Every finding on record at Workmen's Circle Multicare Center

Based on observation, record review, and interview during the Recertification Survey conducted from 04/03/2025 to 04/10/2025, the facility did not ensure that the storage for controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 were safe and secure. This was evident in 1 (Unit 2 South) of 12 units during the Medication Storage Task. Specifically, numerous controlled medications were secured in a one locked instead of double-locked cabinet per the regulations. The findings are: The facility policy titled Controlled Substances-Delivery, Storage, Count, Administration, Wasting and Return effective date of 01/2023 documented All controlled substances will be stored in a double door, double locked, permanently affixed to the wall, narcotic cabinet in the medication room During an observation on 04/07/2025 at 2:52 PM in Unit 2 South, the Medication Room adjacent to the nurse's station was inspected. The Unit 2 South narcotic box was observed with multiple packs of Schedule II - V controlled medications inside the first locked door of the cabinet on top of a smaller second locked narcotic box. The controlled medications were secured with only one lock. Registered Nurse #6 was immediately interviewed after the observation on 04/07/2025. They stated the narcotics that are on the shelf are either discontinued or the resident has been discharged . Registered Nurse #6 stated they are not sure when they were placed there, and they did not count them with another nurse at the change of shift this morning. Registered Nurse #6 further stated the nursing supervisor usually returns the discharged and discontinued narcotics to the Assistant Director of Nursing's office. Register Nurse #6 was unable to explain why the narcotics were not kept in a double locked cabinet. During an interview on 04/07/2025 at 3:08 PM, Registered Nurse #7, who was also the unit supervisor, was interviewed. They stated these medications are discontinued controlled substances which should have been stored in the second double locked cabinet until they were returned to the Assistant Director of Nursing's office. Registered Nurse #7 further stated the Assistant Director of Nursing was not working this past weekend, so they were not removed. The controlled medications may have been placed on the shelf since they didn't fit in the smaller second locked cabinet. During an interview on 04/09/2025 at 10:34 AM, the Assistant Director of Nursing stated when a narcotic is discontinued, or the resident is discharged the nursing supervisor is supposed to return the controlled medications to the Assistant Director of Nursing's office for disposal. Until then, the controlled medications should have been stored in a double locked narcotic cabinet. During an interview on 04/09/2025 at 3:54 PM, the Director of Nursing stated all controlled medications should be stored in double locked narcotic cabinets. The nursing supervisors are supposed to notify the Assistant Director of Nursing when they have controlled medications that are discontinued and need to be returned to the nursing office for proper disposal. 10 NYCRR 415.18(e) (1-4)

Based on observation, record review, and interviews during the Recertification Survey conducted from 04/03/2025 to 04/10/2025, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident in 1 (Unit 2 South) of 12 units observed during the Medication Storage Task. Specifically, controlled medications were not periodically reconciled in Unit 2 South. The Individual Controlled Medication Records forms were missing licensed nurses' signatures validating the correct narcotic count. The Findings are: The facility policy titled Controlled Substances-Delivery, Storage, Count, Administration, Wasting and Return with effective date of 01/2023 documented a narcotic count will be conducted at the change of each shift. The total number of cards, and/or controlled drug containers are to be counted with every narcotic count for accuracy and documented on the unit's narcotic supply shift-to-shift accountability record. All off-going nurses will remain on the unit until the count has been completed and reconciled. During an observation on 04/07/2025 at 2:52 PM in Unit 2 South, the Medication Room adjacent to the nurse's station was inspected. The unit 2 South narcotic box was observed with multiple packs of Schedule II - V controlled medications separately bagged along with the Individual Controlled Medication Record forms. The Individual Controlled Medication Records forms did not document shift-to-shift licensed nurses' signatures validating the correct narcotic counts. Registered Nurse #6 was immediately interviewed after the observation on 04/07/2025. They stated the narcotics that are on the shelf are either discontinued or the resident has been discharged . Registered Nurse #6 stated they are not sure when they were placed there, and they did not count them with another nurse at the change of shift this morning. Register Nurse #6 was unable to explain why the narcotics were not kept double locked or counted at the change of shift that morning. Resident #662's Individual Controlled Medication Record for Morphine Sulfate Solution 5 mg was last reconciled and signed on 03/28/2025. Resident #62 was discharged on [DATE]. Resident #486's Individual Controlled Medication Record for Oxycodone 5mg was last reconciled and signed on 03/07/2025 and the medication was discontinued on 02/26/2025. Resident #663's Individual Controlled Medication Record for Oxycodone 10 mg was last reconciled and signed on 03/08/2025. Pregabalin 200 mg and Clonazepam 1 mg were last reconciled and signed on 03/10/2025. Resident #663 was discharged 0n 02/27/2025. Resident #664's Individual Controlled Medication Records for Oxycodone 5 mg was last reconciled and signed on 03/07/2025 and the medication was discontinued on 03/04/2025. Oxycodone 5-325 mg was last reconciled and signed on 03/08/2025 and the medication was discontinued on 02/17/2025. Oxycodone-Acetaminophen 7.5mg-325 mg was last reconciled and signed on 03/18/2025. Resident #664 was discharged on [DATE]. Resident #665's Individual Controlled Medication Record for Tramadol 50 mg was last reconciled and signed on 03/08/2025. Resident #665 was discharged on [DATE]. During an interview on 04/07/2025 at 3:08 PM, Registered Nurse #7 who was also the unit supervisor was interviewed. They stated these medications are discontinued controlled substances which should have been stored in the second double locked cabinet and counted with 2 nurses every shift, until they were returned to the Assistant Director of Nursing's office. Registered Nurse #7 further stated the Assistant Director of Nursing was not working this past weekend, so they were not removed. Also, the controlled medications may have been placed on the shelf since they did not fit in the smaller second locked cabinet. Registered Nurse #7 was unable to explain why the controlled medications were not being counted and signed by the oncoming and off-going nurses every shift to validate the correct narcotic count. During an interview on 04/09/2025 at 10:34 AM, the Assistant Director of Nursing stated when a narcotic is discontinued or a resident is discharged the nursing supervisor is supposed to return the controlled medications to the Assistant Director of Nursing's office for disposal. Until then, the controlled medications should have been stored in the double locked narcotic cabinet and counted with 2 nurses every shift. During an interview on 04/09/2025 at 3:54 PM, the Director of Nursing stated all controlled medications should be stored in the double locked narcotic cabinets and counted by 2 nurses at each shift change. 10 NYCRR 415.18(a)

