were not appropriately addressed, and physician's orders were not followed. On 11/26/2025, Resident #11 was not adequately monitored when they exhibited respiratory distress and were left unsupervised while waiting for Emergency Medical Services arrival. This resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #11 and placed all residents with potential changes in health status at risk for serious harm, serious impairment, serious injury, or death. Findings include: Findings include:Cross-referenced to F695: Respiratory/Tracheostomy Care and Suctioning Cross-referenced to F580: Notification of Changes (Injury/Decline/Room, Etc.) The undated facility policy Respiratory Care, documented the facility would provide safe and effective respiratory care services to residents with identified needs. All procedures would be performed by trained and competent licensed nursing staff in accordance with physician orders, manufacturer instructions, and applicable federal and state regulations. Oxygen therapy was a medication and required a valid physician order. Staff would verify the order including flow rate, delivery method (nasal cannula, mask, concentrator), and frequency. In the event of respiratory distress, airway obstruction, or equipment failure, staff would initiate emergency response protocols and notify the provider immediately. All respiratory care provided would be documented in the medical record, including the type of intervention, resident response, and any adverse reactions or changes in condition. Resident #11 had diagnoses including respiratory failure, obstructive sleep apnea (interruption of breathing during sleep), and high blood pressure. The 10/21/2025 Minimum Data Set (a resident assessment tool) documented the resident was cognitively intact, able to make themselves understood, and understood others. The Comprehensive Care Plan, revised 11/06/2025, documented the resident was at risk for compromised respiratory status due to obstructive sleep apnea, pulmonary embolism (a blood clot that travels to the lungs), and not using continuous positive airway pressure machine to treat sleep apnea. Interventions included monitor resident's respiratory status: anxiety, restlessness, increased confusion, shortness of breath, dyspnea, lethargy (unusual decrease in consciousness), decreased activity, change in sputum production or change in color, character of sputum; monitor breath sounds, monitor activity tolerance, pace and space activities, provide restful calm environment, monitor vital signs, oxygen per physician order, and consult with respiratory therapist as needed. The 11/18/2024 physician order documented four (4) liters of oxygen via nasal cannula, every day, every shift. The 11/25/2025 at 6:38 PM Respiratory Therapist #6 progress note documented Resident #11 was assessed in their room during dinner in response to a nursing report of intermittent shortness of breath. The resident was alert, oriented, and in no apparent distress at the time of the assessment. Respirations were even and unlabored. The resident was educated on deep breathing techniques, including slow diaphragmatic breathing (a breathing technique to increase oxygen intake), paced inhalation and exhalation, and pursed lip breathing to promote improved lung expansion and assist in managing symptoms during episodes. The resident was encouraged to practice these exercises daily and to notify staff promptly if symptoms increased in frequency or severity. The resident verbalized understanding and was receptive to education. Oxygen saturation level was 92% (normal healthy person 95-100%) on three (3) liters of oxygen. Lung sounds were clear bilaterally (both lungs). There was no documented evidence of a registered nurse assessment when the resident was experiencing shortness of breath or documentation the resident's respiratory status was monitored. The 11/26/2025 at 7:06 AM Licensed Practical Nurse #4 progress note documented at approximately 5:00 AM, Resident #11 was minimally responsive with labored breathing. Oxygen saturation level was 40% on four (4) liters of oxygen via nasal cannula. Licensed Practical Nurse #4 contacted Registered Nurse #8 who arrived to assess the resident. The nasal cannula was switched to a venti mask (oxygen mask). Licensed Practical Nurse #4 checked the resident's oxygen saturation again (no time documented), it remained in the 40's and the resident had increased labored breathing. Registered Nurse #8 was again updated with recommendations by Licensed Practical Nurse #4 to send the resident to the emergency department due to worsening condition. The portable oxygen tank was escalated to ten (10) liters via non-rebreather mask.There was no documented evidence of an assessment by Registered Nurse #8 or documentation that a physician was notified of the declining respiratory status. The Emergency Medical Services Patient Care Record dated 11/26/2025, documented the facility called 911 at 6:04 AM. Upon arrival the resident was unresponsive with agonal respirations (gasping, labored breathing). There were no staff present on the floor (resident's unit), and Emergency Medical Services called the fire department to assist with moving the resident. During an interview on 12/04/2025 at 11:24 AM, the resident's health care proxy stated they and another family member visited Resident #11 on 11/25/2025. The oxygen concentrator was not working and they notified staff. Another family member placed the resident on the portable oxygen tank in the room. When they left at 5:00 PM, no staff had come to address the oxygen.During an interview on 12/04/2025 at 3:56 PM, Licensed Practical Nurse #4 stated that on 11/26/2025 between 4:30 AM and 5:00 AM, they were notified by Certified Nurse Aide #15, the resident was not breathing right. When they entered the room, the resident had labored breathing. They contacted Registered Nurse #8, who came to the bedside and told them to put the resident on a face mask (for oxygen). Registered Nurse #8 did not stay in the room. They stated when they rechecked the resident's oxygen level (time unknown), it was still in the 40's. They told Registered Nurse #8 the resident needed to go to the hospital and turned the portable oxygen tank up to 10liters. They stated there were no provider orders for the 10 liters of oxygen. During an interview on 12/09/2025 at 3:51 PM, Registered Nurse #8 stated on 11/26/2025, they recalled Resident #11's oxygen level was 88%. They could not recall how much oxygen the resident was on, and they did not stay in the room. They did not call the provider as they took it upon themselves to call 911. They stated they did everything they were supposed to do and should have sent the resident to the hospital sooner. During an interview on 12/09/2025 at 4:37 PM, Respiratory Therapist #6 stated on 11/25/2025, Resident #11 complained of shortness of breath. The resident was not in any distress when they saw them. The oxygen was connected to a portable tank and they switched the resident to the oxygen concentrator and put it on three (3) liters. They did not check the resident's oxygen orders, as the resident was on three (3) liters before. During an interview on 12/11/2025 at 12:35 PM, Director of Nursing #1 stated Registered Nurse #8 should have called the provider when the resident's oxygen saturation level was in the 80s. During an interview on 12/15/2025 at 10:36 AM, Medical Director #1 stated not calling the provider or 911 immediately was a delay in care. 10 New York Codes, Rules, and Regulations 415.12 _______________________________________________________Immediate Jeopardy was issued to the Administrator on 01/22/2026 at 3:30 PM. Immediate Jeopardy was lifted effective 01/25/2026. The facility's immediacy removal actions included the following: All residents on oxygen had a pulse oximetry reading completed and any results deviating from the resident's baseline had a registered nurse assessment and physician notification immediately via telephone by the end of the evening shift on 01/22/2026. Any resident demonstrating respiratory distress would not be left unattended awaiting Emergency Medical Services. All resident accident and incident reports have been reviewed for the last 30 days. Any significant change in status (e.g., respiratory distress, unresponsiveness, new pain not relieved), abnormal laboratory results requiring action in the past week were reviewed to ensure they were addressed and the need to alter treatment significantly or transfer the resident was reviewed. Registered Nurse #8 was re-educated on assessments and supervision on 01/08/2026. Education was implemented immediately specific to: Educated licensed nursing staff on Change in Condition Policy for significant change in respiratory status. Educated licensed nursing staff with communication with the registered nurse and proper assessment of respiratory complaints. Educated certified nursing assistants regarding communication with the licensed nursing staff regarding respiratory changes in condition and all others. Educated licensed nursing staff on following physician orders and performing within scope of practice. Educated licensed nursing staff on obtaining vital signs with change in condition. As of 01/25/2026, 90% of licensed nursing staff were educated.

Based on record review and interviews conducted during the survey, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (1) of three (3) residents (Resident #11) reviewed. Specifically, on [DATE] between 5:00 AM and 5:30 AM, Resident #11 had labored breathing and an oxygen saturation level (amount of oxygen in the blood) of 40 percent (normal is 95 -100 percent). The oxygen flow rate was increased to 10 liters per minute without a physician order and the resident's oxygen saturation level dropped to 26 percent on 10 liters of oxygen. The physician was not notified of the resident's significant change in respiratory status. Emergency Medical Services was not called until 6:00 AM, the resident was transported to the hospital and presented to the Emergency Department at 6:30 AM with respiratory distress and a diagnosis of acute respiratory failure with hypercapnia (high levels of carbon dioxide). The resident was pronounced deceased at 8:44 AM, due to respiratory arrest. This resulted in Immediate Jeopardy to Resident #11 and placed all residents with potential significant changes in respiratory status at risk for serious harm, serious impairment, serious injury, or death. Findings include:Cross-referenced to F695: Respiratory/Tracheostomy Care and Suctioning Cross-reference to F684: Quality of CareCross-referenced to F842: Resident Records - Identifiable Information The facility policy Change in Resident Condition, last reviewed 05/2025, documented the Nurse Supervisor/Charge Nurse would notify the resident's attending physician or on-call physician when there was a significant change in the resident's physical/emotional/mental condition or a need to transfer the resident to a hospital/treatment center. The Nursing Supervisor/Charge Nurse would inform the resident's family/designated representative of any changes in the resident's condition and any changes in medical care or treatment(s). Resident #11 had diagnoses including respiratory failure, obstructive sleep apnea (interruption of breathing during sleep), and high blood pressure. The [DATE] Minimum Data Set (a resident assessment tool) documented the resident was cognitively intact, able to make themselves understood, and understood others.The [DATE] physician order documented four (4) liters of oxygen via nasal cannula, every day, every shift. The [DATE] at 7:06 AM Licensed Practical Nurse #4 progress note documented at approximately 1:00 AM, Resident #11 was observed to be resting comfortably with no signs of acute distress. Through the night, the resident remained stable and responsive. At approximately 5:00 AM, Resident #11 was found to have labored respirations and appeared minimally responsive to verbal stimuli. Oxygen saturation level was 40 percent on four (4) liters oxygen via nasal cannula. The supervisor was immediately notified and came to assess at bedside and changed the nasal cannula to an oxygen mask. Oxygen saturation levels were checked again using three (3) separate oximeters (measures oxygen saturation) simultaneously to verify accuracy. The readings obtained were 42 percent, 43 percent, and 26 percent with increased labored breathing. The supervisor was again updated with recommendation to send to Emergency Department due to the resident's worsening condition. Oxygen therapy was escalated to ten (10) liters via non-rebreather mask using the portable oxygen tank. Upon Emergency Medical Services arrival, Resident #11 became unresponsive and was transported to the hospital. There was no documented evidence that the medical provider was notified when the resident had a significant change in respiratory status.The [DATE] at 6:59 AM Registered Nurse #7 progress note documented they received a report from Licensed Practical Nurse #4 the resident's oxygen saturations were 42 percent and 43 percent, the resident was unresponsive, and vital signs were unable to be taken. Registered Nurse #8 assessed the resident and Licensed Practical Nurse #4 sent the resident to the hospital. Registered Nurse #7 notified Nurse Practitioner #44 (time not documented). The transfer from facility report dated [DATE] at 5:58 AM documented the reason for transfer was low oxygen saturation level of 45 [percent].The [DATE] at 6:39 AM Hospital Emergency Department provider notes documented the patient was responding to pain only. The physical exam documented respiratory distress present, with agonal breathing, was currently on 15 liters of oxygen with oxygen levels in the 90's and condition was critical. Resident #11 was pronounced deceased at 8:44 AM. During an interview on [DATE] at 11:24 AM, Health Care Proxy #11 stated they did not receive any calls from the facility about the resident's change of condition and that the resident was sent to the hospital. During an interview on [DATE] at 12:02 PM, Licensed Practical Nurse #19 stated when there was a change in a resident's condition, the certified nurse aide would report it to them. Licensed Practical Nurse #19 would then check the resident, get vitals, and contact the licensed practical nurse manager or the supervisor. They stated any change in condition related to problem with breathing was always an urgent matter. If the resident had oxygen levels in the 40's they should check to make sure the resident was on the correct amount of oxygen per the order and would then contact the supervisor. They stated they would call the medical provider if no one from nursing was available and the nurse manager or supervisor was responsible for notifying the family of a change in condition. During an interview on [DATE] at 12:10 PM, Licensed Practical Nurse #20 stated when there was a change in a resident's condition, the Certified Nurse Aide would take the resident's vitals and report to them. They would check the resident and tell the licensed practical nurse supervisor, who checked the resident and called the nurse practitioner. Respiratory distress meant the resident was having a hard time breathing. They would check the resident's oxygen, respirations, and oxygen saturation level, and would administer a breathing treatment or inhaler if there was an order. They would then notify the registered nurse manager or licensed practical nurse manager, who would call the nurse practitioner or physician. The nurse manager called the family when there was a change in condition. During an interview on [DATE] at 12:20 PM, Licensed Practical Nurse #21 stated for a change in a resident's condition they should tell the registered nurse manager or the supervisor, who would then assess the resident and call the medical provider. The registered nurse, or supervisor was responsible for notifying the medical provider of any change in condition. During an interview on [DATE] at 3:51 PM, Registered Nurse #8 stated they were the nursing supervisor during the night shift on [DATE], from 11:00 PM to 7:00 AM. They recalled Resident #11's oxygen saturation level was 88 percent, could not get the resident up to 90 percent, and ended up sending the resident out to the hospital. They stated they were already in the process of sending the resident out to the hospital when Licensed Practical Nurse #4 nurse called them and told them to send the resident to the hospital. They stated the resident's oxygen saturation level dipped down to 45 percent and they called 911. They stated they forgot to write a note about the resident's change in condition. They did not immediately call 911 because they were trying to do all they could to get the resident's oxygen saturation level up and they were monitoring the resident. They stated Licensed Practical Nurse #4 monitored the resident and kept in touch with them. They stated they did not call the nurse practitioner. They felt it was an emergency and took it upon themselves to call 911. They stated they probably should have sent the resident to the hospital sooner. The family was supposed to be called when there was a change in condition, and they forgot to call the family. During an interview on [DATE] at 3:56 PM, Licensed Practical Nurse #4 stated on [DATE], between 4:30 AM and 5:00 AM, Certified Nurse Aide #15 urgently reported to them Resident #11 was not breathing right and was labored. They stated they went right to the resident, and Resident #11 was minimally verbally responsive. The resident could say their own name and was labored in their breathing. Licensed Practical Nurse #4 stated resident's oxygen level was 40%, they then notified Registered Nurse #8, who came to the resident's room and told them to get an oxygen face mask. They stated Registered Nurse #8 left the room upon their return. The resident was still having labored breathing, and they put three (3) different pulse oximeters on the resident at the same time, using different fingers on both hands. The readings were 42%, 43%, and 26%, the resident was minimally responsive and was lethargic (sluggish, unusual decrease in consciousness). They called Registered Nurse #8 to report the oxygen saturation readings and then put the resident on the portable oxygen tank at ten (10) liters with a non-rebreather mask. They stated Registered Nurse #8 did not instruct them to put the resident on (ten) 10 liters of oxygen. Licensed Practical Nurse #4 put the resident on ten (10) liters because the resident's oxygen level was 26% on four (4) liters, and it scared them that the resident was that low. They stated they told Registered Nurse #8 what the readings were and needed to send the resident out to the hospital. Licensed Practical Nurse #4 stated they checked vital signs and wrote them on a cheat sheet. They stated they did their best to help the resident. They stated they saw Emergency Medical Services arrive and went into the resident's room after them. Licensed Practical Nurse #4 stated the resident was not responding at all at that time. During an interview on [DATE] at 2:30 PM, Registered Nurse #7 stated the only reason they wrote the note about Resident #11 on [DATE] was because Registered Nurse #8 left the building on [DATE], and there was no communication from them. They said they saw Emergency Medical Services transporting the resident out of the building. They talked to Licensed Practical Nurse #4 and told them to write a note. Registered Nurse #7 called the provider to let them know the resident was being sent to the hospital. They were not aware the resident was in respiratory distress because Registered Nurse #8 did not tell them about it. Registered Nurse #7 stated they were a supervisor and split the floor with Registered Nurse #8. They stated it was unacceptable for Registered Nurse #8 to not call the provider. Registered Nurse #7 stated they did not call the resident's family. During an interview on [DATE] at 11:47 AM, Licensed Practical Nurse #5 stated they worked the day and evening shift on [DATE]. They went into the resident's room (time unknown) and the resident's family was present. Resident #11 said they felt like they could not catch their breath. They left the room to get a pulse oximeter, returned and oxygen level was 92-93 percent, which was the resident's usual level. They changed the oxygen tubing and the humidified air water bottle. Because the resident was still having issues, they told the supervisor on the unit, Licensed Practical Nurse #80, and they called Respiratory Therapy. Licensed Practical Nurse #5 recalled the oxygen concentrator being set at four (4) liters or whatever the order was. They stated oxygen checks were done every shift. They stated they did not write a progress note and said Licensed Practical Nurse #80 would have entered a note. During an interview on [DATE] at 11:56 AM, Licensed Practical Nurse #80 stated the protocol for a change in condition was the licensed practical nurse would notify the registered nurse, who assessed the resident and called the provider to get orders. If a resident's oxygen level was 40 percent, they should call 911 or at the very least call a Code Blue, which was for non-life-threatening situations but would get assistance right away. During an interview on [DATE] at 12:35 PM, Director of Nursing #1 stated Licensed Practical Nurse #4 followed protocol by calling Registered Nurse #8 to get the assessment. They stated Registered Nurse #8 should have called 911 immediately when the resident's oxygen was in the 40's and called the provider afterwards. When the resident's oxygen was in the 80's and was minimally responsive, at the very least they should have called the provider who probably would have sent the resident out at that point. The Medical Director preferred to be called prior to sending a resident to the hospital but in an emergency, the resident was to be sent out. They stated it was their understanding that Registered Nurse #8 called the family, and it would have been written in their note they started to write at 5:57 AM but did not save. During an interview on [DATE] at 10:36 AM, Medical Director #1 stated nursing staff knew they were to call Medical Director #1 when they needed to send a resident to the hospital, and if it was emergency they were to call 911. Not calling the provider or 911 immediately, was a delay in treatment. During an interview on [DATE] at 2:08 PM, Administrator #1 stated communication was extremely important. For any change in condition, they would want the registered nurse supervisor and the medical provider to be notified. Immediate Jeopardy was issued to the Administrator on [DATE] at 3:30 PM. Facility Immediacy Removal Plan submitted on [DATE] at 6:30 PM was approved. Immediate Jeopardy was lifted effective [DATE]. The facility's immediacy removal actions included the following: All residents on oxygen had a pulse oximetry reading completed and any results deviating from the resident's baseline had a registered nurse assessment and physician notification immediately via telephone by the end of the evening shift on [DATE].Education for licensed nursing staff was implemented immediately on the Change in Resident Condition Policy requiring documented physician notification immediately via telephone for all significant changes in resident condition.All oncoming licensed nursing staff would be educated on the Change in Condition Policy, with the intent to have 100% of staff educated by midnight on [DATE].As of [DATE], 90% of licensed nursing staff were educated. 10 New York Codes, Rules and Regulations 415.3(e)(2)(ii)(b)

Based on record review and interviews during the survey the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of three (3) residents (Resident #2) reviewed for accidents. Specifically, Resident #2 had an active physician order for a 1:1 supervision safety watch (for prior smoking violations and behavioral symptoms directed toward others) that was not implemented when the resident was readmitted from a hospital stay on 01/15/2025. Subsequently, on 01/17/2025 Resident #2 was found with a self-inflicted laceration to their neck and superficial vertical cuts to both wrists. This resulted in actual harm to Resident #2 that was not Immediate Jeopardy. Findings include:The facility policy 1:1 Supervision, revised 07/2023, documented when a staff member was assigned to provide 1:1 supervision, they would: -Stay within the required distance of the resident at all times unless relieved by another staff member.-Report to the charge nurse before breaks and at the end of their shift and wait to be relieved by another staff member. -Complete necessary documentation. - When the need for continued 1:1 supervision was no longer deemed necessary, a medical order to discontinue the order was to be obtained and the 24-hour report would be updated. Resident #2 had diagnoses including opioid dependence, anxiety disorder, depression, and diabetes. The 12/12/2024 Minimum Data Set (a resident assessment tool) documented the resident had intact cognition, had no behaviors or rejection of care, required partial/moderate assistance for sitting to standing and used a wheelchair. The Comprehensive Care Plan, reviewed 01/15/2025 (upon readmission), documented the resident had behaviors, potential for behaviors, verbal aggression, socially inappropriate behaviors, disruptive behaviors, confabulated stories, and multiple smoking violations. Interventions included: Two (2) staff for care, approach in calm, positive manner, reapproach as needed, delay care until resident is calm and approachable, 1:1 supervision for safety. The care plan was reviewed 10/08/2024 and 01/06/2025 and documented no changes needed. The 09/23/2024 Psychological Evaluation by Psychologist #16 documented the resident had a PHQ-9 (depression assessment) score of 11, which indicated moderate depression symptoms. The resident was actively grieving their medical changes in condition and the resident was not a danger to themselves or others. Follow up would be on an as needed basis. The 12/28/2024 untimed nursing progress note by Registered Nurse Supervisor #19 documented the resident had a room search completed for smoking paraphernalia and was re-educated on the facility's no smoking policy. The 12/28/2024 untimed nursing progress notes by Registered Nurse #7 documented the following: -Resident #2 was re-educated on smoking cessation and facility non-smoking policy. The Interdisciplinary Team met and agreed the resident was to be placed on a 1:1 supervision for safety. -At 6:25 PM, a telephone order was obtained from Nurse Practitioner #21 for a 1:1 safety watch. The 12/30/2024 at 12:17 PM Physician #20 order documented resident was on 1:1 for safety with a start date of 12/30/2024 and end date on-going. The 01/05/2025 and 01/07/2025 Certified Nurse Aide 4th floor assignment sheets did not document the resident was on a 1:1 safety watch. The 01/07/2025 at 1:43 PM nursing progress note by Registered Nurse #7 documented the 1:1 supervision for safety continued. The 01/07/2025 at 3:28 PM nursing progress note by Licensed Practical Nurse #8 documented the resident was out on an appointment and was sent to the hospital for admission via the physician's recommendation. On 01/15/2025 at 3:56 PM, Resident #2 was re-admitted to the 7th floor rehabilitation unit of the facility. The 01/15/2025 at 4:50 PM readmission nursing progress note by Registered Nurse #9 documented the resident was status post incision and drainage of the right thigh, orders were reviewed with Nurse Practitioner #4. Continue with 1:1 supervision as ordered. The 01/15/2025-01/17/2025 7th floor certified nurse aide assignment sheets did not document a 1:1 safety watch for Resident #2. There was no documented evidence the 12/30/2024 physician order the for 1:1 safety supervision watch was discontinued. The 01/17/2025 at 9:26 AM nursing progress note by Registered Nurse #12 documented Resident #2 was found on their bedroom floor with a large amount of blood under their head, both arms and hands. Upon assessment, the resident was observed with a laceration to their right neck and superficial vertical cuts to both wrists. Emergency services were contacted, and Resident #2 was transported to the hospital for evaluation. There were no documented 1:1 assignment sheets indicating the resident continued on 1:1 supervision from 01/15/2025 - 01/17/2025. During an interview on 09/10/2025 at 12:32 PM, Certified Nurse Aide #1 stated if a resident was on a 1:1 safety supervision watch, there would be a binder at the nurse's station for the certified nurse aides to document on. The binder would be kept in the resident's room and the certified nurse aide would hand it off to the next aide during shift change. The certified nurse aide assigned to the 1:1 safety supervision watch could not leave the resident until they were relieved by another staff member. During an interview on 09/16/2025 at 2:37 PM with Social Worker #11, they stated they recalled Resident #2 had gone out to the hospital and was readmitted on [DATE]. Social Worker #11 met with the resident to issue them a smoking violation on 01/17/2025 and stated they did not recall any staff with the resident for a 1:1 safety supervision watch. Resident #2 was alone in their room when they issued the violation. During an interview on 10/20/2025 at 1:05 PM, the Director of Nursing stated when a resident was readmitted from the hospital, they would be reassessed to determine if 1:1 supervision was still required, and they were not sure if this was specifically documented. Resident #1 was excited to return on 01/17/2025, was engaged, and seemed to be a different person upon return to the facility. The admission nurse (Registered Nurse #9) initially made the determination and then the next day, the unit manager (Registered Nurse #12) or another registered nurse reassessed. During an interview on 10/23/2025 at 2:19 PM, Nurse Practitioner #4 stated admission orders were placed by the admission nurse and reviewed either physically in the building or verbally over the phone with the provider. The provider did not have to be in the building, they would review the orders and approve them or discuss any changes. The 1:1 safety supervision watches were not ordered by the physician; they were determined by nursing but would be included in the orders for the physician to sign. They did not have access to Resident #2's records as they were no longer employed at the facility. During an interview on 10/24/2025 at 9:13 AM, Registered Nurse #9 stated they were the admission nurse who placed Resident #2's readmission orders in the electronic medical record. They stated 1:1 safety supervision watches were put into place by nursing and were dependent on the resident's behaviors on their unit. Resident #2 had a 1:1 safety supervision watch in place prior to the resident's hospitalization, and the order continued on readmission. If a resident was on a 1:1 safety supervision watch, staff were expected to be within reach of the resident at all times. There was typically no physician order for a 1:1 safety supervision watch, however, the medical providers reviewed all orders and signed off on them. During an interview on 10/25/2025 at 12:09 PM, Registered Nurse Unit Manager #16 stated Resident #2 was readmitted from the hospital on [DATE] and had a 1:1 safety supervision watch in place per the admission nurse's progress note. The admission nurse was responsible for assessing the resident and placing the orders into the computer, calling the medical provider and having them review the orders. Resident #2's 1:1 safety supervision watch was in effect per the admission nurse's progress note. A 1:1 safety supervision watch was assigned to the certified nurse aides by either the unit manager or medication nurse. The certified Nurse Aides documented every hour in a binder and were expected to stay within reach of the resident. If the resident went to the bathroom or dining room, staff watching them were expected to go with them. During an interview on 10/29/2025 at 10:50 AM, Certified Nurse Aide #17 stated they were familiar with Resident #2 and completed 1:1 safety watches for the resident prior to their hospitalization. Resident #2 was on a safety watch due to smoking. The resident resided on the 4th floor at that time. They stated the resident was independent, they thought the resident had a catheter and would transfer themselves to the toilet, and they would stand outside the door and knock frequently to check on them. Certified Nurse Aide #17 stated they were required to document on the resident's moods and what they were doing in a binder that was kept at the nurse's station. During an interview on 10/29/2025 at 12:58 PM, Certified Nurse Aide #18 stated they used to work on the 4th floor and recalled doing a 1:1 safety watch for Resident #2. They stated 1:1 watches were generally done if a resident was on a suicide watch, was caught smoking or were a danger to themselves or others. Resident #2 was on a watch for smoking. The 1:1 safety watches required the aide to stay within reach of the resident, including accompanying them to the bathroom but most aides just sat outside the door. They recalled sitting at the nursing station with Resident #2 and stated it was harder to do a 1:1 with Resident #2 because the resident was independent and mobile in a wheelchair. During a telephone interview on 12/12/2025 at 9:36 AM, Certified Nurse Aide #22 stated they recalled doing a 1:1 safety watch for Resident #2 on the 4th floor. They stated the resident was on a watch for smoking. 1:1 safety watches were assigned by either the staff scheduler or the nursing supervisor. During a 1:1 safety watch, Certified Nurse Aide #22 stated the required distance depended on the resident. There was no clear definition. Some residents required to be close to them while others just required to be within eyesight. Resident #2 used a wheelchair, had one leg but cared for themselves and only required to have them in eyesight to ensure they were not smoking. They went downstairs by themself for haircuts and shaves. They were not aware of any down or depressed moods and did not see the resident with any razors. During a telephone interview on 12/12/2025 at 12:20 PM, Certified Nurse Aide #23 stated they were familiar with Resident #2 and cared for them on the 4th floor and the 7th floor. Resident #2 had a 1:1 safety watch while on the 4th floor due to smoking. Required distance meant to stay close by the resident and they sat by the door. Resident #2 kept the bathroom door open and required minimal help with toileting unless they felt weak. They stated when the resident returned from the hospital, they cared for the resident on the 7th floor and the resident was not on a 1:1 safety watch. They stated the resident had belongings still in bags, there were no razors observed, and the resident did not state they felt like harming themselves. During a follow-up telephone interview on 12/12/2025 at 1:59 PM, the Director of Nursing stated according to the facility policy, 1:1 Supervision, required distance meant monitoring the resident at a safe distance and the resident would remain within eyesight of staff. The supervision was dependent upon the situation and resident, for example, if a resident had a nothing by mouth order and was observed drinking water from their bedroom sink, then closer supervision was needed. If a resident was a risk for elopement but was in their room with the door closed, then monitoring could be outside the room. 1:1 safety watches required a physician order and would show up on the resident care plan and Kardex. Staff knew a resident was on a 1:1 by their care card. Upon review of Resident #2's care plan, they stated a 1:1 safety watch was listed on the care plan, and they were unsure why. They thought the Unit Manager might have contacted a physician. They stated Resident #2 was re-assessed the following day upon their return from the hospital, but it was not documented in their electronic medical record. They stated Resident #2 was not on a 1:1 safety watch upon return from the hospital and there was no physician order for one. 10 New York Codes, Rules, and Regulations 415.12(h)(2)

Based on observations, record review, and interviews during the extended recertification and abbreviated (NY00376311) surveys conducted 4/6/2025 - 4/18/2025, the facility failed to ensure resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care and the right to participate in social and community activities for two (2) of three (3) residents (Resident #50 and #162) reviewed. Specifically, Residents #50 and #162 were Deaf and were not provided their preferred method of communication and thus were unable to communicate their needs and preferences to staff, socialize with other residents, or participate in meaningful activities. This resulted in actual psychosocial harm to Resident #50 that was Immediate Jeopardy and Substandard Quality of Care. Findings include: The facility policy Language Assistance, last reviewed 7/2021, documented each resident's language access needs would be reviewed and monitored during their comprehensive care plan review and conference. Language assistance would be provided through use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, communication boards, or technology and telephonic interpretation services. If an internal staff member who was fluent in the needed language was not available, Language Line or other local agencies would be contracted for assistance. Family members or friends of a Limited English Proficiency resident would not be used as an interpreter unless specifically requested by the resident and after they understood that an offer of an interpreter at no charge to the resident had been made by the facility. The facility policy Resident Rights, reviewed 8/2023 documented residents had the right to choose activities, schedule, and health care consistent with their interests and plan of care. The facility must promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of their individuality. 1) Resident #50 had diagnoses including deafness, non-speaking and anxiety disorder. The 3/4/2025 Minimum Data Set assessment documented the resident was cognitively intact, had absence of useful hearing and spoken words, their preferred language was sign language, and they sometimes felt lonely or isolated from those around them. The answer to the question How often do you need to have someone help you when you read instructions, pamphlets, and other written material from your doctor or pharmacy? was blank. The Comprehensive Care Plan revised 12/14/2024 documented the resident had highly impaired hearing, absence of useful hearing, did not have the ability to produce speech, was able to understand American Sign Language, and had the ability to read and write. Interventions included anticipate needs due to communication barrier, use simple language and yes/no questions when communicating, ensure access to writing material/white board, utilize picture board for simple American Sign Language communication if requested, writing equipment was available at bedside/table, and make attempts to understand the resident's frustrations, when necessary. The 4/5/2024 Speech Language Pathologist #34 progress note recommended for all communication staff/family continued to utilize live American Sign Language interpreting service via tablet which could be obtained in Administration. Should staff be unable to access live American Sign Language services, it was recommended to utilize written language via whiteboard to ensure Resident #50 was able to effectively communicate wants/needs. Invoices provided by the facility documented interpreting services were contracted twice for Resident #50 on 7/12/2024 for two (2) hours, and on 2/21/2025 for two (2) hours. During an interview on 4/7/2025 at 12:42 PM, Resident #50 communicated via simple word document and gestures. They wanted a tablet to help with interpretation for everyday communication and socialization. The resident provided the surveyor with contact information for interpretation services and asked for them to be contacted to help with communication. During a telephone interview on 4/8/2025 at 11:13 AM, Deaf Services Manager #18 (from local advocacy agency for the Deaf) communicated the facility had a tablet they were supposed to regularly use for interpretation for Resident #50. During an interview on 4/8/2025 at 9:12 PM, Certified Nurse Aide #4 stated Resident #50 communicated with gestures or whiteboard and marker. Certified Nurse Aide #4 took the surveyor to the resident's room to show the whiteboard and Resident #50 began to use signing to communicate. Certified Nurse Aide #4 stated the resident had a tablet for interpreting services but did not use it. The Certified Nurse Aide stated they did not know how to use the tablet. It was important to know how to communicate with the resident to know their needs. Certified Nurse Aide #4 interrupted after overhearing the interview and stated the only means of communication for Resident #50 was the whiteboard and the resident did not use the tablet for communication. During an interview on 4/8/2025 at 11:08 PM, Certified Nurse Aide #19 stated the resident's care instructions documented to use a writing board for communication. The facility had used video services for the residents during the COVID-19 pandemic, but it was not specific for Resident #50. They did not have a tablet on the unit for communication and the Supervisor would have to be called to use that. They did not know how to get video interpretation for Resident #50. They should use the resident's preferred method of communication because it was familiar to them, and it would let staff know what the resident needed. During an interview on 4/8/2025 at 11:08 PM, Certified Nurse Aide #20 stated Resident #50 wrote on a whiteboard for the staff. The resident did not speak and was Deaf. They did not have interpreting services on the overnight shift. During an interview on 4/9/2025 at 9:42 AM, Licensed Practical Nurse #21 stated if a resident's language was other than English, they could not see that information in the computer. Resident #50 used a whiteboard for communication. If the resident needed something they came out of their room carrying their whiteboard. It was important for Resident #50 to be able to communicate with them and feel comfortable asking for things and have open communication. During an interview on 4/9/2025 at 2:20 PM, Resident #50 communicated via in-person certified American Sign Language Interpreter #53 (from local advocacy agency for the Deaf). The resident communicated they felt isolated in the facility because the staff only used a whiteboard to communicate with them. Staff did not acknowledge them when they came to their room because they were Deaf. Their preferred method of communication was American Sign Language, either with use of staff that used American Sign Language, an in person interpreter, or video phone interpretation. English was not their primary language, and they were not comfortable writing in English. They stated they were isolated on the 4th floor, because they could not explain their needs in detail. The video relay phone interpreter would allow them to communicate with Deaf peers outside the facility as well as people in the facility. If the activity programs had an interpreter they would attend, but interpretation was not provided. When medication changes were made, such as adding a new medication, or a change in their regular medication, it was not explained to them. They were expected to take whatever was given to them. There was one point they refused to take their medications because the facility added two (2) pills, and no one explained what they were. The resident stated Deaf Services Manager #18 came to visit, and the facility explained the medication was because other residents in the building had the flu and it was ordered for everyone. The resident stated they lived a very structured life at home, and the routine kept them comfortable. They ate lunch at noon, and the lunch trays at the facility were not delivered until 2:00 PM or 2:30 PM, which caused a stomachache from hunger. They stated they were suffering in the facility, because they could not communicate when they were hungry, did not feel good, or if they had specific needs. They stated they were just alone and that no one cared about them. During an observation on 4/10/2025 at 11:23 AM, Resident #50 walked out of their room and down the hall to the dining area. They passed two (2) unidentified staff members, went to the kitchenette, got coffee and ice from the machine, and there was no staff interaction. The resident walked back towards their room, past the staff at the nurse's station, and no staff interacted with them. An unidentified staff crossed in front of the resident with no interaction. During an interview on 4/10/2025 at 11:30 AM, Licensed Practical Nurse Unit Manager #22 stated the expectation for residents that spoke a language other than English was to use their primary language. The resident's preference for communication should be honored. They stated Resident #50's primary language was English. If they wanted to use a tablet for communication, they should be allowed, and Activities had a tablet that could be used. Use of the whiteboard for communication was done by trial and error. The facility had not set up interpreting services for Resident #50. Resident #50 was a loner and preferred to stay in their room. When there were facility-wide or floor-wide activities there was no interpreter present. The resident should not have to ask for interpreting services to participate in activities. They stated they did not ask the resident if they would attend activities if an interpreter were present. There were three (3) residents on the 4th floor that used American Sign Language. The medical providers did not use an interpreter when they visited the residents. The resident did not have means of communication with friends outside the facility and was not asked if they wanted to communicate with people outside the facility. The resident should not have to ask to communicate with people. During a telephone interview on 4/10/2025 at 12:55 PM, Nurse Practitioner #23 stated the expectation for residents with English as a second language was to use the language line tablet from the business office. The resident's communication preferences should be honored. It was important to allow the resident to speak openly and freely. Resident #50's primary language was English, and they preferred to use the whiteboard for communication. They were not sure how the determination was made the whiteboard was the preferred method. They ensured understanding with teach back methods (return demonstration) and reinforcements of writing on the whiteboard and the resident would respond. If medical consent was needed, they would ensure the interpreting service was contacted first, and the interpreting service was aware of all medication changes for the resident. During a telephone interview on 4/10/2025 at 1:03 PM, the Medical Director stated staff could be used as interpreters and translators, but if that was not available, they could get additional translators. The resident's communication preference should be honored. It was important to get good, detailed information from the resident. The resident needed to be able to explain their concerns freely. During an interview on 4/10/2025 at 2:59 PM American Sign Language Interpreter #53 stated they knew the resident well. The resident had very limited English proficiency and the best access for the resident was live American Sign Language interpretation. If no interpreter was available, a tablet with a video relay interpreter was the best choice. The resident was unable to reach out to Deaf friends in the community or communicate with anyone from the facility. The video relay interpreter was a free service. During an interview on 4/10/2025 at 2:30 PM, the Administrator stated they expected to accommodate residents with English as a second language. They used the language line and picture boards provided by speech therapy. A resident's communication preference should be honored. The language line was easily accessible and accommodating. They stated they had never attempted to communicate with Resident #50. The resident's primary language was American Sign Language and the preferred method of communication for the resident was the whiteboard. They did not know how that was determined. They were not sure if the provider used an interpreter during medical exams, and did not know how they ensured informed consent. The facility did not set up interpreting services to ensure effective communication. They stated the Deaf advocacy organization should have advocated for the resident. They stated they did not feel the resident was socially isolated, even though they did not provide means of communication or means to participate in activities or meaningful discussion. During an interview on 4/10/2025 at 2:48 PM, the Assistant Administrator stated Resident #50's primary language was American Sign Language, and they used a whiteboard for communication. They did not know how the whiteboard was determined to be the resident's preferred method of communication, but that was what the facility used for all residents that could read and write. The providers in the facility did not use an interpreter for every visit, but did have the whiteboard available. They did not use an interpreter to get a better understanding of the resident's needs. Informed consent was done with the whiteboard. When the facility held activities, they did not provide an interpreter, and the resident should not have to ask for interpreting service for activities that were provided to all residents. 2) Resident #162 had diagnoses including degenerative disorder of the retina (part of the eye) and stroke. The 1/20/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, had absence of useful hearing and spoken words, and had highly impaired vision. Their preferred language was sign language; and they needed or wanted an interpreter to communicate with a doctor or health care staff. The Comprehensive Care Plan, revised on 4/10/2025, documented the resident had a communication deficit related to absence of useful hearing, was able to speak and communicate their wants or needs, had vision deficits, and had cognitive impairment related to stroke which affected their ability to understand despite using communication intervention. The 3/21/2025 interventions included to provide and encourage use of communication board, ensure writing equipment was available, and encourage use of and utilize live American Sign Language interpreter services, tablet was available in Administration. The 4/10/2025 interventions included to arrange in-person interpreter services, speech therapy as needed and utilize picture board for simple American Sign Language communication. The 2/1/2024 Speech Language Pathologist #34 progress note documented Resident #162 was provided with basic important medical signs on their wall, in their primary language, American Sign Language. All staff were encouraged to use American Sign Language when communicating with the resident. The 2/2/2024 Social Worker #33 progress note documented Resident #162 was Deaf and communicated through American Sign Language. The resident was able to answer 2-3 word questions with a white board; however, their handwriting was not legible. Speech therapy staff would provide the resident with a white board for short term use. The 3/5/2024 Speech Language Pathologist #34 progress note documented they recommended the facility pursue live, in-person American Sign Language interpreting services, which was also recommended by the resident's Case Manager and an American Sign Language speaking peer. Pending interpreting service, the recommendation was for staff to continue communicating with the resident through 1-3 large written words via whiteboard. The 4/9/2024 Social Worker #35 progress note documented Resident #162's third party social worker had concerns the resident's wishes were not being heard due to the language barrier. The 6/12/2024 Social Worker #36 progress note documented Resident #162 could not hear and had very bad vision, therefore, could not hear staff during assessments nor see when they wrote a question on the white board. The cognition assessment was done by staff. Invoices provided by the facility documented interpreting services were contracted for Resident #162 twice, on 4/5/2024 for 2 hours, and 6/26/2024 for 1 hour. There were no invoices provided for interpreting services in 2025. The 4/8/2025 Speech Language Pathologist #34 Therapy Progress Report documented Resident #162 had precautions listed for low vision, Deaf, and American Sign Language as the primary modality of communication. During an observation on 4/15/2025 at 10:37 AM, Resident #162 was in the hallway with the Assistant Administrator and an in-person interpreter. Resident #162 communicated they needed their ears cleaned, they wanted to go home soon to their own family, and that they knew another person in the building that signed well. During a telephone interview on 4/15/2025 at 11:33 AM, Resident #162's family stated the resident's preferred method of communication was American Sign Language. They could use a tablet for video interpretation, and the facility used one in the beginning, but not anymore. If the resident had concerns, they could not alert staff to their needs. They were told by the former social worker the facility was working on getting a full-time interpreter for the facility. The facility had not attempted to use the tablet or interpreter service since the resident's re-admission after surgery in 3/2025. The facility would call the family when they did not understand what the resident needed, but not everyone in the family used American Sign Language. The family depended on the facility to ensure the resident's needs were met. During an interview on 4/17/2025 at 1:26 PM, Certified Nurse Aide #38 stated Resident #162 had a tablet of their own, it was in the resident's closet. They always had it, but they were not sure if staff knew how to use it. During an interview on 4/17/2025 at 1:27 PM, [NAME] Clerk #39 stated Resident #162 preferred to use the tablet for interpreting or signing. They did not have a tablet for interpreting before this week; it was not available to them. The staff would write or Google signs to help understand. They were taught about the language line but had not used it before this week. During an interview on 4/17/2025 at 1:32 PM, Licensed Practical Nurse Assistant Unit Manager #40 stated Resident #162 did not own a tablet and was provided a tablet by the facility this week. The tablet was not readily available to the resident before then. The resident could see with their glasses on or off, but it was more beneficial when they wore them. Their right eye was much stronger and if staff used the right side the resident could communicate. 10 NYCRR 415.5(b)(1-3) *********************************************************************************************** The facility was notified of the Immediate Jeopardy on 4/11/2025 at 12:42 PM. The Immediate Jeopardy was removed on 4/16/2025 at 10:50 AM prior to the completion of the survey. The facility implemented the following to remove the immediacy: - Initial plan of immediacy was approved on 4/11/2025 at 5:50 PM and included the facility providing Residents #50 and #162 tablets programmed with the video relay interpreting service that were always accessible to the resident. Education was provided to the staff and residents on their use. The tablets were to be kept in the resident's rooms. - The second plan for immediacy was approved on 4/12/2025 at 11:14 PM, following determination staff and residents were unable to use the tablet for communication. - The facility provided in-service education to 89.5% of staff as of 4/16/2025 at 10:50 AM, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift. - Multiple interdisciplinary staff were interviewed during onsite visits through 4/16/2025. All staff demonstrated knowledge of the education provided regarding the communication devices.