Based on observation, record review, and interview conducted during an Abbreviated Survey (NY00325595), the facility failed to protect a resident's right to be free from physical abuse by nursing home staff. This was evident in 1 out of 5 residents (Resident #1) reviewed for abuse. Specifically, on 10/07/23 at approximately 6:06pm, the facility's surveillance camera recording showed Resident #1 struck Certified Nursing Assistant (CNA) #1 with a headphone. CNA #1 then hit Resident #1 on the back of their head. Additionally, CNA #2, #3, and CNA #4 witnessed CNA #1 hit Resident #1 at the back of their head. Registered Nurse Supervisor (RNS) #1 assessed Resident #1 who had no visible injuries. The findings are: The facility policy on Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation, and Mistreatment dated 10/2022 states that the facility will not use or permit physical abuse. This prohibition extends to abuse by anyone, including but not limited to, other residents, staff, consultants, volunteers, and staff of other agencies serving the residents, or other individuals. Resident #1 was admitted to the facility with diagnoses of End Stage Renal Disease and Type 2 Diabetes Mellitus. The Minimum Data Set (MDS, a resident assessment tool) dated 07/20/2023 documented that Resident #1 had intact cognition. An Abuse Care Plan for Resident #1 was implemented on 05/17/2023. The interventions documented that staff should advise Resident #1 to seek out staff assistance if having difficulty with others, to calmly redirect resident away from potential harm, and to intervene as necessary to ensure safety. A Health Status Note by RNS #1, dated 10/07/2023 at 9:38pm documented that on 10/07/2023 at approximately 6:15pm, Resident #1 wheeled themself to Unit #2 dining hall to ask for a sandwich. CNA #1 told Resident #1 that sandwiches on the unit are for other residents. CNA #1 tried to redirect Resident #1 towards their unit. Resident #1 started to argue with CNA #1 and hit CNA #1 with their earphones. CNA #1 hit Resident #1 on the left side of their head. The facility's summary of investigation dated 10/07/2023 documented in their conclusion that staff statements and review of the camera footage showed CNA #1 hit Resident #1 at the back of Resident #1's neck instead of calling for assistance or walking away. Resident #1 was assessed with no visible injuries. A skull x-ray revealed no abnormality. The Occurrence Investigative Form documented that there was probable evidence of abuse since CNA #1 hit Resident #1. The facility's surveillance camera recording reviewed with the Director of Nursing (DON) on 10/17/2023 at 12:09pm. Camera #1 showed on 10/07/2023 at 6:06pm, Resident #1 wheeled themself into the dining room towards CNA #1. Resident #1 and CNA #1 were both motioning and gesturing with their hands. Resident #1 approached the table where CNA #1 was standing and tried to reach for an item on the table. CNA #1 tried to stop Resident #1 from touching the items on the table. CNA #1 approached Resident #1 from behind their wheelchair and wheeled Resident #1 away from the dining room. Camera #3 showed Resident #1 hit CNA #1's left hand with their right hand while being wheeled. CNA #1 continued wheeling Resident #1 in the hallway. Resident #1 dropped their headphones on the floor and CNA #1 picked up the headphone and gave it back to Resident #1. CNA #1 continued to push Resident #1's wheelchair and stopped in the hallway. Resident #1 was observed hitting CNA #1 with their headphone. CNA #2 stepped out of a resident's room and tried to stop Resident #1 from hitting CNA #1. CNA #3 stepped out of the same room and as CNA #3 was moving to the back of Resident #1's wheelchair, CNA #1 struck Resident #1 in the back of Resident #1's head with their right hand. CNA #2 and CNA #3 pushed CNA #1 away from Resident #1 and CNA #1 walked away from camera view. During an interview on 10/17/2023 at 10:55am, Resident #1 stated they wheeled themself to the dining room last Saturday (10/07/23) to asked for a sandwich. Resident #1 stated that they went over to the table where CNA #1 was standing and started checking the food items on the table. Resident #1 stated that CNA #1 got upset, tapped Resident #1's hand, and wheeled Resident #1 back to their room. Resident #1 stated that they hit CNA #1 with their headphone and CNA #1 hit Resident #1 on the left side of Resident #1's neck with CNA #1's right fist. Resident #1 stated that they were not hurt and that they did not feel any pain. Resident #1 stated that the Police Officers came to their room to speak about the incident. During an interview on 10/17/2023 at 1:30pm, CNA #1 stated that on 10/07/2023 at approximately 6:00pm, Resident #1 began cursing at CNA #1 because CNA #1 did not have a sandwich. CNA #1 stated that they wheeled Resident #1 out of the dining room and Resident #1 swung their headphone and hit CNA #1 on the face. CNA #1 stated that they tried to push Resident #1's hand away and accidentally touched Resident #1's head. CNA #1 stated that they did not hit Resident #1. During an interview on 10/17/2023 and 10/18/2023, CNA #2 stated that they witnessed CNA #1 strike Resident #1 on the back of Resident #1's head. CNA #2 stated that they heard a slapping sound but Resident #1 did not have a reaction to the slap. During an interview on 10/17/2023 and 10/18/2023, CNA #3 and CNA #4 stated that they witnessed CNA #1 strike Resident #1 in the back of Resident #1's neck. Both CNA #2 and CNA #4 stated that CNA #1 hit Resident #1 with an open hand. CNA #4 stated that CNA #3 separated CNA #1 and Resident #1, and that CNA #4 called Registered Nurse (RN) #1 immediately. During an interview on 10/19/2023 at 3:13pm, the Director of Nursing (DON) stated that on the evening of 10/07/2023, they received a call from RNS #1 stating that CNA #1 hit Resident #1. The DON stated they went to the facility and initiated an investigation. The DON stated that they reviewed the surveillance camera recording and observed that CNA #1 hit Resident #1. The DON also stated that the incident was witnessed by other staff on the unit. The DON stated that the investigation concluded that abuse did occur. During an interview on 10/19/2023 at 3:45pm, the Administrator stated that the DON notified them of the incident right away. The Administrator stated that based on their investigation, abuse had occurred. 10 NYCRR 415.4(b)(1)(ii)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00319096), the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations of abuse were made to the New York State Department of Health (NYSDOH). Additionally, the facility failed to ensure that an alleged violation of sexual abuse was reported to the local law enforcement. This was evident in 1 of 3 residents sampled for abuse (Resident #1). Specifically, on 06/28/2023, the facility received a report from the hospital Social Worker (SW) stating that Resident #1 alleged that an x-ray technician inappropriately touched their breasts during a chest x-ray procedure. The facility did not report the allegation to the NYSDOH and to local law enforcement. The findings are: The policy titled Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation and Mistreatment with an effective date of 10/2022 stated that all staff members have an obligation to report any reasonable suspicion of a crime to the police and State Survey Agency. The employee must make the report to the police within 2 hours after they suspect that a crime has occurred if the crime involves serious bodily injury to the individual or within 24 hours if there is no serious bodily injury involved. The facility shall ensure that alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator and when required by law or regulation, the facility shall ensure timely notification to the Department of Health. Resident #1 was admitted to the facility with diagnoses including Chronic Kidney Disease (CKD) with Heart Failure and Stage 5 CKD, and Type 2 Diabetes Mellitus. The Minimum Data Set with assessment reference date of 03/19/2023 documented that Resident #1 had intact cognition. A Grievance / Complaint Form dated 06/28/2023 documented that the Director of Admissions (DOA) received a phone call from the Hospital SW regarding Resident #1's allegation against an x-ray technician. The hospital SW advised the facility that they also notified the NYSDOH. The grievance form documented that no other information was provided by the hospital SW. Chart reviewed and the radiology company was notified of the allegation. An interview was not done with Resident #1 as the Resident was discharged to the hospital on 06/06/2023. Unable to obtain date, time, and procedure from the hospital SW. Resident #1 was last seen for arterial doppler on 05/04/2023. Prior to this date there was no concerns expressed by the resident. Unable to reach Resident #1. A copy of investigation was received from the radiology company. The facility concluded that there was no evidence of abuse, neglect, misappropriation, or exploitation. The radiology company's Client Accident / Incident / Grievance Report dated 06/28/2023 documented that the facility contacted the radiology company regarding the allegation made by Resident #1 while at the hospital that they had been a subject to inappropriate conduct by a technologist during a diagnostic test at the facility. The summary of investigation documented that each technologist who performed diagnostic testing on Resident #1 was contacted and each confirmed that they did not have memory of the specific resident and exam. The radiology company's action plan to prevent recurrence documented that the radiology company will perform in-servicing on residents' rights and sexual harassment on a company wide basis and will continue to monitor the technologists. There was no documented evidence that the facility reported the allegation to the NYSDOH and to local law enforcement. During an interview on 08/11/2023 at 11:57 am, Resident #1 stated that they were a resident at the facility and that sometime in May 2023, a technician came to their room to perform a chest x-ray. Resident #1 stated that the technician pulled their gown down to where their breasts were coming out and that the technician kept cupping and bringing their breasts up. Resident #1 stated that they do not know if it was part of the procedure, but that they felt uncomfortable. Resident #1 stated that they reported the alleged incident to the hospital SW. During an interview on 07/31/2023 at 1:25 pm, the DOA stated that they received a call from the Hospital SW on 06/28/2023 at about 9:19 am about an allegation made by Resident #1 against an x-ray technician being inappropriate. The DOA stated that they were not given any details. The DOA said that they reported the allegations to the Director of Social Service (DSS), the Administrator, the Director of Nursing (DON), and the [NAME] President of Admissions. During an interview on 07/31/2023 at 5:15 pm, the DSS stated that they received a grievance on 06/28/2023 about Resident #1 making allegations against a technician. They stated that it is the DON's responsibility to notify the NYSDOH. The DSS stated that they must check to see why the police was not notified. During an interview on 07/31/2023 at 3:26 pm, the DON stated that they found out about the allegation on 07/21/2023 when they received a call from the Attorney General's (AG) office regarding a technician who inappropriately touched Resident #1 during a chest x-ray procedure. The DON said that they did not call the police and did not report the allegation to the NYSDOH because they received the call a month late and that Resident #1 was discharged . The DON stated that the facility policy on sexual abuse states that they must report the allegation to the NYSDOH and immediately call the police. During an interview on 07/31/2023 at 5:48 pm, the Administrator stated that they were made aware of the Resident #1's allegation by the Admissions Department on 06/28/2023. The Administrator stated that for any allegations of abuse, the facility has a 2-hour time frame to report the allegation to the NYSDOH and the police must be called right away. The Administrator stated that the allegation was not reported to the NYSDOH, and the police was not called because Resident #1 was discharged from the facility. 10 NYCRR 415.4(b)

Based on observation, interviews and record review conducted during an abbreviated survey (NY00319096), the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated. This was evident in 1 of 3 residents (Resident #1) sampled for abuse. Specifically, on 06/28/2023, the facility received a report from the hospital social worker (SW) stating that Resident #1 alleged that an x-ray technician inappropriately touched their breasts during a chest x-ray procedure. The facility initiated an investigation but did not thoroughly investigate the allegation. There were no statements from staff members. The findings are: The facility's policy titled Reporting and Investigating of Resident Abuse, Neglect, misappropriation/Exploitation, and Mistreatment with effective date of 10/2022 stated that the facility shall conduct a thorough investigation of all alleged violations involving abuse. The policy also states that staff involved, and other witnesses will be identified and interviewed regarding any knowledge of the allegation. Resident #1 was admitted to the facility with diagnoses including Chronic Kidney Disease (CKD) with Heart Failure and Stage 5 CKD, and Type 2 Diabetes Mellitus. The Minimum Data Set with assessment reference date of 03/19/2023 documented that Resident #1 had intact cognition. A Grievance / Complaint Form dated 06/28/2023 documented that the Director of Admissions (DOA) received a phone call from the Hospital SW regarding Resident #1's allegation against an x-ray technician. The hospital SW advised the facility that they also notified the NYSDOH. The grievance form documented that no other information was provided by the hospital SW. Chart reviewed and the radiology company was notified of the allegation. An interview was not done with Resident #1 as the Resident was discharged to the hospital on 06/06/2023. Unable to obtain date, time, and procedure from the hospital SW. Resident #1 was last seen for arterial doppler on 05/04/2023. Prior to this date there was no concerns expressed by the resident. Unable to reach Resident #1. A copy of investigation was received from the radiology company. The facility concluded that there was no evidence of abuse, neglect, misappropriation, or exploitation. There was no documented evidence that frontline unit staff members were interviewed or provided statements regarding the alleged abuse allegation. During an interview on 08/11/2023 at 11:57 am, Resident #1 stated that they were a resident at the facility and that sometime in May 2023, a technician came to their room to perform a chest x-ray. Resident #1 stated that the technician pulled their gown down to where their breasts were coming out and that the technician kept cupping and bringing their breasts up. Resident #1 stated that they do not know if it was part of the procedure, but that they felt uncomfortable. Resident #1 stated that they reported the alleged incident to the hospital SW. During an interview with the hospital SW on 08/11/2023 at 3:15 pm, the hospital SW stated that they called the facility on 06/28/2023 and notified the DOA that Resident #1 reported that a staff, who performed a chest x-ray, touched Resident #1's breasts inappropriately. During an interview on 07/31/2023 at 3:26 am, the DON said that they initiated the investigation by reaching out to the radiology company. The DON said that they did not gather statements from the staff because they did not receive the report from the staff. The DON stated that the facility policy on sexual abuse states that they must start an investigation by gathering statements from staff, perform a full body assessment on the resident, report the allegation to the NYSDOH and call the police. During an interview on 07/31/2023 at 5:48 pm, the Administrator stated that they were made aware by the Admissions Department, on 06/28/2023, that a technician was inappropriate towards Resident #1. The Administrator said that they did not gather statements from the facility staff because the allegation is not against the facility staff member. During a follow up interview on 08/21/2023 at 4:16 pm, the Administrator stated that they were not able to reach Resident #1 and that they reviewed the Grievance Report and based on their investigation there was no evidence of abuse, neglect, or mistreatment. 10 NYCRR 415.4(b)(3)

Based on observations, interviews, and record review conducted during a recertification survey from 8/1/2023 to 8/9/2023, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #52) of 38 total sampled residents. Specifically, the Licensed Practical Nurse (LPN) #1 did not change gloves after touching Resident #52's soiled dressing during wound care. The findings are: The facility's policy and procedure entitled Clean Dressing Changes, last reviewed 03/2016, states that the treatment nurse washes their hands prior to placing supplies on the overbed table, then dons clean gloves before removing the old dressing. After depositing the used dressing into a disposable trash bag, the gloves are removed, hand hygiene is performed and new gloves are donned. The wound is cleansed and patted dry, then gloves are removed again, hand hygiene is performed and new gloves are donned. The clean dressing is applied, after which hand hygiene is again performed. Resident #52 had diagnoses of right ankle vascular wound. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #52 was cognitively intact, was at risk for pressure ulcers, and received applications of dressings to the feet. On 08/04/2023 at 09:20 AM, LPN #1 was observed providing Resident #52 with wound care to their right ankle. LPN #1 washed their hands, donned gloves, and removed Resident #52's soiled dressing from their right ankle. LPN #1 did not change gloves or sanitize hands after disposing of the soiled dressing in the trash. An unopened border foam packet fell on the floor and LPN #1 picked up the border foam packet with gloved hands. LPN #1 did not change gloves or sanitize hands after picking up the border foam from the floor and proceeded to dress Resident #52's right ankle wound. The Medical Doctor Order (MDO dated 6/28/2023 documented Resident #52 have right ankle cleansed with normal saline, patted dry, apply skin gentian violet and cover with Kerlix and tape. MDO dated 07/25/2023 documented cleanse Resident #52's right heel with normal saline, apply skin prep to the periwound, apply calcium alginate to the wound bed, and cover with border foam. On 08/04/2023 at 10:53 AM. LPN #1 was interviewed and stated they forgot to change their gloves after thy took off Resident #52's soiled dressing. LPN #1 stated they thought it was appropriate to pick up the border foam from the floor and use it because the package was unopened. LPN #1 stated they should have gotten a new border foam and should have changed their gloves. LPN #1 stated the wound care team was supposed to change Resident #52's wound LPN #1 was not supposed to perform the resident's wound care. On 08/04/2023 at 12:30 PM, the Director of Nursing (DON) was interviewed, and stated nurses were educated to open the dressings using a sterile technique and to follow the MDO. When gloves become soiled, they are supposed to be changed. Wound dressing should be continued after changing gloves or using hand sanitizer. Hand hygiene must be repeated following removal of the soiled wound care dressing. Nurses perform wound care competencies upon orientation and quarterly. The facility nurse educator is on medical leave. LPN #1 had their last wound care competency in 9/2022. 10 NYCRR 415.19(b)(4)

Based on observation, record review, and interviews conducted during the recertification survey from 8/1/2023 through 8/9/2023, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident in 1 (Resident #336) of 38 total sampled residents. Specifically, Resident # 336 was observed using oxygen (O2) via Nasal Cannula (NC) with no Medical Doctor's Order (MDO). The findings are: The facility policy titled Care of Oxygen Equipment dated November 2017 documented the facility will provide O2 therapy in accordance with the MDO. Resident #336 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Renal Insufficiency. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #336's was cognitively intact and did not receive O2 therapy. During an interview on 8/8/2023 at 11:48 AM, Resident #336 stated they have been receiving O2 therapy via NC since their admission to the facility. On 8/2/2023 at 9:27 AM, 8/4/2023 at 12:12 PM, 8/7/2023 at 8:45 AM, and 08/8/2023 at 11:07 AM, Resident # 336 was observed receiving O2 therapy via NC. The MDO from 7/14/2023 to 8/7/2023 did not document O2 therapy for Resident #336. Medical Doctor Notes dated 7/15/2023, 8/5/2023, and 8/7/2023 do not document Resident #336 receiving O2 therapy. Nursing Notes from 7/16/2023 to 8/6/2023 documented Resident #336 was provided with O2 therapy daily via NC. During an interview on 8/8/2023 at 11:34 AM, Registered Nurse (RN) #1 stated Resident #336 received O2 via NC at 2 liters per minute (LPM) for COPD and has been receiving O2 therapy since their admission to the facility on [DATE]. RN #1 reviewed Resident #336's medical record and stated there is no MDO for O2 therapy and there should be an MDO to administer O2 to Resident #336. The nurses are supposed to ensure an MDO is in place. During an interview on 8/8/2023 at 12:18 PM, RN Supervisor (RNS) #1 stated there is no MDO for Resident #336 to receive O2 therapy and there should be. The nurses are responsible for obtaining an MDO for O2 therapy. During an interview on 8/8/2023 at 3:06 PM, the Attending Physician (AP) stated they never saw Resident #336 being administered O2 therapy via NC. No one brought it to the AP';s attention. Nursing staff are responsible for ensuring the MDO for O2 therapy was in place. During an interview on 8/9/2023 at 9:18 AM, the Director of Nursing (DNS) stated nurses can administer O2 based on their discretion after an assessment if a resident has shortness of breath. The nurse must obtain an MDO. The DNS stated the nurses should have contacted the AP for a MDO for Resident #336 to receive O2 therapy. 10 NYCRR 415.12(k)(6)

Based on observations, record reviews, and interviews conducted during an abbreviated survey (NY00290784), the facility did not ensure that a resident was free from sexual abuse. This was evident for 2 of 4 residents sampled (Residents #1 and Resident #2). Specifically, on 02/05/2022 at 5:46 PM, the facility's surveillance camera recording showed that Resident #1 entered Resident #2's room. At 7:09 PM, Certified Nurse Assistant (CNA) #2 entered Resident #2's room and exited the room at 7:10 PM and closed the room door. At 7:21 PM, Nurse Liaison (NL) #1 and CNA #1 entered Resident #2's room and exited the room with Resident #1 at 7:23 PM. Review of the facility's investigation revealed that CNA #2 reported that he/she observed Resident #1 and Resident #2 engaged in sexual activity. CNA #2 did not immediately separate Resident #1 and Resident #2. Both residents were left in the room from 5:46 PM to 7:21 PM. The facility did not protect Resident #1 and Resident #2 from sexual abuse. The findings are: The Facility's Policy and Procedure entitled Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation, and Mistreatment effective date 11/2017 stated the purpose of the policy is to ensure that every resident has the right to be free from abuse, neglect, mistreatment of resident property and exploitation. The Policy also documented all personnel has the responsibility to report any incident or suspected incident of resident abuse. A review of the facility's investigation dated 02/05/2022 documented that Resident #1 has a history of wandering into other rooms. CNA #1 observed Resident #1 in Resident #2's bed with clothing down. Resident #2 was in the bathroom at that time. CNA #1 escorted Resident #1 out of Resident #2s' room. CNA #2 approached CNA#1 in the hallway and informed that about 10 minutes ago he/she had gone into Resident #2's room looking for Resident #1. CNA #1 observed Resident #1 in Resident #2's bed with Resident #2 on top of Resident #1 engaging in an intimate act. As per CNA #2, Resident #2 jumped off the bed. CNA #1 left the room looking for the nurse to report the incident. The facility investigation concluded that the camera was reviewed and concluded that Resident #1 entered Resident #2's room and initiated intimate contact. CNA #2 entered the room and interrupted them. As per CNA #2 and Resident #2, when CNA #2 entered the room Resident #2 was startled and jumped up from the bed thus ending the intimate act. Neither resident has any history of sexually inappropriate behavior, therefore the staff could not have anticipated this occurrence. The facility concluded that there is probable evidence of sexual abuse. Review of the facility's surveillance camera recording (of multiple clips, 1-2 minutes short) dated 02/05/2022 revealed the following: 5:46 PM, Resident #2 went to his/her room and Resident #1 followed behind Resident #2 into the room. Staff members were in the hallway but facing the opposite direction of Resident #2's room. 5:46 to 6:56 PM, neither Resident #1 nor Resident #2' exited Resident #2's room. 6:56 PM, Nursing Liaison (NL) #1 went into Resident #2's room; 10 seconds later, exited the room with a meal tray. (DNS reported that NL #1 stated that he/she did not see Resident #1 in Resident #2's room). 7:09 PM, CNA #2 went into Resident #2's room. 7:10 PM, CNA #2 exited Resident #2's room, closed the room door and walked slowly down the hall. 7:15 PM, a family of Resident #2's roommate went into the room and exited 10 seconds later. The family member left the room door open (DNS reported that the family member stated that he/she did not see a female in the room. The family only observed Resident #2 standing by the door fully dressed). 7:21 PM, CNA #1 went into Resident #2's room; CNA #3 and NL #1 went in also. 7:22 PM, CNA #3 went out of Resident #2's room 7:23 PM Nursing Liaison #1 and CNA #1 came out of Resident #2's room with Resident #1. Resident #1 was fully dressed. Staff observed on camera fixing Resident #1's pants at the waist area. CNA #2 approached NL #1 and CNA #1 in the hallway (appeared to be talking). Resident #1 was initially admitted to the facility for medical management and rehabilitation on 09/20/2021 with diagnoses including Alzheimer's Disease, Psychosis and Dementia. The Minimum Data Set (MDS, a resident assessment tool) dated 11/21/2021 documented that Resident #1 had long/short-term memory problems. Resident #1 required limited assistance with bed mobility and extensive assistance of one person for walking in the room and on the unit. Resident #1 currently residing in the facility. A review of Resident #1's Comprehensive Care Plan (CCP) on risk to be a victim of abuse, neglect, and/or mistreatment dated 08/20/2021 documented interventions to advise Resident #1 to seek out staff for assistance if having difficulty with others. Intervene as necessary to ensure the safety of Resident #1 and removed Resident #1 from the area of the aggressor. A review of the Daily Resident Room Check (Rounds) dated 02/05/2022 documented that Resident #1 was on hourly monitoring due to wandering. This document revealed that from 3:30 PM to 6:30 PM Resident #1 was on the unit. A review of the Certified Nurse's Assistant (CNA) Accountability Record dated from 02/01/2022 to 02/05/2022 documented that Resident #1 was on hourly monitoring for unsafe, wandering/elopement, mood, and behavior monitoring, and non-pharmacological interventions. A review of Resident #1's Situation, Background Assessment Recommendation (SBAR) tool dated 02/05/2022 at 11:30 PM, documented that on 02/05/2022 at 7:30 PM, a staff observed Resident #1, with his/her pants down, in a male resident room. Resident #1 was assisted and immediately removed from the room back to his/her room. The Medical Doctor (MD) was made aware and 911 was called. Resident #1 was sent to the hospital for evaluation and a rape kit. A review of Resident #1's Health Status Progress Note dated 02/05/2022 at 11:36 PM documented that Resident #1 was observed by a staff member in another resident's room. Resident #1 was not dressed appropriately. Staff dressed Resident #1 and assisted the resident back to his/her room. A full body assessment was done and there were no signs of visible injury. Resident #1 was calm and not in distress at the time. Review of a Physician's Order dated 02/05/2022, revealed an order to transfer Resident #1 to the hospital for evaluation. Review of a Physician's Progress Note dated 02/06/2022 at 1:11 PM, revealed that Resident #1 was admitted from the hospital with Active Diagnosis: Sexual Exposure. A Hospital After Visit Summary dated 02/05/2022 documented that Resident #1 reason for the visit was Altered Mental Status. Diagnosis: Unprotected Sexual Intercourse. Resident #2 was initially admitted to the facility for medical management and rehabilitation on 11/01/2021 with diagnosis including Dementia and Schizophrenia. Resident #2's MDS dated [DATE], revealed that Resident #2 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 04/15. Resident #2 required extensive assistance of one-person with walking in the room and toileting. Resident #2 was discharged to Adult Home on 02/09/2022. Resident #2's CCP on at risk to be a victim of abuse, neglect, and/or mistreatment dated 11/02/2021, documented that Resident #2 was vulnerable due to cognitive deficits and physical disabilities. The interventions documented to advise Resident #2 to seek out staff for assistance if having difficulty with others. Calmly redirect the resident away from areas of potential harm and intervened as necessary to ensure the safety of the resident. A review of Resident #2's Certified Nurse's Assistant (CNA) Accountability Record dated from 02/01/2022 to 02/05/2022 documented mood and behavior monitoring and non-pharmacological interventions. A review of Resident #2's Daily Resident Room Check document dated 02/05/2022, revealed that Resident #2 was on hourly monitoring. The Daily Resident Room Check indicated that Resident #2 was in the Dining room at 5:30 and in his/her room at 6:30 PM and 7:30 PM. A review of Resident #2's SBAR tool dated 02/05/2022 at 11:43 PM, revealed Resident #2 was in their room and Resident #1 was observed in Resident #2's bed inappropriately dressed. The primary clinician recommended that Resident #2 be moved off the unit. Skin observation revealed no changes. A review of a late entry Care Plan Note dated 02/07/2022 at 9:33 AM documented that Resident #2 was interviewed by Social Worker (SW) regarding an intimate act with another resident on 02/05/2022. Resident #2 stated that he/she had not seen Resident #1 before but when Resident #1 entered his/her room they engaged in an intimate act. Resident #2 shared that he/she stopped when someone came into the room. Resident #2 was very nervous during the interview with SW and was unable to provide detail. Resident #2 became disorganized at times but did express concern in stating that he/she got Resident #1 pregnant. SW provided support with positive effects, psychiatry and psychology consult are pending. Review of Resident #1 and Resident #2's medical records revealed there were no documented evidence that psych consults were done to determine the residents' capacity to make sexual decision. During an interview on 02/15/2022 at 11:30 AM, CNA #1 stated that he/she was assigned to Resident #2 on 02/05/2022. CNA #1 stated that Resident #2 was ambulatory and was on hourly monitoring. CNA #1 stated that Resident #2 had not exhibited any sexual inappropriate behavior prior to the incident. CNA #1 stated that Resident #2 had dinner at 5:30 PM in the dayroom. CNA #1 stated that he/she last observed Resident #2 sometime after 6:00 PM. CNA #1 stated that he/she was passing Resident #2's room at 7:09 PM and observed Resident #1 in Resident #2's bed. CNA #1 stated that he/she was able to see Resident #1 in a semi-lying position (appeared to be getting up) in Resident #2's bed. CNA #1 stated that Resident #2's bed was visible because the bed was close to the door. Resident #1's diaper and clothing were down to the knees. CNA #1 stated that Resident #1's diaper was closed on both sides and that he/she helped Resident #1 to pull the diaper and clothing up. CNA #1 stated that there was no stains, blood, or fluids on the Resident #1's diaper and there were no fluid stains on the bed linens. CNA #1 stated that Resident #1 was calm and in no distress. CNA #1 stated that he/she did not see Resident #2 in the room and Resident #2's roommate was in the dining room at the time. CNA #1 stated that Resident #1 is confused and goes in and out of other residents' room to lay down. Therefore, he/she did not think that anything had happened. CNA #1 stated that Resident #1 needs to be reminded and redirected to their room. CNA #1 reported that Resident #1 was being monitored hourly due to elopement risk. CNA #1 stated that another staff member came to the room and assisted with escorting Resident #1 out of Resident #2's room. CNA #1 stated that while he/she was assisting Resident #1, he/she observed Resident #2 coming out of his/her bathroom fully dressed. CNA #1 stated that he/she did not say anything to Resident #2 because he/she (CNA #1) did not suspect anything. CNA #1 stated that when he/she came out of Resident #2's room, CNA #2 approached him/her (CNA #1) stating that Resident #1 and Resident #2 had intercourse. CNA #1 stated that he/she was in shock but notified the nurse immediately and the nurse called the supervisor. Multiple attempts were made to contact CNA #2 but was unsuccessful. CNA #2 worked for an agency and the CNAs whereabouts are unknown. The Director of Nursing (DON) stated that CNA #2 was suspended and did not return to work after the suspension. CNA #2 Provided the facility with a written statement dated 02/05/2022. The statement documented that CNA #2 observed Resident #2 on the top of Resident #1 penetrating Resident #1. CNA #2 documented that he/she slipped out to call the Charge Nurse. NL #1 was not interviewed as the staff is no longer employed and his/her whereabouts unknown. During an interview on 02/15/2022 at 3:45 PM, RN #1 stated that he/she worked on 02/05/2022 from 7:00 PM to 7:00 PM and left the unit at 7:01 PM but was still in the building when was notified about the incident. RN#1 was not aware of the incident between Resident #1 and Resident #2. RN #1 stated that he/she was informed about the incident when he/she was leaving the building after 7:00 pm. RN #1 stated that she/she did not do round at the end of the shift because he/she was busy. RN #1 stated that CNAs on the unit should have done rounds every 30 minutes and informed the nurse if they observe concerns. RN #1 stated that if staff observed abuse, staff must remove the resident from the aggressor and notify the nurse immediately. RN #1 stated that Resident #1 wanders into other residents' rooms and staff redirect the resident. RN #1 stated that he/she has never observed any inappropriate behavior exhibited by Resident #1 or Resident #2 prior to the incident. During an interview on 02/15/2022 at 4:00 PM, RN #2 stated that he/she worked on 02/05/2022 from 7:00 PM-7:00 AM. RN #2 stated that he/she was informed by CNA #2 that Resident #1 and Resident #2 had sex. RN #2 stated that he/she made sure everyone was safe and notified the supervisor. RN #2 stated that the DON came to the unit and performed a body assessment on Resident #1 and that he/she assessed Resident #2 and called the MD. RN #2 stated that 911 was called and Resident #1 was transferred to the hospital. RN #2 stated that both residents had no prior sexual inappropriate behavior. Subsequent interview with RN #2 on 03/30/2022 at 12:40 PM, revealed that he/she observed Resident #2 fully dressed sitting on their bed. RN#2 stated that he/she assessed Resident #2 and did not observe any wet stains on Resident#2's clothing or diaper. RN #2 stated that he/she performed a head-to-toe assessment and did not observe body fluid or redness on Resident #2's sexual organ. RN #2 stated that there were no signs that Resident #2 had intercourse. During an interview on 02/23/2022 at 2:05 PM, the DON stated that he/she was responsible for investigating the incident involving Resident #1 and Resident #2. The DON stated that Resident #1 was a wanderer and was on hourly monitoring for elopement. The DON reported that Resident #1 has a history of going into other resident rooms and that neither one of the residents had any sexual behavior prior to the incident. The DON stated that Resident #1 and Resident #2 are confused. The DON stated that at the beginning of the investigation, CNA #1 reported that he/she observed Resident #1 in Resident #2' s bed with clothing and diaper down and that Resident #2 was in the bathroom at that time. The DON stated that during questioning of the staff, it was discovered that 10 minutes earlier CNA #2 entered Resident #2's room and observed Resident #2 on top of Resident #1 and that the residents were having sex. The DON verbalized that CNA #2 reported that Resident #2 jumped off Resident #1 as soon as Resident #2 saw CNA #2. The DON stated that CNA #2 left Resident #1 in Resident #2's bed and went to look for the nurse and that CNA #2 should not have left Resident #1 in Resident #2's room. Stated that CNA #2 should have called for help immediately. The DON stated that he/she watched the camera and observed that Resident #1 went voluntarily to Resident #2's room right after Resident #2. Stated that the camera also revealed that NL #1 went in Resident #2's room to take out the roommate's tray. The DON stated that the roommate's bed was by the window and that NL #1 did not see Resident #1 in the room. The DON stated a family stated that they were looking for Resident #2's roommate and that they did not see Resident #1 in the room. The DON stated that Resident#1 could have been in the bathroom at the time. 415.4(b)(1)(i)