Based on observations, record review, and interviews during the recertification survey conducted 4/6/2025 - 4/18/2025, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (6) of eight (8) residents (Residents #160, #417, #425, #461, #485, and #790) reviewed. Specifically: - Resident #485 was on contact precautions for clostridium difficile (a resistant contagious bacterium) colitis (inflammation of the colon) and droplet precautions for COVID-19 (a contagious respiratory disease) and did not have the appropriate isolation precaution signs, precautions were not consistently followed, and contaminated laundry items were not separated from general population laundry. - Resident #790 tested positive for COVID-19 on 4/4/2025 and isolation precaution signs were not observed on 4/6/2025. - Resident #417 tested positive for metapneumovirus (respiratory virus) on 4/4/2025 and did not have an isolation precaution sign displayed until 4/7/2025. - Resident #425 tested positive for metapneumovirus and the isolation precaution sign erroneously identified their roommate as being on isolation precautions and isolation precautions were not followed. - Residents #160 and #461 droplet isolation precautions were not followed. - Housekeeper #105 was observed transferring refuse in an unsanitary manner. These practices resulted in the likelihood of serious harm, serious impairment, or death due to the potential transmission of communicable diseases and infections for all 485 residents of the facility. Findings include: The facility policy Infection Control-Policy #1 revised 1/2024, documented the facility would develop prevention, surveillance and control measures to protect residents and staff from institution-acquired infections. The infection control nurse would monitor infection control practices and employee compliance. The facility policy Infection Control-Policy #3 revised 5/2024, documented three (3) categories of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions. The appropriate sign was to be placed on the resident's door. The contact precaution signs were yellow except for the ones for clostridium difficile colitis (C-diff), which were purple. If a resident was on contact precautions, an effort should be made to utilize disposable items when able and any resident equipment was to be wiped down with the appropriate germicidal wipes upon leaving the room. All personal protective equipment utilized should be removed and disposed of prior to leaving the resident's room. Linen was to be placed into green bags in the bin in the resident's room, tied and then removed and placed in the linen bin in the Soiled Utility Room. Droplet precaution signs were green and were to be placed outside the resident's room. In addition to standard precautions, a mask and eye protection needed to be worn. Staff were to limit movements of the resident outside their room to essential purposes only. The facility policy Infection Control-Policy #14, revised 6/2019, documented residents would be monitored at the first sign of respiratory illness-like symptoms and have exposure to other residents restricted and droplet/contact precautions implemented. The facility policy Infection Control-Policy #17 revised 6/2019, documented for clostridium difficile colitis, contact precautions would be utilized and handwashing with soap and water after glove use was to be done prior to leaving the resident's room. 1) Resident #485 had diagnoses including COVID-19 and enterocolitis (inflammation of the digestive tract) due to clostridium difficile. The 3/16/2025 Minimum Data Set documented the resident had intact cognition and was dependent for toileting hygiene. The resident's bowel continence was not rated. A 4/1/2025 physician order entered by Registered Nurse Unit Manager #9 documented the resident was on contact isolation precautions for diarrhea associated with clostridium difficile. The 4/4/2025 Registered Nurse Unit Manager #9 progress note documented the resident's polymerase chain reaction (a laboratory test) result for COVID-19 was positive. The resident had nasal congestion and a sore throat, was seen by the nurse practitioner, their care plan was updated, and precaution orders were in place. Observations and interviews: - On 4/06/2025 at 10:16 AM, Resident #485 had a contact precaution sign (for the clostridium difficile) on their door however, there was no droplet precaution sign for the COVID-19. Certified Nurse Aide #79 entered the room without personal protective equipment, took the resident's meal tray and touched the bedding, then exited the room without performing hand hygiene. At 10:22 AM, Certified Nurse Aide #106 donned a gown and handed a gown to Certified Nurse Aide #79 before entering the resident's room. Certified Nurse Aide #106 informed Certified Nurse Aide #79 they had to wear a gown due to the resident having clostridium difficile colitis. Both certified nurse aides left the room with their gowns balled up in their hands with gloves on. Certified Nurse Aide #106 disposed of their gown and gloves in the trash can at the nurses' station. They did not perform hand hygiene and walked to the other unit. At 10:24 AM, Certified Nurse Aides #95 and #79 entered the resident's room without donning personal protective equipment. - On 4/06/2025 at 11:39 AM, the resident's room had a droplet/contact precaution sign and a stop sign. Licensed Practical Nurse #17 stated the resident had tested positive for COVID-19 on 4/4/2025, but they did not have the sign posted that morning, so they had [NAME] Clerk #88 get the appropriate sign. - On 4/07/2025 10:28 AM, Physical Therapist #85 entered Resident #485's room and exited the room wearing full personal protective equipment, took a phone call, and paced up and down the short hallway, touching the handrail. Physical Therapist #85 entered and exited Resident #485's room twice to take a phone call and did not change their personal protective equipment. The resident's door was shut during the physical therapy visit. At 10:35 AM, [NAME] Clerk #88 entered the resident's room without personal protective equipment and asked therapy to turn off the call light. At 10:41 AM, Physical Therapist #85 disposed of their personal protective equipment prior to exiting the resident's room with the exception of their N95 mask which they disposed of at the nurses' station. - On 4/07/2025 at 11:10 AM, Registered Nurse Unit Manager #9 entered the resident's room wearing only a surgical mask for protection and was at the resident's bedside. At 11:15 AM, Registered Nurse Unit Manager #9 exited the resident's room, removed their gown, balled it up with gloves on, and carried the balled-up gown, with one glove on, into the soiled utility room down the hall. At 11:40 AM, Certified Nurse Aide #94 entered the resident's room wearing only a surgical mask for protection. - On 4/08/2025 at 10:52 AM, Certified Nurse Aide #96 entered the resident's room wearing a gown, gloves and a surgical mask. Certified Nurse Aide #96 was in the room with the door open and was about to go into the resident's bathroom. They removed one arm from the gown with gloves on. The resident asked for something, and the certified nurse aide went back toward the resident's window and adjusted something. The certified nurse aide entered the resident's bathroom, threw out their gloves and gown, and left the room. When interviewed, Certified Nurse Aide #96 stated they did not wear an N95 mask because there were none in the personal protective equipment caddy. They stated they did not wash their hands in the resident's room, as there were no paper towels. - On 4/08/2025 at 11:27 AM, Physical Therapy Assistant #97 exited the resident's room with the resident's water cup and a to-go container of food, dispensed ice from the communal ice machine into the resident's cup, put the cup on the counter in the unit kitchenette, emptied the to-go container onto a plate, and microwaved the food. Physical Therapy Assistant #97 brought the cup and plate back to the resident and handed it to staff in the room. During an interview at 11:33 AM, Physical Therapy Assistant #97 stated they should not have brought the pitcher out of the room to use communal equipment to refill the cup as items coming out of the resident's room could be contaminated. - On 4/08/2024 at 11:42 AM, Licensed Practical Nurse #98 removed their gloves outside the resident's room and put them in the garbage bag on the housekeeper's cart. They did not wash their hands after removing their gloves and prior to going to the medication cart to access their computer. During an interview Licensed Practical Nurse #98 stated the resident was just on precautions for COVID-19. They were unaware the resident was on precautions for clostridium difficile colitis until they read the resident's orders in the computer and then they went to wash their hands. - On 4/09/2025 at 4:34 PM, Certified Nurse Aide #100 was in the resident's room with the door partially open. Their hands were ungloved and touching the resident's clothing and linen piled in a chair. They took a roll of garbage bags from inside the room, came to the personal protective equipment door caddy to get gloves, and shut the door. At 4:39 PM, Certified Nurse Aide #100 opened the resident's door wearing personal protective equipment and put a plastic bag with the resident's under-pad and linen and a trash bag with briefs on the ground while they removed their personal protective equipment. They did not wash their hands prior to donning new gloves and picking the trash bags off the ground. They placed the resident's linen bag into the regular laundry bin in the soiled utility room. They washed their hands in the soiled utility which did not have paper towels. At 4:44 PM, Certified Nurse Aide #100 stated the isolation precautions a resident was on were listed on the resident's door. They stated gowns, gloves, a mask, and a face shield should be worn in a droplet precaution room. The linen for Resident #485's room should be put in the red precaution bin inside the dirty utility room. Gloves should always be worn in a contact precaution room and handwashing should be completed after taking off personal protective equipment and prior to leaving the resident's room. Wearing the appropriate personal protective equipment helped prevent the transmission of germs to other employees and residents. During an interview on 4/10/2025 at 11:47 AM, Registered Nurse Unit Manager #9 stated if a resident needed to be on precautions, they checked the labs in the computer to see if a resident had a positive result for whatever was tested . They would put signs on the door, place a precaution order in the computer, and then put in a request for central supply to bring up the personal protective equipment. They went into Resident #485's room with just a surgical mask and not an N95 because they could not locate a N95 mask in the resident's personal protective equipment caddy. If a resident was on precautions for clostridium difficile colitis, the only time the red biohazard bags and bin were utilized was if the resident had items saturated with bowel movements. For residents on precautions for clostridium difficile colitis, staff should wash their hands in the resident's bathroom, put on gloves to take out the trash bags, then wash their hands again in the soiled utility room. If a staff member did not wear the correct personal protective equipment, they could transmit the disease to someone else. 2) Resident #425 had diagnoses including COVID-19, acute cough, and pneumonia. The 1/23/2025 Minimum Data Set assessment documented the resident was cognitively intact. A 4/5/2025 laboratory report documented a specimen sample was collected on 4/3/2025 at 2:00 PM and received by the lab on 4/4/2025 at 3:59 AM. The results were reported on 4/5/2025 at 6:58 AM and human metapneumovirus was detected. A physician order documented droplet isolation precautions for metapneumovirus was discontinued on 4/14/2025. The orders did not include the start date for isolation precautions. During an observation and interview on 4/08/2025 at 9:34 AM, Dietetic Technician #102 entered Resident #425's room without donning personal protective equipment or performing hand hygiene. Dietetic Technician #102 stated they were trained on infection control annually and were familiar with the signs for isolation precautions. The sign on the door documented what personal protective equipment was needed when caring for a resident. They stated they did not see the sign on the resident's door to indicate they were on precautions and did not perform hand hygiene because there was no hand sanitizer outside of the room. If the precaution signs were not followed, they could spread the infection. During an observation and interview on 4/09/2025 at 9:15 AM, Licensed Practical Nurse Assistant Unit Manager #40 stated Resident #425 was on droplet precautions for human metapneumovirus and that it started with their roommate, but the roommate was off droplet precautions as it had been 10 days. The sign on the door documented the precautions were for the resident's roommate, not the resident who was currently on precautions. 3) Resident #461 had diagnoses including cough, fever, pneumonia, and COVID-19. The 1/26/2025 Minimum Data Set assessment documented the resident was cognitively intact. A physician order documented the resident was on isolation contact/droplet precautions pending a polymerase chain reaction (lab test) test for COVID-19. The order was discontinued 4/7/2025 (the resident was hospitalized from 4/7/2025-4/10/2025). The orders did not include the start date for isolation precautions. The 4/7/2025 Nurse Practitioner #48 progress note documented the resident was seen for cough, nasal congestion, and a fever. The plan was a chest x-ray, cough medicine, nebulizer treatment, and a respiratory panel. The 4/7/2025 untimed Registered Nurse Unit Manager #9 progress note documented the resident had a cough and nasal congestion. Lungs with crackles bilaterally. A rapid COVID-19 test swab was done with negative results, a polymerase chain reaction (a laboratory test for COVID-19) was obtained and sent to the laboratory, and a chest x-ray was ordered. During an observation on 4/7/2025 at 10:45 AM, the resident's door had a droplet/contact precaution sign. There was no personal protective equipment outside the resident's room. During an observation on 4/7/2025 at 11:36 AM, Certified Nurse Aide #106 walked into the resident's room to talk to the resident, turned their call light off, and left the room. Certified Nurse Aide #106 did not apply personal protective equipment or perform hand hygiene. 4) Resident #790 had diagnoses of chronic obstructive pulmonary disease (lung disease) and Hodgkin lymphoma (cancer of the lymphatic system). The 3/25/2025 Minimum Data Set documented the resident had intact cognition. The 4/4/2025 Registered Nurse Unit Manager #9 progress note documented the resident was swabbed for COVID-19 and the result was positive. A physician order documented droplet isolation precautions, contact precautions, COVID-19 droplet precautions were discontinued on 4/15/2025. The orders did not include the start date for isolation precautions. During an observation and interview on 4/6/2025 at 10:57 AM, there were no precaution signs posted outside of Resident #790's door and no personal protective equipment caddy hanging on or near the resident's door. There were two gowns on a bedside table outside the resident's room. Certified Nurse Aide #79 stated the resident was not on precautions They thought the resident used to be on precautions but did not think they were presently. During an interview on 4/6/2025 at 11:32 AM, Licensed Practical Nurse #17 stated the resident was on droplet/contact precautions due to testing positive for COVID-19. They were informed yesterday the resident was on precautions, but they did not have a proper sign, so they put up a contact precaution sign that was later removed. Housekeeping: During an observation and interview on 4/9/2025 at 9:19 AM, Housekeeper #105 carried a garbage bag with personal protective equipment slung over their shoulder, down the hallway into the soiled utility at the other end of the hall. They were not wearing personal protective equipment. Housekeeper #105 stated the garbage was from their cart with garbage bags from the resident rooms. The garbage bag became full at the end of the C Unit hallway, which was on precautions for droplet. They stated they did not wait to do the isolation precaution rooms last but emptied the rooms in order. During an interview on 4/10/2025 at 11:12 AM, Housekeeper #143 stated they did not wear personal protective equipment, and all rooms were cleaned the same. They stated they cleaned surfaces with a yellow cleaner with water in a basin and a washcloth. They stated they used to use the same cleaner in the mop bucket, but it messed up the floors, so the mop water was now just plain water in every room. During an interview on 4/10/2025 at 1:02 PM, Housekeeper/Laundry Aide #108 stated there was a bin on each unit for the resident laundry and resident linen. They stated they collected the bins from the unit and then the clothes went into the washer and the dryer. All linen was sent out. They stated they were not told if a resident had an illness. They sometimes got a note on the laundry with the resident's name and to wash the items separately. They wore gloves when the items were removed from the bags, but no other protective equipment. There were no separate water temperatures or different detergents used if someone was sick. Staff were supposed to rinse out any stool prior to putting it into a bag, but that did not always happen. They stated they did not wear personal protective equipment as it was hot in the laundry room. During an interview on 4/11/2025 at 10:22 AM, the Infection Preventionist stated they reviewed the labs every morning for residents and then they delegated to the Nurse Managers and told them whom to put on isolation precautions based on that information. Staff were educated on infection control through orientation and yearly competencies. The last education was March 2025. The spread of infection was lessened by housekeeping doing enhanced cleaning with bleach and not floating staff, if possible. Once a resident tested positive for an infectious disease, whoever tested the resident would write a progress note, get a physician's order for isolation precautions, and place the isolation precautions on the care plan. The ward clerk printed out the appropriate isolation precaution sign and made sure the rooms had personal protective equipment. The off-shift nursing supervisor had a folder with the color-coded isolation precaution signs. Purple contact signs were used for residents with clostridium difficile colitis, pink special droplet/contact precaution signs were utilized for COVID-19, and green droplet signs were used for influenza. The isolation sign would designate if it was the window or door bed, if it was a double room. The signs for Residents #417and #790 for COVID-19 and metapneumovirus should have been on the door on 4/6/2025. The risk of not having the appropriate signage was spread of the infection. Staff were expected to wear the personal protective equipment designated on the sign, remove their personal protective equipment prior to exiting the room, and perform proper hand hygiene. Staff should never enter a room on droplet precautions without wearing personal protective equipment. For rooms on contact for clostridium difficile colitis, they let the Housekeeping Director know so they would clean the room last and use bleach. It was also communicated to the direct care staff to use soap and water for hand hygiene and use bleach to clean equipment. Laundry went into a regular linen bag unless it was saturated. Staff should clean their hands with soap and water prior to donning new gloves to carry the linen bag to the soiled utility room. This would limit the spread of infection. Laundry personnel should be wearing gowns and gloves when handling dirty laundry, as there was no way for them to know if they were handling infectious material. During an interview on 4/11/2025 at 10:40 AM, the Medical Director stated isolation precautions should be initiated when the resident became symptomatic. If a resident had respiratory symptoms, they should be on droplet precautions unless the test came back negative. If a resident was positive for COVID-19, influenza, or clostridium difficile colitis, they expected to be notified when the results came back. There should be appropriate signage, so staff knew what personal protective equipment to use. Staff should follow the use of personal protective equipment per policy. If staff were not using the proper personal protective equipment they could spread the infection. Every staff member needed to follow the isolation signage and wear the proper personal protective equipment. During an interview on 4/11/2025 at 10:43 AM, the Administrator stated there was an Infection Preventionist in the facility that led the process for infection control. During morning report, they discussed any infections in the facility. When a resident presented with symptoms, the Registered Nurse Unit Managers or Nursing Supervisor would assess the resident. If the resident required testing, the Infection Preventionist and the Medical Director were informed. The resident should be on precautions from the time they were symptomatic, and precautions only removed if the test was negative. All residents on precautions should have the appropriate sign and personal protective equipment in a caddy on their door. They expected staff to follow the recommendations of personal protective equipment based on the precaution signage and to perform the correct hand hygiene. Residents on precautions for clostridium difficile colitis should have their rooms cleaned with bleach. If proper personal protective equipment was not worn, proper hand hygiene was not done, and the proper chemicals were not used to clean, there was a potential that a disease could spread. During an interview on 4/11/2025 at 11:46 AM, the Director of Nursing stated if a resident had a cough, they should be assessed by nursing, who then reported to medical. The resident would also be placed on precautions in case anything infectious came back from testing. The order for the precautions was put in by either the Infection Preventionist or the Registered Nurse Unit Manager. The signs for the precautions were put up by the ward clerk. If there was no ward clerk on shift, the precaution signs could be placed by the nurse. The door caddy of personal protective equipment was put up by central supply and there were extra personal protective equipment items in the clean utility room. If the resident had a positive result of an infectious disease, there should be the appropriate signage hung. All staff should review the isolation precaution signs prior to entering the room and follow the directions on the sign. If the appropriate sign was not hung or the staff did not wear the correct personal protective equipment, infection could spread. The rooms of residents on precautions for clostridium difficile colitis should be cleaned with bleach. They were unsure how the laundry was separated for a resident on precautions for clostridium difficile colitis, but laundry staff was required to wear personal protective equipment when handling all laundry. 10 NYCRR 415.19(a)(b) ************************************************************************ The facility was notified of the Immediate Jeopardy on 04/11/2025 at 2:03 PM. The Immediate Jeopardy was removed on 4/15/2025 at 2:40 PM prior to the completion of the survey. The facility implemented the following to remove the immediacy: - Initial plan of immediacy was approved on 4/11/2025 at 4:47 PM and included the facility ensuring all residents on precautions were reviewed and had the appropriate isolation precaution signage in place, all in-house staff were educated on infection control with competency-based training, and all oncoming staff would be educated prior to the start of their shift. - The facility provided in-service education to 85% of staff as of 04/15/25 at 1:25 PM, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift. - Multiple interdisciplinary staff were interviewed during onsite visits through 4/15/2025. All staff demonstrated knowledge of the education provided on appropriate infection control precautions. 48446 50561

49448 Based on observations, record review, and interviews during the recertification and abbreviated (NY00374160) surveys conducted 4/6/2025 - 4/18/2025, the facility did not ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality for two (2) of three (3) residents (Residents #170 and #335) reviewed. Specifically, Residents #170 and #335 were continent (able to control bladder and bowel), placed in incontinence briefs, and were told by staff to urinate/defecate in the briefs instead of using the toilet and/or bedpan. This resulted in psychosocial harm to Residents #170 and #335 that was not Immediate Jeopardy. Findings include: The facility policy Dignity and Respect, last reviewed 8/2023 documented residents had the right to be treated with dignity, respect, and consideration at all times. Staff should ensure residents were treated as individuals and encourage them to participate in programs and services of their choice and protect them from any kind of harsh and abusive treatment. 1) Resident #335 had diagnoses including difficulty walking, need for assistance with personal care, and had menstrual cycles. The 2/25/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment, toilet transfer was not attempted due to medical condition or safety concerns, was dependent for toileting hygiene, and did not reject care. The 3/27/2025 Physical Therapist #42 discharge summary documented discharge recommendations of moderate assistance of one (1) for transfers with a stand pivot technique. The undated care instructions documented the resident was dependent on one-person assist for toileting hygiene and required substantial/maximum assist of two (2) staff for toilet transfers; incontinent of bladder, bedpan, assist with changing briefs, and occasionally incontinent of bowel. The April 2025 certified nurse aide Activities of Daily Living Toileting Use record documented the resident was incontinent and toilet transfer was not attempted at the following times: - On 4/6/2025 once on the day shift and once on the night shift. - On 4/7/2025 once on day shift, once on evening shift, and twice on night shift. - On 4/8/2025 once on day shift and once on evening shift. - On 4/9/2025 once on day shift, once on evening shift, and twice on night shift - On 4/10/2025 once on day shift and once on evening shift. - On 4/11/2025 once on day shift, once on evening shift and once on night shift. - On 4/12/2025 twice on day shift, once on evening shift and once on night shift. - On 4/13/2025 - 4/15/2025 once on day shift, once on evening shift and once on night shift Resident #335 was observed and interviewed: - On 4/6/2025 at 2:52 PM, they were in their room sitting up in their wheelchair wearing a hospital gown. They stated when they asked to go to the bathroom, the certified nurse aides would not let them and told them to just go in their incontinence brief. When they told the certified nurse aides they could use the toilet instead of an incontinence brief, the certified nurse aides got mad and wanted to argue. The resident was currently on their menstrual cycle, and they were told they had to have their brief changed in the bed so once they were up for the day, they were not provided with toileting assistance until they wanted to go back to bed. - On 4/8/2025 at 9:19 AM, they were lying in bed in a hospital gown. They stated the certified nurse aides just told them to go in their brief and the next shift would change them. It made them want to cry that they had to soil themself, but it was even worse because it was during their menstrual cycle. The last time they were assisted with a brief change was last night before bed. At 11:50 AM Certified Nurse Aide #43 entered the resident's room with a razor, washcloths, and towels. At 12:17 PM, the resident was up in their wheelchair in the room in a hospital gown. The resident stated Certified Nurse Aide #43 had just changed their incontinence brief, cleaned them, and transferred them from the bed into their wheelchair by stand and pivot. This was the first time their brief was changed since before bed last night. - On 4/9/2025 at 9:37AM, the resident had completed breakfast and was lying in bed in a hospital gown. They stated Certified Nurse Aide #45 changed them around 11:00 PM last night. Their incontinence brief was currently wet and had not been changed since last night. Certified Nurse Aide #43 (the current day certified nurse aide) told them they were not allowed to utilize the bathroom and told them to go in the brief. They got frustrated because they knew when they needed to go to the bathroom and if they put their call bell on, staff just turned the light off and never came. They could not hold it anymore and had to soil the brief. Their menstrual cycle ended yesterday, and they did not like being dirty and it smelled; it was embarrassing. They ate breakfast today and dinner last night with a wet brief. If they told the certified nurse aides they wanted their brief changed before their meal, the certified nurse aides got mad and told them they had to wait. The resident liked going to visit their daughter because their daughter helped them on to the toilet and assisted with wiping and they did not have to use the incontinence brief. The worst was when they had to have a bowel movement; it was embarrassing, it made them feel dirty, and it smelled. - On 4/15/2025 at 10:58 AM, they were lying in bed in a hospital gown. The resident stated they had a new brief placed around midnight last night and had not been provided with any toileting assistance since then. During an interview on 4/15/2025 at 12:12 PM, Certified Nurse Aide #43 stated they always provided incontinence care to the resident before lunch and once the resident was up in their wheelchair, they were good for the shift. The resident was incontinent because they could not walk, and therapy had not cleared them to utilize the bathroom. They were aware the resident wanted to use the bathroom, but they had not mentioned anything to anyone to get them a therapy evaluation. They stated if a resident soiled themself when they could be toileted, it was not appropriate and would not be comfortable. They would not want to be around other people or would not like to eat their meals like that. It was a dignity issue and could make the resident feel like nobody cared. It would not be a good feeling and would be sad and embarrassing. They stated the resident's legs were weak, and they were not comfortable putting them on the toilet and would need assistance of another person to place the resident on the toilet. During an interview on 4/16/2025 at 11:30 AM, the Director of Rehabilitation stated the resident was discharged from physical therapy on 3/27/2025 and their transfer status was moderate assistance of one (1) with a stand and pivot, so there was no reason why they should not be able to use a toilet. The care plan documented toileting was not attempted due to a medical condition/ safety concern and was never updated. The resident was not reassessed for toileting after their transfer status improved but they should have been. It was not good the resident was soiling themself in a brief because the certified nurse aides told them they could not use the bathroom. This was a quality-of-life issue. Nursing should have put in a referral; physical therapy should have communicated with occupational therapy so the toileting status could be updated. During an interview on 4/16/2025 at 2:37 PM, Certified Nurse Aide #45 stated when they started their night shift, the resident was already in bed. Sometimes they were wet and sometimes not. The resident was in their right mind, could ring for help, and did not like being soiled. The resident had reported to them they were left soiled all day until they wanted to go to bed. During an interview on 4/17/2025 at 9:30 AM, Certified Nurse Aide #44 stated Resident #335 could verbalize when they needed to use the restroom and was a stand and pivot of one (1) assist for transfers. When they came in for their evening shift, the resident was in their wheelchair, and they assisted them into the bed during their shift. The bathroom was small, but they did not know why the resident did not have a bedside commode. The resident told them it made them sad the certified nurse aides did not listen to them and they hated sitting in their own feces. Going to the bathroom was a basic human right, this was their home, and the resident should be able to do what they were able to do. It was not right they were being told to just use the brief and wait for hours to be changed. During an interview on 4/17/2024 at 10:10 AM, Licensed Practical Nurse Assistant Unit Manager #46 stated Resident #335 would call for the bedpan. The resident was incontinent at times but was alert and oriented and able to make their needs known. The resident should not be told to soil themselves. It was not appropriate, and it made the resident feel horrible. Even if the resident did not ring their call bell, the certified nurse aides should be checking in every 2-3 hours to ask if the resident needed to use the bathroom. During an interview on 4/17/2025 at 11:14 AM, Assistant Director of Nursing #47 stated Resident #335 was incontinent at times, but they had known the resident to use a bedpan in the past. The resident transferred with a stand and pivot and occupational therapy needed to evaluate the resident for use of the bathroom. During an interview on 4/18/2025 at 11:00 AM, Nurse Practitioner #48 stated Resident #335 was alert and oriented and should not be told to utilize an incontinence brief, as it was a dignity issue. This would be frustrating and upsetting for the resident. It was also a dignity issue to eat their meals with a soiled brief/smell of waste, and the resident should also have regular care for their menses. During an interview on 4/18/2025 at 11:28 AM, the Medical Director stated a continent person should never be told to use an incontinence brief. The facility had a lack of assistance, the staff told the residents just to urinate in their incontinence briefs and put on their call bell, and maybe three (3) hours later someone would come back to change them. All residents should be treated with respect, and this treatment would definitely affect mental health and negatively affect psychosocial well-being. 2) Resident #170 had diagnoses including anxiety disorder, pain, and morbid obesity. The 1/21/2025 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, was occasionally incontinent of urine, frequently incontinent of bowel, and was dependent on staff for toileting. The Comprehensive Care Plan initiated 2/9/2024 and revised 4/14/2025 documented the resident required assistance with self-care and toileting related to impaired mobility. The resident was continent of bladder and bowel, used the bedpan for toileting, was unable to use the toilet, used a lifting device for transferring, and was dependent on staff for toileting. The resident care instructions documented Resident #170 was continent of bladder and bowel, was dependent on one staff for toileting, and used the bedpan. Resident #170 was observed and interviewed: - On 4/6/2025 at 12:41 PM, Resident #170 was sitting in the dining room. They stated certified nurse aides made them wear a brief even though they were continent of urine. Two (2) incontinence briefs were put on in the morning and certified nurse aides told them to urinate in the briefs. The resident preferred to go back to bed and use the bedpan, however staff told them if they went back to bed, they had to stay there for the remainder of the day and would not be able to attend activities they enjoyed. At times they were so soaked with urine there was a puddle underneath their chair, and it was embarrassing. Their lift pad that was underneath them was always wet and smelled of urine. They could not send it to laundry because it never came back and then they were stuck in bed. They did not get changed until after 8:00 PM when they were put to bed for the day. They did not want to be in incontinence briefs, but did not want to be isolated to their room because they were very social. They felt worthless and like they did not matter to staff. They feared retaliation if they refused to wear an incontinence brief. - On 4/7/2025 at 8:07 AM, resident was in the dining room. There was a strong smell of urine coming from the resident. They stated they asked their certified nurse aide for a new lift pad that was underneath them but there was not one available to use so a certified nurse aide sprayed the pad. They wanted their shower last Wednesday (4/2/2025), but did not get it as they required two (2) staff for showering and there was only one (1) staff available. They stated they were wearing an incontinence brief for staff convenience as staff did not want to get them in and out of bed to use the bedpan. They preferred to wear underwear and not being able to wear underwear and having to urinate in the incontinence brief made them feel bad and like they were not human. - On 4/8/2025 at 9:21 AM, resident was wearing a gown in bed. Their hair was greasy, and they had their call bell on. Licensed Practical Nurse #11 entered the room with medication for the resident. An unidentified certified nurse aide called into the room and told Licensed Practical Nurse #11 to cut the light, we are in the dining room, and the nurse turned the call bell light off and left the room without asking the resident what they needed. There was a strong smell of urine from the room that became stronger closer to the lift pad. The lift pad smelled of urine and had a dark outline on the pad where it had been wet and then dried. The resident stated they needed the bedpan and was upset staff left without putting them on the bedpan or even asking why the call bell was on. At 12:59 PM, the resident stated Certified Nurse Aide #124 put them on the bedpan and then put an incontinence brief on them before getting them up for the day. They stated the lift pad underneath them smelled of urine and they called central supply themself yesterday and today for a new pad and was told there were none available. They stated they were wearing two (2) incontinence briefs and did not want to be wearing incontinence briefs or have a lift pad that smelled of urine. They stated wetting themself was embarrassing. During an interview on 4/9/2025 at 12:43 PM, Certified Nurse Aide #124 stated Resident #170 had a routine of asking for the bedpan as soon as they woke up, usually around 9:00 AM. After they were done with the bedpan, staff washed them up and put on powder and incontinence briefs. Utilizing a lifting device, they and another staff member transferred the resident to the chair. They stated they were assigned to Resident #170 on 4/8/2025, but were unable to get the resident on the bedpan because they were assigned to the dining room during mealtimes. Staff covering the unit should have answered the resident's call bell and put them on the bedpan. The resident was continent, but they placed an incontinence brief on them because the resident did not have underwear. If the resident had underwear, they would not put an incontinence brief on the resident. During an observation on 4/9/2025 at 12:34 PM, Resident #170 was in the dining room with a strong smell of urine coming from them. During an observation and interview on 4/10/2025 at 1:09 PM, Resident #170 was in an incontinence brief in their wheelchair with a strong smell of urine coming from them. They stated they were in a dry incontinence brief and did not want to be in the brief because it was embarrassing and degrading to have to wet themself. Their lifting pad underneath them smelled because it was urine soaked and they wanted a new pad. During an observation and interviews on 4/15/2025 9:37 AM, Resident #170 was observed being transferred to their wheelchair and was wearing an incontinence brief. Certified Nurse Aide #124 stated although the resident was continent, they put an incontinence brief on them because the resident would need the bedpan every hour in the morning. Certified Nurse Aide #124 stated months ago, the resident asked the provider to change the time of their water pill to the evening time as they were in bed, and it was easier for staff to get them on the bedpan. They did not want the water pill in the morning because staff made them urinate in the incontinence briefs and they went so much there were puddles underneath them. Certified Nurse Aide #124 stated they also put an incontinence brief on the resident to keep the lifting pad dry, so it did not smell. Lifting pads were washed by laundry. They stated last week the lifting pad smelled so bad they went to laundry, and they did not have a clean lifting pad, so the resident continued to use the lifting pad that smelled of urine. The resident's lifting pad was sent to laundry 4/10/2025 or 4/11/2025 and there was not an available lifting pad when they worked on 4/12/2025 so the resident remained in bed. Certified Nurse Aide #124 stated if a continent resident was wet or if a lifting pad was urine-soaked and smelled it could make the resident embarrassed and feel bad. At 10:28 AM, Resident #170 stated they asked to get out of bed on 4/13/2025 and were told there were no lifting pads available to get them out of bed. They called Assistant Activities Director #125, as that was the only person that helped them. They also told Social Worker #121 about being forced to wear incontinence briefs and nothing was done. During an interview on 4/17/2025 at 10:20 AM, Certified Nurse Aide #127 stated the resident was continent of urine and on their shift (evenings), they asked for the bedpan. The resident was wet most days when they put them back to bed and they had seen them in their wheelchair with a puddle of urine underneath. If a resident was told to wear a brief and was continent it could be uncomfortable and embarrassing. During an interview on 4/17/2025 at 11:33 AM, Social Worker #121 stated residents should not be told to wear an incontinence brief for staff convenience. If a resident sat in a wet incontinence brief all day it could make them feel terrible and a soiled lifting pad could make them feel dirty. During an interview on 4/17/2025 at 11:56 AM, Licensed Practical Nurse #21 stated Resident #170 was continent of urine and should not be put in an incontinence brief because it could make them feel badly. They were unsure if the resident was toileted during the day, and they should be. During an interview on 4/17/2025 at 12:12 PM, Licensed Practical Nurse Unit Manager # 22 stated if a resident required a lifting pad for transferring and there was not one available, the resident would be confined to bed and could feel isolated. If the pad was soiled and smelled of urine it could make the resident feel horrible. Continent residents should not be wearing incontinence briefs unless it was their preference because it could be a dignity issue and was embarrassing. Residents who were able to use the bedpan should be put back to bed for toileting and returned to their wheelchair. When a resident was wet, they should be changed and not left in the wet incontinentce brief. Resident #170 was continent, should not be wearing an incontinence brief, and if they did not have underwear, the social worker should be notified to get some. During an interview on 4/17/2025 at 2:22 PM, Nurse Practitioner #23 stated continent residents should be either taken to the bathroom or placed on a bedpan. No resident should be left in a wet incontinence brief as they could get a urinary tract infection or skin breakdown. More importantly, research showed being left in a wet incontinence brief had a huge negative impact on mental health. Resident #170 was continent and should not be in an incontinence brief. Putting Resident #170 in an incontinence brief and having them wet themself and/or not having a clean lifting pad could cause psychosocial harm. 10 NYCRR 415.5(d)(1)(i)

50561 Based on observations, record review, and interviews during the recertification and abbreviated (NY00325460) surveys conducted 4/6/2025 - 4/18/2025, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (2) of three (3) residents reviewed (Residents #274 and #461). Specifically, Resident #274 was not provided a wound vacuum machine (vacuum assisted closure using negative pressure to assist in wound healing) or the back-up wet to dry dressing treatment as ordered; and Resident #461 did not receive timely follow-up care for their dehisced wound (a surgical incision that reopens) This resulted in harm to Resident #461 that was not Immediate Jeopardy. Findings include: The facility policy Change in Resident Condition, reviewed 12/2022, documented the nursing supervisor would notify the medical provider when there was a change in the resident's condition. All physician's or practitioner's orders would be followed. The nursing supervisor was to notify the resident of any changes in their condition or medical care. The facility policy Negative Pressure Wound Therapy, revised 3/12/2019, documented any resident who has an ulcer would receive care and services to promote healing to include, when needed, negative pressure wound therapy (wound vacuum). Responsible parties include licensed practical nurses and registered nurses who have been trained and have demonstrated competency may apply, change, or remove negative pressure wound dressings. 1) Resident #461 had diagnoses including peripheral vascular disease (poor blood flow) and right above the knee amputation. The 1/26/2025 Minimum Data Set documented the resident had intact cognition and did not have surgical wounds at the time of the assessment. The resident was hospitalized [DATE] - 3/11/2025 for acute lower limb ischemia (lack of blood flow) and underwent a right above the knee amputation. The 3/11/2025 physician's order documented apply abdominal gauze pad to right above the knee amputation surgical site and wrap with kerlix every Tuesday and Friday during the day shift and as needed. The 3/27/2025 Registered Nurse Unit Manager #9 progress note documented the resident returned from their post-operative follow up appointment following a right above the knee amputation. The consult documented the resident did not have significant pain, the stump was soft and nontender, the incision line was intact with the sutures in place without drainage. The incision had necrosis (dead tissue) but was dry. The resident was to return in two (2) to three (3) weeks for suture removal. The incision was to be covered daily. The follow-up appointment was scheduled for 4/15/2025 at 10:15 AM. The 4/4/2025 Licensed Practical Nurse Assistant Unit Manager #7 progress note documented the right above the knee amputation site sutures appeared to have come undone on the inner left side. The dehisced area appeared red with white drainage around the area. The resident had pain to the dehisced area. The nurse practitioner saw the resident and gave new orders for an antibiotic and requested a vascular consult. The 4/4/2025 Nurse Practitioner #48 progress note documented they were following up on a possible wound infection. Staff was giving the resident a shower and noticed the stitches had come out of the right above the knee amputation site. The area looked infected, a couple of sutures came out and an area of the incision had dehisced. The area had redness, pus filled drainage, was warm, and painful. The resident was started on an antibiotic twice a day for seven days. They directed nursing to call and try to get the resident back into the vascular consultant as soon as possible. There was no documented evidence the vascular consultant was contacted for an appointment for surgical wound follow up. During an observation and interview on 4/6/2025 at 11:55 AM, the resident stated they were concerned their right above the knee amputation was opening. The surgical incision was dehisced about two (2) or more inches. The above the knee amputation surgical site was mid/upper thigh. Inside the wound was a whitish, flesh colored lump. The resident stated they had pain, and it had been open for more than two (2) days. The resident's incontinence brief was positioned next to the wound at the upper thigh and had brownish red fluid on the side. The resident's bed sheets also had a brownish red fluid. At 11:57 AM, [NAME] Clerk #88 entered the resident's room and stated they would get someone to look at the resident's surgical site. [NAME] Clerk #88 left the room and came back at 12:02 PM. They asked the resident what happened, and the resident stated their incision site was broken open. At 4:46 PM, the resident had two overlapping pink adhesive bandages over the entire end of their stump and the blankets under resident had dried reddish-brown spots. The 4/6/2025 Registered Nurse Unit Manager #9 progress note documented the resident had an unwitnessed fall in their room. The resident had right above the knee amputation dehiscence with no drainage noted. The resident was on antibiotics and a dressing was applied. The resident denied pain or discomfort. The on-call providers were notified. There was no documented evidence of a planned vascular consultant follow-up. I The 4/7/2025 Registered Nurse Unit Manager #9 progress note documented the resident was seen during rounds by the attending nurse practitioner for respiratory symptoms. There was no documentation regarding the resident's surgical wound dehiscence. The 4/7/2025 progress notes by Licensed Practical Nurse #170 documented they were notified by Licensed Practical Nurse Assistant Unit Manager #7 resident had a fall at 8:30 PM on 4/6/2025. The resident's sutures to their right above the knee amputation had come undone and the resident's bone was protruding. The unit nurse provided wound care. The physician was called and ordered the resident to be sent to the Emergency Department. The resident was hospitalized from 4/7/2025 - 4/11/2025 for post-operative infection and wound dehiscence. During an interview on 4/9/2025 at 10:49 AM, [NAME] Clerk #88 stated they took care of all the appointments for the residents on the unit. If a provider wanted a resident to see an outside provider sooner than what their scheduled appointment was, there would be a consult order in the electronic medical record. They stated they reviewed every resident's chart every day for new consult orders. If a provider ordered a resident to be seen by vascular as soon as possible on a Friday afternoon, the nurse practitioner informed Registered Nurse Unit Manager #9 or Licensed Practical Nurse Assistant Unit Manager #7. The information was passed to them, and they would call the vascular provider. Resident #461 had a vascular appointment scheduled for 4/15/2025 at 10:00 AM and they informed Registered Nurse Unit Manager #9 on 4/4/2025 when they asked about an appointment. They were not asked to schedule the appointment sooner. During an interview on 4/16/2025 at 11:26 AM, Licensed Practical Nurse #17 stated they were informed on 4/6/2025 that Resident #461's surgical incision had opened more. They applied a dry dressing on the surgical incision site early in the morning as the resident's dressing had fallen off. They noted the incision was open about an inch. After the resident's second fall on 4/6/2025, they observed the surgical incision was open about 3 to 4 inches and put a foam dressing on it. During an interview on 4/17/2025 at 12:50 PM, Licensed Practical Nurse Assistant Unit Manager #7 stated when they saw Resident #461's surgical incision on 4/4/2025, the first one (1) to two (2) sutures had come undone and there was some drainage. They called Nurse Practitioner #48 to assess the resident. Nurse Practitioner #48 ordered Bactrim for cellulitis (a bacterial infection) and wanted a vascular consult as soon as possible which meant within the next day or so. If a resident needed an appointment scheduled as soon as possible the nurse or medical provider put in an order for the appointment to be scheduled as soon as possible by the ward clerk. They were unsure if the vascular consult was called for Resident #461 on 4/4/2025. They stated an appointment on 4/15/2025 would not be considered as soon as possible. During an interview on 4/17/2025 at 1:31 PM, Registered Nurse Unit Manager #9 stated if a provider saw a resident and stated they needed a follow up as soon as possible, the ward clerk should call the outside provider to schedule an appointment. They stated if they were unable to get an appointment scheduled, they should notify the nurse practitioner to find out the next steps. During an interview on 4/17/2025 at 1:58 PM, Nurse Practitioner #48 stated they saw Resident #461 on 4/4/2025 for their surgical incision opening. The wound was open two (2) to three (3) centimeters. They stated they started the resident on antibiotics for cellulitis and wanted the resident seen by vascular as soon as possible. They were informed the resident was going to be seen on 4/15/2025 but had instructed the nursing staff to try again as that was too long to wait for the resident to be seen. They stated if they had been informed it had opened to 3 - 4 inches with drainage, they would have sent the resident to the hospital. 2) Resident # 274 had diagnoses including osteomyelitis (bone infection) of the left foot, left toe amputations, and diabetes. The 2/4/2025 Minimum Data Set Assessment documented the resident had intact cognition, was independent with most activities of daily living, had a surgical wound, and received surgical wound care. The Comprehensive Care Plan initiated 1/11/2025 documented the resident had surgical debridement (removal of dead tissue) of the left foot. Interventions included provide wound care as ordered; observe for effectiveness of treatment; wound vacuum-assisted closure; weekly skin evaluations by registered nurse; and monitor for pain prior to dressing change. Physician orders documented: - On 11/14/2024, wet-to-dry dressing as backup if wound vacuum malfunctions or cannot restore vacuum in 24 hours, as needed. - On 11/29/2024, continuous negative pressure wound therapy to left trans metatarsal amputation (removal of toe) open site every day during the day shift. - On 11/29/2024, dressing type: black foam, change wound vacuum dressing every Monday, Wednesday, and Friday; pack 5th toe amputation site with Aquacel Ag (antimicrobial wound dressing) and cover with black foam, three (3) times a week on Monday, Wednesday, and Friday during day shift. - 11/29/2024 change canister and canister tubing (of wound vacuum) weekly on Wednesday day shift. The 1/17/2025 Physician #3 progress note documented the resident had wound vacuum-assisted closure changes three times a week, and recent wound pictures showed good granulation (new tissue). A 1/31/2025 Wound Care Clinic progress note documented the resident had a non-healing diabetic foot ulcer. The ulcer was worsening despite standardized wound care, off-loading, serial debridement (removal of dead tissue), and negative pressure wound therapy. The wound vacuum was not on during the visit. The resident was having issues with the wound vacuum being placed at the facility, the usual wound care nurse was out. The facility was working on finding someone who could replace the wound vacuum regularly as scheduled on Monday, Wednesday, and Friday. Otherwise, the wound appeared stable. A 2/5/2025 Wound Care Registered Nurse #128 progress note documented the surgical wound to the left foot measured 7.0 centimeters x 5.0 centimeters x 0.2 centimeters and had a large amount of drainage with no odor. The wound was pink in color with no signs of infection. The wound was cleaned, and treatment was applied. The 2/2025 Medication Administration Record documented the vacuum-assisted closure dressing was not changed from 2/6/2025 - 2/19/2025. There was no documented evidence of wet-to-dry dressing applied from 2/6/2025 - 2/19/2025 per orders for when the wound vacuum was not used. There were no documented nursing progress notes regarding the resident's wound or dressing from 2/6/2025 - 2/19/2025. The 2/7/2025 Wound Care Clinic visit summary documented the resident had a non-healing diabetic foot ulcer. The ulcer was worsening despite standardized wound care, off-loading, serial debridement (removal of dead tissue), and negative pressure wound therapy. The resident was receiving adjunctive hyperbaric oxygen therapy to improve healing. The wound care instructions included wound vacuum to left foot, black foam, vacuum set to 125 millimeters of mercury, change Monday, Wednesday, and Friday. The 2/21/2025 Medical Director progress note documented the resident had a wound vacuum with dressing changes three times a week. There was no documented evidence the physician was notified of the wound vacuum not being applied. The 2/26/2025 Wound Care clinical communication documented the resident's wound was improving. During an observation and interview on 4/8/2025 at 9:57 AM, Resident #274 stated there was a time when the vacuum assisted closure device had been off for several days in February 2025, specifically during the time the wound nurse was out. They stated there was no one in the facility that was able to provide the care needed for the wound vacuum-assisted closure device. They stated during that time they wheeled around the hallway to find someone who was able to apply their wound vacuum. The resident stated they covered the wound with gauze and tape until the wound care nurse returned. The resident stated they relied heavily on Wound Care Registered Nurse #128, and they had never met the other wound care nurse. During an observation and interview on 4/9/2025 at 8:56 AM, Wound Care Registered Nurse #128 completed wound care and applied Resident #274's wound vacuum. The wound was dry without drainage or redness. Wound Care Registered Nurse #128 stated if the wound vacuum was to come off, a dressing would be put in place until the wound vacuum was able to be replaced. Wound Care Registered Nurse #128 stated in the event of their absence, the nursing supervisor, or the unit nurse would be responsible for applying the device. They stated they were off for 10 days between 2/6/2025 and 2/21/2025 and they expected Wound Care Registered Nurse #136 to monitor or consult for residents with specialized treatments such as Resident #274. Anyone who provided care for the resident was expected to document in the Medication Administration Record to indicate the treatment was done. They stated there was a lack of continuity of care during their absence. During an interview on 4/15/2025 at 11:11 AM, Registered Nurse Unit Manager #9 stated there was a gap in treatment documentation between 2/6/2025 and 2/21/2025 which indicated they forgot to document the wound care. They were confident the care was done; however, it was not documented. Registered Nurse Unit Manager #9 stated in the absence of the primary wound nurse, the other wound nurse should be responsible for changing the wound vacuum-assisted closure. During an interview on 4/16/2025 at 12:38 PM, the Director of Nursing stated all licensed practical nurses completed wound vacuum-assisted closure care competencies annually and were able to provide that care. When the wound team registered nurses were off, it was communicated to the licensed practical nurses they would be responsible for the treatments. They were not aware Resident #274's wound vacuum-assisted closure dressing had not been changed. The Medication Administration Record documented the dressing was on, but not that it was changed. During an interview on 4/18/2025 at 9:30 AM, Licensed Practical Nurse #7 stated nursing staff failed to document the resident's wound care between the dates of 2/6/2025 and 2/21/2025. They stated adhering to a wound care plan was important because the resident was a diabetic and had already lost the top half of their foot and failure to follow physician orders for wound care could result in the wound not healing. During an interview on 4/18/2025 at 10:51 AM, Wound Care Registered Nurse #136 stated they had not provided wound care to Resident #274. They stated they were not responsible for covering the entire caseload of the other wound care nurse during their absence. 10NYCRR 415.12 51469