Based on record review and staff interviews conducted during the recertification survey from 05/05/2021 to 05/11/2021, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. Specifically, the staff did not properly position the Hoyer Lift (mechanical lift) canvas (pad) underneath a resident in preparation for a Hoyer lift transfer. The staff attempted to transfer the resident from the Geri chair (medical recliner) to the bed using the Hoyer lift, and the resident slid off the canvas and fell to the floor. The resident sustained a scalp laceration requiring a staple to the head. This was evident in 1 of 7 residents reviewed for Accidents (Resident #356). This resulted in actual harm that is not immediate jeopardy. The finding is: The facility policy and procedure titled, Lifting and Transferring of Residents (Dated 06/2013) documented the following: All nursing staff (nurses and nursing assistants) are responsible for knowing the proper procedures when operating assistive devices. The Mechanical Lift Skill Competency attached documented that positioning the canvas seat (pad) under the resident, so that the lower edge of the seat is slightly below the knees and the upper edge behind the shoulders is checked during the competency. Resident #356 was readmitted on [DATE] with diagnoses which include Non-Alzheimer's dementia, muscle weakness, and hypertension. The Quarterly Minimum Data Set 3.0 (MDS) assessment, dated 01/12/2021, documented the resident had severely impaired cognition, and the resident required the total assist of two persons for transfer. The resident had bilateral upper and lower extremity range of motion (ROM) impairment, and the resident did not have any falls during the review period. The Comprehensive Care Plan (CCP) titled, The resident has Activities of Daily Living (ADL) Self-Care Performance Deficit related to Activity Intolerance, Cognitive Impairment, Dementia and present medical condition, effective 03/25/2020, documented the resident was totally dependent on staff and required a Hoyer/ Mechanical lift with the assist of two persons for transfers. The CCP titled, Resident is at risk for falls/injury related to Activity level limitation, Cognitive Impairment, effective 03/25/2020, included interventions to follow the facility fall protocol and monitor/anticipate/intervene for factors causing potential/prior falls. The Physician's orders, effective date 03/25/2020, documented orders for the resident to be transferred out of bed to the Geri chair via mechanical Hoyer lift with assist of two persons. The Physician's orders, effective date 03/26/2020, documented the resident was on fall precautions. The monthly maintenance log dated 12/10/2020 documented that the Hoyer lift was inspected and was found to be in good condition and function. The Certified Nursing Assistant (CNA) Kardex and resident care instructions, dated 01/01/2021, documented the Resident #356 was on fall safety precautions and required the total assist of two persons using a Hoyer lift during transfers. The Accident and Incident (A/I) report dated 01/20/2021 documented the following: The resident fell to the floor when being transferred from the Geri chair to bed and sustained bleeding with back of head swelling. The physician was informed of the accident, and the resident was transferred to the hospital. The preliminary finding of the facility investigation documented during the transfer, the strap from the pad slipped out of place resulting in the fall. Staff was provided with education, in-service and completed return demonstration. An addendum was made after an inspection of the Hoyer lift was completed on 01/22/2021. The Hoyer lift was found to be functioning well. The investigation finding written by the Director of Nursing (DON) documented it was possible that the resident was not positioned exactly at the center of the pad, and the unevenness may have caused the resident to slide off the Hoyer pad and fall to the floor. Nursing Note (NN) completed by a Registered Nurse (RN #1) dated 01/20/2021 documented the following. The Resident #356 fell on the floor and resulted in some bleeding and swelling on the back of the head. The physician and family member were notified of incident and resident was transferred to the hospital. NN completed by the RN Supervisor (RN #2) dated 01/20/2021 documented the following. The Resident #356 had a fall from the Hoyer lift during a transfer from the Geri chair to the bed. When the RN and CNA were moving the resident from the Hoyer lift in mid-air, Resident #356 accidently fell hitting their head on the metal base of the lift. Resident #356 was found with bleeding and swelling on the back of the head. Ice was applied on the back of their head. The physician was notified and ordered Resident #356 to be transferred to the hospital. The Physician's Order dated 1/20/2021 documented instructions to transfer the resident to the hospital for evaluation. The CCP titled, The resident has had an actual fall related to Activity level limitation, Cognitive Impairment, [CONDITION(S)], Effective 03/25/2020 and revised 01/20/2021, documented the resident had a fall and sustained bleeding and swelling on the back of the head. On 1/20/21, the intervention to anticipate and meet the resident's needs was added. The hospital summary of medical treatment dated 01/21/2021 documented the resident received an x-ray of the chest and pelvis and a Computed Tomography (CT) of the head and spine which all showed no fracture or other traumatic injury. The resident was treated for a small posterior scalp laceration that was repaired with one staple. A NN completed by a RN dated 01/21/2021 documented the following. The resident returned from the hospital with a small posterior scalp laceration repaired with one staple. Treatment with [MEDICATION(S)] was recommended. Physician orders dated 01/21/2021 documented resident was prescribed with the following treatment. Clean wound with DermaKlenz, apply [MEDICATION(S)], cover with dry protective dressing (DPD) to back of head laceration as needed and every night for wound care for 14 days. Order was discontinued on 02/22/2021. The Director of Maintenance statement dated 01/22/2021 documented the following. The Hoyer lift was inspected by both the maintenance department and Scale USA (lift company). The machine was found to be in good working order. The monthly maintenance log dated 01/22/2021 documented the Hoyer lift was inspected and was found to be in good condition and function. Physician orders dated 01/28/2021 documented orders for the staple to be removed from the back of the resident's head. The Medication and Treatment Administration Records dated January 2021 and February 2021 documented the resident received treatment to the head laceration as ordered. On 05/06/2021 at 10:42 AM, the resident's designated representative was interviewed. The family member stated that the resident had a fall maybe about a month ago in their room. During a transfer from the bed to the wheelchair, the resident slipped out of the lift and fell on the floor hitting their head on a table. The resident was sent to the hospital for observation, and they were okay. The family member stated the facility had provided notification and updates right after the incident occurred and notification on resident's return from the hospital. The family member believed that the resident slipped and fell due to the way the staff lifted the resident, but they were not sure. The Registered Nurse (RN #1) was interviewed on 05/10/2021 at 04:23 PM and 05/11/2021 at 02:30 PM. RN #1 stated CNA #1 asked for assistance with transferring the resident from the Geri chair to bed using the Hoyer lift. The proper way to transfer a resident is to make sure the pad is positioned correctly underneath the resident, by the neck and legs. The straps are hooked to the machine. The RN stated the resident was on the Geri chair at first, and the Hoyer lift pad was already under the resident. RN #1 stated that the pad was under the resident's shoulder area instead of the neck area. Then both RN #1 and CNA #1 hooked the straps onto the machine. As the resident was being lifted, the resident slipped backwards, hitting their head at the edge of the machine. The RN supervisor was contacted right away. RN #1 stated that the padding was not positioned correctly on the resident prior to transfer. RN #1 received an in-service afterwards on how to properly use the Hoyer lift which includes padding placement, checking the straps, and leg positioning. During a follow up interview, the next day, RN #1 stated the padding was not fully underneath the resident during the transfer which resulted in the resident falling. On 05/10/2021 at 04:35 PM, RN #2 was interviewed. Upon notification of the incident, Resident #356 was assessed and found to have bleeding and swelling in the back of the head. The resident was sent to the hospital and had a CT scan which revealed no fractures. The RN #2 further stated that the Hoyer lift padding was not positioned correctly under the resident resulting in the resident falling out. On 05/11/2021 at 11:07 AM, CNA #1 who was involved in the incident was attempted to be interviewed. As per administrative staff, CNA #1 resigned, and the contact number provided was no longer active. On 05/11/2021 at 11:35 AM, the Assistant Director of Nursing (ADON) was interviewed. Resident #356 fell from the Hoyer lift during a transfer from the chair to the bed. RN #1 assisted CNA #1 with transferring Resident #356. The ADON and RN Supervisor assessed the resident, provided first aid, and the resident was transferred to the hospital. They asked the involved staff to do a return demonstration following the incident, and the staff did it correctly by showing how the resident was transferred. At that moment, they concluded that maybe it was a strap malfunction. However, upon completion of investigation, the DON further concluded that equipment malfunction was ruled out and an addendum to the investigation was made that the incident occurred was not due to the pad or machine. It was proposed that the cause of fall was improper positioning of the Resident on the canvas. Resident #356 was not positioned in the center of the pad. On 05/11/2021 at 12:20 PM, the Director of Nursing (DON) was interviewed. The DON was unfamiliar with incident since it occurred before employment at the facility. On 05/11/2021 at 12:42 PM, the Administrator was interviewed. The Administrator was not present during the time of incident since it occurred before employment at facility. 415.12(h)(1)

Based on interviews and record review conducted during an abbreviated survey (NY 199), the facility did not ensure that a resident was free from staff abuse. This was evident in 1 of 3 residents sampled for physical abuse (Resident #1). Specifically, on 03/25/2019, Resident #1 was observed with her hands covered her face and crying. Resident #1 was assessed with [REDACTED]. Certified Nursing Assistant #1 (CNA #1) acknowledged hitting Resident #1 in her eye after the resident became combative during care. The Findings Include: The facility policy and procedure titled, Reporting and Investigation of Resident Abuse/Neglect, or Mistreatment, dated 11/2016 states that, the facility shall not use or permit verbal, mental, sexual or physical abuse, including but not limited to, other residents, staff, consultants, volunteers, and staff or other agencies serving the residents, family members, legal guardians, friends, or other individuals. Resident #1 was admitted to the facility on [DATE] from the Hospital with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool), dated 03/15/2019, documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determined attention, orientation and ability to recall information) score of 08/15, associated with moderately impaired cognition (00-7 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Resident #1 requires extensive assistance of 1 staff assist with bed mobility, transfer, toilet use and personal hygiene. A Comprehensive Care Plan (CCP) initiated on 11/26/2017, identified Resident #1 at risk to be a victim of abuse, neglect, and or mistreatment. Congregate living is vulnerable due to physical disabilities. The interventions included advise resident to seek out staff for assistance if having difficulty with others, calmly redirect the resident away from areas of potential harm, intervene as necessary to ensure safety of the resident, and remove resident from the aggressor. CCP initiated on 11/05/2018 documented the resident is/has potential to demonstrate behaviors (behaviors not specified in the CCP) related to Dementia. Interventions included give resident as many choices as possible about care and activities, monitor and document behavior, report to MD if danger to self and others. Weekly Behavior Progress Note dated 03/29/2019 documented behavior displayed by Resident #1 in the last week as calm and cooperative and involved in recreational activities and Activities in Daily Living. A review of the facility's Accident/Incident Report dated 03/25/2019 at 10:25 PM, documented that Resident #1 was observed by the Registered Nurse Supervisor (RNS) with right periorbital ecchymosis. The summary of the investigation revealed that Resident #1 stated that she was hit in the eye and that she did not know the aide's name that hit her but would be able to identify the person. Resident #1 identified CNA #1 from a photo, as the Aide that hit her in the eye. An SBAR Note, by the Licensed Practical Nurse (LPN), dated 03/25/2019 documented that on 03/25/2019 at 10:25 PM, Resident #1 was observed with swelling and discoloration to her right eye. Resident #1 had reported new onset of pain in the eye. The physician was notified and ordered ice pack to right eye. A Physician's note dated 03/26/2019 documented a Telemedicine Consultation. The physical exam revealed that Resident #1 had right periorbital ecchymosis, and no tenderness to palpation around the facial bones on the right side. Resident #1 was able to open the eye and the eye itself appears to show no evidence of subconjunctival hemorrhage and Resident #1's extraocular movements appeared to be intact. Resident #1 was interviewed on 06/26/2019 at 11:30 AM and stated that she does not remember who hit her in the eye but that she knew someone did. She stated, I'm not crazy, I am not senile. The RNS was interviewed on 06/26/2019 at 11:36 AM and stated that at approximately 10:25 PM, a CNA (CNA #2) reported that she saw redness on Resident #1's right eye that was not present at the beginning of the shift. Resident #1 was crying and was unable to explain what had happened. RNS stated that he called another Supervisor, and both went to see Resident #1. An assessment was conducted and Resident #1's right eye was observed with swelling and redness. Resident #1 had a hard time opening her right eye. Resident #1 reported, in the presence of another Supervisor, that someone hit her. At the time, Resident #1 was unable to name the person who had hit her, but later identified CNA #1 as the person who hit her in the eye. CNA # 2 was interviewed on 06/26/2019 at 3:38 PM. She stated she was at the Nurses Station when CNA #1 called her on her cell phone. She went to the room and observed Resident #1 with her hand covering her right eye and was crying. CNA #1 was in the room and reported to her (CNA #2) that Resident #1 scratched her. CNA #2 stated that she notified the LPN #2, who then notified the RNS. CNA #2 stated that she observed Resident #1's right eye black, swollen and shut. Prior to CNA #1 calling her (CNA #2) in the room, Resident #1 had no swelling on in her eyes. LPN #2 was interviewed on 07/03/2019 at 9:14 AM and stated that CNA #2 informed her (does not remember time) that something was wrong with Resident #1. The resident's eye was swollen and close to shut. LPN #2 stated that she called the RNS right away. LPN #2 stated that she administered medications to Resident #1, prior to dinner, and that the resident did not have any swelling to her right eye. During a follow-up interview with LPN #2 on 08/20/2019 at 04:53 PM, she stated that CNA #1 did not inform her that Resident #1 was combative during care. She did not observe the resident being combative during the shift. CNA #1 was interviewed on 06/26/2019 at 2:55 PM and stated that Resident #1 became combative and was hitting her constantly and hit her on the stomach and that she accidentally hit Resident #1 in the face. On inquiry CNA #1 stated that it happened so fast and my hand hit her in the face. CNA #1 called CNA #2 and CNA #2 called the nurse. CNA #1 stated that she told LPN #2 that when she was changing Resident #1, she saw the swelling in Resident #1's eye. CNA #1 added that she did not tell the nurse that she hit Resident #1 in the eye and that she gave the facility a statement, noting that she observed Resident #1's eye swollen while she was providing care. She also stated that she did not notify the nurse when Resident #1 was being combative. The Police arrested her and that she went to court. The Director of Nursing Services (DNS) was not the DNS at the time of the incident) was interviewed on 06/26/2019 at 4:00 PM. She stated she went to talk to the resident. A print out of pictures of the staff who worked within the last 24 hours, were shown to the resident and she was able to identify CNA #1 as the one that hit her. The Acting DNS called the Police after CNA #1 was positively identified. The Police interviewed Resident #1 and CNA #1. CNA #1 was arrested by the Police. CNA #1 eventually said that she hit Resident #1. 415.4(b)(1)(i)

Based on record review and interview conducted during the recertification survey, the facility did not ensure that a Quarterly Minimum Data Sets (MDS) assessment was completed in a timely manner. Specifically, the Quarterly MDS with an Assessment Reference Date (ARD) of 11/08/18 was not completed as of 12/19/18. This was evident for 1 of the 22 residents reviewed for resident assessment. (Resident # 10) Finding is: The facility policy on the MDS assessment dated ,[DATE] documented that the facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. The policy also documented that each individual completing the portion of the MDS signs and certified the accuracy of that portion of the assessment. The policy further documented that the quarterly MDS assessment must be completed on or before 14 days of the ARD. The resident was admitted to the facility on [DATE]. The resident's medical record was reviewed on 12/19/18. The quarterly MDS assessment dated [DATE] documented in Section O that the assessment was in incomplete status. As such, the assessment was 28 days past due for completion. On 12/19/18 at 12:29 PM, an interview was conducted with the Registered Nurse Supervisor (RN#1). RN #1 stated that she participated in the care plan meeting and makes sure that the care plans are updated accordingly. RN#1 also stated that the MDS assessors are responsible for the completion of the MDS. On 12/20/18 at 12:20 PM, an interview was conducted with the Director of Rehab (DR). The DR stated he has been working at the facility since (MONTH) (YEAR) as a Director of Rehab. He stated he oversees the rehab department and is responsible for completing Section O on the MDS. The DR acknowledged that the ARD for this resident was 11/12/18 , and O section was not completed until 12/19/18. The DR stated that this resident was missed from the list to be completed, it was an oversight. He further stated that he now has 2 assistants, PT/OT who monitor the assessments that are due and go over them, and have them completed. On 12/20/18 at 12:55 PM, an interview was conducted with the MDS coordinator. The Coordinator stated that the interdisciplinary team meets weekly to discuss MDS assessments that are in pending status. Each department head is aware of any assessments that are incomplete. He further stated that each floor has their own MDS coordinator and could not explain the reason why this MDS was incomplete. 415.12(e)(2)