Based on record review, and interviews during the abbreviated survey (NY00351636), the facility failed to protect the resident's right to be free from sexual abuse for one (1) of five (5) residents (Resident #5) reviewed. Specifically, Resident #5, who was not competent to give consent, was sexually assaulted by Resident #4. The facility's failure to protect residents from sexual abuse resulted in harm past non-compliance, that was not Immediate Jeopardy for Resident #5. Findings include: The facility policy Prevention of Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property revised 1/20/2023, documented residents in the facility were to be free from abuse neglect and exploitation. All staff are in-serviced annually and upon hiring on prevention of abuse, neglect, involuntary seclusion, and misappropriation of property and will report abuse immediately. Abuse is a willful act of verbal abuse, sexual abuse, nonconsensual sex contact of any type, physical abuse, and mental abuse. Resident #4 had diagnoses including atrial fibrillation (irregular heart rhythm), weakness with unsteadiness on feet and hyperlipidemia (high cholesterol). The 8/7/2024 Brief Interview for Mental Status (an assessment tool) score was 13/15 indicating the resident's cognition was intact and they were able to make their own decisions and needs known. Resident #5 had diagnoses including epilepsy (neurologic condition that causes seizures), intellectual disabilities, dysphasia (difficulty swallowing), and adult failure to thrive. The 8/9/2024 Brief Interview for Mental Status score was 0/15 indicating the resident had severe cognitive impairment. The 8/07/2024 and 8/08/2024 nursing progress notes documented the resident was alert, confused, nonverbal, and staff were to anticipate their needs. They had a gastrostomy tube (tube inserted into the stomach to receive liquid nutrition) in place and received tube feedings and medications via this tube. The resident was ambulating around the unit. Resident #5's comprehensive care plan, initiated 8/7/2024 documented the resident had potential for wandering and potential to be a victim of abuse. Interventions included: intervene when the resident was wandering into other rooms; monitor the resident's whereabouts and redirect; observe for anxiety; wander alert device to their right ankle; and monitor socialization. The 8/16/2024 nursing progress note by Licensed Practical Nurse #17 documented Resident #5 entered other residents' rooms and took food from meal trays. The 8/17/2024 nursing progress note by Registered Nurse Supervisor #9 documented they were notified Resident #5 was in another resident's room, undressed with their brief on the floor, and sitting on the side of the bed. The resident was removed from the room and was assessed. The resident was guarded, they had no pain, their inner upper thighs were red, labia was red, and they were incontinent of urine. The physician was notified and ordered to send the resident to the emergency department for evaluation. The 8/17/2024 Incident and Accident Report completed by Registered Nurse Supervisor #9 documented: - on 08/17/2024, Resident #5 was last observed walking in the hallway between 2:50 PM to 2:52 PM by assigned Certified Nursing Assistant #12. - At approximately 3:30 PM, Certified Nurse Assistant #10 reported to Registered Nurse Supervisor #9, Resident #5 and Resident #4 were in Resident #4's room and both residents were naked, and Resident #4 was lying over Resident #5 with their clothes on the floor and the feeding tube was no longer connected to Resident #5's abdomen. - Resident #5 was removed from the room and brought to their room where a gown was placed on them, and a certified nursing assistant stayed with Resident #5 until the ambulance arrived. - Registered Nurse Supervisor #9's statement documented when they went to the unit, Resident #4 was lying in bed, there was tube feeding liquid on the floor next to the bed and on the sheets located on the bed, and there was urine on the floor. When Resident #4 was asked what happened they verbalized that they were attempting to have sexual intercourse with Resident #5. They answered questions appropriately. The resident was placed on 1:1 supervision, where a staff person stayed with them until they were discharged and taken into police custody. - The nursing assessment completed by Registered Nurse Supervisor #9 found Resident #5 had redness to inner thighs and labia and was incontinent of bladder and bowel. There was fluid present which appeared to be tube feeding fluid that was leaking from their abdomen. The resident was agitated and visibly upset at the time of the exam. - The Administrator was notified at 3:45 PM, the physician and families were notified at approximately 4:10 PM. - The police were notified, and emergency services summoned for transport to the hospital. - Resident #4 was placed under arrest and discharged to the Sheriff's department at 7:30 PM. - Staff from all shifts were interviewed and there were no previously reported incidents Resident #4 made sexual remarks or attempted any inappropriate physical contact with staff or residents. There were no witnesses to Resident #5 entering Resident #4's room prior to the event. The 8/17/2024 at 6:15 PM hospital emergency department report documented Resident #5 presented with alleged sexual assault. The resident was significantly limited verbally and developmentally delayed. -It was reported that staff walked in on another resident attempting to sexually assault/rape this resident. This resident was unable to consent. -Evaluation showed the resident was alert and able to move all extremities and had no signs of acute distress. Vital signs were within normal limits. The resident had a small abrasion to central forehead. There were no signs of obvious significant injury, deformity, or trauma to their vulva or groin. Mental status was at baseline. -The resident's feeding tube was dislodged during assault and replaced. -The resident had a comprehensive sexual assault examination by a registered nurse with photos and specimens obtained. There was no discharge or bleeding noted from the vaginal area. The resident grimaced during the exam. This resident had entered the accused resident's room and was found with no clothing and the accused resident reported we had sex. -The resident was stable and appeared to have been sexually assaulted by another resident. Concerned that resident may have had a seizure during this event. Findings were noted as sexual assault, breakthrough seizure and dislodged gastrostomy tube. During an interview on 12/16/2024 at 3:22 PM, Licensed Practical Nurse #15 stated on 8/17/2024, Certified Nurse Aide #10 reported they had removed Resident #5 out of Resident #4's bed and put them in their own bed. Licensed Practical Nurse #15, Certified Nurse Aide #9, and Licensed Practical Nurse #14 went to Resident #4's room. Resident #4's pants were partially down. Resident #5's brief was on the floor and there was tube-feeding formula all over. They went back to Resident #5's room; the resident looked sad and was making sounds and different voices. They assisted the resident by trying to clean them up and put clothes on them. Licensed Practical Nurse #14 called Registered Nurse Supervisor #9 who took statements from all staff on the unit. The police were in Resident #4's room for a long time. Resident was on 1:1 observation until the police arrived and left with the police. During an interview on 12/16/2024 at 3:40 PM, Licensed Practical Nurse #14 stated on 8/17/2024 Certified Nurse Aide #10 reported to them Resident #4 was in their room unclothed, on top of Resident #5 who was also unclothed. When the licensed practical nurse arrived at Resident #4's room, the resident was dressed. They then went to Resident #5's room and saw they were covered and in bed. The resident's gastrostomy tube was out, and they notified Registered Nurse Supervisor #11. During a phone interview on 12/17/2024 at 2:36 PM, Registered Nurse Supervisor #9 stated on 8/17/2024, they were notified by certified nurse aides (unnamed) they needed help on the unit. The unit staff had already separated the two residents and stayed with them. The assessment was completed, the physician and Administrator were notified, and an ambulance was called to send Resident #5 to the hospital for evaluation. The Sheriff and a detective arrived and took Resident #4 away. Resident #4 was newer to the facility and had been there about a week prior to the incident. During an interview on 1/13/2025 it 12:35 AM at 1:30 PM, Certified Nurse Aide #12 stated on 8/17/2024 they were assigned to care for Residents #4 and #5, and that was the first time they had cared for either resident. Resident #4 did not come out of their room the entire shift. They saw them several times during the shift in their room when they checked on them and provided care. Resident #5 was at therapy in the morning and when they returned, was observed wandering the unit. Certified Nurse Aide #12 provided care to the resident around 1:50 PM, covered the resident in bed, and turned off their lights. They were directed to go on break from 2:15-2:45 PM. When they returned, they did final rounds on residents and observed Resident #5 wandering the hall. They left the facility for the day around 2:52 PM. During a telephone interview on 1/21/2025 at 11:35 AM, Certified Nurse Aide #10 stated they typically visualized their residents at the beginning and end of their shifts, and throughout the shift as they responded to call lights, checking rooms as they did their rounds. On 8/17/2024, they started their safety rounds and picking up lunch trays left by the previous shift around 3:15 PM. They went to Resident #5's room and the resident was not there. They went to the next room, which was Resident #4's room, knocked on the closed door, and went directly to the second bed by the window to see if there was a tray left in the room. Certified Nurse Aide #10 saw Residents #4 and 5 fully undressed on Resident #4's bed. They immediately took Resident #5 back to their room and called for help. During a phone interview on 1/22/2025 at 10:49 AM the Director of Nursing stated Resident #5 was assessed upon admission for behavioral needs and monitoring, they did not require continuous monitoring for their wandering. All nursing staff were educated on abuse and wandering following the incident. No policy or procedure changes were made. Education was for review, due to the incident. No care plan violations or delays in reporting were identified. The facility Quality Assurance and Performance Improvement meeting was held on the third Thursday of every month and this incident was reviewed and abuse is an ongoing area of review. 10NYCRR 415.4(b)(1)(i) ______________________________________________________________________________ Deficient practice was identified in the area of sexual abuse that resulted in harm to Resident #5 by Resident #4. The facility provided verification the following corrective actions were completed by 8/24/2024: - On 8/17/2024, female residents who reside in the facility on the same unit as Resident #4 were interviewed by the Director of Operations to determine if there was any interaction with Resident #4 prior to this incident and if they felt safe at the facility. There were no female residents who identified they felt unsafe nor had any contact with the resident. There was ongoing evaluation of female residents on the unit for any change in behavior. - The staff on the unit were reinterviewed to determine if Resident #4 demonstrated any behaviors that indicated the potential for abuse by Resident #4 and none were identified. - From 8/17/2024 through 8/24/2025, all staff were educated on abuse, the necessity for prompt action, including securing evidence and to reinforce policies and procedures in response to incidents of actual or suspected sexual abuse and reporting. Additional education included wandering prevention and managing cognitively impaired residents. - This incident was reviewed at the Quality Assurance and Performance Improvement meeting in 8/2024. Abuse and incident reviews continue at monthly Quality Assurance meetings. -Neither resident returned to the facility.

Based on record review and interview during the abbreviated survey (NY00322098 and NY00323044) the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfers or discharges from the facility for 2 of 3 residents reviewed (Residents #1 and 2). On 9/11/2023, immediate jeopardy was identified during an abbreviated complaint survey. Concerns rising to the level of immediate risk to resident health and safety include the provider's failure to provide a safe and orderly discharge for Residents #1 and 2 which had the potential for serious harm for both residents. Residents #1 and 2 were discharged to the Department of Social Services (DSS), which is not a dischargeable location, without a plan for shelter or services; without a discharge plan; without notice, and without following the proper 30-day notice requirements. Both were homeless following discharge, one is currently residing in a homeless shelter, both are without their prescribed medications, and neither have secured permanent housing. Specifically, on 8/8/2023, Resident #1 was given a notice of discharge and on 8/9/2023 was discharged to a DSS building without money or identification to apply for temporary assistance and shelter. The resident was homeless for over 2 weeks until they were found walking on the wrong side of the highway by New York State Police on 8/23/2023. Interviews with the resident confirm that Resident #1 did not agree to a discharge. Interviews with the Director of Social Work revealed the discharge was directed by the facility's Administration. The resident is currently living with a family member but is unable to stay long term and is working to secure temporary assistance. Additionally, Resident #2 has primary diagnoses including diabetes, anxiety, and dementia with behaviors, and was issued a 30-day notice for discharge on 7/18/2023, but the receiving facility ultimately refused to accept the resident. Documentation stated the discharge date was 8/9/2023 due to medical clearance, episodes of violence, and smoking. The resident was discharged to a DSS building, which is not a discharge location, and was extremely confused and attempted to return to the facility as the resident did not know what to do or where to go but was refused re-entry. The resident is currently living in a homeless shelter and has a friend who helped the resident to apply for temporary assistance. Interviews with the Director of Social Work revealed that the discharge was directed by the facility's Administration. This resulted in Immediate Jeopardy to Residents #1 and 2 with the potential to affect all of the facility's 376 residents. Findings include: The Discharge Planning policy, revised 3/2018, documented discharge planning allows for continuity of care in the community. While discharge planning is interdisciplinary, the social worker is responsible for coordination of facility and community services needed to facilitate the resident's transfer to a lower level of care. Nursing staff is responsible for ensuring all education needs are met prior to discharge, including training of the resident and appropriate family members or responsible party. A discharge can be requested at any time by the resident and/or responsible party. If the facility is unable to provide discharge planning, the resident and/or responsible party will be encouraged to stay at the facility until appropriate arrangements can be made. When it is not advisable for the resident to be discharged , and the resident insists upon discharge, the Against Medical Advice (AMA) form must be completed to remove the facility from any liability that may incur resulting from the discharge. The policy noted to see the AMA policy. On 9/11/2023 at 4:08 PM, the Administrator stated in an interview, there were no other polices related to any aspect of discharges, including discharge planning, notices, or facility-initiated discharges. There was no AMA policy provided when additional discharge-related polices were requested. 1) Resident #1 Resident #1 had diagnoses including dementia, PTSD (post traumatic stress disorder), personal history of self-harm, major depressive disorder, and unspecified psychosis. The 7/15/2023 Minimum Data Set (MDS) assessment documented the Brief Interview for Mental Status (BIMS) was not conducted as the resident rarely/never understood others. A staff assessment of mental status was done and documented the resident had moderate cognitive impairment (made poor decisions and required cues/supervision). The resident required supervision with activities of living (ADL) and exhibited behaviors of rejection of care. The resident had an active discharge plan to return to the community. The 7/18/2020 PASRR (Pre-Admission Screening and Resident Review) Level II assessment documented the resident had serious mental illness and recommendations included ongoing psychiatric care and medication management. The 7/12/2023 registered nurse (RN) MDS Coordinator #5's progress note documented they unsuccessfully attempted an interview with Resident #1. They went to the medication nurse who said the resident had paranoia, expressed fear of being poisoned, was afraid people were after them, and appeared to be afraid of their reflection in windows or mirrors and voices on television, computers, or radio. The 7/28/2023 social worker (SW) #3's progress note documented a care plan meeting was held and the resident did not participate. The resident remained appropriate for long term care. The 8/2/2023 and 8/4/2023 SW #2's progress note documented the resident had moderate cognitive impairment and spoke about the food being poisoned and was upset about foreign military action. SW #2 sent a referral to a psychiatric center. The 8/4/2023 SW #3's progress notes documented they contacted 2 local homeless shelters to inquire about placement. SW #3 was advised a temporary assistance (TA) case had to be opened at DSS before the resident could go to a shelter. SW #3 called DSS and left a message to obtain additional information. The 8/4/2023 and 8/5/2023 Director of Social Work's (DSW) progress notes documented they requested referrals to be sent by Medical Records to 11 psychiatric centers and 8 skilled nursing facilities for a transfer. On 8/7/2023, the DSW's progress note documented they spoke to the resident and their relative, who stated they wanted the resident in their county. The relative asked that a referral be sent to a senior living center near them and the DSW sent the referral. The resident and their relative stated they would accept a discharge to a shelter in order to be closer to one another. The Transfer/Discharge Notice dated 8/8/2023, documented the notice was to inform the resident the interdisciplinary team (IDT) determined the resident would be discharged on [DATE]. The discharge location documented the address to a DSS building in another county (71 miles from the facility). The reasons for discharge included the resident's health improved sufficiently and the resident no longer needed services provided by the facility; the resident was medically cleared for discharge by occupational and physical therapy (OT, PT) and medical, and the safety of individuals in the facility would be endangered as evidenced by episodes of violence. The resident and DSW signed the form on 8/8/2023. The 8/8/2023 SW #3's progress note documented they called a shelter in another county and was advised a TA case was required before shelter placement. The 8/8/2023 DSW's progress note documented the DSW was notified by Administration the resident was being discharged to another county (71 miles away) on 8/9/2023 at 9:00 AM. The unit SW advised the resident of the move and the DSW called the resident's relative and explained the discharge plan. The 8/9/2023 DSW's progress note documented the resident was discharged and transported by the facility to another county (71 miles away). The resident planned to seek TA from DSS and obtain housing. The 8/9/2023 Discharge Packet documented the discharge address was the DSS office building in another county; a pharmacy name and address were listed; a psychiatric provider's name and phone number were listed with no appointment date noted; the resident had 5 medications, including an antidepressant, and there were no other providers, community contact/agencies, or service providers noted on the discharge packet. The 8/23/2023, New York State (NYS) police report documented they picked up the resident walking on the wrong side of the highway (7 miles from where they were dropped off on 8/9/2023 and 75 miles from the facility). The resident was brought to the DSS office in the city in which they were initially left by the facility transport vehicle. During an interview with SW #2 on 9/5/2023 at 9:46 AM, they stated if a resident had no residential location for a discharge, the facility would provide assistance in establishing the needed community services. If a resident wanted to go to a shelter, SW #2 thought they had to go through DSS first. Resident #1's discharge was handled by the Administrator and Assistant Administrator #7. SW #2 thought the resident was brought to DSS and assisted in getting placed in a shelter. SW #2 stated DSS was not an appropriate or safe discharge location as it was an office building and not a place to reside. SW #2 stated they did not think Resident #1 was able to live independently due to their history of behaviors, mental illness, and non-compliance with medications. During an interview on 9/6/2023 at 8:46 AM, facility transport person #6 stated they received instructions to take Resident #1 to the DSS office building in another county (71 miles away). The resident had 4 plastic bags and they assisted the resident with the bags. Inside the office building, a security guard was present. They left the resident in the entrance of the office building with their bags. During an interview on 9/6/2023 at 12:00 PM, Adult Protective Services (APS) worker #12 stated on 8/23/2023, the police called APS after picking the resident up on the highway. APS worker #12 suggested they bring the resident to the DSS office building. APS worker #12 stated they did not see the resident that day and there was no record the resident was seen by APS or DSS on 8/23/2023. APS worker #12 reviewed their records and stated the resident arrived to DSS 8/9/2023 for housing assistance. The resident had no identification or Medicaid card and was denied assistance. The resident was advised by DSS to go to the warming shelter in the city. As of 9/6/2023, the resident was listed as homeless in DSS records and had no active case for assistance or housing. During a telephone interview with the resident's relative on 9/6/2023 at 2:05 PM, they stated someone from the facility contacted them at the beginning of 8/2023 to say the resident was being discharged and the relative said they wanted the resident to be near them. The relative was not able to care for the resident and asked the facility to send a referral to an assisted living facility nearby. The facility told the relative they could find a shelter for the resident until they could get into an assisted living. They were told the resident would be brought to the DSS building in their county and would get shelter placement. The relative was not told the resident needed to open a case before getting shelter placement and was not told to meet the resident at DSS to assist with obtaining shelter placement. When the relative called the facility after the resident was discharged , they were unable to tell them where the resident was. The relative called DSS and they did not know anything about the resident so the relative made several posts to social media and located the resident on 9/2/2023. The resident was found very dirty, with no belongings, and no medications. The resident did not know the area or the relative's phone number. The resident's whereabouts was unknown from 8/9/2023 to 9/2/2023. During a telephone interview with Resident #1 on 9/6/2023 at 2:18 PM, they stated they did not know why they left the facility and they were just told they were going. They did not ask to leave and did not want to go to a shelter. They did now know where they were going when they left the facility. They were brought to the DSS building and did not know what to do. They had no identification, money, or telephone and did not know their relative's phone number. From 8/9/2023 through 9/2/2023, they walked around the city, spent time in the bus station, park, and sometimes slept at the shelter or bus station. The shelter opened at 7:00 PM and the resident had to be out by 6:00 AM. The resident was able to have dinner and breakfast at the shelter when they stayed there and had no means to get food otherwise. They did not know what happened to their belongings and they had not taken their medications since they left the facility. During an interview with the DSW on 9/11/2023 at 10:21 AM, they stated a safe discharge included making plans with the resident, family, and IDT to determine what was needed following discharge. Discharge planning included verification of all needed levels of support, including housing, prior to discharge. The DSW stated a DSS case was required before an individual could get into a shelter. Resident #1's discharge was very sudden. The DSW was instructed by Assistant Administrator #7 to see the resident about discharge and they met with the resident for the first time on 8/8/2023 to notify them of the discharge. The DSW called the resident's relative to discuss options and sent a referral to a facility in their county. The DSW asked if the resident was willing to go to a shelter and told them they would have to go through DSS first. The resident and relative agreed. Upon communicating this to Assistant Administrator #7, they instructed the DSW to immediately send the resident to DSS in the relative's county. The DSW did not have an opportunity to verify a TA case could be established with DSS; was unable to verify what the resident needed to do, and was unable to verify what the relative's role would be. The DSW was not aware if the resident had identification or the understanding to establish services with DSS. The resident's relative was informed the resident was going to DSS and was not provided any other information. The DSW did not feel it was a safe discharge, there was no plan for supports in the community, and there was no assessment to determine the resident's ability to live independently. The DSW stated the resident remained appropriate for long term care and should have had time for a lateral move to another facility, or assessed for assisted living. During an interview with Assistant Administrator #7 on 9/11/2023 at 12:04 PM, they stated Resident #1 had been requesting to leave the facility and was agreeable to shelter placement. The discharge occurred rapidly due to the facility having the means to transport the resident to the other county and not wanting to lose a spot at the shelter. Assistant Administrator #7 was unaware of the discharge plan details and stated the DSW handled it. Assistant Administrator #7 stated they did not direct the DSW to initiate Resident #1's discharge and stated it was a team decision. During an interview with the Administrator on 9/11/2023 at 12:41 PM, they stated Resident #1 insisted on discharge and was to obtain shelter placement upon arrival to DSS. The facility was not able to discharge directly to a shelter, individuals must go through DSS in order to obtain shelter placement. The plan was for the resident's family member to meet them at DSS. The Administrator stated they did not have anything to do with the discharges and expected the social worker documented the plan appropriately. The resident insisted on going and the facility did their best to ensure they were discharged with the safest plan, per the resident's wishes. During a telephone interview with nurse practitioner (NP) #8 on 9/12/2023 at 2:12 PM, they stated it was their understanding Resident #1 requested to be discharge to another county to a shelter. The NP was not aware of the details of the discharge or what would make it a safe discharge. The NP stated they would expect the nursing and social work departments to ensure needed areas were addressed. The NP thought the family was involved in the discharge plan and would be available to assist the resident. 2) Resident #2 Resident #2 had diagnoses including unspecified dementia with behavioral disturbance, unsteadiness on feet, contracture of unspecified joint, and type 2 diabetes. The 7/7/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and exhibited physical behaviors directed toward others 1 to 3 day of the assessment period. The resident required supervision with their activities of daily living (ADL). The resident took antipsychotic, antianxiety, and antidepressant medication daily during the last 7 days of the assessment period and took opioids 2 days of the assessment period. The resident did not have an active discharge plan. Social worker (SW) #3's progress notes documented on 11/16/2022, the resident's friend called and reported the resident wanted to be discharged ; on 11/20/2022, an application for the resident to go to a local shelter was submitted, and on 12/23/2022, the shelter application was denied due to the resident's dementia diagnosis. SW #3's progress notes documented on 1/3/2023, an application was submitted to another shelter; on 1/19/2023, a care plan meeting was held, the resident had severe cognitive impairment, and on 3/23/2023, the shelter declined the resident's application due to the resident not being fully independent with cooking, bathing, and medication management. SW #3's progress notes documented on 7/18/2023, SW #3 discussed a third smoking warning with the resident and a 30-day discharge notice was given. The resident refused to sign the notice. A referral was sent to a skilled nursing facility (SNF) in another county and on 7/20/2023, lateral transfer referrals were sent to 6 SNFs in the same county as the facility. SW #3's progress note documented on 7/20/2023, the care plan meeting was held, the resident had severe cognitive impairment and their cognition fluctuated due to dementia. The resident had a 30-day discharge notice and referrals were sent to multiple SNFs. Two shelters in the area declined the resident due to dementia, behaviors, and age. SW # 3's progress notes documented on 8/3/2023 and 8/4/2023, the SW contacted multiple adult homes and skilled nursing facilities for possible transfers. The Director of Social Work's (DSW) progress notes documented: - On 8/5/2023, a call was placed to the resident's relative to inquire if any family members were able to have the resident live with them. - On 8/8/2023, the resident's relative stated there were no family members who could take the resident. The DSW was directed by Administration to set up a discharge for 8/9/2023 to the Department of Social Services (DSS). - On 8/8/2023, the resident's relative called and stated the resident notified them they were being shipped off to a shelter. The relative voiced their frustration and stated they thought they had another week to make a plan. The DSW reminded the relative that no one in their family wanted to take the resident and the relative stated they were still working on some things. - On 8/8/2023, a Medicaid cab was set up for the resident with a 10:00 AM pick up time on 8/9/2023. The Transfer/Discharge Notice dated 8/8/2023, documented the notice was to inform the resident the interdisciplinary team (IDT) determined the resident will be discharged on [DATE]. The discharge location documented the address of the DSS building in the facility's county. The reasons for the discharge included the resident's health improved sufficiently and the resident no longer needed services provided by the facility; the resident was medically cleared for discharge by occupational and physical therapy (OT, PT) and medical; the safety of individuals in the facility would be endangered as evidenced by episodes of violence, and the health of individuals in the facility would be endangered as evidenced by episodes of smoking. The resident and DSW signed the form on 8/8/2023. The DSW's 8/9/2023 progress note documented they spoke to the resident on 8/7/2023 and 8/8/2023 regarding discharge. They discussed issues with smoking and episodes of violent behavior toward staff. The resident stated they wanted to leave due to being followed by staff (1:1 supervision). The DSW explained to the resident and their friend, and the resident's relative in a separate call, that the resident would be able to obtain Temporary Assistance (TA) from the county, who will find the resident temporary housing. They expressed understanding, the resident was discharged from the facility, and transported via taxi to the DSS office building. The 8/9/2023 Discharge Packet documented the resident was discharged to the address of the county DSS office building; a pharmacy name and address were listed; a community health center was listed as the medical provider with no appointment date noted, and 13 medications were listed, including: Buspirone (anti-anxiety), Depakote Sprinkles (seizure medication), Lorazepam (anti-anxiety, controlled substance), Norco (narcotic pain reliever), Quetiapine fumarate (antipsychotic), and Trazadone (sedative). There were no providers, community contacts/agencies, or service providers noted on the discharge packet. During a telephone interview with the resident's relative on 9/8/2023 at 9:45 AM, they stated they knew the facility was discharging the resident due to behaviors. They were told by the DSW the resident had a shelter set up and would have a case manager who would help find more suitable housing. The relative did not agree to shelter placement but felt they had no choice due to the resident being discharged the next day. When the resident was dropped off at DSS, the resident did not know what to do. They had no identification or phone and was not able to receive assistance. The resident went back to the facility that night (8/9/2023) and was told to leave. The resident's friend picked them up and the fried helped the resident get into a homeless shelter. The relative had had to pick the resident up at times to assist them with bathing and other tasks as the resident had contractures in their hands limiting their mobility. At times, the resident called them because they got lost walking the streets during the day. The resident wandered all day until it was time to go to the shelter in the evening. The resident had not lived on their own since going to the facility in 2018 and was not able to safely care for themselves. During a telephone interview with the resident's friend on 9/8/2023 at 10:40 AM, they stated they were told when the resident was discharged that someone would be at DSS waiting to take them to the shelter. Later that evening (8/9/2023), after 9:00 PM, the facility called and told them the resident returned to the facility and if they did not leave, they would call the police. The friend picked up the resident who had a plastic bag full of medications with them. The resident did not know how to take their medications and could not manipulate the packages as their hands were contracted. They brought the resident to a hotel for the night and then assisted the resident in getting into the shelter. The resident remained at the homeless shelter without their medications or a permanent plan for housing. During an interview with the DSW on 9/11/2023 at 10:21 AM, they stated a safe discharge included making plans with the resident, family, and the IDT to determine what they will need following discharge. Facility-initiated discharges should include a safe plan. When Resident #2 was discharged , it was driven by Administration in order to get the residents who smoked out of the facility. There was no time for the resident to be fully assessed for their ability to live independently or to find appropriate placement. The resident was previously declined for the shelters due to their inability to manage their medications and was not fully independent in their ADLs. The discharge to DSS was not safe, it was not a residential location and the resident was not able to obtain their own services needed for placement. During an interview with the Administrator on 9/11/2023 at 12:41 PM, they stated Resident #2 initiated their own discharge, it was not a facility-initiated discharge. The Administrator was unaware of the reasons the Discharge Notices noted otherwise. The resident was medically cleared and had capacity to make their own decisions and they insisted on leaving. The facility could not discharge directly to a homeless shelter and the resident had to go through DSS in order to obtain assistance. The Administrator expected the SW to ensure the resident had the needed documentation and was set up for a case at DSS. The Administrator stated they felt this was a safe discharge since the facility set up transportation, ensured the resident had their medications, gave instructions for applying for assistance at DSS, and notified their family. During a telephone interview with nurse practitioner (NP) #8 on 9/12/2023 at 2:12 PM, they stated it was their understanding Resident #2 requested to be discharged to a shelter. The NP was not aware of the details of the discharge or what would make it a safe discharge. The NP stated they would expect the nursing and social work departments to ensure needed areas were addressed. The NP thought the resident was going to have a SW or case manager assigned upon arrival to DSS to assist them in obtaining shelter placement. 10NYCRR415.11(d)(3) ______________________________________________________________________________ Immediate Jeopardy was identified, and the facility Administrator was notified on 9/11/2023 at 4:42 PM. Immediate Jeopardy was removed on 9/12/2022 at 1:00 PM prior to survey exit based on the following corrective actions taken: - All discharges planned for 9/11/2023 -9/12/2023 were postponed pending verification of post-discharge services, receiving locations, and approval of the correction plan for future discharges. - SW and Assistant Administrators educated on discharge planning process to include verification of safety. - SW and Assistant Administrators were educated on discharges to shelters, proper steps, criteria, needed materials, appointments, and safety assessment. - The DSW was educated and will document review all discharges for needs and safety verification. - All Unit Managers, SWs, Director of Nursing (DON), Assistant Director of Nursing (ADONs), Therapy Director, and Assistant Administrators were educated on the updated discharge policy. - The policy update and education included education on facility-initiated and AMA discharges. - All staff identified for education received education on 9/11/2023 and 9/12/2023, with the exception of 3 staff members who were not available. The individuals who did not received education will complete education upon their return, prior to the start of their shift. - Interviews were completed on 9/12/2023 to determine compliance with staff training and education including the DSW, 1 SW, 1 Assistant Administrator, 1 Unit Manager, and 1 ADON.

35045 Based on observation, record review, and interview during the recertification, abbreviated (NY00317278), and extended surveys conducted from 7/17/23- 7/28/23, the facility failed to ensure each resident received adequate supervision for 3 of 3 residents (Residents #42, 198, 204) reviewed for smoking. Specifically, from 9/22/22-7/24/23 Resident #42 had 15 documented occurrences when they were discovered by staff smoking in the facility. Adequate supervisory interventions were not put into place to prevent additional occurrences. Observation on 7/24/23 revealed cigarette smoke odor near a common bathroom, licensed practical nurse (LPN) #1 was notified, and Resident # 42 was discovered in a bathroom with a strong smell of cigarette smoke and immediately admitted to smoking and flushing the cigarette in the toilet. Resident #198 was a known smoker and was found smoking in the facility and in the possession of smoking materials; and Resident #204 was witnessed by staff smoking in the facility. The facility staff and administration were aware of Residents #42's, 198's, and 204's smoking behaviors and there were no plans in place to supervise the residents. Subsequently, the failure to provide adequate supervision for Resident #42 resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious harm to Resident #42 and the other 106 residents residing on Resident #42's nursing unit. The facility also failed to ensure each resident received adequate supervision for 1 of 2 residents (Resident #763) reviewed for elopement. Specifically, Resident #763 was left unsupervised while waiting for a wander alert device replacement. Subsequently, Resident #763 exited the facility undetected. Findings include: SMOKING The facility policy titled (Resident) No Smoking revised on 1/16/19 documented the facility promoted a smoke-free facility and grounds for their residents and provided a smoke-free community to maintain the health and welfare of the resident's residing at the facility. Prior to offering a bed, the Screener and/or Director of Admission would discuss the no smoking policy with the individual. Upon admission, the social worker would ensure that that resident or designated representative would sign the admission agreement indicating that they understood there was a no smoking policy at the facility. Smoking materials, including tobacco cigarettes, matches, lighters, e-cigarettes would not be allowed in the possession of the residents at the facility. Security may conduct a physical inspection of the resident room and possessions to locate smoking materials. If at any time during the course of the stay the resident is found to be in violation of this policy, the following actions will be taken: 1st Offense: The Social Worker will review no smoking policy and the resident will sign the NO SMOKING NOTICE which states that they agree to follow the smoking policies of the facility. The form will be kept in the resident's Social Services file. Documentation and narrative note by the social worker will be completed at that time. The social worker will review with the resident that continued violation of this policy may/can result in a 30-day discharge letter and transfer to the first appropriate available bed. Physician services will offer smoking cessation again (if not already completed pre-admission by the hospital). 2nd Offense: The social worker will reiterate with the resident that this is a non-smoking facility and will offer transfer to another facility that permits smoking. Document and care plan. 3rd Offense: The social worker will present the resident and first contact with a 30-day letter of discharge/transfer. Document and care plan. The undated facility Resident Orientation Handbook documented residents and visitors were not permitted to smoke in the building or on the grounds of the health care center. On 7/17/23 at 10:07 AM, during the entrance conference meeting with the facility Administrator, they stated the current census was 358 residents and there were no residents in the building who smoked. On 7/23/23 a request for Resident #42's smoking/non-smoking agreement or any resident no smoking notices were requested. The facility did not provide any such documentation. 1) Resident #42 was admitted to the facility with diagnoses including nicotine dependence and hemiplegia (paralysis on one side) following a cerebral infarction (stroke). The 7/3/23 Minimum Data Set (MDS) assessment documented the resident had intact cognition, did not exhibit behavioral symptoms, required supervision with assistance of 1 for locomotion on the unit, extensive assistance of 1 for toileting and personal hygiene, had functional limitation in range of motion in one arm, and used a wheelchair for mobility. The 1/17/23 annual MDS assessment documented the resident did not use tobacco. The admission comprehensive care plan did not include the resident's history of smoking. The 9/22/22 registered nurse (RN) #74's progress note documented the resident's bathroom smelled of cigarette smoke and the resident denied smoking. Security was called to search the room but did not find any cigarettes. The 10/31/22 licensed practical nurse (LPN) #73's progress note documented there was a strong odor of cigarette smoke noted when walking by the resident's room. The resident was observed sitting in their wheelchair in front of the open window. The resident denied smoking and said they did not know why the room smelled like cigarette smoke. When the resident was asked to hand over their lighter and cigarettes, they stated No. I don't have any. The incident was reported to the RN supervisor (RNS). The 10/31/22 social worker #2's progress note documented the resident was found smoking and they reiterated to the resident the facility's non-smoking policy and smoking was dangerous due to oxygen use. (There were no documented orders for the resident to receive oxygen). The 11/1/22 RN #4's progress note documented the resident was smoking in their room again. The social worker was notified. The resident was reminded of the non-smoking policy and offered a nicotine patch. The resident denied smoking but stated they would like a nicotine patch. The room had obvious smoke and a strong odor of cigarettes. The 11/1/22 social worker #2's progress note documented they visited the resident in their room due to being caught smoking again. Upon entering the room, it clearly smelled of smoke. The resident was seen in the hallway and was re-educated about not smoking. The resident responded, Well I can't go outside to do it. The resident was told smoking was not allowed inside or outside the facility. The 11/1/22 nurse practitioner (NP) #21's progress note documented the resident was seen at the request of nursing due to smoking in their room. The resident was found smoking in their room. The plan included to start a 7 milligram (mg) nicotine patch for nicotine withdrawal and dependence. A 11/1/22 physician order documented nicotine transdermal patch 7 milligram (mg)/24 hours, one patch as needed for nicotine dependence. The 11/26/22 RN #4's progress note documented there was a strong odor of cigarette smoke emanating from the resident's room/bathroom. The resident denied smoking and was reminded of the facility smoking policy. The resident was not receptive to the reminder. The 11/30/22 LPN #72's progress note documented a strong odor of cigarettes was smelled within the resident's room. Upon entering the resident room, the resident was sitting on the edge of the bed facing the open window. The resident stated they were not smoking and did not have any cigarettes. The resident was re-educated the facility was a non-smoking facility. The 12/8/22 LPN #72's progress note documented the smell of smoke was noted outside of the resident's room. The staff member heard a spray sound within the room. The resident said they were not smoking and was reminded the facility was a nonsmoking facility. There were no documented Incident/Accident reports for the 9/22/22, 10/31/22, 11/1/22, 11/26/22, 11/30/22, and 12/8/22 incidents; and no documentation the CCP was revised to reflect the resident's history of smoking in the facility. A 1/10/23 at 9:00 PM Incident/Accident Report completed by RN #41 documented upon exiting the elevator the smell of smoke was present in the core (the central area dividing the north and south ends of the unit) and Resident #42 was the only one present. The resident denied smoking and NP #46 was notified. The section care planning interventions currently in place and any changes implemented to care plans had a line drawn through them. The 1/11/23 NP #46's progress note documented the resident was caught smoking again and frequently refused the nicotine patch as they felt it was ineffective. Nicotine lozenges were prescribed to aid the resident in quitting smoking. The 3/13/23 LPN #1's progress note documented the resident was witnessed smoking in the bathroom in the 5 South core bathroom. LPN #1 explained to the resident that smoking was prohibited in the building and the resident began to yell, I cannot go outside to smoke. The social worker and the Unit Manager were notified. A 3/13/23 at 1:44 PM Incident/Accident Report completed by RN Unit Manager #4 documented they were notified by LPN #1 that Resident #42 was found smoking in the core bathroom on the 5th Floor. The resident was re-educated on the no smoking policy and NP #46 was notified. The resident stated they smoked in there because I can't smoke outside. The care plan was reviewed. The section care plan interventions currently in place had N/A written in. Corrective actions included issuance of a smoking violation, education on the policy, and nicotine replacement was ordered. The report was signed by the Administrator with no date. The 3/13/23 RN Unit Manager #4's progress noted documented the resident was found smoking in the core bathroom (the common area between the north and south ends of the units was referred to as the core) against policy. The resident was assessed and did not sustain any injuries or burns. The resident was re-educated on the smoking policy of the facility. Smoking cessation assistance was offered and declined by the resident. The resident had been issued a smoking violation in the past and was issued an additional violation statement which they refused to sign. The incident was reported to the attending nurse practitioner. A 3/17/23 at 9:30 AM Incident/Accident Report completed by RN Unit Manager #4 documented they were notified by staff that Resident #42 was again smoking in the core bathroom. RN Unit Manager #4 knocked on the door and the resident denied smoking. When exiting the room smoke was present and a cigarette butt was found in the toilet. The resident denied smoking. The care plan was reviewed. The sections care plan interventions currently in place and corrective actions were blank. The report was signed by the Director of Nursing (DON) on 3/21/23 and by the Administrator with no date. The 3/17/23 RN Unit Manager #4's progress note documented the resident was found smoking in the 5th Floor core bathroom. RN #4 knocked on the door of the bathroom asking if the resident was smoking in the room and the resident denied smoking. When the resident exited the bathroom, there was an odor of smoke, and smoke vapor was visible. There was a cigarette in the toilet. The resident was educated again about the no-smoking policy, and smoking cessation assistance could be provided. The resident continued to deny they were smoking. The attending NP, administration, and social work were informed of the incident. The 3/20/23 NP #46's progress note documented the resident was caught smoking again in a bathroom and had been caught multiple times for smoking in the facility. The resident was extremely anxious during the bedside evaluation and reported the smoking cessation aids had not worked. They had tried Wellbutrin (antidepressant used as a smoking cessation aid) in the past and that did not work. The resident stated the reason for smoking was anxiety. The resident was started on alprazolam (sedative) 0.25 mg twice a day and was told it was not a long-term solution and the resident would be referred to psychiatry for pain and anxiety. A 3/23/23 at 9:32 AM Incident/Accident Report completed by LPN Assistant Unit Manager #25 documented the resident was caught smoking in the common restroom on the 5th Floor at the end of the hall near the core area. The resident denied they were smoking and refused the offer of smoking cessation. The resident's room was searched, and no smoking materials were found. NP #46 was notified. The Incident/Accident form did include the care plan sections. The report was signed by the DON on 3/24/23 and by the Administrator with no date. There was no documented evidence of a CCP to address the resident's continued incidents of smoking in the facility or interventions to ensure safety from 9/22/22-4/13/23. The CCP initiated 4/13/23 documented smoking as a problem area. The resident had a history of smoking in the community prior to admission. The resident was found smoking in their room and in the bathroom. Goals included the resident would follow the facility No Smoking rules and policy. Interventions included sign smoking contract, monitor compliance with smoking contract, social worker counseling as necessary regarding accepting smoking material from peers, visitors and/or outside contractors, offer nicotine replacement treated, praise all positive efforts to quit smoking. A 4/16/23 at 8:20 PM Incident/Accident Report completed by RN #26 documented the resident fell in the bathroom near the core. The resident stated they were washing their hands and slipped from their electric wheelchair. The resident was smoking in the bathroom, the cigarette had been extinguished upon staff entry. The care plan was reviewed. The section for care plan interventions currently in place documented requested resident to refrain from smoking in building. Security met with the resident. Corrective action documented the resident's cigarettes and lighter were requested and the resident stated they threw them in the garbage can and RN #26 was unable to locate the items. The report was signed by the DON on 4/17/23 and by the Administrator with no date. The CCP was updated on 4/17/23 at 12:22 PM and included the resident was found smoking in the core bathroom and had a fall at that time The 5/12/23 social worker #3 progress note documented they witnessed the resident coming out of the bathroom with an overwhelming smell of cigarette smoke. The social worker educated the resident that there was no smoking allowed in the building and why. The resident refused to sign the smoking agreement. Numerous referrals to other facilities were made and the resident could not be safely discharged to the community. The Unit Manager and the Director of Social Services were made aware. On 6/29/23 at 12:22 PM, the CCP for smoking was reviewed and updated. There were no additional interventions documented. During an observation on 7/24/23 at 2:15 PM, there was a smell of cigarette smoke in the hallway on the 5th Floor North end D side. The surveyor and LPN #1 knocked on the bathroom door and Resident #42 was in the bathroom. There was a very strong smell of cigarette smoke present. The resident stated they were smoking in the bathroom because they were tired of being lied to and wanted to leave the facility against medical advice. The resident stated they found the cigarette on the floor of the elevator, and the lighter was in the bathroom. The resident stated they put the cigarette butt in the toilet. No lighter was observed in the bathroom. The 7/24/23 at 2:20 PM LPN #1's progress noted documented they smelled cigarette smoke when they walked into the core. They searched the area and opened and closed all the doors. When they attempted to open the bathroom door near the core, the door was locked, and the smell was stronger. They knocked on the door and the door was opened by Resident #42. When asked if they were smoking, the resident said yes. Social worker #3 and the RN were made aware. The resident stated the lighter was in the bathroom, but there was no lighter found in the bathroom. The resident stated they flushed the cigarette down the toilet. During an observation and interview on 7/25/23 at 11:04 AM, Resident #42 stated they were aware it was a non-smoking facility. They obtained cigarettes from a resident on the 4th Floor, and they got one cigarette at a time. They stated they had smoked every day for [AGE] years and since being admitted to the facility they only smoked occasionally. They stated they flushed the lighter down the toilet. They had been offered nicotine gum and patches, but they did not work. During an interview on 7/25/23 at 11:27 AM, RN Unit Manager #4 stated that any residents that were caught smoking were given 30-day notice and were now on 1:1 supervision with a staff member. They stated if a staff member was aware of a resident smoking, they should report it to the Unit Manager or the RN supervisor during an off shift. They had never seen Resident #42 actually smoking but there was evidence of smoking, such as the smell of smoke and a cigarette in the toilet. During an interview on 7/26/23 at 12:47 PM RN #41 stated they remembered doing an Accident/Incident report regarding smelling cigarette smoke for Resident #42. They were aware Resident #42 was suspected of smoking in the past. They stated a more thorough investigation may have been needed due to the resident's history of smoking. A prevention plan included offering cessation several times, and violations and 30 day notices were given to the resident. The process for Accident/Incidents was to determine a root cause and try to prevent recurrence. They stated if someone smoked in the facility it could put all residents and staff in danger. During an interview on 7/26/23 at 2:02 PM LPN Supervisor #25 stated they previously worked on the 5th Floor. Their duties included reviewing 24 hour report and filling out Accident/Incident paperwork. The RN was responsible for the actual assessment. An Accident/Incident was used to document an occurrence and identify ways to prevent it from happening again. They stated they caught Resident #42 smoking in April 2023, they completed an Accident/Incident report, and spoke to the resident about smoking. The social worker and security were called, and there was a possibility of the resident having to leave if they were caught again. Smoking in the building presented a danger of starting a fire. There was oxygen in use throughout the building which would put both residents and staff at risk. During a follow-up interview on 7/26/23 at 2:07 PM, RN Unit Manager #4 stated they wrote progress notes on 3/13/23 and 3/17/23 about the resident smoking in the bathroom. They stated they did not witness the resident actively smoking, but the area around the resident looked smoky and they saw a cigarette butt in the toilet. They stated they reported it to the social worker. They did not complete the accident and incident report, and they reported it to the social worker, DON, and the Administrator. RN Unit Manager #4 stated when a staff member observed a resident smoking, they should notify security, the DON, a medical provider, administration, and the family. They thought verbally reporting the smoking incidents to the appropriate staff was the start of the investigation but stated they should have started a written accident and incident report. The resident care plan should be updated, and a referral should be made for discharge. They stated the resident care plan was updated on 4/17/23 with a smoking care plan. During an interview on 7/26/23 at 2:28 PM social worker #3 stated they had not witnessed the resident smoking. They stated no one had actually caught the resident smoking but staff had suspicions the resident was smoking because of smelling cigarette smoke. No smoking materials had ever been found on the resident. The resident had been educated on not smoking. They stated they were not involved with completing Accident/Incident reports and nursing was responsible for care plans. They stated they informed their supervisor of the resident potentially smoking in the facility. Security was also made aware so they could perform a search for smoking materials. The resident was offered smoking cessation and the facility looked into discharge planning and had sent referrals. During an interview on 7/26/23 at 3:37 PM, NP #46 stated Resident #42 had been seen on many occasions for witnessed smoking in the facility. The facility should complete investigations for the smoking, and they were not involved in that. The resident was accepting of treatment for anxiety but would not accept any smoking cessation aides. During an interview on 7/26/23 at 3:51 PM, the Medical Director stated the facility was a non-smoking facility. All residents should have received an admission packet that stated the facility was a non-smoking facility. The residents would also be told by the hospital that discharged them to the facility, that the facility was a non-smoking facility. They stated it was the facility's job to do their best to keep all residents safe. Smoking in the facility could potentially cause an unsafe situation as there were several residents that utilized oxygen. During an interview on 7/26/23 at 4:29 PM, the facility Administrator stated that if residents were smoking in in the building, they wanted to be made aware. They stated when there was an incident, an investigation must be completed. The purpose of an investigation was to determine a root cause of the incident and information should be obtained from all parties involved. The Administrator stated they were not sure if they were made aware of all the smoking incidents with Resident #42 since September 2022, but the facility dealt with each issue daily. They stated when there was an odor of cigarette smoke, they could not accuse a resident, because they worked with a very dynamic patient population. They stated they did not want their staff to be accusatory toward the residents. They should investigate right away and do whatever was needed to keep the resident safe. They stated the resident would be at risk for being burned if they had a physical disability. The resident was aware they were not supposed to smoke in the facility and was able to make their needs known. They stated they thought the front-line staff did what they should do when they observed a resident smoking. 2) Resident #204 had diagnoses including nicotine dependence with withdrawal, schizophrenia, and chronic obstructive pulmonary disease (COPD, restricted airway). The 9/21/22 admission Minimum Data Set (MDS) assessment documented the resident currently used tobacco. The 4/5/23 MDS documented the resident was cognitively intact and required supervision with setup for most activities of daily living (ADLs) The 9/14/22 admission assessment did not document a history of smoking. The 10/6/22 at 6:53 AM, licensed practical nurse (LPN) #23 progress note documented the resident attempted to go outside to smoke. A staff member brought the resident back to the unit, informed the LPN, and handed the LPN two cigarettes wrapped in a paper towel. The resident refused to tell the LPN where the cigarettes were obtained from. The supervisor was made aware. The 10/14/22 at 8:27 PM, registered nurse (RN) #24 progress note documented a cigarette smell was evident when the RN exited the 7-South elevator. There were 2 residents observed in the unit TV area corner. The residents were sitting in wheelchairs smoking cigarettes. Both residents were educated on the safety aspect of not smoking in the building and were encouraged to try nicotine replacement programs. Education had been provided previously. The residents were told the incident would be reported to medical, social services and nursing administration. The 10/14/22 at 8:27 PM unsigned Incident/Accident Report documented Resident #204 was found by the RN Supervisor (RNS) smoking in their wheelchair in the 7th Floor dining room. The resident was counseled and told How would you feel if you hurt someone by causing a fire? The section for care plan interventions currently in place was not completed. Corrective action included verbal education and nicotine replacement treatment. The medical provider was notified on 10/14/22 at 8:50 PM. The incident report was signed by the Director of Nursing (DON) on 10/19/22 and signed by the Administrator with no date. The 10/14/22 social worker #3's progress note documented the resident was spoken to about their first smoking violation. The social worker clearly outlined the policy and reviewed the rules. The social worker made the resident aware they would receive a 30-day letter of discharge if smoking in the building. The resident signed the smoking agreement. The resident apologized and stated they would not smoke in the facility again. The 10/14/22 Resident No Smoking Notice, signed by the resident, documented the social worker reviewed the Smoking Contract and Rules with the resident. The resident agreed to abide by the terms and a violation could result in a 30-day discharge letter and transfer to the first appropriate available bed at another facility. There was no documented evidence of a CCP to address the resident's continued incidents of smoking in the facility or interventions to ensure safety. The 4/17/23 at 4:29 AM RN #26 progress note documented security addressed the resident that evening due to the resident being found smoking in the building. The 4/17/23 at 4:29 AM, Incident/Accident Report completed by RN #26 documented the resident was found by security smoking in the building. The report did not document where in the building the resident was found. Verbal education was provided, and the resident apologized. The resident refused to sign a statement and nicotine was offered to the resident. The section for care plan interventions currently in place was not completed. Corrective action included social worker counseling as needed and nicotine was offered. The on-call provider was notified on 4/17/23 at 4:29 AM. The report was signed by the DON on 4/19/23 and by the Administrator with no date. The 4/17/23 comprehensive care plan (CCP) documented the resident had a long history of smoking and was found smoking in the facility. Interventions included offering nicotine replacement treatment, all lighting materials would be removed and maintained by the facility, social work counseling as necessary about accepting smoking materials from peers/visitors/outside contractors, praise positive efforts, social work/Activity Director would review smoking policy with resident and issue violations as needed. When interviewed on 7/25/23 at 11:06 AM, certified nurse aide (CNA) #27 stated the facility was a non-smoking facility and staff were to immediately inform the charge nurse if a resident was caught smoking. Security then came to the resident's room and searched for smoking materials. The CNA was not aware if Resident #204 had been caught smoking in the past. The resident had not smelled like smoke, and they had not noticed burn marks on their clothes. The resident was usually not in their room during the day but downstairs or out on the unit. When interviewed on 7/25/23 at 11:17 AM, LPN Assistant Unit Manager #25 stated there was to be no smoking on the premises and signs were posted everywhere. They thought there was a section on the admission assessment for the resident's smoking history. LPN Assistant Unit Manager #25 stated the resident had not been caught smoking recently. Social services and the NP became involved if a resident was caught smoking and a warning was issued to the resident and smoking cessation was offered. The LPN accessed the resident's records and stated the resident was caught smoking on 4/17/23. The RN was responsible for initiating care plans, but the LPNs were able to add to any topic initiated by the RN. The resident had a care plan for smoking that was initiated on 4/17/23. 3) Resident #198 was admitted to the facility with diagnoses including nicotine dependence and dementia with behavioral disturbances. The 7/7/23 MDS assessment documented the resident had severely impaired cognition, required supervision of 1 for most activities of daily living (ADL), and used a wheelchair. The 1/20/23 NP #46's progress noted documented the resident was seen for medication management and documented the resident was a long-term resident of the facility and had no alcohol or tobacco use. The 5/18/23 social worker #3's progress note documented they were made aware the resident was caught smoking in the clinic (health clinic on the 2nd floor) on 5/15/23 at around 10:05 PM. The resident became hostile with security staff. The resident was issued a smoking warning but refused to sign it. The resident denied smoking and stated they did not smoke. They state they were closing the clinic door and the smoke smell was not from them. The 6/13/23 social worker #3's progress note documented the resident was caught smoking in the bathroom last evening on 6/12/23. The social worker met with the resident to review the smoking policy. The resident denied smoking and refused to sign the smoking notice. The undated resident care instructions documented the resident was ambulatory and had behaviors, and staff should redirect, avoid over stimulation, and offer to take the resident outside for walks. There was no documentation the resident had history of smoking and was caught smoking in the building. The 7/18/23 social worker #2's progress note documented they met with the resident to issue a third smoking warning. The resident stated, I was not caught smoking. Social worker #2 explained to the resident cigarettes were found in their room. The resident nodded and said, Yeah, I smoke them when I walk outside. Why can't I have them? I don't smoke in the building. Social worker #2 tried to explain why the resident could not have cigarettes and the resident walked away. Resident #198 declined to sign the smoking notice. This was the resident's 3rd offense. The resident was given a 30-day notice, which the resident did not sign. A referral was sent to another facility. The 7/18/23 transfer/discharge notice documented the resident was informed they would be discharged on [DATE] because the safety of individuals in the facility would be endangered, as evidence by continued smoking. The facility documented the resident refused to sign the notice. The form was not signed by a facility representative. The 7/20/23 social worker #2 progress note documented the resident was resident given a 30 day notice recently due to the continued smoking. Lateral transfers to various skill nursing facility were sent. During the meeting, the resident became upset when confronted about smoking and said, I am going to keep doing it. Social worker #2 stated to the resident it was a non-smoking facility. During an observation and interview on 7/24/23 at 4:55 PM, Resident #198 was sitting in the lobby and stated, I got smokes on the outside and I sell them to the residents on the 4th floor, 3 cigarettes for $20, but I don't smoke. Resident #198 stated they did not have a lighter on them. The resident smelled of cigarette smoke. During an interview on 7/24/23 at 12:28 PM social worker #3 stated they were familiar with Resident #198, and they were a smoker. The resident was not supposed to smoke, had been caught smoking in the facility, and would always deny they smoked. During an interview on 7/25/23 at 11:23 AM, CNA #75 stated Resident #198 had been caught smoking in the past. They stated they did not confront them because some of the residents were violent. They stated the residents should have a place to smoke. During an interview on 7/25/23 at 11:54 AM, RN Unit Manager #4 stated they we [TRUNCATED]

Based on interview and record review during the abbreviated survey (NY 155) completed on [DATE], the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1's blood sugar reading was high (glucose > 500 milligrams/deciliter, mg/dL, very high) and a follow up blood sugar was not completed after treatment was administered. When subsequent blood sugars were taken and read high 2 more times, the medical provider was not notified and no orders were implemented. This resulted in actual harm to Resident #1 who was sent to the hospital unresponsive, diagnosed with diabetic ketoacidosis (DKA, serious complication of diabetes causing high levels of ketones (blood acids), and expired the next day with their final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: The ,d+[DATE] facility's Diabetic Management Policy documents all resident with diabetes will be treated by the following guidelines to foster their safety and well-being. The purpose is to ensure the resident with [CONDITION(S)] (low blood sugar) or [CONDITION(S)] (high blood sugar) is treated. When the diabetic protocol is initiated, the Nurse Manager/Nursing Supervisor will be notified and will assess the affected resident. The CNA (certified nurse aide) reports any resident who is not acting their baseline to the LPN (licensed practical nurse). The LPN reports to the RN (registered nurse) Supervisor or RN Manager any issues with a resident's blood sugar. The RN reports to the physician any issue with resident blood sugars and transfers resident to the emergency room if needed. [CONDITION(S)] is considered to be a blood sugar reading of 450 mg/dL or above and when identified, staff were to notify the medical provider and administer anti-diabetic medication(s)/insulin per physician orders. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had clear speech, made themselves understood, and usually understood others. The resident required extensive assistance with activities of daily living (ADL) and did not receive insulin or injections in the last 7 days. The [DATE] comprehensive care plan (CCP) documented the resident had diabetes with goals to be free from signs and symptoms of hypo/[CONDITION(S)]. Interventions included finger stick blood sugar monitoring as ordered, medications, and monitoring for signs/symptoms of [CONDITION(S)] (flushed skin, drowsiness, nausea/vomiting, increased respirations, decreased blood pressure). Staff were to report and document if symptoms were observed. The [DATE] nurse practitioner (NP) #5's progress note documented the resident was seen for an interval visit and evaluated and treated over the last 30 days for falls. For diabetes, the resident was on [MEDICATION(S)] (antidiabetic), [MEDICATION(S)] (antidiabetic) and [MEDICATION(S)] (antidiabetic). Review of their most recent glucose trends showed control and the plan was to continue medications without adjustment. The [DATE] at 10:56 AM licensed practical nurse (LPN) #1's progress note documented the resident was in bed, made no eye contact and was not able to make needs known. Their head was tilted back, they were assisted at mealtime, and consumed 100% of fluids. The [DATE] at 2:30 PM LPN #1's progress note documented the resident was mouth breathing. They consumed 0% at lunch, pulse was 136 BPM (beats per minute-normal range ,d+[DATE]), temperature was 97.5 F (Fahrenheit) and they had no signs of pain. The [DATE] at 3:31 PM registered nurse (RN) Manager #2's progress note documented the resident continued to be difficult to arouse. Blood sugar was done and read high. Medical provider was updated and ordered 5 units [MEDICATION(S)] (insulin) STAT (immediately) and the [MEDICATION(S)] was administered by RN Manager #2. Finger stick blood sugar was ordered at each meal and staff were to call provider for further orders. The [DATE] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - at 3:17 PM, [MEDICATION(S)] 5 units one time; and - at 3:21 PM, finger stick blood sugar daily with meals, call medical on-call for orders. The [DATE] Medication Administration Record (MAR) did not document a finger stick blood sugar was completed at meals on [DATE] on the evening shift and did not document that the one time dose of [MEDICATION(S)] (5 units) was administered as ordered at 3:17 PM. There was no documentation of a follow-up finger stick blood sugar to determine if further medication management was necessary. On [DATE] at 11:29 AM, LPN #1 stated in a telephone interview, the physician would be notified for a blood sugar over a certain number and parameters were part of the orders. On [DATE], LPN #1 worked the day shift and when LPN #1 noticed the resident's change in condition, LPN #1 notified RN Manager #2 and RN #2 took over the resident's care. RN Manager #2 called the physician and LPN #1 believed 5 units of insulin was ordered. When a glucometer read high that meant the blood sugar was greater than 500 mg/dL. After insulin was given for a high reading, the blood sugar should be rechecked after 15 minutes and the reading should be documented in a progress note. LPN #1 stated they thought blood sugars would be ordered routinely after a high glucometer reading but that was up to the physician. On [DATE] at 12:51 PM, RN Manager #2 stated in a telephone interview: - When a glucometer read high, the nurses would repeat the finger stick in 10 minutes. If the glucometer continued to read high, the nurses would notify the physician to see what the physician wanted to do. Follow-up blood sugars would be done by the LPN and the LPN would notify the Manager if the reading continued to be high. - RN Manager #2 recalled the resident and on [DATE], the resident's blood sugar was high, and RN #2 notified the NP and gave insulin per the order. RN Manager #2 stated they always sent a text or called the provider to notify of the repeat blood sugar. - When the provider ordered finger sticks at each meal and call provider on [DATE], that meant to do the finger stick three times daily and update the provider with the result. - RN Manager #2 would have reported the resident's blood sugar issue to the incoming evening shift Supervisor on [DATE] and did not recall who the Supervisor was. - RN #2 stated they were not sure why blood sugars ordered by the provider on [DATE] were not on the resident's MAR and that was RN #2's responsibility to ensure the orders were on the MARs so that the nurses could implement the orders. On [DATE] at 11:57 AM, LPN #7 stated in a telephone interview, LPN #7 did not recall the resident or the events that occurred during their shift (evening shift) on [DATE]. When a glucometer read high, that meant the blood sugar was very high and was usually over 500 mg/dL. If LPN #7 was told in report about high blood sugars, LPN #7 would have paid extra attention to the resident. LPN #7 stated RNS #4 would have seen the resident that evening if their glucose was reported high to them during report. If LPN #7 did a blood sugar that read high, they would have notified the Supervisor. LPN #7 did not recall receiving report on [DATE] evening shift about the resident having high blood sugars. LPN #7 was not sure why evening shift medications were not documented on the MAR and LPN #7 was responsible to administer medications or document why they were not given. LPN #7 stated if they had concerns about the resident that evening, they would have documented a note. The [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:34 PM, RNS #4 stated in a telephone interview they were a Supervisor on the evening shift in ,d+[DATE]. RNS #4 stated their shift started at 5:30 PM and a few hours into the shift, they received report from another RNS. A high reading on a glucometer meant a blood sugar was over 500 mg/dL and without follow-up could lead to a serious medical problem. RNS #4 stated they were not told in report on [DATE] the resident had high glucose readings or that the resident received insulin and needed a follow-up. RNS #4 stated if they had known the resident had a high reading, RNS #4 would have had the LPN repeat the resident's blood sugar. The next nursing progress note in the resident's medical record was on [DATE] at 6:09 AM, written by the Assistant Director of Nursing (ADON) who worked the 11 PM to 7 AM shift and documented: - The ADON was told in report the resident's family member wanted a call that night with an update on the resident and especially about their laboratory (lab) results. - The family asked what the resident's glucose was on the evening shift after receiving the 3:30 PM dose of insulin, the ADON could not find a glucose level, so another one was obtained and it registered high on the glucometer. - The ADON called the provider who ordered 5 units of insulin, recheck glucose, and call the provider back. The ADON suggested to the provider IV (intravenous, in a vein) fluid or Clysis (an infusion of fluid subcutaneously, under the skin) if the family was receptive and orders were obtained for normal saline via IV or Clysis 1000 cc (cubic centimeters) at 60 cc/hour. - The ADON notified the Administrator the resident did not look well at all and called the family again. The ADON documented they explained to the family member the resident's blood sugar was retaken and was still high. There were orders for 5 more units of insulin, and if family was interested, IV or Clysis could start. The family member agreed to the orders. The [DATE] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - at 7:11 AM, Novolog (insulin) 10 units, one dose; and - at 7:17 AM, Basic Metabolic Panel, Complete Blood Count (blood tests). The [DATE] MAR documented: - At 6:59 AM by LPN #1, Novolog 10 units administered. - At 8 AM by LPN #1, finger stick not completed, Other: obtained blood sugar reads high, call medical on call for orders. - At 12 PM by LPN #1, finger stick not completed; Other: blood sugar continued to read high, call medical on call for orders. On [DATE] at 11:46 AM, the ADON stated in a telephone interview, the ADON was currently filling in as the night Supervisor (11 PM to 7:30 AM). The ADON did not recall who they received report from and the ADON's shift started on [DATE] at 11 PM. The ADON did not recall what time the ADON spoke to the family that night but believed they spoke to them twice during their shift. The ADON recalled the family approved Clysis being given. The ADON did not need an order to recheck a blood sugar and thought the blood sugar would have been rechecked on the evening shift on [DATE] before the ADON came on duty. The ADON called the provider during their shift and received orders for 5 units of insulin which the LPN administered. The ADON did not recall if they rechecked the resident's blood sugar afterwards and if they did, it would be documented on the MAR. The ADON did not recall if they obtained orders for another 5 units of insulin during their shift. There was no documentation the physician was notified of the 8 AM and 12 PM blood sugar readings. There were no nursing notes from the day shift (7 AM to 3 PM shift) on [DATE]. On [DATE] at 11:29 AM, LPN #1 stated in a telephone interview, on [DATE] at 8 AM and 12 PM, when they documented the glucometer read high, they would have notified RN Manager #2 or the Supervisor if it was the weekend and the RN would have notified the physician. LPN #1 did not recall what was done on [DATE]. On [DATE] at 12:51 PM, RN Manager #2 stated in a telephone interview on [DATE], when the resident's insulin was given in the morning, RN #2 expected a follow up blood sugar and note to be documented about what the blood sugar was and what was done. At 8 AM and 12 PM on [DATE], the resident's high blood sugar glucometer readings should have been reported to the RN or Supervisor for follow up with the provider. The next documented nursing note was on [DATE] at 5:36 PM, written by RNS #6 and documented RNS #6 was called to the unit as the resident's blood pressure dropped to ,d+[DATE]. The resident was diaphoretic (sweating heavily) and tachypneic (rapid respirations) at 50 breaths per minute (normal range 12 to 16) and was still unresponsive. The family was updated, they asked to have orders changed and wanted Clysis changed to IV fluids. The family member asked that 10 more units of insulin be given, and a priest called to give last rites. NP #5 was notified, and a message left for the family. NP #5 ordered 20 units of insulin and to start IV fluids. NP #5 called back a few minutes later and said the family wanted the resident sent to the hospital. 911 was called and the resident was taken to the hospital. The [DATE] at 12:12 PM, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MAR did not document that 20 units of insulin was administered or IV started. The [DATE] hospital report documented, per EMS (Emergency Medical Service), the resident was going downhill for a few days, finger stick blood sugars at the facility were high and the resident had become less responsive. Fluid hydration was being given through what appeared to be a subcutaneous catheter in the right thigh and per EMS, was placed at the facility. The resident had a 103 F fever, BP ,d+[DATE], pulse 167, respirations 45 and they were unresponsive. Blood glucose was 591 mg/dL. The resident was diagnosed with DKA (diabetic ketoacidosis), severe septic shock (a significant drop in BP that can lead to respiratory or heart failure/death) with an elevated troponin level (protein, heart muscle damage), EKG (electrocardiogram) changes and acute kidney injury. The [DATE] hospital record documented the resident expired. The resident's autopsy report finalized on [DATE], documented the resident's final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:13 PM, RNS #6 stated in a telephone interview, they did not recall the resident or the issue with their blood sugar on [DATE]. When a glucometer read high, the blood sugar was typically over 500 mg/dL. If a resident had a high glucometer reading, RNS #6 would have notified the provider to see if the provider wanted repeated blood sugars or medications ordered, and it was the provider's responsibility to direct when the blood sugar should be repeated. When LPN #1 gave insulin in the morning on [DATE], RNS #6 expected a follow up blood sugar be repeated in 30 minutes. RNS #6 did not recall LPN #1 notifying them of the resident's high blood sugars at 8 AM and 12 PM and if RNS #6 had known, RNS #6 would have called the provider. On [DATE] at 1:46 PM, NP #5 stated in a telephone interview, a high reading on a glucometer could be the result of an error or it could mean the resident's blood sugar reading could be over 500 mg/dL. If the reading was high, the provider should be notified to determine what needed to be done. NP #5 expected a follow up finger stick to occur if an intervention such as insulin was given and expected it to be done before the next meal if there was no concern with DKA. When the resident had a high glucometer reading and required insulin, the NP expected the blood sugar to be rechecked within an hour or two and documented. NP #5 would have wanted to know what the repeat glucose level was to be sure glucose was coming down into normal range and that would determine how to move forward because they may have needed other interventions if the glucose was not coming down. When blood sugar was ordered at meals, the resident should have been checked at 7:30 AM, 11:30 AM, 4:30 PM and 7:30 PM. If instructions were given to call the provider with results, then that should have happened. On [DATE] at 8 AM and 12 PM when the nurse documented the blood sugar was high, the provider should have been notified and a note documented on what the provider wanted. NP #5 stated they were not on duty on [DATE] but did get a call from RNS #6 in the early afternoon the resident's family member was upset and wanted to speak with them. RNS #6 made NP #5 aware the family was struggling to determine whether to make the resident full comfort measures which could mean oral medications could be potentially discontinued and the resident kept comfortable. NP #5 ordered insulin and IV but the family called them back within a few minutes and wanted resident sent to the hospital. The resident's attending physician no longer worked at the facility and was not available for interview. 10NYCRR 415.12

Based on observation, record review, and interview during the abbreviated survey (NY 771) the facility did not ensure residents were free from abuse/neglect for 1 of 4 residents (Resident #4) reviewed. Specifically, the facility did not prevent Resident #4 from being injured by certified nurse aide (CNA) #16, who did not know the resident's care needs when she provided care to the resident. When CNA #18 noticed the resident's injury, she did not immediately report the injury to Administration. This resulted in actual harm that was not immediate jeopardy to Resident #4 who sustained soft tissue swelling to the tibia and fibula (lower leg bones), a large bump on the leg, and pain. Findings include: Resident #4 had [DIAGNOSES REDACTED]. The 11/15/2019 Minimum Data Set (MDS) assessment documented the resident's cognition was intact. The resident required extensive assistance from one person with transferring, locomotion, toilet use, and personal hygiene. The comprehensive care plan (CCP) with an effective date of 11/5/2019, documented the resident had a decline in activities of daily living (ADLs) and needed extensive assistance with all ADLs except eating as the resident was able to feed self after set-up. The Nursing Instructions, effective 11/5/2019, documented the resident needed to be wheeled by another person in the wheelchair and required extensive assistance from one person with personal hygiene, transferring, and toileting. The incident report dated 11/27/2019, documented the resident had a large lump on her right shin that measured 10 centimeters (cm) x 10 cm and was raised 6 cm. The registered nurse (RN) noted there was no obvious bruising, but the resident had a dark complexion. The resident reported the injury occurred when CNA #16 became frustrated and pushed the resident aggressively forward causing the resident's leg to hit the wall. Medical, social work, and the family were notified. An x-ray was ordered, and ice was applied. CNA #16 was suspended. Statements obtained by the facility included: - CNA #16's statement dated 11/27/2019, documented on 11/26/2019 at 9 PM, she toileted the resident, assisted with changing the resident into a nightgown, and transferred the resident to bed. CNA #16 documented there was no incident and the resident had no bruising to report. - Certified occupational therapy assistant (COTA) #17's statement dated 11/27/2019, documented the resident was brought to therapy on 11/27/2019 at 9:30 AM, and had a large bump on the right shin that was painful with even the lightest touch. The resident was brought back to the unit, the nurse was notified, and the resident reported the night before, a staff member was bringing the resident into the bathroom and hit the resident's leg on the corner of the wall. - CNA #18's statement dated 11/27/2019, documented she got the resident up that morning and noticed a bump/lump on the resident's leg. She did not document that she notified anyone of the resident's injury. - RN #15's statement dated 11/27/2019 at 7:03 PM, was an email to the Administrator. The email documented on 11/27/2019 at 11:30 AM, RN #15 was notified the resident had a large lump and possible hematoma (a collection of blood under tissue) on the right shin. She assessed the resident and asked what happened. Initially, the resident was reluctant to tell her what happened but after more questioning, the resident said the previous night, CNA #16 became frustrated and pushed the resident hard forward in the wheelchair. The resident used both arms to show the RN the aggressive way CNA #16 pushed them. The resident said this was done purposely and the resident identified the accused as CNA #16. - Social worker #19's statement dated 11/27/2019, documented the resident scored a 15 out of 15 on the Brief Interview of Mental Status (BIMS) done that day. The resident was cognitively intact. The resident stated to SW# 19 that the lump on the leg hurt when it was touched. The resident said CNA #16 rolled them into the wall, made comments about the resident urinating too much, and was very aggressive as soon as she entered the room. 11/27/2019 x-ray results documented the resident had localized soft tissue swelling adjacent to the tibia/fibula (lower leg bones). On 1/23/2020 at 9:40 AM, the resident was observed sitting a wheelchair. The resident lifted the right pant leg and pointed to a bump on the shin. The resident had a large, raised bump on the right shin and no bruising was observed. The resident stated the bump hurt when it was touched. Immediately following the observation, the resident was interviewed and stated the night of the injury, CNA #16 came into the room and told the resident to walk to the bathroom. The resident could not do it on their own and CNA #16 got upset and pushed the wheelchair hard. The resident's leg hit the wall causing much pain and the resident told CNA #16 the leg hurt. After the resident went to the bathroom, CNA #16 assisted the resident into bed. The resident stated CNA #16 knew the leg was injured when she left the room. The next morning, a different CNA (CNA #18) helped the resident and when CNA #18 touched the leg, the resident cried out in pain. The resident stated CNA #18, who helped the resident in the morning, knew the resident was hurt, saw the bump, and did not ask what happened. Later that day, the nurse asked what happened and the resident told her. As the resident was telling the nurse what happened, CNA #16, who hurt the resident, walked by the room. The resident pointed out CNA #16 as the accused CNA. On 2/10/2020 at 12 PM, CNA #16 stated in an interview, on 11/26/2019 during the day, she left the facility to take another resident out to an appointment and when she returned at around 5:30 PM, she was told the resident was on her assignment. She never took care of the resident before but heard from CNA #18 that the resident was independent with feeding and was an assist as needed, and the resident could do a lot on their own. At around 8:30 PM, the resident rang the call bell to use the bathroom. She told the resident to wheel themself to the bathroom and the resident said they could not do it. The resident got stuck near the bathroom door. CNA #16 stated she was frustrated and stressed and wheeled the resident to the bathroom. She stated she either hit the resident's leg on the wall or the bed and did not see a bruise right after it happened. The next day she was told the resident had a bruise and she did not tell anyone about hitting the resident's leg the night before because she was scared. She did not review the resident's care instructions and she followed what she heard from CNA #18 regarding the resident's care needs. She stated an assist as needed meant that if the resident needed help, the resident could ask. On 1/23/2020 at 11:37 AM, CNA #18 stated in an interview, on 11/27/2019 at 7 AM or 7:30 AM, she helped the resident get dressed. She saw a bump or lump on the leg and made sure not to hit it when providing care. The area looked like a little egg and she did not ask the resident what happened. CNA #18 did not provide an answer when she was asked if she reported the resident's injury to anyone. CNA #18 stated she was supposed to report injuries to the nurses. CNA #18 stated later in the shift, someone asked her about the bump, and she wrote a statement. On 1/23/2020 at 1:40 PM, COTA #17 stated in an interview, as soon as the resident arrived at therapy on 11/27/2019, the resident showed her the bump on the leg. The resident said it hurt and was not able to participate in therapy. She returned the resident to the unit immediately and told the nurse. On 1/23/2020 at 11 AM, RN #15 stated in an interview, between 11:30 AM and 12:00 PM on 11/27/2019, someone from therapy told her the resident had a large bump on the leg. She assessed the resident and documented the measurements of the injury on the incident report. She stated the bump was soft and raised. The resident told her CNA #16 pushed her into the wall and the resident thought the leg hit the corner of the wall. The resident said CNA #16 was upset with the resident. The resident identified CNA #16 as the person who hurt them. RN #15 stated she immediately notified Administration and CNA #16 was suspended. She did not know if anyone followed up with CNA #18 who documented in her statement that she saw the bump earlier that morning and did not report it. She stated she did not follow up with CNA #18. On 1/23/2020 at 2:30 PM, the nurse practitioner (NP) stated in an interview, she was told by RN #15 the resident was pushed into the wall by CNA #16. The resident had a bump on the right shin and the x-ray showed a soft tissue injury. She stated the bump was still present and the plan was to continue to monitor to ensure there was no infection or changes in the area. 10NYCRR 415.4(b)

Based on observation, record review, and interview conducted during the abbreviated survey (NY 952), it was determined for 2 of 11 residents reviewed for abuse (Residents #10 and 11), the facility did not ensure residents were free from abuse. Specifically, - The facility assessed Resident #10 to be at risk for abusing others and did not develop and implement a plan to prevent abuse. - Resident #11 had a history of [REDACTED].#10's room where he was assaulted. - Following the incident of resident to resident abuse, interventions were not implemented as planned and ordered to prevent Resident #10 from abusing other residents in the future including a physician's orders [REDACTED]. This resulted in actual harm for Resident #11 that is not immediate jeopardy. Findings include: The facility's Victim Aggressor policy and procedure (undated) documented the registered nurse (RN) would assess residents to determine their potential for abusing others and assessments would be done according to the Minimum Data Set (MDS) schedule and following resident to resident incidents. Residents who scored 1-8 were at risk for abusing others and an at risk care plan was to be implemented. Residents who scored a 9 or higher were at high risk for abusing others and a high risk preventative care plan was to be implemented. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition was moderately impaired per the 8/29/2017 Minimum Data Set (MDS) assessment. Resident #10 scored a 5 on the potential to abuse others assessment completed on 8/29/2017 by registered nurse (RN) #25. The assessment documented he had a history of [REDACTED]. Resident #10's comprehensive care plan (CCP), revised on 8/29/2017, contained no documentation related to Resident #10's risk for abusing others and did not include a plan to prevent abuse. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's 9/6/2017 admission nursing assessment completed by registered nurse (RN) #14 documented the resident was confused, oriented to person only, and the resident wandered. Resident #11's medical record documented the following in nursing progress notes: - RN #15's progress note at 8:54 PM, documented Resident #11 wandered into another resident's room, the other resident asked him to leave, and then the other resident hit Resident #11 over the head with a cane. Resident #11 had a large gash on the left side of his head that was bleeding. - RN #15's second progress note at 10:06 PM, documented an ambulance arrived, Resident #11 was not moving his left arm, had lacerations to the right arm and hand, and could not say what happened. The 9/6/2017 at 10:10 PM, emergency room (ER) record for Resident #11 documented the resident was sent to the hospital following an assault at the nursing home. The resident wandered into another resident's room and was struck repeatedly with a cane until the cane broke. The resident had multiple wounds and a headache. The bleeding from the resident's head was controlled when emergency medical technicians (EMTs) arrived at the nursing facility but resumed again and was bleeding significantly upon the resident's arrival to the ER. The record documented Resident #11 would not be returning to the facility per his family and the resident's injuries were documented as follows: - Six centimeter (cm) laceration to the left scalp with active arteriolar bleeding that required 4 staples. A head CT report documented there was subcutaneous soft tissue swelling and a left scalp hematoma to the left frontal parietal and supraorbital region. - Bruising and swelling to the left frontal region of the head. - Tenderness and bony tenderness to the left shoulder, right hand, left hand, right lower leg, pelvis, and right hand - Bruising to the left knee, left and right hands, and an 8 centimeter (cm) x 4 cm bruise to the right leg. - Swelling and significant bruising to the left thumb that was found to be fractured. - Red linear marks to the lower extremities consistent with a cane. - A full thickness wound to the right forearm measuring 1.2 cm x 2.5 cm with the central cavity measuring 0.4 cm in depth that required wound care. The facility's investigation summary dated 9/7/2017 documented: - At 8:40 PM, staff heard loud voices and responded to Resident #10's room. Resident #10 was holding half of his cane in each hand and Resident #11 was on the floor. - Resident #10 had a history of [REDACTED]. He also had a history of [REDACTED]. Resident #10 reported Resident #11 came into his room, was going through his personal property, would not leave, and that Resident #11 hit him first. - Resident #11 was admitted to the facility hours before the incident with a known history of wandering at home. He had dementia and was unaware of his new surroundings. - Licensed practical nurse (LPN) #16's statement, written by the Assistant Administrator, documented she was the nurse on Resident #11's unit when the incident occurred. Resident #11 was brought the unit between 6 and 6:30 PM by the admissions staff member and was accompanied by his family member. The admissions staff told her the resident had dementia and was pleasantly confused and did not tell her the resident wandered. The resident's family member left at 7:15 PM, and at that time, the resident was lying in his bed, and the resident's family member told her that the resident may get up after he left and to look for him. The next time she saw the resident was 8:45 PM, when staff told her he was in an altercation with Resident #10. - Certified nurse aide (CNA) #17's statement, written by the Assistant Administrator, documented the resident was admitted around 6:30 PM with his family member present. She was told the resident had dementia and was confused and was not told that he wandered. The resident's family member left at 7:30 PM and she saw the resident at that time. The next time she saw the resident was at 8:45 PM after the incident had occurred. - CNA #18's statement documented she heard yelling and when she responded to Resident #10's room he met her at the door and handed her his cane that was in 2 pieces and covered in blood. Resident #11 was lying on the floor covered in blood, blood gushing out of his head. Resident #10's CCP was updated on 9/7/2017 and documented he was at risk for abusing others related to being possessive of his personal items, history of homelessness, cognitive deficits, and TBI. Interventions included a private room, stop sign on his door to prevent other residents from entering his private space, and a psych referral. The 9/8/2017 physician's orders [REDACTED].#10. On 9/8/2017, social worker #21 documented in Resident #10's medical record that he was moved to a private room. On 9/14/2017, the LPN's progress note in Resident #10's medical record documented the resident stated he did not want or need the stop sign outside of his door and he did not care who came into his room. On 9/14/2017, social worker #21's progress note in Resident #10's medical record documented the resident had more confusion lately and did not feel remorse for hurting the other resident. Resident #10 told her that the other resident scared him when he wandered into his room and that he hit the resident because the other resident hit him first. A psychology consultation was ordered. Resident #10's CNA Kardex (care instructions) was printed on 11/14/2017, and did not document the resident had behaviors or was at risk for abusing others. The Kardex did not document the use of the stop sign across the resident's door. Resident #10's room was observed on 11/8/2017 at 10:49 AM. The door was closed and there was not a stop sign across the doorway. RN Supervisor #15 was interviewed on 11/14/2017 at 1:25 PM, and stated she was called to the unit to assess Residents #10 and 11 and when she arrived, the incident was over. Resident #10 stated that Resident #11 came into his room, he told him to leave, and that Resident #11 hit him first. She observed Resident #11 sitting on the floor with his back against the wall, he had a wound on the side of the head that was bleeding, and many other injuries. Resident #11 was conscious but could not say what happened. RN #14 was interviewed on 11/14/2017 at 2 PM, and stated she worked in the clinic and when residents were admitted to the facility, they came in through the clinic where they were assessed and then were sent to their units. She did not recall Resident #11 but reviewed his medical record during the interview. She stated she did not recall giving report to anyone when this resident was sent to the unit but she tried to give report for every resident either over the phone or in person. She stated she could not remember what she told the unit about the resident when he was transferred to them. On 11/14/2017 at 3:15 PM, LPN #19 stated in an interview, on the night of the incident, she was working on Resident #10's unit and Resident #11 was admitted to the other unit on the same floor. She stated staff heard yelling and found Resident #10 with his cane in his hand and Resident #11 on the floor. She stated Resident #11 was new so they did not know who he was when they found him. She stated the floor that the two units were on did not usually have a lot of wandering residents, they normally had more alert and oriented residents and some residents who were admitted for rehabilitation. On 11/15/2017 at 9:32 AM, social worker #21 stated in an interview, she found out about the incident the next day and at that time, Resident #11 was at the hospital and Resident #10 was seen by the nurse practitioner (NP). Resident #10 was soon moved to a private room, they monitored his behavior, and a psychology consultation was ordered. She interviewed Resident #10 and when she asked him what would happen the next time someone wandered into his room, he stated no one should come in his room. She stated he was very protective of his possessions as he had a history of [REDACTED]. She stated he refused a stop sign across his door and she did not know if any other interventions were tried to keep residents out. Social worker #21 stated she knew of one other incident involving Resident #10 and another resident and the staff intervened and there was no physical contact between the residents. Social worker #21 stated when the psychology referral was ordered, she would have emailed the Unit Manager and Director of Social Services to set up the appointment. She stated she did not know if the evaluation occurred and did not know if there were any recommendations. On 11/15/2017 at 10:05 AM, RN Manager #22 stated in an interview, they did a medical work up on Resident #10 and ordered a psychology referral for him. She stated she did not know if the psychology referral happened and that the resident probably refused. She stated the plan to prevent recurrence included a private room for Resident #10, he did not have a cane anymore, and staff were to monitor him. She stated he refused the stop sign so that was taken down and she did not know if anything else was tried to prevent people from entering his room. RN Manager #22 stated in 8/29/2017, the resident should have had a risk to abuse others CCP in place based on the potential to abuse others assessment completed by RN #25. She stated herself or RN #25 should have implemented that CCP. On 11/15/2017 at 11:55 AM, CNA #23 stated in an interview, when she heard yelling she responded to Resident #10's room. He was standing over Resident #11 who was on the floor. The cane was broken in half and covered in blood. She stated Resident #11 was a new admission and wandered to her unit from the other unit. She stated they did not know how he made it to their unit without anyone noticing. She stated she took care of Resident #10 before and in the past saw him get upset with other residents and raise his cane at them but to her knowledge, he had never hit another resident. On 11/15/2017 at 12:20 PM, LPN #16 stated in an interview, she was Resident #11's nurse when he was admitted . She stated she did not know he wandered so was not looking out for him that evening. On 11/15/2017 at 1:14 PM, CNA #17 stated in an interview, she was Resident #11's assigned CNA when he was admitted . She did evening care on him so she knew he could stand and walk. She also knew he was confused but did not realize how confused he was as he seemed intelligent. She stated normally she would have known more about the resident from his Kardex but since he was a new admission, she did not know that he wandered. On 11/15/2017 at 3 PM, Director of Social Services #24 stated in an interview, she never received an email from RN Manager #22 or social worker #21 asking her to set up a psychology referral for Resident #10 so an appointment was not made for him. On 12/19/2017 at 10:14 AM, NP #31 stated in an interview, she saw Resident #10 the day after the incident, assessed him, and had the social worker obtain a statement from him. She stated after the incident he was moved to a private room, assessed him medically, ordered a psychology consult, and ordered a medication for him to treat pain and depression, [MEDICATION NAME]. She stated she sent him to the hospital for an evaluation as he reported being hit by Resident #11 first and there were no findings at the hospital. She stated from her experience with the resident he was always compliant with her and she had not heard of him having prior incidents. 10NYCRR 415.4(b)