Based on record review and interview conducted during the Recertification survey, the facility did not ensure that an Minimum Data Set (MDS) assessment accurately reflected the resident's status. Specifically, Resident #343 was coded as receiving the Influenza vaccine on 10/10/18. However, the resident's family refused it on 10/10/18 because she is allergic to the Influenza vaccine. This was evident for one (1) of five (5) residents reviewed for Unnecessary Medication. The finding is: Resident #343 was admitted to the facility on [DATE]. The Quarterly MDS dated [DATE] was reviewed and it was documented that the resident received the Influenza vaccine on 10/10/18. The Immunization tab in the Electronic Medical Record (EMR) dated 10/10/18 was reviewed. It documented that on 10/10/18 the resident's family refused the Influenza Vaccine and cited the resident's allergy to the Influenza vaccine as the reason. The physician's orders [REDACTED]. Resident #343's allergy to the [MEDICAL CONDITION] Vaccine was listed in the Physician orders [REDACTED]. There was no documented physician's orders [REDACTED].#343. The Comprehensive Care Plan documented on 8/1/18 the resident has an allergy to Influenza vaccine. On 12/12/18 at approximately 11:44 AM, this State Surveyor and the MDS Assessor/Coordinator, Registered Nurse (RN)#1, reviewed the 10/31/18 Quarterly MDS in the Electronic Medical Record (EMR) which documented that resident received the Influenza immunization on 10/10/18. He stated that random second checks on MDS are done to ensure accuracy but it is not documented anywhere and this record may not have been selected for a random review for accuracy. On 12/12/18 at approximately 11:46 AM an interview was conducted with the RN #2, MDS Assessor. She stated that she documented in the MDS that the resident received Influenza vaccine in this facility on 10/10/18. She continued to state that she located the information when she opened the Immunization tab in the EMR. She further stated that she overlooked the documentation in the Immunization tab that the resident has an allergy to Influenza vaccine and it was refused by the family on 10/10/18. Lastly, she stated that when she enters and signs her name on the MDS that indicates that the information is correct. She stated she is going to submit a correction for this today. 415.11(b)

Based on interviews and record review conducted during an abbreviated survey (NY 073), the facility did not ensure that a resident was treated with respect and dignity. This was evidenced by 2 out of 5 residents sampled (Resident #1 & Resident #2). Specifically, on 4/10/2018, the Administrator and the Assistant Administrator went in the room of Resident #1 & Resident #2; without any explanation, they opened and searched the residents' bedside drawers and threw out unopened food items for Resident #2 without his permission. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 11/17/2017 documented Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) 15/15 (00-7 Severe Impairments, 08-12 Moderate Impairment & 13-15 Cognitively Intact). Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 11/17/2017 documented Resident #2 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) 15/15 (00-7 Severe Impairments, 08-12 Moderate Impairment & 13-15 Cognitively Intact). The policy and procedure on Resident Room Cleaning updated 10/01/2007, documented Responsible Parties: Nursing - The evening shift CNA will be responsible to go through the resident drawers and closets. Nursing and housekeeping - If any resident is identified as a hoarder with excessive amount of linen, food or other issues, notify Administration immediately. Administrative Team - Will approach the resident and or family and clean the room eliminating the risks of hoarding food, newspapers and other items. Social Work - Will set up a meeting to discuss the issue found and try to address it cooperation from the resident and family. Administration - Will remind families and residents about ensuring a safe and clean environment in resident council and family meetings. The policy and procedure on Care and treatment of [REDACTED]. This consists of the resident's bed. Bedside table, chair, furniture and any designated equipment. The CNA is to ensure that: a). Bedside unit is free of clutter. The bedside drawers shall be checked daily for inappropriate food storage, which will be brought to the Charge Nurse's attention. Resident #1 was interviewed on 4/27/2018 at 12:20PM and stated that the Administrator and two men came in his room and took the food from his drawers without an explanation of what they were going to do before taking the food items from his drawers. He stated that he observed the Administrator and the two men did the same thing to his roommate's (Resident #2) drawers. Resident #2 was interviewed on 4/27/2018 at 12:40PM and stated, a bunch of people came in my room and without explanation, opened my drawers, took two packs of unopened(NAME)Tea Biscuits from London and threw them in the garbage. His relatives gave him the biscuits and that the facility did not replaced the biscuits. The Director of Social Worker (DSW) was interviewed on 4/27/2018 at 5:15 PM and stated that Resident #2 told her somebody threw out two unopened packs of(NAME)Tea Biscuits that his family brought for him from London. She stated that Resident #2 did not specify who threw away the biscuits. She stated that last week she asked the resident for the name brand of biscuit so it could be replaced. The Administrator was interviewed on 4/27/2018 at 4:30PM and stated that on 4/10/2018 he opened the drawers of Resident #2 and discarded an open pack of biscuit. He stated that he will not throw it out if it was unopened. He stated that he ordered three packs of biscuits from London to replace the ones he discarded on 4/10/2018. The Assistant Administrator (AA) was interviewed on 5/1/2018 at 3:12PM and stated that they did not throw out Resident #2's food. He stated that they knocked on the door and asked permission before going through the drawers. The Administrator went through the drawers and they asked the residents if the food could be thrown out. The Director of Nursing (DON) was interviewed on 6/8/2018 at 10:50AM. She stated that the assigned CNA on the 3-11 shift conducts a minimum of three drawers to be checked every night. She stated that the CNA should introduce self and ask permission from the resident before opening the resident's drawers as per protocol. The DON stated that if a resident refuses the drawer check; the Charge Nurse must be notified. She stated that for a difficult and challenging resident, the Social Worker and the Administration are notified for intervention to search and clean the resident's personal space. There is no documentation to support that on 4/10/2018, Resident #1 and Resident #2 refused to have their drawers searched by a CNA. 415.5(h)(I)

Based on record review and interviews during an abbreviated survey (NY 019), the facility did not ensure that a resident received the necessary care and services to maintain the highest practicable well-being in a timely manner for 1 out of 3 residents sampled (Resident #1). Specifically, on 10/15/2017 at 5:57 p.m. the Nurse Practitioner assessed Resident #1 for reports of right shoulder pain and swelling. During assessment by the NP, Resident #1 was observed with facial grimacing with movement. Record review revealed no documented evidence that Resident #1 was given pain medication. Additionally, the NP ordered a STAT x-ray of Resident #1's right shoulder and right upper arm. The STAT x-ray was performed approximately 13 hours after the x-ray was ordered. The x-ray results dated 10/16/2017 at 8:10 a.m. documented an acute [MEDICAL CONDITION] humeral shaft. Resident #1 was transferred to the hospital on [DATE] at 1:33 p.m. The findings include: A review of the facility policy and procedure titled, Pain Assessment and Management, dated 08/2013, states, if the resident reports pain, the nurse will rate the pain using one of the following rating scales according to the resident's ability to communicate: Numeric rating Scale and the Faces Scale-Revised if the resident screens positive for pain, a pain assessment that includes the following should be conducted: location, intensity (including scale used) at present, current treatment, if any, response to treatment. Resident # 1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) on 10/01/2017, indicated a Brief Interview for Mental Status (BIMS - used to determine attention, orientation and ability to recall information) score of 3/15, associated with severe impairment (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). A physician progress notes [REDACTED]. Diagnosis, Assessment and Plan documented right arm pain, STAT x-ray of the right shoulder and upper arm to rule out fracture. An Order Summary Report dated 10/01/2017 to 11/30/2017 revealed there was no order for pain medication prior to Resident #1's transfer to the hospital (10/15/2017 to 10/16/2017). A Pain Level Summary document dated 10/01/2017 to 10/16/2017, revealed that there was no pain assessment documented on the Pain Level Summary document. A Nurse's Progress Note by Registered Nurse #1 (RN #1) dated 10/16/2017 at 12:06 a.m., documented that Resident #1's right arm was noted with swelling and the resident was referred to NP. The NP ordered a STAT x-ray of right shoulder and arm. The note indicated that the pending order was endorsed to the 11-7 shift nurse. There was no documented evidence that a follow up call was made to the x-ray company regarding the STAT order. A Nurse's Progress Note dated 10/16/2017 at 5:53 a.m., by RN #2 documented swelling on the right arm persist, waiting for STAT x-ray of right upper arm and shoulder. There was no documented evidence of a follow up call to the x-ray company regarding the STAT x-ray nor was there documented evidence of pain assessment. A Nurse's Progress Note dated 10/16/2017 at 6:36 a.m., documented that the x-ray was done. A Radiology Results Report dated 10/16/2017 at 8:10 a.m., documented examination of the right shoulder demonstrates an acute separated [MEDICAL CONDITION] humerus. A Nurse's Progress Note dated 10/16/2017 at 1:01 p.m., by RN #3 documented that the x-ray result of the right shoulder revealed separated [MEDICAL CONDITION] humeral shaft and marked [MEDICAL CONDITION]. The physician was informed with an order to transfer Resident #1 to the hospital for further evaluation. Resident #1 left for the hospital via stretcher at 1:33 p.m. A review of the SBAR (Situation, Background, Assessment, Recommendation) notes by LPN #1 dated 10/16/2017 at 2:54 p.m., documented that Resident #1 was noted with swelling and fracture to the right shoulder. The tool also documented that Resident reports new onset of pain. Pain when touching right shoulder and arm. The resident's primary MD was notified at 10:30 a.m., with a recommendation to send resident to the hospital. There was no documented evidence that pain medication was ordered to address the complaints of pain. A Nurse's Progress Note dated 10/16/2017 at 2:49 p.m., by LPN #1 documented that Resident #1's primary physician was notified on 10/16/2017 at 10:30 a.m. with recommendations to send Resident #1 to the hospital. A Nurse's Progress Note dated 10/16/2017 at 1:32 p.m., by RN #3 documented that Resident #1 left for the hospital via stretcher at 1:33 p.m. Plan of Care note indicated alteration in musculoskeletal status related to [MEDICAL CONDITION] shoulder. On 01/05/2018 at 1:20 p.m., during an interview with RN# 3, she stated that a STAT x-ray was ordered at 5:25 p.m., on 10/15/2017, and the x-ray completed on 10/16/2017 at 8:00 a.m. She stated that when the x-ray result was received indicating fracture, the Nurse Practitioner (NP) was called. The MD ordered for the resident to be transferred to the hospital for further evaluation. RN #3 responded to a question regarding pain assessment. She stated that she did not observed resident with facial grimacing. There was no documented evidence of pain assessment for Resident #1. On 01/05/18 at 3:00 p.m., during an interview with RN #1, who worked on the 3 p.m.-11 p.m. shift, stated that on 10/15/2017 during the 3-11 p.m. shift, the resident's daughter came to her and stated that the resident's right arm was swollen. RN #1 also stated the resident was seen by the NP after she informed her about the swelling on the resident's right arm. According to RN 1 an order for [REDACTED]. On 01/31/2018 at 3:31 p.m., during a follow-up phone interview with RN #1, she stated she did not notify the physician or the NP regarding the STAT x-ray not being done during her shift. RN #1 responded to a question regarding calling the x-ray company. She stated that she did not call the company to follow up on the STAT order. On 02/07/18 at 3:00 p.m., during a follow-up phone interview with RN#1, she stated she assessed the resident's right arm swelling and conducted a pain assessment but did not document the assessment. RN # 1 also stated NP #1 did not give an order for [REDACTED].>On 01/31/18 at 3:45 pm., during a phone interview with the NP, she stated she ordered a STAT x-ray because when she assessed Resident #1, there was swelling and pain in the right shoulder and that the protocol dictates an x-ray immediately. The NP added she was not informed that the STAT x-ray was not taken right away. On 2/12/18 at 1;34 p.m., during a follow-up phone interview with NP #1, she stated that she no longer works at the facility and does not have access to the resident's. records. When asked if she ordered medication to manage the resident's pain, she stated she cannot confirm and or give any more details but stated, more than likely if there was a PRN medication, it was given. Review of the doctor's order for 10/2017 revealed no orders for pain medication. On 01/31/18 at 4:30 p.m., during a phone interview with RN #2, she stated that the x-ray was completed at approximately 6:35 a.m. on 10/16/2017. RN #2 stated she did not notify the NP or the MD regarding the delay on getting the STAT x-ray completed nor did she make a follow-up call to the x-ray company. On 02/06/18 at 10:58 a.m., during a phone interview with the President of the x-ray company, she stated that the order was called at 5:25 p.m. on 10/15/17. She stated that the order was a STAT x-ray but due to the poor connection, the operator did not hear the order as STAT and entered it as a routine order. She further stated that a STAT order is usually completed within four hours and if the company is unable to deliver the services within the said timeframe, the x-ray company notifies the facility that it will be unable to fulfill the STAT order/s. On 02/07/2018 at 3:20 p.m., during a phone interview with LPN #1 who worked on 10/16/2017 on the 7-3 shift, she stated she was unable to confirm if the resident was given pain medication on 10/16/2017. When asked about timeline for a STAT x-ray she stated that the x-ray is usually done within an hour if the technician is in the building but added a call is usually placed to the x-ray company within an hour to confirm a STAT order. On 02/13/18 at 9:30 a.m., during a phone interview with NP #2, she stated she assessed Resident #1 before the resident was transferred to the hospital for evaluation of right shoulder fracture. NP#2 stated the resident was non-verbal and at the time of the assessment the resident did not have indicators of pain such as facial grimacing. She also stated she does not recall if the resident was medicated with pain medication. She also stated she did receive report from the nurses that the resident was assessed as having pain or reported pain. On 02/12/18 at 1:00 p.m., during a follow-up phone interview with the Director of Nursing Service (DNS), he stated that there was no order for pain medication on 10/15/2017-10/16/2017 to address the resident's reported pain in the right shoulder. The DNS stated that NP# 1 assessed the resident as having pain on 10/15/17 at 5:57 p.m., but did not order pain medication. The DNS stated that during the investigation of the right arm swelling and fracture he was not aware that the resident's pain was not managed. According to the DNS, per facility policy and procedure, pain assessment should have been conducted and documented to manage the resident's pain. The DNS responded to a question regarding timeline for STAT x-ray. He stated if the STAT order is taking more than four hours, the nurse should call the supervisor. 415.12