Based on observation, interview, and record review conducted during the standard survey, it was determined the facility failed to ensure food was stored, prepared, and served under sanitary conditions in the main kitchen and on 6 of 9 resident units (Units 3 North, 4 North, 5 North, 5 South, 6 North, and 7), and failed to have an effective system in place to ensure potentially hazardous food was properly stored within safe temperatures to prevent foodborne illness. Specifically, the facility failed to keep potentially hazardous foods within a safe temperature zone; failed to maintain unit refrigerators within safe temperature zones; failed to repair malfunctioning refrigerators in a timely manner when the temperatures were in unacceptable ranges; failed to consistently monitor refrigerator and food temperatures on all 5 resident floors; and failed to ensure accurate thermometers were in place in each of the multiple refrigerators on the 5 resident floors. Additionally, the facility failed to prevent potentially hazardous food from being restocked in previously identified malfunctioning refrigerators with the plan to serve it to residents that evening; outdated foods continued to be stored in multiple unit refrigerators; prepared food was not returned to refrigeration in a timely manner in the main kitchen; floors, walls, and equipment were not maintained in a sanitary manner; inadequate strength sanitizer was present near the cook station; and insects were present in multiple areas of the main kitchen. This resulted in no actual harm with potential for serious harm that was immediate jeopardy to the health and safety of the 465 current residents. The Immediate Jeopardy for tag F371 was removed prior to survey exit on 10/14/2015. THIS IS A REPEAT DEFICIENCY FROM THE 2/13/2015, 9/20/2014, and 6/6/2014 SURVEYS. Findings include: 1) IMPROPER COLD HOLDING OF POTENTIALLY HAZARDOUS FOODS: A) Unit Refrigerators On 10/6/2015 at 10:10 AM, a surveyor observed the Unit 4 C/D core nourishment station. The station contained 2 refrigerators; a top refrigerator, and a bottom refrigerator with a sign marking it out of service. When the surveyor opened the bottom refrigerator marked out of service, a putrid smell was present and a tray containing 5 dairy shakes dated 9/27/2015 and a dairy pudding labeled 8/28/2015 were present. The bottom refrigerator was not operating. On 10/6/2015 at 10:15 AM, the surveyor returned to the kitchen to request a dietary staff member to accompany the surveyor to observe unit refrigerators. The Food Service Director requested the Corporate Regional Food Service Manager and Corporate Dietitian to accompany the surveyor. On 10/6/2015 at 10:20 AM, the surveyor returned to the Unit 4 C/D core nourishment station with the Corporate Regional Food Service Manager and Corporate Dietitian. The Corporate Regional Food Service Manager stated the maintenance department was responsible for checking and recording the refrigerator temperatures and kept a log of temperatures. He stated the facility policy was to keep all cold products below 41 degrees Fahrenheit (F), and the facility would try to set the coolers at 37-38 degrees F. When the top refrigerator was opened, the thermometer indicated an ambient air temperature was 45 degrees F. The refrigerator contained 5 cartons of 2% milk and 10 containers of perishable dairy pudding. Product temperatures at the time of the observation were determined by the facility below: - carton of 2% milk was 49 degrees F; and - perishable dairy pudding was 52 degrees F. When the lower cooler marked out of service was opened, a putrid odor was present. A tray of nourishments containing dairy shakes, juices, and dairy pudding was present. The Corporate Regional Food Service Manager stated the products in the cooler did not belong there, and was unsure why they were there. On 10/6/2015 between 10:20 AM and 10:35 AM, the Unit 4D nourishment station refrigerator was observed. The thermometer inside the refrigerator showed the ambient air temperature was 50 degrees F. A container of chocolate milk was determined to be 45.9 degrees F. On 10/6/2015 at 11:10 AM, the air temperature was observed to be 54 degrees F by a surveyor. On 10/6/2015 between 10:38 AM and 10:45 AM, the Unit 3D nourishment station refrigerator was observed. The refrigerator lacked a thermometer. A turkey salad sandwich was determined to be 52 degrees F. The refrigerator contained a pool of water at the bottom of the unit and contained dairy shakes and containers of thickened water. On 10/6/2015 at 10:45 AM, the Unit 6 C/D core nourishment station refrigerator was observed. The thermometer inside the refrigerator showed the ambient air temperature was 45 degrees F. A container of 2% milk was determined to be 46.6 degrees F and an egg salad sandwich was 53 degrees F. The refrigerator contained 10 milk containers and 3 egg salad sandwiches. At the time of the observation, the Corporate Regional Food Service Manager stated all the products would be discarded, because he did not like products stored at 45 degrees F. On 10/6/2015 at 11:00 AM, the Unit 5 B nourishment station refrigerator was observed. The refrigerator contained an undated and unlabelled container of turkey, mashed potatoes, and carrots, and a container of fermented orange juice in a distended container under pressure. On 10/6/2015 between 11:00 AM and 11:05 AM, the Unit 5 C/D core nourishment station refrigerator was observed. The thermometer indicated an ambient air temperature of 46 degrees F. An egg salad sandwich was determined to be 55 degrees F. and a container of milk was 54 degrees F. The refrigerator contained 13 milk cartons and 5 egg salad sandwiches. On 10/6/2015 between 11:05 AM and 11:30 AM, the Unit 7 core nourishment station refrigerator was observed. The thermometer indicated an ambient air temperature of 43 degrees F. Dairy pudding was determined to be 53 degrees F, and a 2% half gallon of milk to be 50 degrees F. The refrigerator contained 20 dairy puddings, and 10 containers of lactose free milk and several half gallons of milk. On 10/6/2015 between 11:05 AM and 11:30 AM, the Unit 7 lounge nourishment station refrigerator was observed. The thermometer indicated an ambient air temperature of 20 degrees F. Dairy pudding was determined to be 51 degrees F, a carton of milk to be 49 degrees F, and an egg salad sandwich to be 58 degrees F. The refrigerator contained 12 milk cartons, 6 egg salad sandwiches, 6 dairy puddings, a sandwich from a fast food restaurant with no date or name, and an undated resident container of turkey and rice. B) Main Kitchen On 10/6/2015 at 9:40 AM, approximately 75 egg salad sandwiches were observed stored on 2 carts near the sandwich preparation station. The temperature of the sandwiches was determine by the facility to be 68 degrees F. The ambient air temperature near the sandwich prep station determined by the surveyor to be 67 degrees F. In an interview with Food Service Worker #48, who was in the process of wrapping approximately 100 peanut butter and jelly sandwiches, she stated she had just started preparing the egg salad sandwiches at 9:30 AM. When the Food Service Director told her it was 9:40 AM, she stated she may have started them earlier. She stated it may have been 8:30 AM or earlier. C) Restocked potentially hazardous foods On 10/6/2015 at 2:40 PM, a surveyor again observed the Unit 4 C/D core nourishment station, which contained 2 refrigerators. The top refrigerator previously determined to be malfunctioning contained a carton of white milk. The dietary supervisor determined the milk temperature to be 52 degrees F. Additional observations of unit refrigerators on 10/6/2015 between 2:00 PM and 2:50 PM were as follows: - Unit 3 Core refrigerator contained a resident bag lunch with a hard boiled egg at 47 degrees F; - Unit 3D refrigerator contained an open container of prune juice at 53 degrees F; - Unit 4D refrigerator contained a Mighty Shake (nutritional supplement) at 50 degrees F, dairy pudding at 48 degrees, and outdated perishable resident food dated 10/1/2015; - Unit 5 Core refrigerator contained a carton of chocolate milk at 57 degrees F; - Unit 5B refrigerator contained an open container of orange juice at 48 degrees F; - Unit 7 kitchen refrigerator contained lactose free milk at 46.6 degrees F, and an egg salad sandwich at 50 degrees F. Refrigerators on Unit 3D, 4D, 4C/D Core, 5C/D Core, and 7 Core were previously observed to be malfunctioning on 10/6/2015 between 10:10 AM and 11:45 AM. The undated Cold Food Policy documented food would be stored at 40 degrees Fahrenheit (F.) or lower, and corrective action would be implemented if cold food was found to be 40 degrees F. or higher. The undated Dating and Labeling Policy documented food would be labeled with an expiration date no more than 72 hours after opening, and foods that expire should be discarded immediately. The undated Floor Stock policy documented food service staff would remove outdated food items. The nourishment refrigerator policy, revised 1/2007, documented nourishment station refrigerators were to be checked and have temperatures recorded daily prior to 4 AM, with the acceptable range between 34 and 40 degrees F. The General Food Preparation and Handling policy, dated 2013, documented the kitchen and equipment were to be cleaned and sanitized as appropriate; potentially hazardous (cold) food would be prepared from pre-chilled products and refrigerated below 41 degrees F. immediately after preparation. The policy Taking Accurate Temperatures, dated 2013, documented thermometers should be accurate to plus or minus 2 degrees F. 2) UNIT REFRIGERATORS NOT REPAIRED/REMOVED FROM SERVICE TIMELY On 10/6/2015, a surveyor requested unit refrigerator temperature log records 4 different times for October 1 and 2, 2015; the records were never provided. There was no documented evidence nourishment refrigerator temperatures were checked on 10/1 or 10/2/2015. Nourishment refrigerator temperature logs (Nourishment Centers and Dietary Temperatures) dated 10/3/2015, 10/4/2015, and 10/5/2015 documented the refrigerator air temperature: - in the 6 North core top refrigerator was 56 degrees F. on 10/3/2015; 56 degrees F. on 10/4/2015, and 56 degrees F. on 10/5/2015. Nothing was documented on the daily log under corrective action taken. All 3 days the temperature log was completed by maintenance staff #45. - in the 4 North core top refrigerator was 62 degrees F. on 10/3/2015, 62 degrees F. on 10/4/2015, and 62 degrees F. on 10/5/2015. Nothing was documented on the daily log under corrective action taken. All 3 days the temperature log was completed by maintenance staff #45. During an interview with the Plant Operations Director on 10/6/2015 at 12:30 PM, he stated: - maintenance staff checked the temperature of all the unit refrigerators, daily, and it was done at night (meaning not during the day shift); - sometimes staff used a heat gun (infrared thermometer) to check the refrigerator temperature; - there were a lot of new maintenance staff; - in the event a refrigerator thermometer was missing, maintenance staff should replace the thermometer; - in the event of a refrigerator temperature problem, maintenance staff should discard the food in the refrigerator and inform dietary staff about the problem; - some days were missed in August and September 2015 for refrigerator temperature checks; - work orders in the facility were done electronically; - in the event of a refrigerator problem, the problem might be addressed by maintenance staff, who may or may not inform him. When the Plant Operations Director was interviewed on 10/6/2015 at 2:05 PM, he stated: - he was aware of many of the work orders, but not all of the work orders; - he had been checking the unit refrigerator temperature logs, but recently had not been checking them consistently; - there was no system to formally notify dietary department of a refrigerator work order; - refrigerator temperature logs would normally be left in the maintenance office; - out of service signs were normally available with the refrigerator temperature logs, in the event a maintenance staff needed to take a refrigerator out of service; - maintenance staff #45 was recently put on the night shift, when he would need to start checking refrigerators; - refrigerator temperatures would be checked by maintenance between 7 PM and 3 AM the following day. During an interview with the Food Service Director on 10/6/2015 at 2:24 PM, he stated: - if a refrigerator was out of service, normally it would be posted on the refrigerator by maintenance; - maintenance would not normally notify dietary if a refrigerator was taken out of service; - if a refrigerator thermometer was missing, maintenance might request a thermometer from dietary, and dietary did stock thermometers; - the facility's refrigeration temperature standard was for food to be 40 degrees F. or below; - if refrigerator air temperature was high, he would expect dietary staff to notify food service management staff and discard the food; - dietary staff were not doing any routine refrigerator temperature checks; - the last refrigerator work order the Food Service Director was aware of was for the 6 North D refrigerator to be defrosted; - dietary staff did check unit refrigerators related to cleaning and need for defrosting. During a follow up interview with the Plant Operations Director on 10/6/2015 at 4 PM, he stated: - maintenance staff checked refrigerator temperatures; - he trained maintenance staff #45; - there was no training record for maintenance staff #45; - he was not aware some of the nourishment refrigerators were not operating properly; - he found only one work order for the time period 10/1 through 10/6/2015. The only work order for unit nourishment refrigerators was dated 9/2/2015 to defrost the 6 D North refrigerator, related to ice buildup. 3) INACCURATE THERMOMETERS The nourishment refrigerator temperature log dated 10/3/2015 (Nourishment Centers and Dietary Temperatures) documented the refrigerator air temperature was as follows: - 7 North (D) top refrigerator -10 degrees F., - 6 North (D) top refrigerator 11 degrees F., - 6 South (B) top refrigerator -13 degrees F., - 5 South (B) bottom refrigerator 23 degrees F. The nourishment refrigerator temperature log dated 10/4/2015 (Nourishment Centers and Dietary Temperatures) documented the refrigerator air temperature was as follows: - 7 North (D) top refrigerator -10 degrees F., - 6 North (D) top refrigerator 11 degrees F., - 6 South (B) top refrigerator -13 degrees F., - 5 South (B) bottom refrigerator 23 degrees F. The nourishment refrigerator temperature log dated 10/5/2015 (Nourishment Centers and Dietary Temperatures) documented the refrigerator air temperature was as follows: - 7 North (D) top refrigerator -10 degrees F., - 6 North (D) top refrigerator 10 degrees F., - 6 South (B) top refrigerator -13 degrees F., - 5 South (B) bottom refrigerator - 23 degrees F. Nothing was documented on the daily log under corrective action taken. All 3 days the temperature log was completed by maintenance staff #45. A surveyor observed the 4 South refrigerator on 10/6/2015 at 10:44 AM; the refrigerator thermometer displayed an air temperature of 60 degrees F. The surveyor determined the temperature of a milkshake in the refrigerator to be 41 degrees F. A surveyor observed the Unit 5B bottom refrigerator on 10/6/2015 at 2:16 PM; the refrigerator thermometer displayed an air temperature of 75 degrees F. The surveyor determined the temperature of apple juice in the refrigerator to be 30 degrees F. The policy Taking Accurate Temperatures, dated 2013, documented thermometers should be accurate to plus or minus 2 degrees F. The maintenance staff member #45 was unavailable for interview throughout survey when a surveyor attempted to call him multiple times during the survey. 4) REFRIGERATORS WITHOUT THERMOMETERS A surveyor observed the 3 North core refrigerators on 10/6/2015 at 9:25 AM; the upper refrigerator contained 4 milk cartons; the lower refrigerator had a bag labeled breakfast; both refrigerators lacked thermometers. A surveyor observed the Unit 3 North (D) top refrigerator on 10/6/2015 at 9:55 AM. There was no thermometer, the refrigerator contained a milkshake and cheese, and there was 1/8 inch of pool of liquid in the bottom of the refrigerator. On 10/6/2015 at 10:38 AM, the Unit 3 C/D core nourishment station refrigerators were observed; the top and bottom refrigerators lacked thermometers. A surveyor observed the Unit 6 North staff refrigerator on 10/8/2015 at 9:20 AM; refrigerator contents included residents' milk, including an 8 ounce whole milk in a carton, and a 4 ounce 2% milk in a carton; there was no thermometer present in the refrigerator. 5) MAIN KITCHEN SANITATION On 10/6/2015 at 9:15 AM, a surveyor observed the following in the main kitchen: - the floor under the hand washing sink was unclean with substantial buildup around the foot operated controls; - dry good storage room floor was unclean with dust, tape, and lids; - wall and floor area under the 3-bay sink was not smooth and cleanable; - blade on the can opener near the sandwich station was unclean; - sanitizer strength near the cooks' area was inadequate (below the required level); - floor under the trayline was unclean with buildup; - floor and baseboard under sandwich prep station was unclean; - floor under the racks near the juice station was unclean with heavy buildup along the edges of the cabinet without doors. On 10/6/2015 between 9:45 AM and 10:05 AM, in an interview with Food Service Worker #50, he stated he just filled the sanitizer bucket from the dispenser near the 3-bay sink. When the Food Service Director and the surveyor observed the sanitizer dispenser, the Food Service Director identified the dispenser was empty. The General Food Preparation and Handling policy, dated 2013, documented the kitchen and equipment would be clean and sanitized as appropriate. 6) INSECT CONTROL On 10/6/2015 between 12:30 PM and 4:05 PM, and on 10/7/2015 at 11:25 AM, the following was observed in the main kitchen by a surveyor: - 3 live cockroaches near the puree station; - 5 live cockroaches near the hot box by the slicer; - 3 live cockroaches behind the convection oven; - 5 live cockroaches under the food processor; - 1 live cockroach near the floor mixer; - 1 live cockroach under the trayline. On 10/6/2015 in an interview with the Food Service Director at 12:40 PM, he stated the pest management contractor was in the facility every Wednesday. He stated the contractor checked in with the housekeeping department that oversaw pest management. He stated when insects were spotted and recorded in a log, the pest management contractor would review them when he was in the facility. On 10/6/2015, the insect sighting log was reviewed by a surveyor. Cockroach sightings were documented on 8/18, 8/18, 8/26, 9/9, 9/10, 9/14, 9/15, 9/22, 9/26, 9/28, and 10/5/2015. The contractor documented in the log treating the areas on 8/26, 9/9, 9/16, 9/23, and 9/30/2015. Review of the Pest Management Company invoices on 10/9/2015 documented cockroach treatments were provided in the kitchen on a weekly basis (on average) in 2015. Treatments were provided: - 3 weeks in the months of January 2015 and August 2015; - 4 weeks in the months of February, March April, May and June 2015; and - 5 weeks in the months of July and September 2015. On 10/9/2015 at 1:30 PM, the Director of Housekeeping was interviewed. He stated the pest management company was in the facility weekly and checked the pest logs and treated as needed. He stated if there were additional complaints, he would meet personally with the pest company when the contractor was in the building to address issues. He stated he has spoken to the corporate office about changing the contractor, to see if the outcome would be different, as the current contractor stated the insects may be developing a resistance to the chemicals used. He stated currently there was no plan for widespread treatment. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 10/9/2015 based on the following corrective actions taken. The facility: - Implemented a staff training program in food safety; - Developed a system to adequately maintain and monitor refrigerator temperatures; - Educated the majority of facility staff on roles and responsibility regarding food safety; - Revised policies and procedures to address cold holding; and - Quality assurance monitoring was initiated by administrative staff to ensure compliance with the new/revised policy and procedure. 10NYCRR 415.14 (b)(2)(h), 14-1.112, 14-1.40(a), 14-1.44, 14-1.160, 14-1.170,

Based on observation, record review, and interview conducted during the standard survey and abbreviated surveys (#NY 097, #NY 816 and #NY 643), it was determined for 7 of 33 sampled residents (Residents #1, 19, 20, 29, 30, 31 and 32), the facility did not provide the necessary care and services to attain or maintain the highest practicable well-being. Specifically, - Resident #31 experienced harm when physician orders for a urinalysis (U/A, urine test for possible infection) on 2 different dates were not performed as ordered. A third U/A was ordered 5 days later, with the resident was being hospitalized 2 days later with septic shock (a system wide response to infection) related to UTI and pneumonia. - Resident #1's physician orders were not consistently followed regarding monitoring the resident's vital signs and documenting progress notes; when the resident did not receive 6 treatments in a 9 day period to her abdominal surgical wound; and when staff did not provide the type of treatment ordered to her abdominal surgical wound, as they were unaware of the difference between the wound care products. Additionally, the facility did not schedule wound treatments at a time that did not conflict with her rehabilitation (rehab) therapy, to ensure these treatments were consistently provided as ordered. - Resident #20's skin care recommendation by a surgical consult was not implemented and no rationale was provided. Additionally, the resident's treatment for [REDACTED]. - Resident #30 had orders for urinalysis in August and September 2015 that were not carried out as planned before the resident was discharged . - Resident #32 had an order for [REDACTED]. - Resident #19 was not provided with a routine narcotic medication as planned. - Resident #29 did not receive two medications as planned. This resulted in actual harm that is not immediate jeopardy for Resident #31. Findings include: 1) Resident #31 was admitted on [DATE] for rehab with [DIAGNOSES REDACTED]. A physician order dated 8/26/2015, documented a 16 French (F) Foley catheter (urinary drainage tube), monitor every shift and change as needed. The comprehensive care plan (CCP) dated 8/26/2015, documented the resident required extensive assistance with bathing and dressing. There was no documented evidence in the CCP for a plan of care for the Foley catheter. A physician progress notes [REDACTED]. While in the hospital, the resident had a Foley catheter placed for [MEDICAL CONDITION] and was treated with antibiotics for a UTI. The 5 day course of [MEDICATION NAME] (antibiotic) was to be completed on 8/28/2015. The physician documented the resident reported she felt great, did not have any signs or symptoms of infection and had no significant pain while lying in bed. A nurse practitioner (NP) progress note dated 8/28/2015, documented the resident was seen for complaints of increased pain in the pelvic region and overall not feeling well. The plan was to start her on Tylenol and change the [MEDICATION NAME] (pain medication) from twice a day to every 6 hours as needed. The August 2015 Medication Administration Record [REDACTED]. The Minimum Data Set (MDS) assessment, dated 9/2/2015, documented the resident's cognition was moderately impaired. The resident had an indwelling catheter and required extensive assist for most activities of daily living (ADL). A NP progress note, dated 9/2/2015, documented the resident was seen for complaints of not feeling well and pain with moving, transferring and ambulation. The NP documented the resident stated she had some gastrointestinal upset on the previous day and it had resolved. The NP documented the resident's Foley catheter was draining dark-yellow urine with some sediment and had a slight foul odor. The NP documented she may have an underlying urinary tract infection. We will dip her urine, if positive, we will send out a urinalysis (UA) and culture and sensitivity (C&S) and treat as indicated. A physician order, dated 9/2/2015 at 5:15 PM, documented to obtain a UA and C&S for malaise and fatigue. There was no documented evidence in the medical record the UA and C&S were completed. A physician order, dated 9/3/2015 at 2:53 PM, documented to obtain a UA and C&S for malaise and fatigue. There was no documented evidence in the medical record the UA and C&S were completed. During an interview with the registered nurse (RN) Unit Manager on 10/8/2015 at 10:30 AM, she stated she entered the resident's order for the UA and C&S and thought the order had been carried out on 9/2/2015. She stated she could not recall if she had followed up and checked the results of the urinalysis. She stated when there was an order to obtain a UA and C&S, the nurse who obtained the urine sample would document in the progress note that the order was completed and the sample was sent to the laboratory for testing. Review of nursing progress notes revealed no nursing notes were documented between 9/1/2015 and 9/8/2015. A NP progress note, dated 9/8/2015, documented the resident was not feeling well. The resident stated she was just very uncomfortable lying in her bed. The NP documented the resident continued to complain of pelvic pain and remained weak upon exam. The Foley catheter was draining yellow urine. A nursing progress note dated 9/8/2015 at 6:17 PM, documented a UA and C&S was obtained and sent. Results were pending. A NP progress note dated 9/9/2015, documented the resident had a poor appetite and abdominal discomfort. The NP documented the resident's vital signs were stable and a UA and C&S had been sent. The NP's plan was to order medication for nausea, abdominal x-ray and await the UA results. A laboratory report documented the resident's urine was collected on 9/8/2015 and received by the laboratory on 9/9/2015 at 6:08 AM. A urinalysis was performed on the resident's urine and reported to the facility on [DATE] at 3:13 AM. The laboratory report documented the following results of the urinalysis: the urine's appearance was dark yellow and cloudy, [MEDICATION NAME] were positive (normal negative), Leukocyte Esterase was 3+ (normal negative), white blood cells >60 (normal 0-5), red blood cells 20-40 (normal 0-2) and the urine contained many bacteria >50 (normal none). The laboratory report documented receipt of a urine culture tube with no test indicated on it. Based on the appearance of the urine, a urine culture was performed and results were pending. A physician order dated 9/10/2015 at 12:26 PM, documented to obtain a urine culture and at 2:10 PM an order was documented to obtain the resident's vital signs. The Medication Administration Record [REDACTED]. A NP progress note dated 9/10/2015 documented the staff reported the resident had no urinary output and he did not observe any urine in her Foley catheter drainage bag. The resident was lethargic and continued with a poor appetite. The resident's blood pressure was 86/58 and she was not speaking, only nodding her head yes or no. The NP documented the resident had pneumonia, failure to thrive and was dehydrated. He documented speaking to the resident's family who declined treatment at the facility and requested she be transported to the hospital. A physician order, dated 9/10/2015 at 4:09 PM, documented to transfer the resident to the hospital. emergency room records, dated 9/10/2015, documented the resident was admitted for treatment of [REDACTED]. A representative from the facility's laboratory was interviewed on 10/9/2015 at 12:30 PM, and stated the resident's urine was tested on [DATE] and that dated order was the only order they had received from the facility for a UA and C&S. During an interview with the physician on 10/14/2015 at 10:35 AM, he stated when he ordered a UA and C&S for a resident, he would expect the sample to be obtained as soon as it had been ordered. He stated if the resident had a Foley catheter in place, then obtaining the urine sample would only take a couple of minutes to do. He stated obtaining a urine sample 7 days after it was ordered was unacceptable and if the resident did not have any antibiotic therapy during the course of those 7 days, it was quite possible the development of septic shock from a UTI could have been avoided. 2) Resident #1 had [DIAGNOSES REDACTED]. The nursing admission note dated 9/10/2015 documented the resident's orders were reviewed with the attending physician; and the resident had a 15 centimeter (cm) abdominal wound present upon admission. The physician's orders dated 9/10/2015 documented to complete nurses notes and to monitor vital signs every shift for 5 days and notify the physician/nurse practitioner for a temperature greater than 100.5 degrees Fahrenheit (F). The physician's orders did not document a treatment for [REDACTED]. The physician's progress note dated 9/11/2015 documented the resident had a midline Wound VAC. The nursing progress note dated 9/13/2015 at 6:49 AM documented the physician was notified of the resident's abdominal area and a new order was given for a wet to dry dressing daily. (There were no other nursing progress notes in the medical record from the time of admission on 9/10/2015 to this note on 9/13/2015.) The nursing note dated 9/13/2015 at 7:21 AM documented the resident's abdominal dressing was soiled and changed. Oral temperature 100.7 degrees Fahrenheit (F), Tylenol was given and retake of temperature was 98.5 degrees F. The certified nurse aide (CNA) documentation history showed the temperature of 100.7 degrees at 4:36 AM. (There were no temperatures documented prior to this date.) The physician's order dated 9/13/2015 documented a wet to dry dressing with normal saline pack and cover with 2 ABD pads. The treatment administration record (TAR), dated September 2015, documented a wet to dry dressing with normal saline to pack the wound and cover with 2 abdominal pads (ABD pads) with a start date of 9/13/2015. The TAR did not document a treatment for [REDACTED]. The treatment was scheduled daily at 10 AM and was not done on 9/15 and 9/17/2015, with no rationale documented. The nurse practitioner's (NP) progress note, dated 9/15/2015, documented the resident had an open wound to the abdomen that was packed. The resident had an elevated temperature the past few days, especially at night, up to 101 degrees Fahrenheit (F). The plan was to continue to monitor, the resident had an elevated white count at 12.8 and was not showing signs of infection. The physician's order dated 9/15/2015 documented to monitor vital signs daily until 9/20/2015. The nursing progress note dated 9/16/2015 at 2:20 AM documented the resident's abdominal dressing was displaced and soiled. The treatment was done per order and the resident was medicated for level 8 (pain scale 1 to 10 with 10 being the most pain) abdominal pain. Her oral temperature was 99.3 and Tylenol was given with her pain medicine. The Minimum Data Set (MDS) assessment, dated 9/17/2015, documented the resident's cognition was intact; she required extensive assistance with bed mobility, dressing and toilet use, and limited assistance with transferring. She had a surgical wound and treatments included surgical wound care. There were no temperatures documented on 9/17 and 9/18/2015. The September 2015 TAR documented to pack saline soaked gauze to open abdominal area and cover with 2 ABD pads twice a day and as needed, starting on 9/18/2015. The treatment was scheduled to be done once on the 7 AM - 3 PM shift and once on the 3 - 11 PM shift. There was no documentation in the medical record for September 2015, including the 9/2015 TAR, that the ordered treatment was provided 6 times in 8 days, (and the reason why if it was not provided) for: - both shifts on 9/19; - on the evening shift on 9/20; - on the day shift on 9/21; - on the day shift on 9/25; and - on the evening shift on 9/27/2015. The nursing progress note dated 9/28/2015 at 11:47 AM documented the resident had a moderate amount of blood draining from her wound, the nurse practitioner (NP) was in to evaluate and sent the resident to the emergency room (ER). The NP's progress note, dated 9/28/2015, documented the resident's abdominal wound was grossly bleeding; the packing was removed; and there was a large clot in the upper portion of the wound. The resident was sent to the emergency room (ER) for further evaluation. The Medication Administration Record [REDACTED]. There were no documented nursing progress notes regarding the resident's return from the ER. The October 2015 TAR documented the resident's treatment was to pack saline soaked gauze to open abdominal area and cover with 2 ABD pads twice a day and as needed. The treatment was scheduled to be done on the 7 AM - 3 PM shift and on the 3 PM - 11 PM shift. There was no documentation in the October 2015 TAR that the ordered treatment was provided for the 7 AM - 3 PM shift on 10/2 and 10/4/2015 (treatment performed 2 out of the 4 times it was planned). During an interview with the resident on 10/6/2015 at 12:20 PM, she stated her abdominal dressing was supposed to be changed twice a day and sometimes it was only changed once. She also stated they once left the wound uncovered all day. The physician's order, dated 10/7/2015 at 6:54 PM, documented Wound VAC to abdominal wound with setting at 125 mmHg (millimeters of mercury) continuously. If Wound VAC was not available, apply [MEDICATION NAME] AG (absorbent calcium alginate dressing with silver (AG) infused for antimicrobial effect) to wound bed, cover with ABD pad, secure with tape, and change daily. During an interview on 10/8/2015 at 12 PM, LPN #41 stated she was responsible for the resident's treatments. She stated the 7 AM - 3 PM treatments were done in the afternoon and, if the resident was at therapy or off the unit, the treatment did not get done. During a dressing change observation on 10/8/2015 at 10:55 AM, licensed practical nurse (LPN) #1 performed a dressing change with the assistance of LPN #41. The old dressing was removed by LPN #41 and had dark brown, purulent (containing pus) drainage. The wound was cleansed with normal saline by LPN #1. The wound was deep and moist yellow dead tissue was observed at the edge of the wound base. LPN #1 covered the wound base with a 4 x 4 (inches) [MEDICATION NAME] Extra (absorbent calcium alginate dressing) and covered with 2 ABD pads and taped the dressing in place. During an interview on 10/8/2015 at 12:30 PM, the wound care registered nurse (RN) #9 stated when dressings did not get changed as ordered, wounds could deteriorate. She stated if the LPN did not have time for a treatment, the RN Manager or the RN Supervisor should be notified. Wound care RN #9 stated the resident went to the wound care center on 10/7/2015 and a Wound VAC was ordered. She stated she did not know how long it took to get the Wound VAC, and an alternative dressing ([MEDICATION NAME] AG) was in place until the VAC was available. She stated she was unsure if [MEDICATION NAME] AG and [MEDICATION NAME] Extra were the same product, and then stated she thought one had silver and did not know which one. During an interview on 10/9/2015 at 3:28 PM, LPN #41 stated she did not perform the resident's treatment that day, as the resident was at physical therapy when she went to do it. The surveyor and LPNs #1 and #41 entered the resident's room on 10/9/2015 at 3:28 PM to observe the treatment product currently being used on the resident. LPNs #1 and 41 both stated [MEDICATION NAME] AG and [MEDICATION NAME] Extra were the same product. They said they did not see AG on the package, and thought the current product ([MEDICATION NAME] Extra) was the right product. During an interview on 10/13/2015 at 10 AM, the RN Manager #11 stated she gave the treatment nurse [MEDICATION NAME] AG to put in the resident's room for dressing changes. She stated she did not know the difference between [MEDICATION NAME] AG and [MEDICATION NAME] Extra. She stated the physician was looking for a product to absorb and there might be one or two slight differences between the products. She stated when treatments were missed, the resident was usually off the unit at therapy. She stated she expected the treatments to be done when the resident returned, and if not done, she expected to be notified. RN Manager #11 also stated she did not know why a treatment was not put into place until 3 days after the resident's admission. 3) Resident #20 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 9/16/2015, documented the resident had an abdominal abscess wound (collection of pus) and the goal was to be free of signs and symptoms of infection. Interventions included weekly wound measurements, follow-up with surgical appointments, and treatment as ordered. The Minimum Data Set (MDS) assessment, dated 9/23/2015, documented the resident was cognitively intact and required limited assistance for bed mobility, locomotion, dressing, toilet use, hygiene, and bathing, and was independent for transfer, walking, and eating. The MDS did not document the resident had any skin impairments. WOUND The nursing progress note, dated 9/30/2015 at 9:58 AM, documented the resident was seen on skin rounds and the abdominal abscess wound measured 0.4 cm (centimeters) x 0.4 cm x 0.2 cm with 100% yellow moist slough (dead tissue) in the wound bed, and light serous (clear straw colored) drainage; the periwound (skin around the wound) was healthy with induration (hardness) 3.5 cm around the wound. The plan was to follow-up with surgical as scheduled. The surgical progress note, dated 9/30/2015 at 12:23 PM, documented the resident had a surgical wound on her upper left abdomen. The note specified the resident appeared to have had a reaction to the dressing with dry, scaly skin and scattered little blisters in the center of the vertical incision line, approximately 6 cm long. At the base of the incision line was a small round open area about 2 mm (millimeters) around. The surgical progress note recommended continuing the dry dressing and using liberal skin prep (liquid film barrier) to protect the skin. The treatment administration record (TAR) documented from 9/30/2015 to 10/6/2015, the resident's wound site was cleaned with normal saline, patted dry, covered with a dry sterile dressing and paper tape once a day. (There was no evidence skin prep was used as recommended by surgical). The nursing progress note, dated 10/7/2015 at 1:41 PM, documented the resident was seen on skin rounds and the abdominal abscess wound was intact. She had no discomfort on palpation of the wound and had an intact blister above the site measuring 4.0 cm x 1.0 cm. The resident was observed and interviewed on 10/7/2015 at 3:35 PM, in her wheel chair in the main dining room. The resident stated she had blisters on her stomach and was supposed to have cream or something applied to them. She stated a physician looked at it last week and said no one was doing anything except putting a dressing on it. The resident pulled up her shirt; revealed a large dry gauze dressing; and wanted to remove the dressing to show the wound to the surveyor. At 3:45 PM, the wound care registered nurse (RN) # 9 walked through the dining room and saw the resident lifting her shirt. The resident wanted to show the RN her wound, stating it hurt. RN #9 took the resident out of the dining room and on the way to the resident's room, summoned the nurse practitioner (NP) #26 and RN Manager #11 to come with her. The resident laid down on the bed, the dressing was removed. The dressing had yellow drainage and when removed, revealed a broken blister that covered an old incision; the area surrounding was red and hard. NP #26 stated it was her first time seeing the resident's wound and recommended a dressing change. NP #26 also stated the resident's pants might be too tight; the waist line of the resident's pants was observed approximately 6 inches below the wound. RN Manager #11 stated there were no new orders when seen last week by surgical consult. During an interview with RN #9 on 10/8/2015 at 12:30 PM, she stated she saw the blister intact over the incision line and had not seen any blisters in the past. She stated if the surgical consult saw the resident on 9/30/2015, she would have expected the recommendations to be put in place by the next day. During an interview with RN Manager #11 on 10/13/2015 at 10 AM, she stated she reviewed the surgical consult with NP #26 and they did not want to use skin prep. She stated she did not document she notified NP #26. Yeast Infection The physician's progress note dated 10/5/2015, documented the resident complained of vaginal itching and discharge. The plan was to treat the resident with [MEDICATION NAME] vaginal cream (treatment for [REDACTED]. The Medication Administration Record [REDACTED]. When the resident was interviewed on 10/9/2015 at 3:20 PM, she stated she had a yeast infection, was very uncomfortable, and tried not to think about it. She stated the physician ordered [MEDICATION NAME] for her earlier in the week and she did not get it. She stated she could administer it herself if they would get it for her. During an interview with licensed practical nurse (LPN) #46 on 10/9/2015 at 3:35 PM, she stated the [MEDICATION NAME] should have come in from the pharmacy on 10/5/2015. She stated she had not worked on the unit during the week and did not know why the [MEDICATION NAME] was unavailable. She stated the nursing supervisor should have been notified or the pharmacy should have been called. The October 2015 MAR indicated [REDACTED]. During an interview with LPN # 47 on 10/10/2015 at 5:25 PM, she stated the [MEDICATION NAME] was not available when she worked on 10/5, 10/7, and 10/8/2015. She stated she did not remember if she notified anyone. During an interview with the registered nurse (RN) Manager on 10/13/2015 at 10 AM, she stated she was unaware the resident was not getting the [MEDICATION NAME] last week and she expected the nurse to call the pharmacy or the nursing supervisor when treatments were missing. 10NYCRR 415.12