Based on record review and interviews during an abbreviated survey (NY 019), the facility did not ensure that a resident received radiology services in a timely manner for 1 out of 3 residents sampled. (Resident #1). Specifically, the Nurse Practitioner (NP) assessed Resident #1 on 10/15/2017 with swelling on the right shoulder and facial grimacing with movement. A STAT order was given for x-ray. The STAT x-ray was performed approximately 13 hours after the order was given. The x-ray results dated 10/16/2017 at 8:00 AM documented that Resident #1 had sustained an acute separated [MEDICAL CONDITION] humeral shaft. Resident #1 was transferred to the hospital on [DATE] at 1:33 PM. The findings include: Resident # 1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) on 10/01/2017, indicated a Brief Interview for Mental Status (BIMS - used to determine attention, orientation and ability to recall information) score of 3/15, associated with severe impairment (00-7 severe impairment, 08-12 moderate impairment & 12-15 cognitively intact). A Physician's Progress Note dated 10/15/2017 at 5:57 p.m. documented that Resident #1 was seen and examined by the Nurse Practitioner (NP) for reports of right shoulder pain, right shoulder and upper extremity [MEDICAL CONDITION], and resident grimaces with movement. Diagnosis, Assessment and Plan indicated right arm pain, STAT x-ray of the right shoulder and upper arm to rule out fracture. A Nurse's Progress Note by Registered Nurse #1 (RN #1) dated 10/16/2017 at 12:06 a.m., documented that Resident #1's right arm was noted with swelling and the resident was referred to NP. The NP ordered a STAT x-ray on right shoulder and arm. The note indicated that the pending order was endorsed to the 11-7 shift nurse. There was no documented evidence that a follow up call was made to the x-ray company regarding the STAT order. A Nurse's Progress Note dated 10/16/2017 at 5:53 a.m., by RN #2 documented swelling on the right arm persist, waiting for STAT x-ray of right upper arm and shoulder. There was no documented evidence of a follow up call to the x-ray company as the order was STAT. A Nurse's Progress Note dated 10/16/2017 at 6:36 a.m., documented that the x-ray was done. A Radiology Results Report dated 10/16/2017 at 8:10 a.m., documented examination of the right shoulder demonstrates an acute separated [MEDICAL CONDITION] humerus. A Nurse's Progress Note dated 10/16/2017 at 1:01 p.m., by RN #3 documented that the x-ray result of the right shoulder revealed separated [MEDICAL CONDITION] humeral shaft and marked [MEDICAL CONDITION]. The physician was informed with an order to transfer Resident #1 to the hospital for further evaluation. Resident #1 left for the hospital via stretcher at 1:33 p.m. A Nurse's Progress Note dated 10/16/2017 at 2:49 p.m., by Licensed Practical Nurse #1 (LPN #1) documented that the resident's primary physician was notified on 10/16/2017 at 10:30 a.m. with recommendations to send Resident #1 to the hospital. On 01/05/2018 at 1:20 p.m., during an interview with RN# 3, she stated that a STAT x-ray was ordered at 5:25 p.m., on 10/15/2017, and the x-ray was completed on 10/16/2018 at 8:00 a.m. She stated that when the x-ray result was received indicating fracture, the Nurse Practitioner (NP) was called. The physician ordered for the resident to be transferred to the hospital for further evaluation. On 01/5/18 at 3:00 p.m., during an interview with RN #1, who worked on the 3 p.m.-11 p.m. shift, she stated that on 10/15/17 during the 3-11 p.m. shift, a family member that was visiting with the resident reported that the resident's right arm was swollen. RN #1 stated that on assessment, there was no bruising noted, no complaints of pain when area was touched. RN #1 also stated the resident was seen by the NP after she informed her about the swelling on the resident's right arm. According to RN #1 an order for [REDACTED]. On 01/31/2018 at 3:31 p.m., during a follow-up phone interview with RN #1, she stated she did not notify the physician or the NP regarding the STAT x-ray not taken during her shift. RN #1 responded to a question regarding calling the x-ray company. She stated that she did not call the company to follow up on the STAT order. On 01/31/2018 at 3:45 pm., during a phone interview with the NP, she stated she ordered a STAT x-ray because when she assessed the resident, there was swelling and pain in the right shoulder and that the protocol dictates an x-ray immediately. The NP added she was not informed that the STAT x-ray was not taken right away. On 01/31/2018 at 4:30 p.m., during a phone interview with RN #2, she stated that the x-ray was completed at approximately 6:35 a.m. on 10/16/2017. RN #2 stated she did not notify the NP or the MD regarding the delay on getting the STAT x-ray completed. On 02/06/2018 at 10:58 a.m., during a phone interview with the President of the x-ray company, she stated that the order was called at 5:25 p.m. on 10/15/2017. She stated that the order was a STAT x-ray but due to the poor connection, the operator did not hear the order as STAT and entered it as a routine order. She further stated that a STAT order is usually completed within four hours and if the company is unable to deliver the services within the said timeframe, the x-ray company notifies the facility that it will be unable to fulfill the STAT order/s. On 01/10/2018 at 2:00 p.m., during an interview with the Director of Nursing Service (DNS), he stated that the facility investigated the delay in the STAT x-ray and that the order was indeed a STAT order based on the nurse's documentation. 415.21