Based on record review, observation and interview conducted during the standard survey, it was determined for 6 of 9 residents (Residents #7, 11, 13, 16, 25, and 28) reviewed for pressure ulcers, and 5 additional residents (Residents #34, 35, 37, 38, and 39), the facility did not ensure necessary treatment and services were provided to promote healing. Specifically, - Resident #13 did not receive pressure relief as ordered and recommended; and the pressure ulcer treatments and interventions were not consistently completed on his right outer ankle pressure ulcer. Wound vac for the resident's right ischium (the back lower part of the hip bone) Stage IV pressure ulcer was left disconnected for extended periods of time. - For Resident #25, pressure ulcer interventions and treatments were not initiated timely; recommendations from the Wound Care Team were not implemented; and the pressure ulcer became larger. - Resident #7 had a sacral pressure ulcer was observed without the ordered dressing in place; pressure ulcer treatments were not consistently provided; and the sacral pressure ulcer increased in size and progressed from a Stage II to a Stage III. - Resident #34 had dementia with behaviors and agitation. When the resident refused pressure ulcer treatments, the interdisciplinary team did not develop alternative protective/preventative measures/treatment; the resident's heel pressure ulcer deteriorated, with the resident expressing pain. - For Resident #28, a recommendation for a cast shoe was not addressed timely. - Resident #11's dressing change order was not completed following a surgical consult. - Residents #16, 34, 35, 37, 38, and 39 did not have pressure ulcer treatments completed as ordered. This resulted in actual harm that is not immediate jeopardy for Residents #13 and 25. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS OF 2/13/2015, 6/6/2014 AND 9/20/2013. Findings include: 1) Resident #13 had [DIAGNOSES REDACTED]. RIGHT OUTER ANKLE: An admission assessment completed by registered nurse (RN) #16 on 10/1/2015 documented the resident had a Stage II pressure ulcer to his right outer ankle measuring 1 centimeter (cm) x 1.8 cm. There was no documented description of the wound bed. A physician order, dated 10/1/2015, documented to cleanse ankle with normal saline, pat dry and apply nickel thick layer of Santyl (ointment that breaks down dead skin/tissue) to the wound bed, cover with Vaseline gauze and wrap with Kerlix. The comprehensive care plan (CCP), dated 10/2/2015, documented the resident had a Stage II pressure ulcer on his right outer ankle related to decreased bed mobility and desensitization to pain/pressure. The goal was the pressure ulcer would show healing. Interventions includedblue booties vs pillows to off load as tolerated. The October treatment administration record (TAR) documented the resident did not receive the Santyl treatment to his right ankle on 10/2, 10/5 and 10/6/2015. The resident was observed on 10/6/2015 at 12:35 PM and 2:10 PM, sitting up in a geri chair. The resident was wearing non-slip socks and both feet were turned outward with his outer ankles lying directly on the geri chair foot rests. During a wound observation with the wound care Nurse Practitioner (NP) consultant on 10/7/2015 at 8:50 AM, the resident's outer ankles were resting directly on the mattress. The resident was wearing non-slip socks and did not have a pillow under his feet or blue booties on. The NP removed the resident's dressing to his right ankle. The old dressing contained brownish drainage that was dry and crusted on the gauze. There was no Vaseline gauze observed. The NP stated the wound was a Stage IV pressure ulcer that went down to the bone and measured 1.4 cm x 1 cm. There was a small amount of dead tissue next to an area that had white tissue directly over the middle of the ankle bone. There was a small amount of slough to the right aspect of the pressure ulcer. The rest of the pressure ulcer's wound bed was red and moist. The NP reapplied a clean, dry gauze to the resident's right outer ankle and stated nursing staff would replace the dressing. She then positioned the resident's feet on a pillow. The resident was observed on multiple occasions on 10/7/2015 from 9 AM - 2:30 PM. He remained in bed with the same gauze on the right outer ankle that had been applied by the NP that morning. At 2:30 PM, registered nurse (RN) #16 was observed in the resident's room applying a dressing to the resident's buttock. The RN completed the dressing and left the resident's room. The gauze on the right outer ankle applied by the NP remained in place, with a small amount of bloody drainage seeping through the gauze. At 3:40 PM, the resident had a new dressing covering the right ankle. During an interview with licensed practical nurse (LPN) #17 on 10/7/2015 at 3:45 PM, she stated she changed the dressing to the resident's left ankle sometime between 2:30 PM and 3 PM, when she realized his treatment had not been done. During an interview with LPN #21 on 10/7/2015 at 3 PM, she stated on 10/6/2015 RN #16 completed some of the treatments at the end of the shift. LPN #21 looked to see what treatments still needed to be done. She stated she completed some of the remaining treatments, not all of them. She stated she did not complete Resident #13's treatment. A progress note dictated by the wound care NP consultant, dated 10/7/2015, documented the resident had an ulcer to his right outer ankle. There was an inner ring of open tissue, maybe 0.4 or 0.5 centimeters around and white tissue was visible at the base. She documented she had no doubt this may go down to bone. The surrounding skin of the pressure ulcer was intact and purpuric (purplish discoloration). The NP documented the resident's heels needed to be offloaded at all times; and if he did not have specialty boots, the facility needed to get him some. During the wound care registered nurse (RN)'s weekly rounds on 10/8/2015 at 7:50 AM, the surveyor observed the resident in bed with his right outer ankle resting directly on the mattress. The RN removed the dressing from the resident's right ankle. She stated the pressure ulcer to the right outer ankle measured 1.5 cm x 1.5 cm and was unstageable, as the wound bed was mostly covered with dry necrotic tissue, with a small amount of slough remaining to the right aspect of the pressure ulcer. She stated the skin surrounding the pressure ulcer was red and unblanchable. The RN reapplied a clean gauze to the resident's right ankle and set his foot back on the mattress, without offloading the feet or applying booties. At 8:30 AM, a nurse went in the resident's room and applied a new dressing to the right ankle, and a pillow was placed under the resident's feet. During an interview with RN #16 on 10/8/2015 at 11:20 AM, she stated she was the staff RN on the unit and was not responsible for doing treatments, as it was the responsibility of the LPNs. She stated occasionally she helped the LPNs with treatments and had not done the treatment to Resident #13's ankle since his admission on 10/1/2015. During an interview with the resident's certified nurse aide (CNA) #27 on 10/9/2015 at 9:45 AM, she stated the resident's heels were supposed to be elevated on a pillow; and said the resident did not have any blue booties. She stated the resident did not resist care and always left his feet where they were placed. She stated the resident never seemed bothered by the pillow or try to remove his feet off of it. During an interview with the RN Unit Manager on 10/9/2015 at 10:30 AM, she stated it was the responsibility of the staff RN to complete treatments on the unit. She stated the staff RN was aware the resident needed the dressing replaced after he was evaluated by the NP wound care nurse on 10/7/2015 and the dressing should have been replaced shortly after it was removed. The RN Unit Manager stated she was aware the resident's treatments were not done one day and was not aware they were not done more than one day. She stated if treatments were not done as prescribed, pressure ulcers could get bigger, worsen and get infected. A follow up interview with RN #16 was conducted on 10/9/2015 at 11:20 AM. RN #16 stated the LPNs were responsible for completing the treatments on the unit and the LPN should have replaced the dressing sooner than at the end of the shift on 10/7/2015. She stated when the resident was admitted on [DATE], she assessed the pressure ulcer on his right ankle and it was a Stage II. She could not remember exactly what the wound bed looked like, and thought she remembered being able to visualize some of the wound bed. During an interview with the wound care RN on 10/9/2015 at 12:10 PM, she stated she first evaluated the resident's ankle on 10/8/2015. It was unstageable as she was not able to visualize the wound bed. She stated she was aware the pressure ulcer was a Stage II when he was admitted , and was not aware his treatments were not getting completed daily. She stated if his treatments were not completed daily and offloading of the feet was not getting done, his pressure ulcer could worsen or get infected. During an interview with the resident's physician on 10/14/2015 at 10:35 AM, he stated if interventions such as pressure relief and treatments were not being done, a pressure ulcer could worsen or get infected. He stated he has not seen the resident's pressure ulcers and was just notified yesterday some of the treatments were not completed. He stated that should not happen. WOUND VAC An admission assessment completed by registered nurse (RN) #16 on 10/1/2015 documented. The comprehensive care plan (CCP) dated 10/2/2015, documented the resident had a Stage IV pressure ulcer on the right ischium. Interventions included to turn and position every 2 hours, monitor progress and report changes to physician or nurse practitioner. A physician order [REDACTED]. Change wound vac dressing on Monday, Wednesday, Friday and as needed. If the wound vac malfunctions or was unavailable apply normal saline wet to dry dressing to the the right buttock pressure ulcer. The resident was observed on 10/10/2015 at 6:15 PM in bed, sleeping. The wound vac tubing was attached to the resident and the wound vac machine was off. The resident was again observed with the wound vac remaining off at 6:30 PM, 6:45 PM, 7:10 PM and at 7:20 PM. During an interview with LPN #33 on 10/10/2015 at 7:22 PM, she stated she was responsible for making sure the wound vac was on and functioning. If the machine was not working she would apply a wet to dry dressing. She stated she did not check on the resident's wound vac yet as she just started at 7 PM and it was not reported to her there was a problem with it. The LPN went in the resident's room with the Surveyor and looked at the wound vac machine and stated the machine was off and it was not plugged in. The LPN plugged in the wound vac, turned it on and the machine read 80 mmHg. The LPN did not check the wound vac dressing. She stated she was going to go check his orders and see what the settings were suppose to be. At 7:36 PM, LPN #33 entered the resident's room with Nursing Supervisor RN #34. RN #34 went to look at the wound vac machine and pushed buttons on the control. A certified nurse aide (CNA) and LPN #33 rolled the resident to his side to adjust the sheets underneath him. The wound vac dressing to the resident's right ischium was observed to be loose at the bottom (no suction). The resident was rolled on his back and the RN was not observed assessing the resident's dressing. The RN stated he was able to get the wound vac working. RN #34 was interviewed on 10/10/2015 at 7:40 PM, he stated he did not know how long the wound vac had been off. He stated, I was just asked to come up and fix the machine and now I have and it's running at 125 mmHg. He stated he observed the resident's wound vac dressing and it had a good seal on it. As the RN was walking back into the resident's room, he stated the wound vac would have to have some air in it to work right. The RN then observed the resident's wound vac dressing and stated, Oh, I didn't see that the seal is broken. We can reinforce that. The RN left the room to get supplies. While the RN was out of the room the wound vac machine started beeping. The screen read, warning: check dressing, low vacuum. The RN returned to the resident's room and stated he called the physician and got an order to reinforce the dressing to the wound vac. The RN applied a wound vac drape (a clear, adhesive sheet) to the dressing to reinforce it. He stated there was a good seal and then left the room. During an interview with LPN #17 on 10/10/2015 at 8 PM, she stated she worked 3 PM- 7 PM today and was responsible for the resident. She stated she gave the resident his medications around 4 PM and she had noticed the wound vac cord coming off the blanket. She stated she did not check the machine to ensure it was working, she did not hear any beeping while in the room and could not recall if I even heard it running. During an interview with the Negative Pressure Wound Therapy Representative and facility supplier on 10/14/2015 at 2 PM she stated she provided education to some of the Unit Managers in the facility and her understanding was the Unit Managers would be training their staff. She stated if a wound vac dressing was leaking or compromised for greater than 2 hours or for an unknown length of time, the dressing should be removed and a new dressing applied. She stated if the dressing was not changed it could increased the chances of the wound getting infected. 2) Resident #25 had [DIAGNOSES REDACTED]. A nursing progress note, dated 10/1/2015, documented the resident was admitted to the facility on that date and had multiple open areas to his buttocks and a small open area on his heel that measured 0.5 centimeters (cm) x 0.5 cm. There was no description of the wound bed. An admission assessment, dated 10/1/2015, did not contain any documentation regarding a pressure ulcer to the resident's left heel. A physician order, dated 10/1/2015, documented to apply an [MEDICATION NAME] (type of dressing) to the small open area on the left heel, until resident was evaluated by the skin team on 10/2/2015. A skin rounds progress note, dated 10/2/2015, documented the resident had multiple areas of breakdown to his buttocks. There was no documented evidence in the progress note the resident's left heel open area was assessed. A skin rounds progress note dated 10/9/2015 documented the resident had a Stage II pressure ulcer on the left heel that was present on admission. The pressure ulcer measured 1.2 cm x 0.4 cm x 0.1 cm and the wound bed was pink and moist. The wound care RN documented, he is wearing sneakers & would benefit from a cast shoe; would recommend treating wound with wound gel & foam dressing. The Unit Manager was to follow up with medical regarding the recommendations. During a record review on 10/9/2015 at 8 AM, there was no documented evidence the physician was notified regarding the pressure ulcer on the left heel or consulted regarding the treatment recommendations. The resident was observed on 10/9/2015 at 8:55 AM, eating breakfast, wearing non-slip socks and sneakers to both feet. At 9:10 AM, the resident was ambulating down the hallway with sneakers on his feet. At 9:15 AM, the resident was observed in his room and told the surveyor he did not have a dressing on his left heel. The resident removed his sneaker and sock. There was no dressing to the heel, and there was a pressure ulcer measuring approximately 1.5 cm in diameter with depth of 0.1 cm. The wound bed was red and moist with a small amount of yellowish drainage. During an interview with the RN Unit Manager on 10/9/2015 at 10:30 AM, she stated she did skin rounds with the wound care RN the previous day. She stated before 10/8/2015, she was not aware the resident had a pressure ulcer on his left heel. She stated she was aware of the recommendations the wound care RN made regarding interventions and treatments, and did not agree with the type of dressing she recommended. She stated she notified the physician yesterday and he was coming in today to assess the pressure ulcer. The RN Unit Manager stated she did not get an order for [REDACTED]. During an interview with the wound care RN on 10/9/2015 at 12:10 PM, she stated she was notified of resident's pressure ulcers by reviewing the admission assessments. She stated when she saw the resident initially on 10/2/2015, she was not aware he had a pressure ulcer on his left heel. She stated her first assessment of the heel was 10/8/2015 and the measurements were larger. She stated she was not aware the Unit Manager did not agree with her recommendations, as all recommendations were team decisions made during skin rounds. She stated the Unit Manager was responsible for calling the physician to obtain the treatment order, and she was not aware that the physician was not notified. The wound care RN stated the resident needed a treatment in place to the left heel pressure ulcer to prevent the area from worsening or getting infected. On 10/10/2015 at 6:17 PM and 6:30 PM, the resident was observed sitting in his room wearing non slip socks and sneakers on both feet. At 7:15 PM, the resident was observed in bed, with his sneakers off and placed next to the bed. Both of the resident's heels were resting directly on the mattress. The resident said he had worn the sneakers all day and did not recall being told by staff not to wear the sneakers. A follow up interview with the RN Unit Manager was conducted on 10/13/2015 at 10:30 AM. She stated the plan for the resident was to wear a cast shoe to both feet, not sneakers. At 10:35 AM on 10/13/2015, the resident ambulated past the Unit Managers office wearing sneakers to both feet. The resident's physician was interviewed on 10/14/2015 at 10:35 AM. He stated he was not aware the resident had a pressure ulcer to his left heel and could not recall being notified or having a discussion with the Unit Manager regarding interventions or treatments. The physician stated if he had been notified, he would have ordered what the wound care nurse recommended. 3) Resident #7 had [DIAGNOSES REDACTED]. The resident's comprehensive care plan (CCP), initiated 6/18/2014, documented the resident was at risk for skin breakdown. Preventative measures included: a Roho cushion in the wheel chair/reclining chair; protective ointment with incontinence care; maintain turn and positioning every 2 hours and adequate nutrition. The resident's 7/16/2015 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, required extensive assistance with most activities of daily living (ADLs), was 61 inches tall and weighed 81 pounds; and was at risk for pressure ulcers. On 8/11/2015 at 5:17 PM, registered nurse (RN) progress note documented staff reported an open area to the resident's buttocks. Upon assessment, there was a small open area on the sacrum which is very boney and measures 0.8 centimeters (cm) x 0.8 cm. The wound base color was unclear due to the presence of skin protectant residue. The resident was noted to be incontinent and her last weight was 73.2 pounds. The note documented the area was reported to the nurse practitioner (NP). A 8/13/2015 NP progress note documented nurses reported the sacral pressure ulcer yesterday. It is draining serous sanguineous fluid in small amount, measuring 4 cm x 2 cm, and showed no signs of infection. physician's orders [REDACTED]. The resident's CCP documented on 8/14/2015, the resident had an Unstageable (unable to see wound bed) pressure ulcer to the sacrum related to decreased bed mobility, incontinence and skin desensitized to pain/pressure. Staff were to provide the treatment per order, to keep it clean and dry, and to monitor the progress. On 8/14/2015, the dietitian made changes to the resident's meal plan that already contained fortified food and fluids. On 8/21/2015, the dietitian noted the resident weighed 76.2 pounds (up from 73.2 pounds); more food was added to her lunch meal plan. A 8/24/2015 NP progress note documented the resident had a 2 inch by 1 inch pressure ulcer over her coccyx that was treated over the week with [MEDICATION NAME]. The note specified there was no sign of redness or infection, and the site has closed up, with a small open area in the center of the wound, but granulated tissue is visible. On 8/25/2015 at 10:03 AM, RN skin round progress note documented the resident's Stage II sacrum pressure ulcer improved to 0.5 x 0.5 x 0 cm with a dry, pink, wound bed with no drainage. The treatment administration record (TAR) on 8/25, 8/28, or 8/31/2015 had no documentation the resident's pressure ulcer treatments were completed to the the sacral pressure ulcer. A 9/1/2015 at 8:49 AM, RN skin round progress note documented the resident had a Stage II pressure ulcer to the sacrum that was improved, measuring 1.2 x .5 x 0 cm with a moist, pink, wound bed with no drainage. A 9/8/2015 11:36 AM, RN skin round progress note documented the resident's Stage II pressure ulcer was now Unstageable and measured 1.8 x 0.5 x 0 cm with a moist yellow slough (dead tissue) in the wound bed, with no draining, and the periwound was healthy. A 9/9/2015 NP progress note documented the wound had been healing nicely; However, was noted just today there is an open area in the center of the wound that needs to be reassessed. A 9/10/2015 at 10:31 AM, physician order [REDACTED]. On 9/11/2015, the dietitian noted the resident's nutrient needs assessment remained appropriate; a Magic Cup (supplemental ice cream product) was added to her lunch plan. A 9/14/2015 at 12:56 PM, RN progress note documented the resident's sacrum pressure ulcer now measured 1.8 x 0.8 x 0.1 cm, the wound base was black with watery black drainage, and a new order was implemented. A 9/14/2015 NP progress note documented the pressure ulcer on her sacrum had opened back up, and there is an area of a eschar (dark, dead tissue) with some draining. A 9/14/2015 at 1:12 PM, physician order [REDACTED]. The resident's pressure ulcer treatment administration record (TAR) did not document treatments were completed to the sacral pressure ulcer on 9/14 or 9/15/2015. A 9/15/2015 at 2:09 PM, RN skin round progress note documented the resident's Unstageable pressure ulcer to sacrum was now a Stage III and measured 1.2 x 0.4 x 0.2 cm with 100% granulation, with moderate serous drainage and slight discomfort on palpation, periwound was deep purple in color to the lateral aspect 0.2 cm and may further deteriorate. The CCP, updated on 9/15/2015, documented the resident was provided with a prime air mattress (a weight distributing mattress used for pressure ulcer prevention). A 9/16/2015 at 9:23 AM, physician order [REDACTED]. A 9/20/2015 NP progress note documented the resident now has developed a sacral ulceration; was seen by the wound team; and had a change in her mattress. A 9/21/2015 NP progress note documented the resident has a running history of a coccyx pressure ulcer that at one point was almost healed. However, over the course of this last week, it has gotten progressively worse. Today, the area has a dime size opening, a little bit of purulent sloughing noted. The area had become very [DIAGNOSES REDACTED]tous (reddened) and warm to touch. A 9/22/2015 at 10:19 AM, RN skin round progress note documented the Stage III pressure ulcer was now Unstageable and measured 2.0 x 0.5 x 0 cm with 100% yellow slough with light yellow drainage. A 9/29/2015 at 10:15 AM, RN skin round progress note documented the resident's Unstageable pressure ulcer to sacrum measured 1.5 x 0.8 x 0 cm with 80% yellow slough 20% of wound was pink and granulating. On 9/29/2015, the dietitian documented the resident weighed 69.8 pounds, reflecting a 14% weight loss in 3 months. The meal plan was modified to add more nutrient dense food and fluids that were better accepted by the resident. During an observation of the resident's sacral pressure ulcer treatment on 10/8/2015 at 10:02 AM, a dressing was not in place prior to start of the treatment. LPN #24 stated when she provided the resident with a daily pressure ulcer treatment, the dressing from the previous day was not usually in place, as there was nothing to secure the dressing to the resident. When completing the pressure ulcer treatment, LPN #24 placed a 4 x 4 gauze over top of the sacral pressure ulcer, and adjusted the incontinent brief. LPN #24 stated she was not supposed to secure the gauze/dressing after it was placed over the pressure ulcer, and she had clarified this with management in the past. During an interview with licensed practical nurse (LPN) #19 on 10/8/2015 at 2:50 PM, she stated the resident had various treatments since 8/2015. During the interview, the LPN reviewed the medical record. She stated treatments were not completed for the resident's sacral pressure ulcer on 8/25, 8/28, 8/31, 9/14, or 9/15/2015, and she could not determine from the record why the treatments were not completed on those dates. During an interview with LPN #18 on 10/9/2015 at 10:35 AM, she reviewed the resident's medical record. She stated she did not know why the treatment was not completed on 8/31/2015, and did not know why she signed that it had not been administered. She stated at times treatments were not completed when there would only be one LPN assigned to the unit, as there was not time to administer all medications and treatments. She stated sometimes the dressing from the previous day would not be on the resident or present when she went to provide the scheduled treatment. During an interview with certified nurse aide (CNA) #23 on 10/9/2015 at 11 AM, she stated when she provided care to the resident, the dressing would sometimes come off. She stated that it usually happened in the afternoon, as that was when the resident routinely had a bowel movement. She stated she would have to notify the nurse to come and change the dressing. During an interview with CNA #22 on 10/9/2015 at 11:20 AM, she stated she provided care the morning of 10/7/2015. At that time, the resident's brief needed to be changed, the resident was not dry, and she could not recall if there was a dressing in place at the time she changed the brief. During an interview with RN #25 on 10/9/2015 at 2:20 PM, the resident's medical record was reviewed. She stated a pressure ulcer was found on the resident's sacrum on 8/11/2015 and it was reported to the NP. She stated an order was not put in place until 8/13/2015 when the NP ordered to cleanse the sacral area and provide a dressing. She stated the resident was not provided a pressure mattress until 8/14/2015 following the wound nurse's assessment of the pressure ulcer. She stated the record revealed treatments were not completed for the resident's sacrum on 8/25, 8/28, 8/31, as scheduled on every third day, or for daily treatments on 9/14 and 9/15/2015. RN #25 stated she was not made aware treatments were not being done. After reviewing treatment changes and records, RN #25 stated the pressure ulcer worsened from 8/2015 through 9/2015. She stated the worsening was evident in the nursing progress notes. During an interview with NP #26 on 10/13/2015 at 10:12 AM, she stated the resident was found with a pressure ulcer in 8/2015, and several changes had been made to treatments following that date. She stated on 9/9/2015 the treatment had to be changed as the resident's pressure ulcer had new slough and drainage. The resident's pressure ulcer did not improve with treatment and on 9/21/2015 the resident had sloughing and the area was more purulent drainage. NP #26 stated she was only notified one time the resident's treatment dressing needed to be replaced in the evening. She stated when the [MEDICATION NAME] dressing was in place, it was to be taped on, as it was not self-adhering. She stated she was not aware or notified treatments had not been completed in 8/2015 or 9/2015, and not providing the treatments would effect the healing process to the sacral pressure ulcer. 4) Resident #34 had [DIAGNOSES REDACTED]. A nursing note, dated 7/10/2015, documented the resident was admitted that date with soft heels. A physician order [REDACTED]. A physician progress notes [REDACTED]. There was no apparent bony tenderness. The plan included the resident would need a meticulous skin care plan. The Minimum Data Set (MDS) assessment, dated 7/17/2015, documented the resident had moderate cognitive impairment, was dependent with 2 people physical assist for most activities of daily living (ADLs) and required limited assistance with eating. The resident was frequently incontinent of urine and bowel. The resident was at risk for developing pressure ulcers and did not have any unhealed pressure ulcers at Stage I or higher, had moisture associated skin damage (MASD) and received pressure reducing devices for chair and bed, nutrition or hydration intervention, application of ointments/medication and a nonsurgical dressing. A physician order [REDACTED]. A nurses progress note dated 7/27/2015 documented the resident's feet were elevated on a pillow due to having a pressure area on her right heel. A registered nurse (RN) Wound Care progress note dated 7/27/2015, documented the right heel had a suspected deep issue injury (SDTI) measuring 4.0 centimeters (cm) x 1.5 cm. The area was intact and purple in color. Recommendations included elevation on pillows or blue booties to off load, and to apply skin prep twice daily. The comprehensive care plan (CCP) dated 7/27/2015 documented a pressure ulcer to the right heel with a goal of the ulcer showing healing process as evidenced by decreasing in size. A physician progress notes [REDACTED]. The area was difficult to measure, appeared at skin level and appeared to be more of a brown skin level type scab rather than deep tissue injury. We will need to let this evolve and declare itself. The physician documented he felt the area may resolve uneventfully. An RN Wound Care progress note dated 7/30/2015, documented the right heel was seen by surgical yesterday and presented as a brown scab and not SDTI, and measured 1.0 cm x 1.5 cm. A physician progress notes [REDACTED].

Based on record review and staff interviews completed during an abbreviated survey (Complaint #NY 056), the facility did not ensure 1 of 4 residents(Resident #1) sampled was provided the proper mattress to prevent an accident. Specifically, Resident #1 was not given a perimeter guard (concave)mattress, fell out of bed and fractured the upper left arm. This resulted in actual harm that is not immediate jeopardy. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Fall Risk assessments dated September 28, 2012 and October 29, 2012 documented the resident at a score of 14 out of 26 which is a high risk. The Minimum Data Set (MDS) dated [DATE] documented the cognitive assessment of the resident was severe impairment. The current comprehensive care plan (CCP) dated August 1, 2012 for falls/mobility documented the resident had impaired judgment, cognition, and mobility. It was documented on the CCP that the resident required a perimeter guard mattress since February 28, 2011. A review of the resident's assignment sheet for November 2012 documented the resident had a low bed and a concave mattress. Review of this documentation showed that the PDA (personal data assistant which is an electronic device where each resident's care needs/orders are documented) had this information from February 28, 2011 until the resident fell on [DATE]. The November 18, 2012 nursing progress note documented the bed alarm sounded and the resident was found lying on his left side and with a small amount of frank blood on the floor. The blood was noted coming from the left nostril. The resident was alert and able to move all extremities, pupils were equal and reactive to light, and the nasal septum appeared straight during the assessment. Multiple bruises were noted and the skin tear to the left forearm was treated. Following the fall, the resident was placed in a low bed with perimeter guard mattress and blue mats on either side. Head precautions were initiated and the physician, who was on the unit at the time, was notified. The November 19, 2012 Nurse Practitioner (NP) note documented the resident was seen in follow up to a fall documented on the 24 hour report. The NP documented the resident was sitting comfortably in his chair, was alert but not oriented, and had limited range of motion of the left arm. The resident complained of pain of his left upper arm where bruising with some swelling was noted. The NP ordered an x-ray to rule out a fracture of the upper left arm. The November 19, 2012 x-ray of the left arm completed at the facility documented that there was a minimally displaced supracondylar fracture of the distal humerus. A new order was obtained to send the resident to the hospital. The Incident Report dated November 19, 2012 documented that on November 18, 2012 at 7:55 PM, Resident #1 was found on the floor of his room, lying on the right side of the bed. His bed alarm was sounding which alerted the staff to come to the room. The resident was found with his left nostril slightly bleeding, bruises, and a skin tear. At the time, the resident was assessed and did not have any other injuries. The resident was last seen by staff at about 7:15 PM when they performed PM care and got him into bed for the night. On November 19, 2012, the resident had complaints of the left upper arm pain. An x-ray was ordered and revealed he had a fracture to his left distal humerus. During the investigation, it was discovered, the resident did not have the perimeter guard mattress as ordered by his physician. The original order for the perimeter guard mattress was dated February 28, 2011. One was ordered and placed on the bed. As a result of the information, no staff person could be identified as being the person responsible for failing to place the perimeter guard mattress on his bed. On November 29, 2012 at 1:00 PM, the Unit Manager was interviewed. She stated that the mattress was ordered in 2011 prior to when she became Unit Manager. At the time of the resident's fall out of bed on November 18, 2012 he did not have a perimeter mattress. There is no evidence the mattress was ever discontinued, but no staff members realized that the perimeter guard mattress was removed from the bed at some point. The Unit Manager stated that the whole team checks the care plan and is responsible to carry it out. She stated she wondered if with restraint reduction if someone removed the mattress, but she does not specifically recall this resident being impacted by restraint reduction efforts at the facility. On November 29, 2012 at 3:00 PM, the Assistant Director of Nursing was interviewed. She stated that the perimeter guard mattress was delivered on February 28, 2011 and she provided a voucher from the central supply documenting this. She stated she does not know what happened to the mattress. When a resident is care planned, the team reviews the written physician orders [REDACTED]. On November 29, 2012 at 4:00 PM, the Assistant Administrator was interviewed. She stated that she has been unable to determine when the perimeter guard mattress provided on February 28, 2011 was removed. Our corrective actions have been that all residents who have an MD order for a perimeter guard mattress were checked on November 19, 2012. If a resident did not have the proper mattress, we provided it immediately. The staff has also been re-educated on the need to follow the MD orders and to ensure the residents have the safety devices they are care planned for. On December 5, 2012 at noon the Assistant Administrator was interviewed again and stated that on November 19, 2012 they identified two additional residents who did not have perimeter guard mattresses, though they were care planned for them. The resident's primary aide was interviewed on December 4, 2012 at 11:00 AM. She stated the resident has not had a perimeter guard mattress for a year. She stated that she never noticed the resident had a concave mattress ordered on the PDA (personal data assistant which is an electronic device where each resident's care needs/orders documented). The Director of Central Supply was interviewed on December 4, 2012 at 1:00 PM. He stated that he had not finished going through all of the orders, but he had not identified an order to remove the resident's perimeter guard mattress which was delivered on February 28, 2011. In summary, the facility failed to supply a perimeter guard mattress for the resident and the resident sustained [REDACTED]. NYCRR 415.12 (h)(1)(2)

Based on observations, record reviews, resident and staff interviews, and a review of facility policies and procedures conducted during the partially extended abbreviated surveys (NY 767 and NY 145), it was determined for 2 residents (Residents #1 and 3) reviewed for alleged violations involving mistreatment or abuse, and for 12 residents reviewed for adequate supervision and assistance devices to prevent accidents related to falls (Residents #2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, and 14), that the facility's administration (including Administrators and the Director of Nurses) failed to administer the facility in a manner that protected the health and safety of its residents, in accordance with accepted professional standards. Specifically, the facility failed to have a system in place to: - report all alleged violations involving mistreatment or abuse to the New York State Department of Health (NYSDOH); - ensure all alleged violations were thoroughly investigated; - ensure interventions were implemented to prevent further injuries; - provide adequate supervision and assistance devices to prevent accidents related to falls; - determine an accurate root cause analysis of the cause of each fall; - develop and implement a care plan to supervise the residents, and replace inadequate interventions with effective interventions; - communicate the interventions to direct care staff; and - ensure that care-planned safety devices were consistently utilized and functional. This resulted in Immediate Jeopardy, Substandard Quality of Care, and actual harm to the health and safety of Residents #1, 2, 3, 7, 8, 9, 13, and 14, and the potential for serious harm that is Immediate Jeopardy to the health and safety of Residents #4, 5, 10, 11, and 12, and all facility residents at risk for falls. Refer to F225 and F323. Findings include: ********************************************************************* The Immediate Jeopardy situation was removed on October 5, 2011, based on the following corrective actions taken by the facility: - identification of all residents with a history of falls and/or at high risk for falls, and revision of their Fall Risk care plans; - revision of the facility Fall Policy to include re-evaluation of resident risk to fall after each fall; - implementation of a plan to train registered nurse (RN) staff to review and revise residents' Fall Risk Assessments, Fall Risk care plans, and initiate appropriate interventions; - inservices to all staff regarding the new policies and procedures; - development of a procedure to assess residents' need for bed/chair alarms, and to monitor the alarms for utilization and functioning; - administrative review of all falls within the previous 24 hours; - rehabilitation department screening of each resident after a fall; and - staff monitoring to ensure compliance with the new policies and procedures. ******************************************************************** The Administrator was interviewed at 2:30 PM on September 27, 2011. She stated: - the facility has no Falls Committee. The interdisciplinary team (IDT) meets daily regarding falls, and reports the results to the Assistant Director of Nursing (ADON) of each unit. Each ADON is responsible for 4 units. - IDTs are comprised of the unit Head Nurse, social worker, activities and nutrition staff, and sometimes physical therapy or occupational therapy staff. Two Assistant Administrators recently began attending IDT meetings and reporting to the Administrator regarding resident falls. - Except for a log of resident falls on each unit, the facility does not evaluate trends of resident falls. - During the past year, the facility completed no quality assurance audits regarding resident falls, and has no audit tool. - She was unaware of any specific residents with history of multiple falls and ineffective interventions to prevent repeated falls. The Director of Nursing was interviewed at 2:45 PM on September 27, 2011. She stated: - The results of IDT meetings regarding resident falls are not documented. The results are discussed with the 2 Assistant Administrators. Suggested interventions are given to the Assistant Administrators. - The facility does not identify units that have more resident falls than other units. - The facility does not have records of staff training regarding fall prevention. - The facility has no audits regarding staff completion of Incident/Accident reports. During an interview with the Administrator and an Assistant Administrator at 4:00 PM on September 27, 2011, the Administrator stated the facility had no Falls Committee, and no Falls Manual. She stated the facility's current Fall Policy was the one that was provided to surveyors during survey. She stated that resident falls were reviewed by the interdisciplinary teams on each of the 9 units. In summary, the administration failed to administer the facility in a manner that protected the health and safety of its residents, in accordance with accepted professional standards regarding supervision and assistance devices to prevent accidents related to falls; and failed to thoroughly investigate alleged violations involving mistreatment or abuse and report them to the NYSDOH; 10NYCRR 415.26(a)

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during the partially extended abbreviated survey (Complaint #NY 767), it was determined for 12 sampled residents (Residents #2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, and 14), that the facility failed to look at the root cause of resident falls and to evaluate the effectiveness of interventions instituted to prevent future accidents (falls). Specifically, for Residents #2, 11, and 13, the facility failed to: - develop and implement a care plan to supervise the residents, and replace inadequate interventions with effective interventions; - communicate the interventions to direct care staff; and - ensure that care-planned safety devices were consistently utilized and functional. Resident #2 subsequently expired due to a fall with fractured hip after 10 falls; Resident #13 sustained a head injury after 17 falls; and Resident #11 sustained multiple bruises and skin tears related to 15 falls. Additional residents for whom the facility did not provide timely, effective interventions to prevent falls include: - Resident #3 sustained a fall with injury, and care-planned interventions were not communicated to direct care staff; - Resident #4 fell 9 times since [DATE], and staff did not address the contributing factors of the resident's behaviors and psychotropic medications; - Resident #5 fell out of bed in [DATE]; - Resident #7 had multiple falls, including a fall with injury; - Resident #8 had a history of [REDACTED]. - Resident #9 had a fall with injury when a care-planned safety device did not function; - Resident #10 fell from a wheelchair in [DATE]; - Resident #12 had a fall with injury in [DATE], and had persistent symptoms of unsteady gait after the fall; and - Resident #14 fell 6 times since February 12, 2011, including a fall with injury. This resulted in Immediate Jeopardy, Substandard Quality of Care, and actual harm to the health and safety of Residents #2, 3, 7, 8, 9, 11, 13, and 14, and the potential for serious harm that is Immediate Jeopardy to the health and safety for Residents #4, 5, 10, and 12, and all facility residents at risk for falls. Findings include: ********************************************************************* The Immediate Jeopardy situation was removed on [DATE], based on the following corrective actions taken by the facility: - identification of all residents with a history of falls and/or at high risk for falls, and revision of their Fall Risk care plans; - revision of the facility Fall Policy to include re-evaluation of resident risk to fall after each fall; - implementation of a plan to train registered nurse (RN) staff to review and revise residents' Fall Risk Assessments, Fall Risk care plans, and initiate appropriate interventions; - inservices to all staff regarding the new policies and procedures; - development of a procedure to assess residents' need for bed/chair alarms, and to monitor the alarms for utilization and functioning; - administrative review of all falls within the previous 24 hours; - rehabilitation department screening of each resident after a fall; and - staff monitoring to ensure compliance with the new policies and procedures. ******************************************************************** The facility policy and procedure for "Reporting and Monitoring of Accidents /Incidents," revised [DATE], documents: - "Neglect" is "failure to care for the resident in a manner that would avoid harm or injury, or failure to react to a situation that may be harmful;" and - the Incident Review Committee will convene "at least weekly and as necessary" to review incidents, including those related to neglect." The facility policy, "Fall Management Program," revised [DATE], documents: - "When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again;" and - "All reported falls will be reviewed daily during incident rounds, with the objective to "discuss root cause and evaluate the potential comprehensive care plan approaches." 1) Resident #2 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) initiated the resident's problem of "Mobility/Falls" on [DATE]. Interventions through February 17, 2011, included transfers with minimum assist of 1 person; ambulation with hand assist of 1 person; bed and chair alarms; ambulation program; private room across from nurses' station for close supervision; do not allow to be in room unattended; utilize stop sign; toileting schedule; psychiatry follow-up PRN (as needed); hip protectors (padded devices) at all times; and skilled physical therapy 5 times/week (documented on February 17, 2011). Nurses' notes documented the resident had an unwitnessed fall from a chair on February 28, 2011 at 6:17 PM. The related incident report documented the resident's chair alarm was not attached to her, "but she knows how to unhook it." Nurses' notes documented the resident had an unwitnessed fall on [DATE] at 6:30 AM. The related incident report, signed by the unit Assistant Director of Nursing (ADON) on [DATE], documented the resident removed her chair alarm, and it did not sound. Nurses' notes documented the resident had an unwitnessed fall in the hallway on [DATE] at 1:30 AM. The related incident report documented staff observed the resident ambulating independently in the hallways all night prior to being found on the floor. The report, signed by the unit ADON on [DATE], documented the resident was not safe to ambulate independently, and required hand held assistance at all times. Nurses' notes, dated [DATE], documented an unwitnessed resident fall that evening. The related incident report documented that at 7:30 PM that day, a licensed practical nurse (LPN) heard a "loud noise, then a chair alarm." The resident was found sitting on the floor in her room, between her bed and wheelchair. The related incident report documented the root cause analysis of the incident was "Impaired safety awareness." Nurses' notes, dated [DATE] at 10:37 PM, documented the resident was found lying on the floor on her left side, by housekeeping staff when they got off the elevator. The related incident report documented the resident was seen walking in the hallway unassisted that evening, and the chair alarm did not sound at that time. The root cause analysis of the incident was "Impaired safety awareness." The most recent Fall Risk Assessment, dated [DATE], documented the resident had multiple fall risk factors, including age of 80 or greater; altered mental status; attempts to get out of bed or chair unsafely; previous falls in the past 6 months related to medical factors; impaired mobility; generalized weakness; alterations in elimination; factors related to medications; and additional characteristics that increase fall risk, such as postural instability and "does not call for help." Nurses' notes, dated [DATE] at 9:46 PM, documented the resident was found on the floor in her room, attempting to get up by herself. The related incident report documented the care-planned stop sign was not in place at the time of the fall; staff heard the chair alarm, and found the resident lying on the floor in front of her wheelchair. The root cause analysis of the incident was "Impaired safety awareness." Nurses' notes, dated [DATE] at 8:45 PM, documented the resident was found lying on the floor in front of her wheelchair across from the nurses' station, with her head against the entertainment center. The related incident report documented staff heard the resident's chair alarm, and "at the same time heard a boom." The report documented the resident was non-compliant; got out of her chair frequently; and attempted to ambulate. The root cause analysis of the fall was "poor safety awareness." The plan was to order a scoot chair (low, wheeled chair that prevents rising). Nurses' notes, dated [DATE] at 10:16 PM, documented the resident was "continuously standing and transferring unsafely from scoot chair. Chair alarm did not remind resident to sit down." Subsequent nurses' notes between [DATE] and [DATE], documented the resident continued to stand up from her chair and attempt to ambulate unassisted on 17 of 42 days. physician's orders [REDACTED]. Nurses' notes between [DATE] and 13, 2011 continued to document the resident's persistent attempts to stand up from her scoot chair. On [DATE] at 8:05 AM, a nurses' note documented the resident was found sitting in dried feces in front of the bathroom door in her room. The accompanying incident report documented the resident had a reddened area on her left outer calf; the resident's hip protectors were not on; the bed alarm did not sound; and the bed alarm's sensor mat was unplugged. The incident report documented the CNA (certified nurse aide) PDA (electronic device containing resident care instructions) did not include the hip protectors. The root cause analysis of the incident, as determined by the interdisciplinary team (IDT), was "Ongoing behavior modification; attends BCU (Behavioral Care Unit) daily; restless." The Resident Nursing Instructions, used by CNAs to provide care, were last revised on [DATE], to include the following safety precautions related to the resident's risk for falls: bed and chair alarms; sensor pad on chairs; Wanderguard (electronic device used to prevent elopement); hip protectors on at all times; and observation every 2 hours. The CCP documented an intervention, dated [DATE], for staff to check the resident's bed and chair alarms at the start of each shift to ensure they were plugged in and operational. Nurses' notes, dated [DATE] and 18, 2011, documented the resident frequently got out of her scoot chair and attempted to ambulate independently. A physician's note, dated [DATE], documented the resident was restless in her chair and at high risk for falls, and her most recent fall was on [DATE]. She received 5 psychoactive medications per suggestion of psychiatric consultants, and was not lethargic. The plan was to continue the psychoactive medications and continue to watch for falls A nurses' note, dated [DATE] at 8:30 AM, documented the resident was found lying on her right side in the hallway, and a 1 centimeter (cm) x 1 cm ecchymotic (bruise) area was noted on her right hip. The related incident report, initiated by an RN shift supervisor on [DATE], documented the resident's scoot chair was ,[DATE] feet away from her when she was found on the floor, and her chair alarm was not sounding. The IDT determined the root cause of the fall was "agitation - trying to stand." The Summary/Analysis of the incident, signed on [DATE] by the unit ADON, documented unit staff was unable to manage the resident's constant standing. The report documented the fall event was not referred to the Incident review Committee. The CCP did not contain revised interventions after the resident's fall on [DATE]. A nurses' note, dated [DATE] at 7:07 AM, documented the resident was found on the floor, repeatedly crying out, "Oh my legs." The resident was sent to the hospital following the fall. The related incident report, initiated by the RN shift supervisor on [DATE], documented that a contributing factor to the resident's fall was improper positioning of the chair alarm in the resident's scoot chair. The root cause of the fall, as determined by the IDT, was "constant agitation; wanting to stand and move; attempting to be independent, but unsafe secondary to unsteady gait, closes eyes, poor balance, impulsive." The fall event was not referred to the Incident Review Committee. The discharge Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had moderate cognitive impairment; short and long term memory deficits; signs and symptoms of delirium including fluctuating altered levels of consciousness; behaviors of hallucinating and being short-tempered or easily annoyed; required extensive assistance of 2 or more persons for most activities of daily living, including transfer and ambulation; was unsteady, and only able to stabilize with human assistance during transitions and walking; used no mobility devices; had 2 or more falls without injury, and 1 fall with injury since the prior MDS assessment; and utilized a chair that prevents rising daily. The hospital history and physical examination tries to walk, at which time she falls." The report documented the resident sustained [REDACTED]. Review of hospital physicians' notes revealed the resident's family decided against surgical repair of the resident's hip fracture, and she expired on [DATE]. The resident's autopsy report, dated [DATE], documented: - review of the resident's medical records revealed she could not ambulate alone and used a scoot chair to move around. She "constantly tried to get out of it, forgetting she could not walk without help, and then would fall. During the first half of 2011 alone, she had fallen 11 times." - the resident was in pain from the hip fracture and was placed on comfort care with morphine for pain. Her condition deteriorated until she expired on the fourth hospital day. - the medical examiner's opinion was that the resident's death was "due to complications of a right hip fracture due to a fall." At 10:05 AM on [DATE], a surveyor interviewed a staff RN/ supervisor regarding the resident's pattern of falls, and interventions to prevent falls. He stated he did not know if any restraint device was utilized, other than the scoot chair; the resident sometimes had 1:1 observation; and the resident never had a low bed. A surveyor interviewed the resident's physician via telephone at 3:30 PM on [DATE]. He said he was unsure of the types of interventions staff used to prevent the resident's repeated falls. When asked what staff might have done to prevent the falls, he stated, "These are difficult problems with a resident who is combative - possibly occupational therapy evaluation and pain assessment." A surveyor interviewed the Director of Rehabilitation Services at 3:30 PM on [DATE]. She stated she was involved in care planning related to resident issues such as restraints, falls, and appropriate seating, only for residents who were actively receiving physical or occupational therapy. She stated she would have expected to be consulted regarding interventions for the resident's repeated falls, and needed a physician's orders [REDACTED]. In summary, Resident #2 experienced harm and subsequent death related to a fractured hip when the facility failed to protect her health and safety related to repeated falls as: - the IDT failed to determine an accurate root cause analysis of the cause of each fall; - as the resident continued to fall, the IDT failed to assure a care plan was developed and implemented to supervise the resident consistently, eliminate inadequate interventions, and replace them with effective interventions; and - staff failed to ensure the care-planned safety devices were consistently utilized and functional. 2) Resident #13 was initially admitted on [DATE], and readmitted from the hospital on [DATE] after a fall at home. The resident had [DIAGNOSES REDACTED]. An incident report, dated February 14, 2011, documented staff heard a noise in the resident's room and her chair alarm sounding, then found the resident on the floor at her closet door at 12:00 PM. The RN physical assessment documented 2 abrasions near the resident's spine. The report documented that at the time of the fall, the resident was not wearing her hip protectors (padded devices) as care planned. Nurses' notes, written at 9:40 PM on February 15, 2011, documented the resident continued to "transfer herself from her wheelchair to the recliner, stands up and tries to walk," and became angry when "staff tells her to sit back down." Nurses' notes, dated February 17, 2011 at 1:27 PM, documented the resident had a Velcro belt (trunk restraint) in her wheelchair "and was able to unfasten it. She was found standing up in her room closet trying to pack her clothes, got in the elevator, and tried to push the buttons." A nurses' note, dated February 17, 2011 at 2:46 PM, documented the "resident's Velcro belt was unsuccessful and so was switched to a scoot chair (low, wheeled chair that prevents rising)." Later that day, at 9:32 PM, a nurses' note documented the resident was able to climb out of her scoot chair. A nurses' note, dated February 21, 2011, documented the resident was discharged to her home. A nurses' note, dated [DATE], documented the resident was readmitted that day, and was at high risk to fall. Bed and chair alarms were ordered. The quarterly Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had severe cognitive impairment; required limited assistance for bed mobility and transfer; did not walk in her room or the corridor; required extensive assistance for locomotion on and off the unit and for toileting; was unsteady, and only able to stabilize with human assistance for moving from a seated to a standing position, moving on and off the toilet, and for surface to surface transfer; utilized a wheelchair for mobility; was frequently incontinent of urine; had 2 or more falls without injury since the prior assessment; and utilized a chair that prevents rising as a physical restraint. A nurses' note, dated [DATE] at 6:20 PM, documented the resident was found on the floor in the hallway after staff heard her chair alarm. The related incident report documented the resident's fall was unobserved because staff were in the dining room with other residents at the time. The resident was leaning over in her wheelchair attempting to open a file cabinet drawer and fell out of the chair. The root cause analysis documented contributing factors of "confusion, dementia with delusions, impaired safety awareness." A nurses' note, dated [DATE] at 7:12 PM, documented the resident was "witnessed to slide out of her wheelchair and onto her buttocks. An intervention was to place Dycem (anti-slip material) in her wheelchair to "reduce incidents of sliding." A nurses' note written later that day, at 9:37 PM, documented the resident "continued to try to slide out of wheelchair after Dycem was put in wheelchair." The comprehensive care plan (CCP), dated [DATE]. 2011, documented the resident was "at risk for falls related to impaired safety awareness and judgement due to dementia with impaired mobility; resident can propel own chair; resident attempts to stand unsafely, even from scoot chair; propels scoot chair out of visibility quickly." The CCP documented the resident had a history of [REDACTED]. Interventions included a chair alarm with a sensor pad and Dycem in her wheelchair. A nurses' note, written at 8:00 AM on [DATE], documented the resident was found sitting on her buttocks next to her bed. The RN assessment documented the resident had bruising, and did not specify the location/description. The related incident report documented the root cause of the event was "Poor safety awareness." A nurses' note, dated [DATE], documented that at 5:40 PM, the resident was found on the floor in her room next to her wheelchair after an unwitnessed fall. The accompanying incident report documented the resident stated she slid out of the wheelchair, and the resident was not wearing hip protectors. The root cause analysis of the incident was "(the resident) slid out of chair." A nurses' note, dated [DATE] at 9:49 PM, documented the resident had an unwitnessed fall in her room while attempting to get herself into bed. The resident's roommate called for help "via her call bell as the chair alarm was sounding." The related incident report documented factors contributing to the fall were fatigue, desire to go to bed, independence, and confusion. A nurses' note, dated [DATE] at 3:16 PM, documented a certified nurse aide (CNA) witnessed the resident "easing herself from her wheelchair" onto the floor in the hallway. The related incident report documented the resident had stood up and "grabbed the hallway hand rail and stood up;" and the resident had a pattern of "numerous falls, all standing up." A nurses' note, dated [DATE], documented the resident had an unwitnessed fall in her room at 7:00 PM, and was found kneeling on the floor after her chair alarm sounded. The related incident report documented the resident was out of her scoot chair at the time of the fall. The Summary/Analysis the incident, signed by the unit ADON on [DATE]. 2011, documented the resident self-propelled and was quick to go to her room and attempt to stand. A nurses' note, dated [DATE], documented the resident had an unwitnessed fall in her room at 2:30 PM. The resident was found sitting on her buttocks on a floor mat next to her bed, with her wheelchair "close by." The related incident report documented the resident's bed alarm was broken, and she was not wearing hip protectors. The report did not clearly document if the resident had fallen from her bed or from the wheelchair. The root cause analysis was " (the resident) falls out of bed - restless." Nurses' notes on [DATE] and 10, 2011, documented the resident attempted to get out of her wheelchair and walk multiple times. An RN note, dated [DATE], documented the resident had an unwitnessed fall in her room, and the resident stated she was trying to get her clothes and leave to go home. The note documented the resident had "three large bruises on her back already (origin of bruises not documented) and no signs of any new bruises at this time." The related incident report documented the resident was anxious and agitated, repeatedly attempting to go into her room to get out of her wheelchair unassisted; she was sitting in a scoot chair at the time of the fall, which occurred at 4:45 PM that day; the chair alarm was covered with a pad, causing it not to sound when she fell ; use of hip protectors was not documented; and she was given Xanax (anti-anxiety medication) 0.25 mg after the fall, at 5:00 PM. The root cause analysis was "disoriented to surroundings; poor safety awareness." Nurses' notes, dated [DATE], documented that at 2:00 PM, the resident was found sitting on her buttocks on the floor beside her bed "rummaging through her suitcase." The resident was placed back in her scoot chair after the fall. The related incident report documented the resident was not wearing hip protectors, and staff were informed by the resident's roommate that she was on the floor packing her suitcase. The report documented the resident had a chair alarm, and did not document if the alarm was functioning properly. The root cause analysis was "disorientation and poor safety awareness." A nurses' note, written by an RN on [DATE] at 1:49 PM, documented that as the RN was passing the resident's room, she heard a "clunk" and saw the resident lying on the floor on her right side, with her right arm under and slightly behind her body. The resident stated she "bumped her head a little." The related incident report documented there was no chair alarm on the resident's wheelchair, and there was an alarm on her scoot chair. The Summary/Analysis of the incident, signed by the unit ADON on [DATE], documented the resident should not be in her room unassisted when not in bed; she utilized a wheelchair in the morning and was transferred to the scoot chair after lunch and rounds in the afternoon; both chairs should have alarms on them; the facility would not authorize use of 2 chair alarms; and staff must move the alarm from one chair to the other. The root cause analysis was "Bladder urgency." A nurses' note, dated [DATE], documented the resident had an unwitnessed fall from her scoot chair near the doorway to her room at 5:20 PM. The related incident report documented the root cause analysis was "old obsessive behavior of transferring self. Independent mobility in scoot chair." Review of the Resident Nursing Instructions between [DATE] and [DATE], revealed no instructions regarding the resident's scoot chair; did not document staff's need to monitor the resident's behavior of unsafe self-transfers from her wheelchair/scoot chair; did not specify the resident's chair alarm was to be transferred between the wheelchair and scoot chair; did not document the resident's behaviors of repeatedly packing her clothing to go home; and did not include instructions to observe the resident to prevent falls except for an [DATE] update for the resident to remain out of her room and within staff view between 3:00 PM and 8:00 PM. A nurses' note, dated [DATE] at 3:50 PM, documented the resident had an unwitnessed fall while attempting to get out of her chair. The related incident report documented that when staff found the resident in front of the nurses' station, her scoot chair alarm was sounding, and she was crawling on her hands and knees trying to pull herself up with the scoot chair. "The resident stated that she got up out of her chair and fell backwards on her bottom and hit her right elbow." The root cause analysis was "Brakes were locked on scoot chair, has ability to get out of scoot chair with impaired judgment." A nurses' note, dated [DATE], documented the resident was found in her room sitting on the floor at the foot of her bed in front of her manual wheelchair at 8:40 AM. "She said she slid out of the chair trying to pack up a few things to go pay her bills." The root cause of the fall was that the resident was independent with mobility in her wheelchair; was toileted within the hour; and had her "usual behavior of wanting to pack stuff." A nurses' note, dated [DATE] at 1:30 PM, documented the resident had an unwitnessed fall from her scoot chair in her room. The related incident report documented the resident's "usual behavior" as a contributing factor to the fall; the resident was not wearing hip protectors; and the portions of the fall investigation related to the possibility of head injury and factors related to a fall from a chair were not completed. The root cause analysis was "Usual behaviors."The Summary/Analysis of the incident, completed/not dated by the unit ADON, documented the resident had multiple falls; attempted to frequently get out of bed and out of her chair; and utilized a scoot chair or wheelchair. A nurses' note, written by the RN Unit Manager on [DATE], documented the resident had an unwitnessed fall in her room at 1:50 PM. A CNA entered the room after hearing the resident's chair alarm, and found her on the floor at the foot of her bed packing to go home. The RN documented the resident sustained [REDACTED]. After notification of the physician, the resident was sent to the hospital. Later that day, at 7:28 PM, a nurses' note documented the resident returned from the hospital with 2 staples closing the laceration on her right temple. The note documented the resident told staff she "fell on the floor, and let me tell you, it is hard." The related incident report documented the resident had "fallen 15 times related to packing clothing and going home." The IDT root cause analysis of the fall was, "Resident gets very restless after lunch, attempting to pack her clothes, transfer herself, and looking to 'go home'." Review of the 17 incident reports related to the resident's falls between February 14, 2011 and [DATE], revealed that none of them were referred to the facility Incident review Committee. Review of the Resident Nursing Instructions, dated [DATE], revealed the resident was to be observed every 2 hours, rather than every hour per the CCP. During an interview with an RN staff nurse/supervisor on the resident's unit on [DATE] at 10:05 AM, he identified the resident with a history of frequent falls. He stated she had not fallen since she was provided with a lap buddy (trunk restraint) after her fall on [DATE]. A surveyor interviewed the resident's physician via telephone on [DATE]. He stated he was aware the resident had a history of [REDACTED]. After reviewing with him the circumstances of the resident's falls, he stated he would have expected staff to notify him about the repeated falls, and that physical therapy staff should be involved in assessing the resident for interventions to prevent falls. In summary, Resident #13 experienced harm and sustained a head injury when the facility failed to protect her health and safety related to repeated falls as: - the IDT failed to determine an accurate root cause analysis of the cause of each fall; - as the resident continued to fall, the IDT failed to assure a care plan was developed and implemented to supervise the resident consistently; eliminate inadequate interventions; and replace them with effective interventions; - care-planned interventions were not consistently and accurately communicated to direct care staff; and - staff failed to ensure the care-planned safety devices were consistently utilized and functional. 3) Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the comprehensive care plan (CCP) initiated the resident's problem of mobility/risk for falls related to pain; lack of safety awareness; unsteadiness; intermittent lethargy and agitated episodes; keeps eyes closed at times; and "resident continuously attempting to stand unsafely from chair or attempts to get out of bed." Interventions included bed and chair alarms, and transfers to be done with minimum assistance of 1 staff person. A nurses' note, dated February 19, 2011, documented that at 7:35 AM, staff found the resident in another resident's room on the bathroom floor, with her head near the door frame. The resident stated she hit her head; was drowsy and moaned; and was found to have redness on her right elbow and bruising on her left thigh. The related incident report did not document whether the resident's chair /bed alarm was present and sounded, nor whether the resident fell from her chair or was ambulating independently at the time of the fall. The root cause analysis on the Fall Assessment Report was blank. The cause of the event was identified by the unit Assistant Director of Nursing (ADON) on [DATE], as a "fall responding to bowel urgency." A physician's note, dated [DATE], documented the resident ambulated with a walker and had a history of [REDACTED]." A nurses' note, dated [DATE], documented that at 9:30 AM, the resident was found on the floor in her bathroom. The resident stated she "blacked out" and hit her head. The related incident report documented the resident stated she "turned over multiple times;" and a chair alarm was not in the resident's chair at the time of the fall because the alarm was previously broken and not replaced. On [DATE], the RN supervisor documented the resident should not have been left in her room without a chair alarm. A nurses' note, dated [DATE] at 3:13 PM, documented the