Based on interviews and record review during an abbreviated survey, the facility did not ensure the services provided met professional standards of quality. This was evident for 1 of 3 sampled residents (Resident #1). Specifically, the physician ordered to administer [MEDICATION NAME] (cardiac glycoside) 125 micrograms (mcg), 1 tablet by mouth every other day. The nursing supervisor entered on the electronic Medication Administration Record (MAR) to administer [MEDICATION NAME] 125 mcg, 7 times a day, every other day. The nurses did not notice the error and administered incorrect dosage of [MEDICATION NAME] to Resident #1 between 8/13/2014 to 8/21/2014. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Complaint # NY 674 The findings include: Resident #1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident received [MEDICAL TREATMENT] 3 times weekly. The Minimum Data Set (MDS) 3.0 dated 8/19/2014 documented that the resident's cognitive skills were intact. The resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS). The physician's orders [REDACTED]. The Medication Review Report dated 8/12/2014 revealed that two nurses reviewed the physician's orders [REDACTED]. The MAR from 8/1/2014 to 8/31/2014 documented that [MEDICATION NAME] 125 mcg was scheduled for administration at 6:00AM, 9:00AM, 12:00PM, 3:00PM, 6:00PM, 9:00PM, and 11:00PM from 8/13/2014. The MAR documented that the nurses administered [MEDICATION NAME] 125 mcg tablet to the resident 26 times between 8/13/2014 to 8/21/2014. The facility's Medication Incident Report dated 8/21/2014 documented that [MEDICATION NAME] 125 mcg tablets were administered to Resident #1 with "incorrect frequency." The nurse's progress notes dated 8/21/2014 documented that [MEDICATION NAME] was discontinued. The physician ordered [MEDICATION NAME], potassium and electrocardiogram levels. The physician's progress note dated 8/22/2014 documented that a medication error with [MEDICATION NAME] was noted. The physician documented that the resident had "no complaints, no nausea, no change in appetite, no visual changes." The facility's investigation dated 8/25/2014 documented that the frequency of the administration of [MEDICATION NAME] was entered incorrectly on the MAR. The investigation documented "This case was a human error in the part of the transcribing RN (Registered Nurse) supervisor in which the next nurse failed to intercept before reaching the patient." The facility's Medication Pass Protocol (undated) documented that the nurses must "read label, read MAR and re-read label to verify dosage, time, and med route as transcribed with each medication." On 9/5/2014 at 11:14AM an interview was conducted with RNS #2. RNS #2 stated that on 8/21/2014 RN #11 notified her of the [MEDICATION NAME] medication error. RNS #2 stated that she notified the physician of the error and initiated the medication error report. On 9/5/2014 at 2:55PM and on 9/9/2014 at 11:30AM, interviews were conducted with the RN supervisor (RNS) #1. RNS #1 stated that after he received the physician order [REDACTED]. RNS #1 stated the physician order [REDACTED]. However, RNS #1 stated that he incorrectly entered the frequency of administration for [MEDICATION NAME] 125 mcg on the MAR. He stated he entered [MEDICATION NAME] to be administered 7 times a day, every other day, rather than 1 tablet, every other day. On 9/5/2014 at 12:00PM an interview was conducted with the physician. The physician stated that he ordered [MEDICATION NAME] 125 mcg 1 tablet every other day, which was a reasonable dosage for Resident #1, who was on [MEDICAL TREATMENT] and had a [DIAGNOSES REDACTED]. He stated that he evaluated the resident and ordered electrocardiogram, [MEDICATION NAME] level, and other blood works. The physician stated that based on the results of the blood work and electrocardiogram, the resident had no adverse effect from the medication error. On 9/5/2014 at 3:40PM an interview was conducted with the RN charge nurse. The RN charge nurse stated that she reviewed the Medication Review Report on 8/13/2014 to ensure the order was transcribed correctly on the MAR. She stated that she reviewed the MAR, but missed that [MEDICATION NAME] was scheduled for 7 times a day, every other day. On 9/5/2014 at 6:00PM and on 9/8/2014 at 12:31PM, interviews were conducted with RN #11. RN #11 stated that she reviewed the Medication Review Report on 8/12/2014 to ensure the physician orders [REDACTED]. She stated that her review did not reveal any discrepancy. RN #11 stated that she was not aware that [MEDICATION NAME] was scheduled to be administered 7 times a day because she did not review the MAR. On 9/8/2014 at 4:53PM an interview was conducted with the Licensed Practical Nurse (LPN). The LPN stated that on 8/19/2014 she noticed that 3 doses of [MEDICATION NAME] was scheduled to be administered during her shift. She stated that she did not question this schedule on the MAR even though she was aware that [MEDICATION NAME] should only be administered once a day. On 9/15/2014 at 1:29PM an interview was conducted with RN #2. RN #2 stated that on 8/13/2014, she was not aware that [MEDICATION NAME] was administered to the resident at 6:00AM. RN #2 stated that she administered [MEDICATION NAME] to the resident on 8/13/2014 at 9:00AM as scheduled on the MAR. 415.11(c)(3)(i)

Based on record reviews and facility staff interviews, the facility did not ensure that resident was free of receiving excessive dose of insulin medication that was not precribed by a physician. This was evident for one (1) of thirty (30) sampled Residents. (Resident # 17). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident # 17 was admitted with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] documented that the resident is assessed with [REDACTED]. The physician's orders [REDACTED]. Twice A Day with ([MEDICATION NAME] R Insulin Vial 10ML) Coverage, Inject Subcutaneously. If reading: Between 100 and 150 give 2 units. Between 151 and 200 give 4 units. Between 201 and 250 give 6 units. Between 251 and 300 give 7 units. Between 301 and 350 give 8 units. If reading above 351 and below 70 call MD," on 8/20/12 the above order was documented as disconutined. physician's orders [REDACTED]. Twice A Day with ([MEDICATION NAME] R Insulin Vial 10ML) Coverage, Inject Subcutaneously. If reading: Between 200 and 250 give 3 units. Between 251 and 300 give 4 units. Between 301 and 350 give 5 units. Between 351 and 400 give 6 units. If reading above 401 and below 70 call MD." The Diabetic Report Sheet/ Capillary Blood Reading/ Fingerstick Results sheet documented that on the following dates the resident received the wrong Insulin doses based on finger stick (FS) results: 8/31/12, before breakfast finger stick result 314, Insulin 8 u (units) was documented and signed as given, instead of 6 units ordered. 8/31/12, before afteroon feeding, finger stick result 264, Insulin 7 u was documented and signed as given, instead of 4 units ordered. 9/1/12, morning finger stick result 185, Insulin 4 "u" was documented and signed as given, instead of zero units. 9/2/12, before afteroon feeding, finger stick result 210, Insulin 6 u was documented and signed as given, instead of 3 units ordered. 9/8/12, morning finger stick result 252, Insulin 7 u was documented and signed as given, instead of 4 units ordered. 9/8/12, before afteroon feeding, finger stick result 232, Insulin 6 u was documented and signed as given, instead of 3 units ordered. Resident had (6) incidence of increase blood sugar results requiring coverage and the resident received increased doses of insulin instead of the insulin coverage ordered. The LPN who gave the insulin on 8/31/12 in the morning was interviewed via telephone on 9/12/12 approximately 12:00pm and stated that for the F/S result of 314, he should have given 5 units instead of the 8 units and did not recall why 8 units was written or given. On 9/12/12 at approximately 4:30pm, the 3pm-11pm shift LPN was interviewed and confirmed that he was the nurse who administrated the insulin to the resident on 8/27/12, 8/31/12, 9/1/12, 9/2/12 and 9/8/12. He reviewed the F/S result sheet and verified that the wrong doses of insulin were given on those dates and that the physician's orders [REDACTED]. He further stated that he might have reviewed the old order dated 8/15/12. 415.12(I)(1)

Based on record reviews and facility staff interviews, the facility did not ensure that nursing services provided met the standards of professional quality. This was evidenced by: 1) The Licensed Practical Nurses (LPN) provided insulin coverage to a resident based on an outdated order and resident received wrong dose of insulin. 2) Licensed Nurse did not document the specific time that insulin was given. This was evident for one (1) of thirty (30) sampled residents. (Resident # 17). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident # 17 was admitted with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] documented that the resident is assessed with [REDACTED]. Review of resident's physician's orders [REDACTED]. Twice A Day with ([MEDICATION NAME] R Insulin Vial 10ML) Coverage, Inject Subcutaneously. If reading: Between 200 and 250 give 3 units. Between 251 and 300 give 4 units. Between 301 and 350 give 5 units. Between 351 and 400 give 6 units. If reading above 401 and below 70 call MD." The Diabetic Report Sheet/ Capillary Blood Reading/ Fingerstick Results sheet documented that on the following dates the resident received the wrong Insulin doses based on finger stick (FS) results: 8/31/12, before breakfast finger stick result 314, Insulin 8 u (units) was documented and signed as given, instead of 6 units ordered. 8/31/12, before afteroon feeding, finger stick result 264, Insulin 7 u was documented and signed as given, instead of 4 units ordered. 9/1/12, morning finger stick result 185, Insulin 4 u was documented and signed as given, instead of zero units. 9/2/12, before afteroon feeding, finger stick result 210, Insulin 6 u was documented and signed as given, instead of 3 units ordered. 9/8/12, morning finger stick result 252, Insulin 7 u was documented and signed as given, instead of 4 units ordered. 9/8/12, before afteroon feeding, finger stick result 232, Insulin 6 u was documented and signed as given, instead of 3 units ordered. There is no documented evidence of the actual time the insulin coverages were given. Additionally, on 8/27/12 and 9/10/12 there is no dcoumented evidence that the finger stick was done twice a day as ordered. There is only documentation of one result. The LPN who gave the insulin on 8/31/12 in the morning was interviewed via telephone on 9/12/12 approximately 12:00pm and stated that for the F/S result of 314, he should have given 5 units instead of the 8 units and did not recall why 8 units was written or given. On 9/12/12 at approximately 4:30pm, the 3pm-11pm shift LPN was interviewed and confirmed that he was the nurse who administrated the insulin to the resident on 8/27/12, 8/31/12, 9/1/12, 9/2/12 and 9/8/12. He reviewed the F/S result sheet and verified that the wrong doses of insulin were given on those dates. The physician's orders [REDACTED]. He further stated that he might have reviewed the old order and on 8/27/12,the F/S that was not done was an omission and does not recall the reason why. Resident had (6) incidences of increased blood sugar requiring coverage and the resident received wrong doses of insulin ordered. On 9/13/12 at approximately 9:30am, the Director of Nursing was interviewed and stated that the staff was following a memo dated 5/22/09 that documented "... 2. For physician orders [REDACTED]. do not enter a specific time for the fingerstick to be taken. It is appropriate to simply enter for BID ac 'before breakfast' and 'before dinner'. For TID ac, it is appropriate to enter before breakfast, before lunch and before dinner." The staff should have documented the actual time insulin was given and are currently being in-services that the actual time are required. 415.11(c)(3)(i)

Based on record reviews and facility staff interviews, the facility did not ensure that a Physician's order was followed. This was evident for one (1) of thirty (30) sampled residents. (Resident # 17). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident # 17 was admitted with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] documented that the resident is assessed with [REDACTED]. Review of resident's Physician's Order Form dated 8/20/12 documented "Finger Stick Blood Sugar. Twice A Day with ([MEDICATION NAME] R Insulin Vial 10ML) Coverage, Inject Subcutaneously. If reading: Between 200 and 250 give 3 units. Between 251 and 300 give 4 units. Between 301 and 350 give 5 units. Between 351 and 400 give 6 units. If reading above 401 and below 70 call MD." The Diabetic Report Sheet/ Capillary Blood Reading/ Fingerstick Results sheet documented that on the following dates the resident received the wrong Insulin doses based on finger stick (FS) results: 8/31/12, before breakfast finger stick result 314, Insulin 8 u (units) was documented and signed as given, instead of 6 units ordered. 8/31/12, before afteroon feeding, finger stick result 264, Insulin 7 u was documented and signed as given, instead of 4 units ordered. 9/1/12, morning finger stick result 185, Insulin 4 u was documented and signed as given, instead of zero units. 9/2/12, before afteroon feeding, finger stick result 210, Insulin 6 u was documented and signed as given, instead of 3 units ordered. 9/8/12, morning finger stick result 252, Insulin 7 u was documented and signed as given, instead of 4 units ordered. 9/8/12, before afteroon feeding, finger stick result 232, Insulin 6 u was documented and signed as given, instead of 3 units ordered. Additionally, on 8/27/12 and 9/10/12 there is no dcoumented evidence that the finger stick was done twice a day as order. There is only documentation of one result. Resident has (6) incidences of increased blood sugar requiring coverage and the resident received wrong doses of insulin ordered. The LPN who gave the insulin on 8/31/12 in the morning was interviewed via telephone on 9/12/12 approximately 12:00pm and stated that for the F/S result of 314, he should have given 5 units instead of the 8 units and did not recall why 8 units was written or given. On 9/12/12 at approximately 4:30pm, the 3pm-11pm shift LPN was interviewed and confirmed that he was the nurse who administrated the insulin to the resident on 8/27/12, 8/31/12, 9/1/12, 9/2/12 and 9/8/12. He reviewed the F/S result sheet and verified that the wrong doses of insulin were given on those dates. The Physician's Order dated 8/20/12 was not followed. He further stated that he might have reviewed the old order and on 8/27/12,the F/S that was not done was an omission and does not recall the reason why. 415.11(C)(3)(iii)