Based on observations, record review, staff interviews, and a review of facility policies and procedures conducted during the partially extended abbreviated survey (Complaint NY 145), it was determined for 2 residents (Residents #1 and 3), that the facility did not ensure all alleged violations involving mistreatment or abuse were reported to the New York State Department of Health (NYSDOH); did not ensure all alleged violations were thoroughly investigated; and did not ensure interventions were implemented to prevent further injuries. Specifically, Resident #1 sustained 2 fractures of her right leg, and subsequently died , as the facility failed to: - communicate to direct care staff the correct method of bathing the resident; - ensure staff consistently transferred the resident according to plan; - provide a timely, accurate assessment after the injury; - ensure timely physician notification after the injury; - conduct a thorough investigation to determine the cause of the injury and implement measures to prevent recurrent injuries; and - report the injury to the NYSDOH as required. Resident #3 sustained a [MEDICAL CONDITION] as the facility failed to: - conduct a thorough investigation of the cause of a significant injury; - implement appropriate measures to prevent recurrent injuries; - ensure direct care staff consistently used care planned medical devices; and - report the injury to the NYSDOH as required. This resulted in Immediate Jeopardy, Substandard Quality of Care, and actual harm to the health and safety of Residents #1 and 3. Findings include: ********************************************************************* The Immediate Jeopardy situation was removed on [DATE], based on the following corrective actions taken by the facility: - identification of all residents with a history of falls and/or at high risk for falls, and revision of their Fall Risk care plans; - revision of the facility Fall Policy to include re-evaluation of resident risk to fall after each fall; - implementation of a plan to train registered nurse (RN) staff to review and revise residents' Fall Risk Assessments, Fall Risk care plans, and initiate appropriate interventions; - inservices to all staff regarding the new policies and procedures; - development of a procedure to assess residents' need for bed/chair alarms, and to monitor the alarms for utilization and functioning; - administrative review of all falls within the previous 24 hours; - rehabilitation department screening of each resident after a fall; and - staff monitoring to ensure compliance with the new policies and procedures. ******************************************************************** The facility policy and procedure for "Reporting and Monitoring of Accidents /Incidents," revised [DATE], documents: - the facility will maintain compliance with State and Federal regulations regarding abuse prevention and reporting requirements; - "Neglect" is "failure to care for the resident in a manner that would avoid harm or injury, or failure to react to a situation that may be harmful;" and - the Incident Review Committee will convene "at least weekly and as necessary" to review incidents, including those related to neglect." 1) Resident #1 had [DIAGNOSES REDACTED]. On [DATE] and 15, 2009, the comprehensive care plan (CCP)documented the resident's problems of impaired cognitive function, hallucinations, and paranoia. The most recent intervention for both problems, dated [DATE], documented the resident was to be provided a "bed bath only on shower days, as showers significantly increase agitation." On [DATE], the CCP documented the resident's mobility problem, with gait disturbance related to strength/balance deficit, [MEDICAL CONDITION], and history of falls. Interventions, last updated on [DATE], included hip protectors (padded devices) at all times, and transfer with mechanical lift and assistance of 2 persons. Resident Nursing Instructions, dated February 9, 2011, used by certified nurse aides (CNAs) to provide care, documented the resident was to be transferred with a mechanical lift, assisted by 2 persons. On [DATE], the Resident Nursing Instructions documented the resident was to be provided a bed bath on Wednesdays. The Fall Risk Assessment, dated [DATE], documented the resident was at risk to fall related to risk factors including age 80 or greater; altered mental status; generalized weakness; alterations in elimination; medications that increased fall risk; and additional characteristics that increased fall risk, such as impaired vision, and "does not call for help." The quarterly Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had severe cognitive impairment; physical behavior symptoms directed toward others; rejected care; required extensive assistance of 2 or more persons for all activities of daily living; including bed mobility and transfer; was non-ambulatory; and was totally dependent upon staff for bathing. A nurses' note, dated [DATE] at 1:57 PM, documented that during transfer from a shower chair to bed by a licensed practical nurse (LPN #1), the "resident would not let go of the shower chair, and that, combined with her weight, caused the LPN to have to lower her to the floor to keep her from falling." The resident was observed "lying on her right side on the floor next to her bed," and had "no apparent injuries." The incident report, dated [DATE], documented the resident fell at 12:15 PM that day while being transferred from a shower chair to bed by LPN #1. The resident's description of the event was, "She was trying to get me up and my legs were sticking straight out." The section of the report regarding family notification of the incident was blank. The report documented the care plan was not followed, as the "resident was transferred back to bed with one assist. She is a mechanical lift with 2 assist." The report documented the root cause of the incident, as determined by the IDT (interdisciplinary team), was that the LPN showering the resident did not verify the resident's transfer status before transferring her back to bed; modification to the resident's care plan was "N/A" (not applicable), and there was no "reason to suspect abuse/neglect/mistreatment." The Summary/Analysis of the incident, signed by the unit Assistant Director of Nursing (ADON) on [DATE], documented that LPN #1 was counseled "on proper transfer of elders per CCP and transfer evaluation," and the incident was not referred to the Incident Review Committee. A nurses' note, dated [DATE] at 12:17 PM, documented the resident was given Tylenol (mild [MEDICATION NAME]) 650 mg for right knee pain. A nurses' note, written by registered nurse (RN #1) charge nurse on [DATE] at 12:30 PM, documented that when the resident had morning care that day, staff noticed the resident had a "swollen right knee and a bruise on her left shoulder." The bruise appeared to be old, with "yellow edges" and measured 3 cm (centimeters) in diameter. The resident's "right knee was assessed, and the resident stated 'ouch' when range of motion was checked, and stated the pain was 4 out of 10." The note documented the nursing supervisor would notify the physician. Nurses' notes between [DATE] and 12, 2011, documented: - [DATE] at 11:22 PM - the resident's right knee continued to remain swollen and was tender to touch; - [DATE] at 6:13 AM - the right knee continued to be swollen; - [DATE] at 10:16 AM - Tylenol 650 mg was given for right knee pain at level 5; - [DATE] at 9:16 PM - the right knee remained swollen; - [DATE] at 10:50 AM - the nurse practitioner (NP) evaluated the resident for right knee pain, ordered an x-ray, and prescribed [MEDICATION NAME] ([MEDICATION NAME] for moderate pain) 50 mg; - [DATE] at 2:00 PM - the physician was notified the resident had a large bruise on her left shoulder; - [DATE] at 8:28 PM - the facility received a verbal x-ray report, with the results of an "acute, impacted (wedged, pressed closely together), angulated [MEDICAL CONDITION] femur (long thigh bone attached to the knee). The note documented the resident yelled in pain with any manipulation. The physician was notified, and the resident was sent to the hospital. The facility investigation of the resident's fall on [DATE], documented: - LPN #1 and CNA #1 transferred the resident to a shower chair for a shower that day; - the method transfer to the shower chair was not documented; - after the shower, LPN #1 attempted to transfer the resident from the shower chair to her bed by lifting her under both arms; and - the NP documented that when she assessed the resident on [DATE], she had severe pain when range of motion was done on her right knee. The hospital emergency department record (dictated [DATE]) documented the resident had a left shoulder contusion; fracture, dislocation, and impaction of her distal femur; and would be admitted to the hospital. The hospital history and physical examination [REDACTED]. In addition to the distal right femur fracture, the resident was diagnosed with [REDACTED]. The orthopedic physician's hospital admission note, dictated on [DATE], documented that surgical repair of the resident's fractured femur and tibia was not recommended due to her high risk for surgical complications, including death. Immobilization of the resident's right leg was implemented. The hospital physician wrote an order at 7:50 PM on [DATE], for the resident to be on comfort care. Hospital nurses' notes, dated [DATE], documented the resident was found to be deceased at 10:00 AM that day. A surveyor interviewed LPN #1 at 1:15 PM on [DATE]. She stated that on [DATE], the day of the resident's fall from the shower chair, she did not refer to the PDA (electronic device used by CNAs to provide care) to determine the resident's transfer instructions. She stated a CNA gave her written instructions for the resident's care, which did not include the method of transfer. LPN #1 stated that after she showered the resident, she put the shower chair next to the resident's bed and lifted her out of the chair. The resident held onto the chair, and LPN #1 lowered her to the floor after she was unable to lift the resident back into the chair. At 12:00 PM on [DATE], a surveyor interviewed RN #1, who assessed the resident following her fall on [DATE]. She stated the assessment was done with the head nurse (RN #2), and the resident was difficult to assess due to her contractures (loss of joint motion caused by chronic muscle shortening). Range of motion of the resident's legs was performed, and the resident refused further assessment. The resident said, "No more. No More." At 12:30 PM on [DATE], a surveyor interviewed RN #2. She stated she performed range of motion on all the resident's extremities after she fell on [DATE]. She stated that due to a staff shortage that day, LPN #1 was assigned to care for the resident (rather than a CNA). She stated she did not know why LPN #1 was unaware the resident required transfer with a mechanical lift. During an interview at 1:15 PM on [DATE], LPN #2 stated she assisted LPN #1 and RN #1 when the resident was transferred to bed after her fall on [DATE]. She stated the resident was upset that she was on the floor. LPN #2 stated that she and the other 2 nurses picked up the resident, put her into bed, and did not use the mechanical lift for the transfer. At 1:30 PM on [DATE], a surveyor interviewed CNA #1, who assisted LPN #1 to place the resident in a shower chair on [DATE]. She said she did not know the resident required a mechanical lift for transfers, and helped LPN #1 lift the resident into the shower chair. When RN #1 was re-interviewed at 1:35 PM on [DATE], she stated she was unaware the resident required a mechanical lift when she assisted 2 nurses to lift the resident into bed after she fell on [DATE]. In summary, Resident #1 experienced harm and subsequent death related to 2 fractures of her right leg as the facility failed to: - communicate to direct care staff the correct method of bathing the resident; - ensure staff consistently transferred the resident according to plan; - provide a timely, accurate assessment after an injury; - ensure timely physician notification after an injury; - conduct a thorough investigation of the cause of a significant injury, and implement measures to prevent recurrent injuries; and - report the resident's injuries to the NYSDOH as required. 2) Resident #3 had [DIAGNOSES REDACTED]. On [DATE], the comprehensive care plan (CCP) the resident's problem of mobility/falls related to severe spinal stenosis (narrowing), [MEDICAL CONDITION] drug use, and [MEDICAL CONDITION] disorder. Interventions were for the resident to ambulate to and from the bathroom using a front-wheeled walker, with close supervision of one person. The resident was to wear a "TLSO" (thoraco-lumbo-sacral orthosis - a body brace used to prevent motion of the spine). For the resident's problem of chronic pain, the CCP documented on [DATE], that the resident was to wear the TLSO brace when out of bed. A CCP intervention, dated [DATE], was for the resident's call bell and personal items to be within reach. The care planned intervention of a bed alarm was initiated on [DATE]. The Resident Nursing Instructions, used by certified nurse aides (CNAs) to provide care, documented on [DATE], that the the resident was to wear the TLSO brace when out of bed. An incident report, dated [DATE], documented the resident had an unwitnessed fall in her room at 10:15 AM. The report documented the resident was found lying on her back, and stated she had dropped her phone, then slid out of her wheelchair when she reached to pick it up. The resident was sent to the hospital due to complaints of mid back pain. A CNA Investigative Statement documented that 15 minutes before the resident's fall, the CNA had completed the resident's morning care, and left her sitting in her wheelchair next to her bed with her call bell and phone next to her on the bed. The Fall Investigation documented the resident had a bed alarm, and did not have a chair alarm. The CCP was updated on [DATE], with interventions of Dycem in the resident's wheelchair, and to remind the resident to lock the wheelchair brakes. The CCP did not include provision of a chair alarm. The Fall Risk Assessment, dated [DATE], documented the resident was at risk for falls related to age between ,[DATE]; attempts to get out of bed or chair unsafely; previous fall in past 6 months; impaired mobility; generalized weakness; alterations in elimination; medications that increased fall risk; immobility; and additional characteristics, such as postural instability and "does not call for help." The quarterly Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had normal cognition; was non-ambulatory; required assistance of 1 person for most activities of daily living, including bed mobility and transfer; was unsteady, and only able to stabilize with human assistance for moving from a seated to a standing position, for surface to surface transfer, and for moving on and off the toilet; had frequent bowel and bladder incontinence; and was totally dependent upon staff for toilet use. A nurses' note, dated [DATE], documented resident was transferred to her commode and given a call bell to ring when finished. The resident fell from her commode at 8:00 AM after getting up by herself to go to her closet. The resident "lost her balance," landed on her left hip, and stated she struck the back of her head. The note documented the resident complained of back pain; her left leg was externally rotated; and she was sent to the hospital. The incident report related to the resident's fall on [DATE], initiated by the registered nurse (RN #3) unit head nurse on [DATE], documented the resident's call bell was near her at the time of the fall, and "instead of ringing, resident got up from her commode to her closet." An Investigative statement, written by the resident's assigned CNA (CNA #2), documented that when she transferred the resident to the commode, the resident was wearing her TLSO brace, and was given her call bell. CNA #2 documented she removed the resident's TLSO brace after putting her on the commode. The IDT documented the root cause of the resident's fall was that she was "self ambulatory." The Summary/Analysis of the incident, signed by the Director of Nursing (DON) on [DATE], documented the resident was placed on a commode with a call bell in reach, decided to go to the closet to pick out clothes, and fell in the process. The report did not address the removal of the resident's TLSO brace when she was out of bed at the time of the fall, nor did it include a plan to update the CCP and Resident Nursing Instructions regarding the resident's non-compliance with use of her call bell. Hospital emergency room records, dated [DATE], documented the resident sustained [REDACTED]. The resident stated she "got dizzy and fell back. States she hit her head, and complained of left hip pain." The hospital discharge summary, dictated on [DATE], documented the resident underwent [REDACTED]. A surveyor interviewed RN #3 at 3:00 PM on [DATE]. She stated the resident was not always compliant with using her call bell, and had a previous fall when she got up without ringing her call bell. A surveyor interviewed CNA #2 at 12:55 PM on [DATE]. She stated that on the day of the resident's fall, [DATE], she placed the resident on the commode, gave her the call bell, and told her to ring when she was finished. The resident fell about 2 minutes later, while a nurse was standing outside her room. CNA #2 stated she did not think the resident rang the call bell, and she would not have left the resident alone if she knew the resident would not use the call bell. Review of CCP, last updated [DATE], and the Resident Nursing Instructions, last updated [DATE], revealed no instructions/interventions regarding the resident's non-compliance with use of her call bell. In summary, Resident #3 experienced harm related to a [MEDICAL CONDITION], as the facility failed to: - implement appropriate measures to prevent recurrent injuries after a fall; - conduct a thorough investigation of the cause of a significant injury; - ensure direct care staff consistently used a care planned medical device; and - report the resident's injury to the NYSDOH as required. 10 NYCRR 415.4 (b) (3, 4)

Based on staff interviews and record reviews conducted during an abbreviated survey (Complaints #NY 732 & NY 159), it was determined the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 2 (Resident #1 and #2) of 5 residents, whom were reviewed because of a change in condition. Resident #1 sustained bruises of unknown origin and a head injury. The facility did not ensure Resident #1's attending physician was notified in a timely manner regarding the resident's continued development of bruises and change in status due to the head injury. Nor was this resident assessed in a timely manner by a registered nurse. Resident #2 was not treated for [REDACTED]. Nursing staff were aware of these changes and did not notify the physician. Both residents died . This resulted in actual harm for both residents that is not immediate jeopardy. Findings include: Resident #1 was admitted from home on [DATE] with [DIAGNOSES REDACTED]. The medical note, written by the physician at the medical day program the morning of admission to the facility (on [DATE]), documented: " head is normocephalic, atraumatic; her neck is supple; lung fields are currently diminished, but there is no adventitial sounds noted; and there is no breakdown in any places on her skin at present." The next physician note was written on [DATE]; the day the resident expired. According to the MDS (Minimum Data Set) dated [DATE], the resident was assessed to be feeling down, depressed, or hopeless nearly every day; had disorganized thinking, with some verbal behavioral symptoms directed towards self and others; is usually understood and usually understands others; has highly impaired vision; and has severely impaired cognition. It was also noted that the resident needs extensive assistance of one with activities of daily living (ADLs); for transfers, the resident needs the assistance of two staff; and uses a wheelchair for mobility and has wandered. The resident's comprehensive care plan (CCP) dated [DATE] (updated [DATE]) documented the resident is a PACE participant (a managed care long term health care provider) and had attended a PACE Day Program seven days a week prior to admission. The resident was noted to have "Transfer Trauma" (meaning problems with adjustment to the facility); risk for falls related to wandering and agitated behavior, use of [MEDICAL CONDITION] ([MEDICATION NAME] and [MEDICATION NAME]) and anti-hypertensive medications, and impaired judgement, cognition, and safety awareness. Interventions included: staff were to monitor and provide increased supervision for this resident. The resident was also identified to be at risk for skin breakdown due to incontinence and decreased mobility. Interventions included: daily skin inspection by CNA (certified nurse aide) and cool cloth to eyes prn (whenever necessary as of [DATE]). The social services admission note, dated [DATE], documented the resident had comfort measures including no hospitalization unless pain or symptoms cannot be managed at the facility. Per this note, the resident does not use side rails and is not restrained. The resident is alert with impaired cognition, is verbal and can make simple needs known. "At admission, the resident was a transfer with two assist" was also included in the note. The nursing admission note, dated [DATE] at 3:40 PM documented the resident was confused and alert; anxious, verbally abusive, agitated, restless and does not wear glasses. It was documented that the resident had no history of falls and used a wheelchair. The skin portion of the admission assessment is blank. In a nursing progress note dated [DATE] at 10:55 PM, it was documented the resident was restless, very confused, talking nonsensical phrases throughout the shift, and was removing her socks and shoes. The note also documented that the resident "is a mechanical lift" per the PACE nurse. Another RN admission assessment dated [DATE] at 7:03 AM noted the resident's skin was intact with bruising. It was documented the resident did not wear glasses. No further description of the bruising was noted. On [DATE] at 2:40 PM, the resident was noted to have a "purple area under her left inner eye" per the nursing note written by a licensed practical nurse (LPN). At 5:30 PM another LPN documented that she was called to the resident's room by the resident's family who were concerned about the resident's lethargy and bruises on her left knee. The LPN documented the resident was "asleep" with two bruises on the left knee: one anterior measuring 5 centimeters (cm) x 2 cm and another on the medial knee measuring 4 cm x 1.5 cm, "origin unknown." The resident was assessed by the nursing supervisor. At 7:30 PM as the CNA removed the resident's stockings, a larger bruise which measured 16 cm x 4 cm was noted on the resident's lateral left shin, "origin unknown." The area was assessed by the nursing supervisor. The LPN note continued and documented the resident appeared lethargic at the time of the family visit, but then woke to verbal stimulation. The LPN wrote an addendum at 10:57 PM that documented the resident remained with a bruise to the inner aspect of the left eye, purple in color. An incident report regarding the eye bruise was completed on [DATE], by the unit head nurse (an RN) with an uncertain date and time of the occurrence (both have a question mark). The resident was noted to have a dark purple bruise, measuring 1 cm x 2 cm, to her left inner eye area. The resident was unable to state how she got the bruise. According to the incident report, the physician was not notified. The incident report specified that contributing factors to this incident included: "resident was day two of admission; she had bruising on her legs at admission; and she is confused and unable to state what happened." It was also documented that a photo was taken of the injury. The cause of the area was thought to be from the resident's glasses; "this may be why resident is not currently wearing glasses." The incident report contained two statements from LPNs. There is no documented evidence that statements were obtained from certified nurse assistants (CNAs) caring for the resident. There were no photos included with the incident report. Additionally, there were no incident reports found for the bruises of unknown origin on the resident's knees. A Memorandum for Record, dated [DATE], completed by the Director of Operations (DO) was given to the surveyor on [DATE]. The memo stated that photos were taken of the resident's arms and legs and "the bruising already had a yellow tint to the outside of the bruised area and the bruising was more consistent with a possible fall or legs being swung into a hard object." Another addendum nursing progress note was written on [DATE] for [DATE] by the RN Supervisor. The RN Supervisor noted that the family was concerned about the bruise by the resident's eye and the two bruises on the resident's left knee. The measurements were recorded; although there was no documentation of the third bruise. Measurements for the eye area bruise were not documented. This RN reported that the resident was put back to bed at 3:30 PM by the CNA because of "not feeling well." The resident's vital signs were noted to be stable. The resident became restless after the family left. The RN further documented that the upper side rails were up. There was no documented evidence that the resident sustained [REDACTED]." The [DATE] evening shift LPN, documented the resident had multiple bruises noted to both upper and lower extremities and the corner of her left eye. There was no documented evidence that the bruises of unknown origin on the resident's extremities were investigated and there was no further documentation concerning the resident's bruises of unknown origin on her face. In a nursing progress note dated [DATE] at 1:29 PM, the resident was noted by an LPN to have a "bruise, green in color, scratch and lump noted to left forehead." An incident report was completed by the unit LPN on [DATE] at 9:30 AM with an uncertain date of occurrence (having a question mark). She described a "small lump, green bruise, and scratch to the resident's left forehead" were found. The resident was reported to state "I don't know (what happened), but there's a big bump." According to this form, the physician was not notified. This report was stamped that it was faxed on [DATE] to the PACE clinic and the family was also notified. The RN assessment (by the head nurse) of the resident's forehead was not completed until [DATE]. This bruise was noted to be "the second bruise since admission." The cause of this bruise was documented as "resident had been very restless and after this bruise was found, she hit her head on the nursing station desk and got a bruise on back side of head." This information was signed by both the incident review committee nurse and the head nurse on [DATE]. The resident hit her head on the nursing station on [DATE]. The incident report was signed two days earlier on [DATE]. A review of [DATE] and [DATE] Hour Reports revealed there was no documentation of any bruises regarding this resident until [DATE]. There was no documentation of physician notification regarding the resident's bruises of unknown origin and the striking of her head on the nursing station on [DATE]. On [DATE] at 12:24 PM, a nursing note by the RN stated the resident was in her wheelchair at the nursing station mid morning, when she backed herself up hitting the back, left side of her head, on the corner of the nursing station desk. According to this note; the resident had no injury; the resident was placed on "head precautions" (neuro checks); and a message was left for her daughter. The evening shift (3 PM-11 PM) LPN documented at 11:21 PM that the resident had complained of head pain early in the shift and took her 4 PM medications with effect. The resident was documented to be responding slowly and that her [MEDICATION NAME] (blood pressure medication) was held. The resident refused her night time medications and the daughter had been in to see the resident. There was no documentation that the physician was notified the resident refused her medications. Per the [DATE] nursing progress note the resident continued on "head precautions" and was noted to have a dark purple bruise on the right side of the back of her head. In a nursing progress note dated [DATE] at 2:02 PM, the RN recorded the resident had a "large" deep purple bruise on the back of her head "where she bumped it a few days ago." On [DATE] at 2:32 PM, the LPN nursing note documented the "resident was very lethargic today." Vital signs were recorded as: temperature 97.8 axillary, blood pressure ,[DATE], and oxygen saturation on room air 86%. The LPN placed the resident on oxygen at 3 liters via nasal cannula and the oxygen saturation increased to 88%. The LPN then placed a mask on the resident and the oxygen saturation rose to 99%. The LPN documented that she did not give the resident her [MEDICATION NAME] and [MEDICATION NAME] because she was lethargic. The LPN documented the dark purple bruise remained on the back right side of the head and that the resident's family was in and "wants her to be evaluated by the MD tomorrow. Offered to send her to the hospital to be evaluated, but family refused." In a nursing progress note dated [DATE] at 8:06 PM another LPN recorded that all oral medications were held due to lethargy. The resident's oxygen saturation was 93% on room air. There is no documentation that the physician was notified of the resident's lethargy or that the physician was consulted about not administering the resident's medications. In a [DATE] 5:41 AM nursing progress note it was documented the resident's oxygen saturation was 91% on room air. The RN noted the resident was "unresponsive during morning care" and "did not respond to a sternal rub." The resident was pale and warm to touch. The resident's oxygen saturation was 99% on 4 liters of oxygen by nasal cannula. The MD was in to see the resident around 9 AM. Orders were written and the resident expired at 1:44 PM. The physician progress notes [REDACTED]. He documented that the resident was "clearly having evidence of intracranial trauma." The RN unit head nurse was interviewed on [DATE] at 4:05 PM. She stated that she did not have time to look at the resident's skin upon admission and asked the evening nurse to get this information. She could not remember what nurse she asked to complete the skin assessment. She stated that when staff documented bruises, the bruises need to be described and an incident report has to be initiated. The LPN, who was called by the resident's family to look at the resident's knee bruises and mental responsiveness on [DATE], was interviewed on [DATE] at 3 PM. She stated that the resident was lethargic and an RN assessed her. She said she could not remember what nurse supervisor did the assessment. She had no explanation for the origin of the 16 cm x 4 cm shin bruise found by the CNA. The LPN stated that this area was assessed by the same RN. She was not sure if the RN assessed the resident's eye, during the two times she "assessed the resident." The DO was interviewed at 4:45 PM on [DATE]. He stated he took pictures of the resident's bruised knees on [DATE] and noticed the resident had a "pencil tip" sized purple bruise to the inner aspect of the left eye. The DO stated that he could not retrieve the photos because he did not realize the camera did not date, number and/or identify the pictures so he could not tell which pictures were those of this resident. During the interview at 1:05 PM on [DATE], the incident review committee nurse stated that a different incident report should be used for each bruise or injury of unknown origin. She stated that the incidents pertaining to Resident #1 were not thoroughly completed and that more staff, especially CNAs, should have been interviewed. At 2 PM on [DATE], the resident's PACE social worker was interviewed. She stated she had no knowledge of the resident having any bruises prior to admission and that she saw the resident on [DATE], the day she was admitted to the facility. The LPN who documented on [DATE] (that the resident was very lethargic with a low blood pressure and decreased oxygen saturation) was interviewed on [DATE] at 1:30 PM. The LPN stated that the family wanted the physician called the following day, so she put this request in the book. The LPN stated that the PACE physician usually comes to the facility on Tuesdays, but he will come on other days if needed. When asked why she did not call the physician, she stated that calling a PACE physician is involved and she did not want to bother the supervisor, who was already busy. The LPN acknowledged that she withheld medications from the resident without a physician's orders [REDACTED]. The resident's attending physician was interviewed on [DATE] at 2:15 PM. He stated there was a breakdown in communication between the facility nursing staff and himself. He further stated that he was unaware of the resident's bruises, head trauma, mental and physical status changes, and the holding of the resident's medications, until [DATE]. He stated he would have expected to be called for the above changes. The physician also stated that he was not aware of the resident's large bruise on the back of her head, until he "went downstairs and was discussing the case" and he thought the bruises under her eye and on her forehead were due to the resident hitting her head on the nurses station. The physician stated that the resident was falling a lot, had increasing behaviors and the family could no longer take care of her at home. Two CNAs were interviewed separately on [DATE] at 2:30 and 2:45 PM. Both stated that the CNA who was assigned to the resident was out on leave. The resident was reassigned to different staff on a rotational basis, including float staff. Both CNAs stated that they report any bruises or marks to the charge nurse. These two CNAs, took care of the resident (together) on [DATE], when they noticed a "brown lump with a scratch on the resident's forehead." The RN unit head nurse, was again interviewed on [DATE] at 3:30 PM. She stated because the resident moves her head around a lot, maybe she hit her head on something and staff were unaware of it. The unit head nurse could not give a reason why the resident was not assessed by an RN, until two days after finding the bruise/lump on her forehead. Although the nurse stated and showed the DOH surveyor that incident reports were faxed to the PACE program, this information as well as other concerns/symptoms, were not communicated to the attending physician. No reason was given for untimely notification of the physician. The night supervisor who documented that she called PACE in the addendum for [DATE] was interviewed on [DATE] at 12:15 PM. She stated that she could not remember calling PACE. In summary, the resident experienced harm and expired. The facility did not: - ensure the resident's attending physician was notified in a timely manner regarding the resident's bruising, head trauma and change in mental and physical status, - ensure the resident's bruises were thoroughly assessed and monitored by a qualified professional, -thoroughly investigate the resident's bruises, did not investigate all of the resident's bruises and documented inconsistencies regarding the nature of the bruises (i.e.. if the resident wore glasses, had a history of [REDACTED]. -complete the nursing admission assessment and follow the resident's CCP which indicated her skin would be assessed daily. 2) Resident #2 was admitted to the facility on [DATE] for short term rehabilitation. He had [DIAGNOSES REDACTED]. The resident's comprehensive care plan (CCP) last updated [DATE], documented the goals of keeping the resident free from dehydration and UTI, no ill effects from Foley catheter and have no signs and symptoms of infection. Interventions included monitor for signs and symptoms of dehydration and UTI, irrigate Foley catheter per policy, and monitor for signs of infection. The facility Infection Control Policy notes that for residents with indwelling catheters the resident must meet two criteria in order to be diagnosed with [REDACTED]. The UTI section of the policy includes an asterisks which states, "Note that culture results are not included. Pyuria (the presence of pus in urine) may be considered a change in the character of the urine...." On [DATE] the facility physician documented in a progress note that prior to admission the resident had been in the hospital with a UTI secondary to a chronic Foley catheter, [MEDICAL CONDITION] and dehydration. The physician documented that the resident was alert and oriented to person, place and time and that if the resident had any fever, blood pressure drop, [MEDICAL CONDITION](elevated heart rate) or any evidence of infection [MEDICAL CONDITION], he needed to go back to the hospital right away. On February 11, 2011 a nursing progress note documented the resident's urine was light mustard colored with a lot of mucous and that a urinalysis and culture and sensitivity (UA and C&S are tests to look for infection in the urine) were ordered. The resident was noted to have refused physical therapy for the last two days and was quiet and depressed. On February 13, 2011 a nursing progress note timed 10:16 AM documented the resident's urine was dark amber with some mucous threads. He refused fluids and had a noticeable behavior change. The resident was noted to be barely talking. A 10:39 PM nursing progress note on February 13, 2011 documented the certified nurses aide (CNA) reported the resident's urine was dark orange. The resident refused all medication this shift, except for [MEDICATION NAME], and was barely responding when spoken to. A February 15, 2011 nursing progress note documented the UA and C&S were completed and revealed the resident had a urinary tract infection. The Nurse Practitioner was contacted and ordered [MEDICATION NAME] (an antibiotic) for 7 days and that the resident will be monitored for improvement. The Quest Diagnostic Laboratories report dated February 15, 2011 documented the resident had gram negative bacilli greater than 100,000 cfu/ml. A February 16, 2011 nursing progress note documented the resident's sister indicated he had not been answering the phone and she was informed by his roommate that he had been sick for 3 days. The nurse documented that she assured the sister the resident had a UTI and he was being treated with antibiotics. A NP wrote a surgical consultation note on February 16, 2011 and documented that the greatest concern with the resident was that he was not eating. The NP was told by staff that he was eating 25% of his meals. The NP documented that the resident had a "definite difference" in his personality and appeared quiet and depressed. The resident's weight on February 16, 2011 was documented on the weight record as 95 pounds. His admission weight was 102.5 pounds. On February 17, 2011 the psychiatric nurse clinician documented in a progress note that she was asked by the Unit Nurse Manager and Assistant Director of Nursing to conduct an urgent assessment of the resident due to a "significant change in presentation." The psychiatric nurse documented that the resident was conversive, out of bed, and attended physical therapy upon admission, but was presently withdrawn with no eye contact, flat affect and mono-syllabic responses. A brief mental status assessment showed disorientation to place, date and he was unable to name common objects or the people in his room (his sister and her husband). The psychiatric nurse concluded that his clouded cognition was from a medical cause and she noted the 20 pressure sores, 60 pound weight loss and current UTI. She indicated that the resident should be transferred to the emergency room due to possible [MEDICAL CONDITION]. A February 17, 2011 social work note and late entry progress notes (dietary on February 18, nursing on February 21 at 9:21 AM and 9:58 AM) documented an initial refusal by the resident to go to the hospital. The ambulance crew arrived, asked the resident questions, and then it was decided, in consultation with the health care proxy, that the resident would be taken to the hospital over his objection. The February 17, 2011 history and physical in the hospital record documented that the resident was referred to the hospital for further evaluation of a urinary tract infection and confusion. The white blood cell count was more than 150,000, leukocyte esterases 3+, positive [MEDICATION NAME] and blood 3+. The assessment was recurrent urinary tract infection. The hospital discharge summary, dated [DATE], documented the resident was admitted on [DATE] after previous admissions for urosepsis secondary to a permanent indwelling Foley catheter. He was resuscitated with fluids and antibiotics with a history of [MEDICAL CONDITION], proteus and pseudomonas in his urine, but on February 20, 2011 he became more unstable. After discussions with the family the resident was made a do not resuscitate and do not intubate. The resident expired on [DATE]. The documented discharge [DIAGNOSES REDACTED]. The RN (registered nurse) Unit Nurse Manager was interviewed on [DATE] at 2:45 PM and 3:50 PM, [DATE] at 11:30 AM, [DATE] at 9 AM and [DATE] at 1:00 PM. She stated that the resident's urine was mustard colored on February 11, 2011 and he was put on antibiotics on February 15, 2011. She could not recall if the urine culture returned in the evening of February 14 or February 15 during the day shift. She was notified of the results on February 15 and called the NP for the antibiotic. The RN stated she did not notify the physician when the urine was mustard colored. She stated that the psychiatric nurse clinician came to her and said that the resident needed to be sent to the hospital. The RN talked to the physician and obtained an order to send the resident to the hospital. She stated that the resident acted differently the last few days he was in the facility. He was withdrawn and not talking, eating or drinking. Staff did not suspect the change in behavior was from the UTI. Staff thought the resident was depressed and the family also thought so. The RN stated she did not inform the physician of the change in the resident's urine and behavior. She filled out a requisition for the UA and C&S and wrote the physician's name. She did not call the physician for an order for [REDACTED]. When informed the resident could [MEDICAL CONDITION] while she awaited the test results, the RN stated that they were more concerned with the resident's wounds. The RN stated that she started her position as Unit Manager in [DATE] and she was trained at that time to dip the urine and to independently order a UA and C&S. She stated that they call the physician when the UA and C&S is positive and if it is negative they place the lab report in a folder for the physician to review at a later date. She thought that another RN had dipped the urine, but learned later that she had not. A CNA was interviewed on [DATE] at 4 PM. She stated that the resident was very nice and was very ill. She fed the resident and he would often eat 50 to 75% of his food. Towards the end of his admission everything changed and he didn't talk or joke. He just shut down. His urine was brownish and cloudy with a strong smell for about a week. An LPN was interviewed on [DATE] at 4:15 PM and stated that initially the resident was very upbeat and optimistic. He tolerated everything and did his best to take in nourishment. The last week he seemed depressed and he had an argument with his roommate. The LPN could not recall what the resident's urine looked like. She recalled that he had a UA and C&S ordered and that the RN Unit Manager stated the changes in his behavior could be because of a UTI. On [DATE] the DOH surveyor attempted to interview the facility DON (Director of Nursing) who stated that she wanted to review the chart before she would agree to interview. The DON sent in a written statement to DOH on [DATE]. The statement documented that the urine was not dipped before it was sent out for the UA and C&S. The resident's urine was light mustard color on February 11 (Friday) and was dark amber in color over the weekend. He was also noted to have copious amounts of drainage from one of his decubitus ulcers. The resident was withdrawn and did refuse some medications and nourishments, but ate ,[DATE]% of his meals. On February 15, 2011 the test results returned and an antibiotic was started. The DON wrote that it is not uncommon for clinicians not to order antibiotics until the C &S results return in the absence of tissue invasion (hematuria, increased temperature and flank pain) and that this is especially true for residents with Foley catheters who tend to always present with bacterial growth. On [DATE] at 1:25 PM the physician was interviewed. The physician stated that he was not informed of the changes with the resident and that if he had been informed he would have seen the resident. The physician stated that he was not aware a UA and C&S was ordered in his name and that he has never given an RN permission to order tests in his name without first calling him. He stated that he expects the RN to dip the urine and if it is positive to contact him. The physician stated that he did not know about the changes to the resident until February 17, 2011. On [DATE] at 8:45 AM, 9:20 AM, 9:40 AM, 9:45 AM and 9:50 AM, five RN Unit Managers were interviewed. Four out of five indicated they independently order UA and C&S tests without communication with the physician. They stated that the physician assigned to their unit permits this freedom and signs off on the order at a later time. In summary, the resident experienced harm and expired. The facility did not; -notify the physician of changes to the resident's urine and behavior, -comply with the physician's directive that if the resident had any evidence of infection [MEDICAL CONDITION] he would be sent back to the hospital "right away," -ensure the scope of practice of RN's was appropriate in that RN's have been permitted to order UA and C&S tests without communication with and orders from the physician, and -follow the resident's CCP and recognize the changes in the resident's status were indicative of infection. NYCRR 415.12

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during an abbreviated survey (complaint #NY 625), it was determined the facility's administration failed to administer the facility in a manner that protects the health and safety of residents. Specifically, for 1 sampled resident (Resident #1) of the 177 residents with "out on pass" medical orders, the facility's administration failed to: - have a system in place to determine the level of supervision required by Resident #1 to maintain his health and safety when out on pass; - permit Resident #1 to remain in the facility, and not discharge him from the facility unless the discharge was necessary for the resident's welfare, and the resident's needs could not be met in the facility; and - inform Resident #1 he would be discharged AMA if he did not return from OOP at a predetermined time. This resulted in Immediate Jeopardy, Substandard Quality of Care, and actual harm to the health and safety of Resident #1, and the potential for serious harm that is Immediate Jeopardy to the health and safety for the 177 residents with out on pass medical orders. The Immediate Jeopardy situation was removed on April 18, 2011 prior to survey exit based on the following corrective actions taken by the facility: - OOP orders for all residents were discontinued; - a revised OOP assessment and care plan was developed; - implementation of a plan to train RN staff of the revised process before conducting a reassessment of residents for OOP privileges; - implementation of a plan for an RN to reassess residents wishing to go OOP in the immediate future, to determine if the resident and/or individual accompanying the resident could meet the safety and medical needs identified for the resident; - supervisory review of the results of each revised RN OOP assessment; - supervisory notification of the Medical Director, who (alone) would provide a resident OOP order; - all staff were in-serviced on the new policies and procedures; - the resident council was notified of the revised OOP procedures; and - facility administrative staff monitored all staff to ensure compliance with the new policies and procedures. Findings include: F201 - Resident's right to remain in the facility - The administrator failed to to readmit the resident when he wished to return to the facility after going out on pass. F284 - Post discharge plan of care - The administrator failed to ensure the resident was discharged with an appropriate discharge plan, and failed to assist the resident and his family to access appropriate placement and medical care upon discharge. F323 - Accidents - The Administrator failed to have a system in place to conduct an appropriate and thorough resident assessment to determine the level of supervision required to maintain the resident's health and safety when out on pass with untrained individuals. The Administrator was interviewed at 1:03 PM on April 15, 2011 about the facility's decision to discharge Resident #1 AMA after he did not return from pass at a predetermined time. She stated it was her understanding that the resident knew the meaning of the Discharge AMA policy, and he was aware he would not be allowed to return to the facility if he remained away from the facility overnight. 10NYCRR 415.26(a)

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during an abbreviated survey (complaint #NY 625), it was determined for 1 sampled resident (Resident #1) of the 177 residents with "out on pass" medical orders, the facility did not permit the resident to remain in the facility, and not discharge the resident from the facility unless the discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility. Specifically, the facility discharged Resident #1 AMA (against medical advice), and the facility refused to readmit him when he wished to return to the facility. Subsequently, the resident required emergency medical care and this lead to an acute hospitalization and admission the hospital intensive care unit. This resulted in Immediate Jeopardy and actual harm to the health and safety of Resident #1, and the potential for serious harm that is Immediate Jeopardy to the health and safety for the 177 residents with out on pass medical orders. Findings include: The Immediate Jeopardy situation was removed on April 18, 2011 prior to survey exit, based on the following corrective actions taken by the facility: - OOP (out on pass) orders for all residents were discontinued; - a revised OOP assessment and care plan was developed; - implementation of a plan to train RN staff of the revised process before conducting a reassessment of residents for OOP privileges; - implementation of a plan for an RN to reassess residents wishing to go OOP in the immediate future, to determine if the resident and/or individual accompanying the resident could meet the safety and medical needs identified for the resident; - supervisory review of the results of each revised RN OOP assessment; - supervisory notification of the Medical Director, who (alone) would provide a resident OOP order; - all staff were in-serviced on the new policies and procedures; - the resident council was notified of the revised OOP procedures; and - facility administrative staff monitored all staff to ensure compliance with the new policies and procedures. ******************************************************* 1) Resident #1 was admitted to the facility on [DATE] after treatment for [REDACTED]. The resident had [DIAGNOSES REDACTED]. The facility Discharge Against Medical Advice (AMA) Policy, dated June 2009, documents: - a resident who wishes to leave the facility against the advice of the administration, attending physician, and interdisciplinary team will be considered a "self-discharge" AMA; - documentation in nurses' notes and social work progress notes will reflect the circumstances surrounding the resident's decision to discharge AMA, and outline the information provided to the resident to assist in the decision making process; and - a physician order [REDACTED]." The facility's Transfer and Discharge policy, included in the June 2010 publication, "Your Rights as a Nursing Home Resident in New York State," documents a nursing home may transfer or discharge a resident only after the interdisciplinary care team, in consultation with the the resident, determines: - that the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met after reasonable attempts at accommodation at the facility; - that the transfer or discharge is appropriate because the resident's health has improved sufficiently to the point where the resident no longer needs the services provided by the facility; - that the health and safety of the resident or other individuals in the facilty would be otherwise endangered; and - the resident has failed to pay for a stay at the facility. The admission Minimum Data Set (MDS) assessment, dated March 1, 2011, documented the resident had normal cognitive ability; had the behavior of rejecting evaluation or care that is necessary to achieve the resident's goals for health and well-being; was non-ambulatory; was totally dependent upon staff for all activities of daily living (ADLs); had functional limitation in range of motion of upper and lower extremities on both sides, that interfered with daily functions or placed the resident at risk of injury; had an indwelling urinary catheter; was always incontinent of bowel; had a [MEDICAL CONDITION] disorder; had difficulty breathing when lying flat; was at risk of developing pressure ulcers; had 2 Stage II pressure ulcers when admitted to the facility; and received antidepressant and antipsychotic medications. The CCP (comprehensive care plan), dated March 2, 2011, documented a plan for the resident to go out on pass with a responsible person (time parameter not specified). The goal was for the resident to benefit from the out on pass (OOP) experience with no ill effects. physician's orders [REDACTED]." A nursing progress note, written by the registered nurse (RN) Unit Manager on March 31, 2011, documented the resident said he wanted to go OOP on April 1, 2011. He stated he planned to depart on a public bus, and wanted to stay overnight. The note documented the RN told the resident he had an order for [REDACTED]. A licensed practical nurse (LPN) progress note, dated April 4, 2011 at 11:04 PM, documented the resident "went OOP at approximately 6:30 PM. Has not returned as of 11 PM, unable to reach him by phone. Supervisor notified." A late entry nursing progress note, written by an RN nursing supervisor at 12:24 PM on April 5, 2011, documented: - on April 4, 2011 at approximately 10:45 PM, she was notified the resident was due to return at 9:00 PM that evening, and had not returned; - the OOP log book did not specify the time the resident left the facility, nor the signature of a nurse who co-signed (with the escort) that the resident left the facility; - staff were unable to contact the resident, family, and friends by telephone; - staff were asked when the last bus would arrive that evening, and stated, "Close to 12:00 AM;" and - the last bus arrived at 11:57 PM, and the resident was not on the bus. A nursing progress note, written by the RN Unit Manager at 5:15 PM on April 5, 2011, documented the resident failed to return from OOP as ordered, and the resident was notified he would not be able to return to the facility "per policy." Adult Protective Services was notified, and the resident was advised to go to a hospital emergency room "to get further medical assistance if needed." The resident's physician was notified and provided an order for [REDACTED]. The facility Accident/Incident Report, signed by the former Assistant Administrator on April 5, 2011, documented the resident had been made aware of the OOP policy, and chose to remain OOP beyond the time authorized. A care plan modification was not needed, and the resident was discharged AMA on April 5, 2011. The resident's April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An emergency medical service (EMS) report, dated April 5, 2011 at 1:27 PM, documented an ambulance was called that afternoon to evaluate the resident in a private apartment. The Resident told EMS staff he was "kicked out" of the facility. He stated facility staff had advised him to call 911, whereupon an ambulance would take him to the hospital to obtain his medications and bring him back (to the apartment). The EMS team directed the resident to contact a medical provider for his medications and left the resident in the company of several friends after he denied the need for emergency medical care. A second EMS report, dated April 5, 2011 at 3:38 PM, documented the resident was brought to the hospital emergency department unresponsive, hypotensive (low blood pressure), and having [MEDICAL CONDITION]. The hospital admission history and physical examination [REDACTED]. The report documented a plan for case management consultation for placement of the resident upon his discharge from the hospital because he was not allowed to return to the facility. A hospital physician's progress note, dated April 6, 2011, documented the resident stated he was staying with friends on April 4 and 5, 2011, and missed his medications. He stated he was having issues of sludge in his Foley (urinary) catheter, and foul-smelling urine prior to being brought to the emergency department on April 5, 2011. The physician's assessment included [MEDICAL CONDITION] due to being off his medication, [MEDICAL CONDITION] secondary to UTI. Hospital case management notes, dated April 6, 2011 at 12:00 PM, documented the resident stated he did not return to the facility from a pass as planned on April 4, 2011, after he was unable to board a bus (which left him) at 7:30 PM that day. The resident stated he called the facility and talked to a nurse about his medications, and wanted to return to the facility. He stated he would "never go out on leave until his van gets fixed." A case management note written later that day, at 12:40 PM, documented an administrator from the facility stated the resident would not be readmitted because the facility could not meet his "social needs." A surveyor interviewed the current Assistant Administrator at 11:30 AM on April 13, 2011 regarding the facility Discharge Against Medical Advice policy. She was unable to explain why the AMA policy does not include a procedure for staff to follow if a resident fails to return to the facility at the time previously planned. She was also unable to explain why the policy does not contain a procedure to ensure written information is given to residents advising them of the facility AMA discharge policy. When asked about staff responsibility to assist Resident #1 to return to the facility in a timely manner when using public transportation, the Assistant Administrator stated this was left up to the resident because he was alert and oriented. A surveyor interviewed the RN Unit Manager at 2:00 PM on April 13, 2011. When asked about staff responsibility to verify the resident would have been able to safely return to the facility on a public bus on the evening of April 4, 2011, the RN stated the only facility requirement was for the resident to have an escort. She stated the resident telephoned her at 8:00 AM on April 5, 2011, and told her he was unable to call the facility while he was OOP on April 4, 2011 because his cell phone could not access service. He stated the bus he planned to take back to the facility did not arrive. The RN stated she spoke to the resident later that day, and told him to go to the local hospital to obtain his medications. When asked about the facility policy for AMA discharge, the RN stated the facility will not allow a resident to return in the event of intentional elopement. A surveyor interviewed the Medical Director at 11:50 AM on April 15, 2011, regarding the decision to discharge the resident AMA after he failed to return from pass at a predetermined time on April 4, 2011. The Medical Director stated the facility policy does not need to document that a resident who leaves the facility AMA will not be allowed to return. He stated, "The resident "discharged himself." A surveyor interviewed the social worker at 12:45 PM on April 15, 2011. She stated that on April 5, 2011, she called Adult Protective Services staff to notify them the resident was discharged AMA that day, and they were confused about the reason the facility would not allow the resident to return to the facility. The social worker said she told them the resident could not return to the facility because he had a day pass, and stayed overnight. The social worker stated the resident called her on April 5, 2011, and said he was on his way to the hospital because his urinary catheter bag had burst. She stated the resident was not provided written notice he would be discharged from the facility if he failed to return from OOP on time. In summary, the facility failed to ensure the resident would not be discharged from the facility unless the discharge was necessary for the resident's welfare and needs as: - he was discharged AMA after he did not return from a pass at a predetermined time; - the facility refused to readmit him when he wished to return to the facility. 10NYCRR 415.3(h)(1)(i)(a-c)

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during an abbreviated survey (complaint #NY 625), it was determined for 1 sampled resident (Resident #1) of the 177 residents with "out on pass" (OOP) medical orders, the facility failed to ensure a post discharge plan of care was developed with the participation of the resident and his/her family, which will assist the resident to adjust to his/her new living environment. Specifically, the facility discharged Resident #1 against medical advice (AMA) without an appropriate discharge plan, resulting in the need for emergency care and hospitalization for serious medical problems. This resulted in Immediate Jeopardy and actual harm to the health and safety of Resident #1, and the potential for serious harm that is Immediate Jeopardy to the health and safety for the 177 residents with out on pass medical orders. Findings include: The Immediate Jeopardy situation was removed on April 18, 2011 prior to survey exit, based on the following corrective actions taken by the facility: - OOP orders for all residents were discontinued; - a revised OOP assessment and care plan was developed; - implementation of a plan to train RN staff of the revised process before conducting a reassessment of residents for OOP privileges; - implementation of a plan for an RN to reassess residents wishing to go OOP in the immediate future, to determine if the resident and/or individual accompanying the resident could meet the safety and medical needs identified for the resident; - supervisory review of the results of each revised RN OOP assessment; - supervisory notification of the Medical Director, who (alone) would provide a resident OOP order; - all staff were in-serviced on the new policies and procedures; - the resident council was notified of the revised OOP procedures; and - facility administrative staff monitored all staff to ensure compliance with the new policies and procedures. ******************************************************* 1) Resident #1 was admitted to the facility on [DATE] after treatment for [REDACTED]. The resident had [DIAGNOSES REDACTED]. The facility Discharge Against Medical Advice (AMA) Policy, dated June 2009, documents that a resident who wishes to leave the facility against the advice of the administration, attending physician, and interdisciplinary team, will be considered a "self-discharge" AMA. The facility's Transfer and Discharge policy, included in the June 2010 publication, "Your Rights as a Nursing Home Resident in New York State," documents that when a resident is transferred or discharged from a nursing home, the resident has the right to receive sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility, "including an opportunity for (the resident) to participate in deciding where to go." The admission Minimum Data Set (MDS) assessment, dated March 1, 2011, documented the resident had normal cognitive ability; was totally dependent upon staff for all activities of daily living (ADLs); had functional limitation in range of motion of upper and lower extremities on both sides, that interfered with daily functions or placed the resident at risk of injury; had an indwelling urinary catheter; was always incontinent of bowel; had a [MEDICAL CONDITION] disorder; had difficulty breathing when lying flat; was at risk of developing pressure ulcers; and had 2 Stage II pressure ulcers when admitted to the facility. The facility Accident/Incident Report, signed by the former Assistant Administrator on April 5, 2011, documented the resident did not return from a pass on the evening of April 4, 2011. The resident had been made aware of the out on pass (OOP) policy, and chose to remain OOP beyond the time authorized. A care plan modification was not needed, and the resident was discharged AMA on April 5, 2011. The report did not specify a discharge plan with interventions to ensure the resident's health and safety. review of the resident's medical record revealed [REDACTED]. time. The hospital admission history and physical examination [REDACTED]. The report documented a plan for case management consultation for placement of the resident upon his discharge from the hospital because he was not allowed to return to the facility. A surveyor interviewed the resident's physician via telephone at 10:50 AM on April 15, 2011. He stated the resident failed to return from a pass on April 4, 2011, and a nurse telephoned him on April 5, 2011 to request an order to discharge the resident from the facility per policy. He stated he was required to follow facility policies. In summary, the facility failed to protect the health and safety of this resident with multiple medical problems as: - the resident was discharged AMA while OOP without an appropriate discharge plan, resulting in the need for emergency care and hospitalization for serious medical problems; - the facility failed to assist the resident to develop a care plan for the OOP time and for later when the facility discharged the resident AMA. 10NYCRR 415.11(d)(3)

Based on record reviews, staff interviews, and a review of facility policies and procedures conducted during an abbreviated survey (complaint #NY 625), it was determined for 1 sampled resident (Resident #1) of the 177 residents with "out on pass" medical orders, the facility failed to have a system in place to conduct an appropriate and thorough resident assessment to determine the level of supervision required by the resident to maintain his health and safety. Specifically, the facility failed to ensure that Resident #1's health and safety needs were considered prior to allowing him to leave the facility with an out on pass (OOP) medical order. The facility failed to ensure a care plan was developed to address this disabled resident's needs while he would be OOP. The resident subsequently required emergency medical care and hospitalization for multiple serious medical problems after the facility discharged the resident AMA. This resulted in Immediate Jeopardy, Substandard Quality of Care, and actual harm to the health and safety of Resident #1, and the potential for serious harm that is Immediate Jeopardy to the health and safety for the 177 residents with out on pass medical orders. Findings include: THIS IS A REPEAT DEFICIENCY FROM SURVEYS OF MAY 29, 2009 AND DECEMBER 14, 2010. The Immediate Jeopardy situation was removed on April 18, 2011, based on the following corrective actions taken by the facility: - OOP orders for all residents were discontinued; - a revised OOP assessment and care plan was developed; - implementation of a plan to train RN staff of the revised process before conducting a reassessment of residents for OOP privileges; - implementation of a plan for an RN to reassess residents wishing to go OOP in the immediate future, to determine if the resident and/or individual accompanying the resident could meet the safety and medical needs identified for the resident; - supervisory review of the results of each revised RN OOP assessment; - supervisory notification of the Medical Director, who (alone) would provide a resident OOP order; - all staff were in-serviced on the new policies and procedures; - the resident council was notified of the revised OOP procedures; and - facility administrative staff monitored all staff to ensure compliance with the new policies and procedures. ******************************************************* 1) Resident #1 was admitted to the facility on [DATE] after treatment for [REDACTED]. The resident had [DIAGNOSES REDACTED]. The facility Out on Pass (OOP) Policy, dated June 2009, documents: - upon admission to the facility, the social worker will meet with the resident and/or designated representative and review the OOP policy, including "the responsibility of the facility to assess and to assure the safety of the resident while out on pass;" - the interdisciplinary OOP care plan will include the ADL (activities of daily living) needs of the resident and how they will be met while out on pass, and education of the resident /escort about their responsibilities while out on pass; and - when a resident is ready to leave the facility, the charge nurse will review the care plan to determine that all necessary interventions as identified on the care plan have been addressed with the resident/responsible escort. The facility Discharge Against Medical Advice (AMA) Policy, dated June 2009, documents: - a resident who wishes to leave the facility against the advice of the administration, attending physician, and interdisciplinary team will be considered a "self-discharge" AMA; - documentation in nurses' notes and social work progress notes will reflect the circumstances surrounding the resident's decision to discharge AMA, and outline the information provided to the resident to assist in the decision making process; and - a physician order [REDACTED]." The facility Pre Admission Evaluation, dated February 22, 2011, documented the resident no longer needed rehabilitation therapy, and was to be transferred from another facility to receive long term care. The evaluation documented the resident's family had a wheelchair van to use when the resident went OOP. The resident's admission physician's orders [REDACTED]." The admission Minimum Data Set (MDS) assessment, dated March 1, 2011, documented the resident had normal cognitive ability; had the behavior of rejecting evaluation or care that is necessary to achieve the resident's goals for health and well-being; was non-ambulatory; was totally dependent upon staff for all ADLs; had functional limitation in range of motion of upper and lower extremities on both sides, that interfered with daily functions or placed the resident at risk of injury; had an indwelling urinary catheter; was always incontinent of bowel; had a seizure disorder; had difficulty breathing when lying flat; was at risk of developing pressure ulcers; had 2 Stage II pressure ulcers when admitted to the facility; and received antidepressant and antipsychotic medications. A registered nurse (RN) Unit Manager progress note, dated March 1, 2011, documented the resident had been asking to go OOP, and was told he did not yet have an OOP physician's orders [REDACTED]. Later that day, the resident left the facility with family members. Facility staff telephoned the resident, who said he "had the OK to leave," and was told he did not. The note documented the RN then obtained a verbal OOP order from the resident's attending physician. The Out on Pass Risk Assessment, dated March 1, 2011, documented the resident planned to leave the facility with a responsible person who was able to meet the resident's ADL care needs as identified in the CCP (comprehensive care plan). The interdisciplinary team decision was, "Resident safe for OOP with responsible party. Resident has own wheelchair van for transportation." The resident's CCP, dated March 2, 2011, included the following problems: - new admission to facility, with difficulty adjusting to placement related to new surroundings, and [DIAGNOSES REDACTED]. - long term Foley catheter for urinary retention, with interventions including use of a leg bag for urine collection when out of bed; - bipolar disorder, with interventions including medications per physician order [REDACTED]. - total dependence for ADLs; and - out on pass with a responsible person (time parameter not specified). Goal for the resident to benefit from the out on pass experience with no ill effects. Interventions included: a) completion of Out on Pass Log by resident/responsible party including signatures of resident/responsible party and time of departure and return; b) resident's individual needs will be addressed in these areas when applicable for mealtime/consumption (blank); c) education of resident/responsible party of expectations and responsibilities when out on pass; and d) observe for significant symptoms of change in condition or behavior when resident returns to facility. A nursing progress note, written by the RN Unit Manager on March 17, 2011, documented the resident wanted to go OOP, but his wheelchair van was not functioning. The resident stated 2 of his friends could lift him into a car, and the RN told him this would not be safe for him. A social services progress note, dated March 18, 2011, documented the resident questioned why he could not be lifted into a car by his friends. The social worker explained this was not safe because the resident needed a mechanical lift for transfers, and verified this with the Director of Physical Therapy. The resident became upset and stated "if this continues to be an issue, (he) may leave AMA in the future." physician's orders [REDACTED]. Medication orders included Keppra (antiseizure drug) 500 mg twice daily; Zoloft (for treatment of [REDACTED]. A nursing progress note, written by the RN Unit Manager on March 31, 2011, documented the resident said he wanted to go OOP on April 1, 2011. He stated he planned to depart on a public bus, and wanted to stay overnight. The note documented the RN told the resident he had an order for [REDACTED]. A progress note, written by the physician on April 1, 2011, documented the resident had a history of [REDACTED]." Nursing progress notes, dated April 2, 2011 at 11:53 AM, documented a CNA asked the nurse to assess the resident for a possible UTI. The note documented the resident's urine was cloudy, and the supervisor would be notified. Later that day, at 12:51 PM, a second nurse's note described the resident's urine as cloudy. A nursing progress note, dated April 3, 2011 at 10:38 PM, documented the resident's urine continued to have a cloudy appearance. Nursing progress notes between April 2 and April 3, 2011 did not include documentation of physician notification of the change in the appearance of the resident's urine. A licensed practical nurse (LPN) progress note, dated April 4, 2011 at 11:04 PM, documented the resident "went OOP at approximately 6:30 PM. Has not returned as of 11 PM, unable to reach him by phone. Supervisor notified." A late entry nursing progress note, written by an RN nursing supervisor at 12:24 PM on April 5, 2011, documented: - on April 4, 2011 at approximately 10:45 PM, she was notified the resident was due to return at 9:00 PM that evening, and had not returned; - the OOP log book did not specify the time the resident left the facility, nor the signature of a nurse who co-signed (with the escort) that the resident left the facility; - staff were unable to contact the resident, family, and friends by telephone; - staff were asked when the last bus would arrive that evening, and stated, "Close to 12:00 AM;" and - the last bus arrived at 11:57 PM, and the resident was not on the bus. A nursing progress note, written by the RN Unit Manager at 5:15 PM on April 5, 2011, documented the resident failed to return from OOP as ordered, and the resident was notified he would not be able to return to the facility "per policy." Adult Protective Services was notified, and the resident was advised to go to a hospital emergency room "to get further medical assistance if needed." The resident's physician was notified and provided an order for [REDACTED]. The facility Accident/Incident Report, signed by the former Assistant Administrator on April 5, 2011, documented the resident had been made aware of the OOP policy, and chose to remain OOP beyond the time authorized. A care plan modification was not needed, and the resident was discharged AMA on April 5, 2011. The resident's April 2011 medication administration record (MAR), documented the following medications were not administered because the resident was out on pass: - April 4 at 8:00 PM: Keppra 500 mg, Zoloft 50 mg, Zyprexa 5 mg, and albuterol inhaler; - April 4 at 10:00 PM: Depakote sprinkles 250 mg; - April 5 at 8:00 AM: albuterol inhaler; - April 5 at 10:00 AM: Keppra 500 mg and Depakote sprinkles 250 mg; - April 5 at 12:00 PM: albuterol inhaler. An emergency medical service (EMS) report, dated April 5, 2011 at 1:27 PM, documented an ambulance was called that afternoon to evaluate the resident in a private apartment. The Resident told EMS staff he was "kicked out" of the facility. He stated facility staff had advised him to call 911, whereupon an ambulance would take him to the hospital to obtain his medications and bring him back (to the apartment). The report documented the resident was told he needed to find another way to get to the hospital, since the ambulance was to be used for emergency services only. A second EMS report, dated April 5, 2011 at 3:38 PM, documented the resident called for ambulance transportation to the hospital to evaluate a problem with his urinary catheter. The report documented the resident's blood pressure was 140/102 mm Hg (millimeters of mercury) at 3:45 PM, and the resident began to experience a seizure at that time. EMS staff then administered midazolam (sedative, anti-seizure drug) 5 mg intravenously, and again at 3:52 PM. At 4:05 PM, the resident's blood pressure increased to 199/174 mm Hg. The resident became unresponsive, and required placement of an oral/nasal airway device. Upon arrival at the hospital at 4:14 PM, the resident became "notably hypotensive (low blood pressure)," with a blood pressure of 63/33 mm Hg. The hospital admission history and physical examination [REDACTED]. The report documented the resident's urinalysis was abnormal, with increased protein, glucose, white blood cells (sign of infection), bacteria, and large amounts of blood. The report documented a plan for case management consultation for placement of the resident upon his discharge from the hospital because he was not allowed to return to the facility. A hospital physician's progress note, dated April 6, 2011, documented the resident stated he was staying with friends on April 4 and 5, 2011, and missed his medications. He stated he was having issues of sludge in his Foley (urinary) catheter, and foul-smelling urine prior to being brought to the emergency department on April 5, 2011. The physician's assessment included seizures due to being off his medication, and sepsis secondary to UTI. A hospital physician's progress note, dated April 18, 2011, documented that per laboratory report, the resident had a multi-drug resistant UTI. A surveyor interviewed the current Assistant Administrator at 11:30 AM on April 13, 2011 regarding the facility Discharge Against Medical Advice policy. She was unable to explain why the policy does not include a procedure for staff to follow if a resident fails to return to the facility at the time previously planned, nor a procedure for written information given to residents advising them of the facility AMA discharge policy. When asked about staff responsibility to assist Resident #1 to return to the facility in a timely manner when using public transportation, the Assistant Administrator stated this was left up to the resident because he was alert and oriented. A surveyor interviewed the RN Unit Manager at 2:00 PM on April 13, 2011. When asked about staff responsibility to verify the resident would have been able to safely return to the facility on a public bus on the evening of April 4, 2011, the RN stated the only facility requirement was for the resident to have an escort. She stated the resident telephoned her at 8:00 AM on April 5, 2011, and told her he was unable to call the facility while he was OOP on April 4, 2011 because his cell phone could not access service. He stated the bus he planned to take back to the facility did not arrive. The RN stated she spoke to the resident later that day, and told him to go to the local hospital to obtain his medications. When asked about the facility policy for AMA discharge, the RN stated the facility will not allow a resident to return in the event of intentional elopement. A surveyor interviewed the Assistant Director of Nursing (ADON) at 8:40 AM on April 15, 2011. When asked how the resident's needs for ADL assistance, such as transfer, positioning, incontinence care, feeding, skin care, and urinary catheter care would be met by the person who accompanied the resident OOP, the ADON stated nursing staff would review the care planned interventions with the responsible person. After reviewing the resident's CCP, the ADON stated this information was not included. When asked about staff training of the resident's friends/family to assist him to travel to and from the facility on a public bus, the ADON stated the resident's care plan would be changed if he experienced an adverse event while using the bus. When asked for documentation that facility staff trained and assessed responsible persons for their ability to care for the resident while OOP, she stated the resident's medical record contained no documentation of this. When asked about the lack of care planning related to the resident's seizure disorder, she stated this should have been included on the CCP. The ADON stated the facility did not provide medications to residents when they went OOP in the event they were unable to return on time. The ADON stated that prior to April 5, 2011, the resident's medical record contained no documented evidence he was told he would be discharged AMA if he failed to return at the predetermined time. A surveyor interviewed the resident's physician via telephone at 10:50 AM on April 15, 2011. He stated the resident failed to return from a pass on April 4, 2011, and a nurse telephoned him on April 5, 2011 to request an order to discharge the resident from the facility per policy. He stated he was required to follow facility policies. The physician stated he was aware the resident's family wheelchair van had broken down, and he had no opinion regarding the feasibility of the resident using a public bus for transportation. He stated the resident had the right to make his own decisions. The physician stated he was not informed of the resident's cloudy urine on April 2 and 3, 2011, and had no knowledge about the resident's seizure history. A surveyor interviewed the Medical Director at 11:50 AM on April 15, 2011 regarding the decision to discharge the resident AMA after he failed to return from pass at a predetermined time on April 4, 2011. The Medical Director stated: - he had no information about the resident's leaving the facility on March 1, 2011, without an OOP order; - he did not have enough detail about the resident's use of a public bus rather than the care planned wheelchair van for transportation. "The resident can make his own decisions;" - training of a person responsible for this quadriplegic resident with a urinary catheter and seizure disorder while OOP was unnecessary due to the length of time the resident was to be out of the facility; - regarding the resident's behaviors, and [DIAGNOSES REDACTED]. "Mental illness does not exempt people from being able to make decisions;" and - the facility policy does not need to document that a resident who leaves the facility AMA will not be allowed to return. "The resident "discharged himself." A surveyor interviewed the social worker at 12:45 PM on April 15, 2011. She stated that on April 5, 2011, she called Adult Protective Services staff to notify them the resident was discharged AMA that day, and they were confused about the reason the facility would not allow the resident to return to the facility. The social worker said she told them the resident could not return to the facility because he had a day pass, and stayed overnight. The social worker stated the resident called her on April 5, 2011, and said he was on his way to the hospital because his urinary catheter bag had burst. In summary, the facility failed to protect the health and safety of this quadriplegic resident with multiple medical problems as: - the interdisciplinary team failed to assess the resident's ability to remain safe when out on pass; - the facility failed to assure a care plan was developed and implemented to address the resident's multiple physical and medical problems while he was out on pass and subsequently discharged him AMA whch resulted in the need for emergency medical care and hospitalization for seizures and multi-drug resistant urinary sepsis; - the facility failed to readmit the resident when he stated he wished to return to the facility from pass; and - the facility failed to implement safe discharge planning. 10 NYCRR 415.12 (h)(2)

Based on staff interviews and record reviews conducted during an abbreviated survey (# NY 632), it was determined the facility did not provide the necessary care and services to maintain the highest practicable physical well being for 3 (Resident #27, 28, and 31) of 31 sampled residents reviewed for bowel and skin care. Specifically, the facility did not ensure Resident #31 was assessed by a registered nurse (RN) and did not ensure Resident #31 was administered the physician-ordered "as needed" suppository (laxative) when he went extended periods without a bowel movement (BM). For Residents #27 and 28, the facility did not ensure pressure-relieving devices were implemented as planned. This resulted in actual harm that is not immediate jeopardy for Resident #31 when he developed a fecal impaction; and resulted in the potential for more than minimal harm that is not immediate jeopardy for Residents #27 and 28. THIS IS A REPEAT DEFICIENCY FROM THE [DATE] SURVEY. Findings include: 31) The facility policy titled "Bowel Program," written [DATE] and revised February 2010, specified staff (aides or nurses) were to document (in the electronic medical record) whether every resident had a bowel movement (BM), or not, during each shift. Staff were to complete the defecation worksheet each shift on every resident. On a daily basis, the Charge Nurse was required to review the defecation worksheets to determine "the need for assistance with bowel evacuation. All residents who have not moved their bowels or documented less than large/medium results in 9 consecutive shifts, will be addressed either through obtaining bowel medication orders from the physician, if no results from the medication, send to 24 hour report, notify the physician, and review" for chronic bowel irregularity by the Interdisciplinary Care Team. Resident #31 was a long time resident of the facility with [DIAGNOSES REDACTED]. The resident expired on [DATE]. The Minimum Data Set (MDS), dated [DATE], documented the resident's cognitive status was severely impaired; was rarely understood by others; had bowel incontinence all the time; and required total assistance with activities of daily living (ADLs). Physician orders, dated [DATE] and renewed on [DATE], documented Physician #1 ordered: [MEDICATION NAME] (laxative) twice a day (at 8 AM and 8 PM) for constipation; routine [MEDICATION NAME] (stimulant laxative) suppository 10 mg every Monday, Wednesday, and Friday at 6 AM for constipation; and a [MEDICATION NAME] suppository 10 mg at 12 AM, "as needed", if the resident had "no bowel movement in 3 days and routine suppository not effective." The "CNA Documentation History Detail" sheets (PDA, computer data entry system), dated [DATE], documented the resident did not have a bowel movement (BM) for 19 consecutive shifts (from [DATE] on the 11 PM to 7 AM shift, through the 7 AM to 3 PM shift on [DATE]). A hand written bowel sheet, dated [DATE] through [DATE], documented information not included in the resident's medical record. Thirty residents were documented on this paper, including Resident #31, with hand-written information on their BM status. This hand-written bowel sheet documented the resident had a BM on [DATE]. On [DATE], 5, 7, 8, 2010, this hand written sheet documented the resident did not have a BM. The resident did not have a BM, per this hand written bowel sheet from [DATE] on the ,[DATE] shift through [DATE] on the ,[DATE] shift, revealing the resident went 10 shifts without a BM. On [DATE], there was an illegible mark on the ,[DATE] shift, not clearly documenting whether the resident had a BM that day. Review of the electronic nursing notes from [DATE] through [DATE] revealed no documented RN assessment of the resident's bowel status during that time. The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"as needed" [MEDICATION NAME] suppository after he went more than 10 shifts without a BM. Physician orders [REDACTED]. The surveyor interviewed registered nurse (RN) #1 Head Nurse on [DATE] at 2:45 PM, regarding the procedure for monitoring residents' bowel status. RN #1 stated "everyday we go through the BM sheets." She stated if the resident went 9 days without a BM, "we would give him what the physician prescribed." The RN did not clarify which "BM sheet" was monitored Review of the electronic records (CNA Documentation History Detail sheets) and the submitted hand written sheets for [DATE], revealed conflicting information regarding the resident's BM status. The surveyor re-interviewed RN #1 on [DATE] at 2:15 PM , regarding the reason the resident was not administered a suppository when he went extended periods without a BM in [DATE]. RN #1 stated there was an error in documentation in the "PDA"; and that they "used both systems" for tracking: a "paper sheet" and the PDA. She stated "we have a paper sheet showing he (the resident) had a BM on [DATE]. The RN did not comment on the lack of documentation in nursing notes related to the resident's bowel status. A hand-written bowel sheet, dated [DATE], 15 and 16, 2010, documented the resident had a moderate bowel movement on the 7 AM-3 PM and the 3 PM-11 PM shifts on [DATE]. On this hand written sheet, the resident was documented to have no BM on [DATE]; and had a large BM on 2 shifts on [DATE] and on one shift on [DATE]. There was a line drawn through [DATE], with the note hand written documenting: "This sheet was copied by hand to a new sheet because of these incorrect entries." The resident's [DATE] electronic CNA Documentation History Detail sheets documented the resident did not have a BM from [DATE] on the 7 AM to 3 PM shift, to [DATE] on the 7 AM to 3 PM shift (11 shifts without a BM). Review of the resident's [DATE] MARs revealed no documentation the resident was administered the "as needed" suppository after going 11 shifts without a BM (between [DATE] and [DATE]). Nursing notes, dated [DATE] at 1:53 PM, documented registered nurse (RN) #1 was called to see the resident. The RN documented the resident was "hot to touch", with a rectal temperature of 104 degrees F. and an oxygen saturation of 86%. The resident was placed on oxygen at 4 liters per minute, via facial mask, and a Tylenol suppository was administered. A message was left with the on-call Physician #1. At 5:28 PM on [DATE], a nursing note documented the resident's temperature was 100 degree F; "appears to be in pain judging by the looks on his face." Tylenol suppository was administered and urine was collected and sent out for an urinalysis. At 6:42 PM, nursing notes specified the resident was lethargic and his urine was thick and foul-smelling. The resident's family wanted him sent to the hospital for an evaluation. The note documented there was no response when physician #1 was called again. Physician #2 was contacted at 6:35 PM. At 7:05 PM, nursing notes specified physician #2 ordered antibiotics started, and to send a urinalysis. At 10:56 PM, nursing notes documented the resident remained on 4 liters of oxygen. Fluids were encouraged and staff would "continue to monitor." At 1:39 AM, on [DATE], nursing notes specified the resident's temperature was 102.9 degrees at 12:10 AM, a Tylenol suppository given and at 1:37 AM, the resident's temperature was 99 degrees. At 11:44 AM, the nursing note documented the resident was lethargic, taking no medication or fluids by mouth, had upper respiratory congestion, and dyspnea (difficulty breathing). The resident's sister requested the resident be transferred to the emergency room . Nursing notes specified physician #1 was left a message at 10:30 AM, and had not returned the call by 11:44 AM. The Nursing Supervisor was made aware, saw the resident, and send the resident to the hospital for evaluation by ambulance. Review of the resident's electronic nursing notes from [DATE] through [DATE], revealed no documentation that an RN assessed the resident's bowel status during that time. The admission hospital physician note, dated [DATE] at 5:50 PM, documented the resident was admitted with fevers, [MEDICAL CONDITION], [MEDICAL CONDITIONS], respiratory distress", with "markedly elevated creatinine" and "elevated white count". The resident was provided with intravenous (IV) fluids in the emergency room , and 2 units of blood. The note specified the resident had signs and symptoms [MEDICAL CONDITION] (systemic infection) with a probable "gastrointestinal source". Abdominal films revealed "distal fecal impaction" with "abdominal distention". A surgical consult was ordered. The surgical consultation note, dated [DATE] at 3:53 PM, documented the resident "was given some enemas, and he has had several huge bowel movements." Repeat abdominal x-ray revealed there was "still a large amount of stool in the rectal area." The surgeon documented the resident received fluids aggressively" and examination revealed the resident had diminished bowel sounds. The recommendations were to "treat conservatively at this time." The hospital discharge summary, dated [DATE], documented the resident expired at 12:40 AM that date. The death certificate documented the cause of the resident's death [MEDICAL CONDITION]. In summary, the resident experienced harm with a fecal impaction, as: - the facility did not ensure an RN assessed the resident's bowel status when he went extended periods without an BM in [DATE] and [DATE]. - the facility did not ensure the resident was administered the physician-ordered "as needed" suppository for bowel eliminations, when the resident did not have a BM after 9 shifts in August and [DATE]. - facility staff did not comply with the facility policy titled "Bowel Program." - facility staff did not accurately assess the resident's bowel status, as 3 different sources (with conflicting data) were utilized to document the resident's bowel movements: the hand written BM sheet, the electronic BM record on the "PDA", and nursing notes. 2) Resident #28 had [DIAGNOSES REDACTED]. On [DATE], a Braden Scale (identify risk for skin breakdown) was completed and documented the resident was a moderate risk for skin breakdown. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short term memory loss, and was moderately impaired in decision making. The resident was non-ambulatory and required extensive assistance with transferring and locomotion, and was incontinent of bowel and bladder. The resident had a pressure relieving device in bed and was on a turn and positioning program. The comprehensive care plan (CCP) printed on [DATE] and identified as the current plan of care, documented the resident was out of bed to a wheelchair with an Ultrafoam cushion, related to his risk for skin breakdown with impaired mobility, incontinence, history of [MEDICAL CONDITION], dementia, arthritic pain, and a history of a Stage 1 area on his left foot and toe. The certified nurse aide (CNA) instructions for providing care to the resident, printed on [DATE], identified the resident used a posture guard chair for locomotion and documented the resident used a pressure relieving cushion. An ultra foam cushion was specified for the wheelchair; and the resident was encouraged to "sit in a recliner" after lunch. The surveyor observed the resident to be seated without a cushion in the chair as follows: - on [DATE] at 6:00 PM, the resident was seated in a recliner chair (Posture Guard) at the table in the unit dining room/activity area (Core); - on [DATE] from 12:12 PM to 1:20 PM, the resident was seated in a recliner chair (Posture Guard) in the unit Core; - on [DATE] from noon to 12:30 PM, the resident was seated in the Posture Guard chair in the Core; - on [DATE] at 6:00 PM, seated in the Posture Guard chair in the Core. On [DATE], the surveyor interviewed the Director of Rehabilitation Therapy at 9:00 AM. She stated nursing assessed the residents for positioning devices, including cushions, and ordered them from Central Supply. She stated currently, the therapy department was not doing rounds and only attended care planning meetings for residents in rehabilitation. She said positioning concerns related to skin breakdown were not routinely discussed at the care plan meeting when she was in attendance. The registered nurse (RN) Head Nurse on 3 South was interviewed on [DATE] at 3:00 PM. She stated when a new resident was admitted , a request was sent to Central Supply for an Ultra Foam cushion. She stated cushions were not used in the Posture Guard chairs as it "puts them up too high". The RN said if a resident was restless and they were elevated "too much", it was "more of a problem". A certified nurse aide (CNA) was interviewed on [DATE] at 9:35 AM regarding Resident #28 and pressure relieving devices. She stated when the resident was in the lounge chair (Posture Guard), it was "kind of high" and the cushion was not placed in the chair. The Director of Rehabilitation Therapy was re-interviewed on [DATE] at 9:55 AM. She stated she was not aware of any chairs in the facility that provided pressure relief, without the use of a pressure relieving cushion. In summary, the facility did not provide a pressure relieving device as planned in the Posture Guard chair, for this resident assessed to be at moderate risk for skin breakdown, and the plan included the use of a pressure relieving cushion. 3) Resident #27 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] identified the resident with poor short and long term memory and severely impaired decision making ability. The resident required assistance transferring, supervision with ambulation, and extensive assistance with locomotion on the unit. The resident was identified to have a pressure relieving device in bed and in her chair. The comprehensive care plan (CCP), printed on [DATE] as the "active" plan, specified the resident had a potential for skin breakdown related to her dementia, impaired nutritional status with ongoing significant weight loss, and impaired mobility. The plan included an Ultrafoam cushion provided in the resident's wheelchair when utilizing the chair. The Resident Nursing Instructions, printed on [DATE], as the current instructions to be used by the certified nurse aides (CNAs) documented the use of a pressure relief cushion. When the resident was observed with no cushion in her wheelchair on [DATE], a family member who was with the resident since 10:30 AM, was interviewed at 11:45 AM. She stated the resident usually had a cushion and she did not know why one was not present on this date. The resident was observed seated on a Dycem (non-skid surface) and a soaker pad (with no cushion) from 11:30 AM through 1:15 PM. A CNA on the resident's floor was interviewed on [DATE] at 12:15 PM. She stated the information identifying the use of a cushion, was in the "PDA" (hand held computer data entry device). The CNA stated when the wheelchairs were washed, the cushions were removed from the chair; sometimes float CNA did not leave them in the resident's room for the next day. As a result, they were not always placed back in the chair for the resident's use. In summary, for this resident who was at risk for skin breakdown, the facility did not provide the pressure relieving device in the resident's chair on a routine basis as planned. 10 NYCRR 415.12