Every finding on record at Wyoming County Community Hospitals SNF

Based on observation, interview, and record review conducted during the survey, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases and infection for one (Resident #33) of four residents observed for Enhanced Barrier Precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) and one (Resident #41) of five residents reviewed for infection control during medication administration. Specifically, Enhanced Barrier Precautions were not initiated for Resident #33 who had a chronic open wound to their right buttock and staff did not wear appropriate personal protective equipment while providing wound care. Additionally, during a medication administration observation the nurse did not maintain infection control procedures during administration of eye drops for Resident #41. The findings include:The facility policy titled Enhanced Barrier Precautions dated 05/08/2024 documented enhanced barrier precautions were utilized to decrease the transmission of multidrug-resistant organisms in the nursing facility. Enhanced barrier precautions are initiated once a resident has been identified as being colonized or infected with a multidrug-resistant organism and are utilized for any resident with an open wound or indwelling medical device. Implementation of enhanced barrier precautions included a physician order would be obtained, signage placed on the resident's door, and the resident care plan would be updated to include Enhanced Barrier Precautions. Enhanced Barrier Precautions required the use of gowns and gloves during high contact resident care activities including wound care.The facility policy titled Administration of Ophthalmic Solution/Ointment (Eye Drops) dated 08/11/2025 documented it shall be the policy for a nurse to administer ophthalmic solution/ointment into and around the eye in a safe and accurate manner. The procedure included the nurse was to wash their hands, explain procedure to residents and don (put on) gloves, remove cap taking care to avoid touching the tip, place cap on a clean, dry surface, and avoid putting open end down. The policy documented when completed the nurse was to remove their gloves, wash hands, replace the cap on the container, and wait at least five minutes before applying additional medications.The facility policy titled Hand Hygiene Guidelines revised 08/2021 documented handwashing was the single most important method of preventing the spread of infection. The following was a list of some situations that required hand hygiene: when coming on duty; before and after performing any invasive procedure; upon and after coming in contact with a resident's intact skin; after contact with a resident's mucous membranes and bodily fluids or excretions; before donning gloves, and after removing gloves.1.Resident #33 had diagnoses that included dementia, open wound to the right buttock, and peripheral vascular disease (poor circulation of the lower extremities). The Minimum Data Set (a resident assessment tool) dated 05/27/2026 documented Resident #33 had moderate cognitive impairment, was sometimes understood and usually understands. The Minimum Data Set documented Resident #33 was dependent on staff for bed mobility and transfers, there were no pressure ulcers documented.Review of the Kardex Report (a guide used by staff to provide care) dated 06/09/2026 revealed no documented evidence that Resident #33 required Enhanced Barrier Precautions.Review of the current comprehensive care plan revealed it was not revised until 06/10/2026 to include Resident #33 required Enhanced Barrier Precautions and gowns and gloves were required during high contact care activities.Review of the Wound Consultants Skin and Wound Note dated 06/04/2026 revealed Resident #33 had an open wound to their right buttock that was classified as a shearing (a mechanical force that that occurs when gravity pulls the body downward while the skin remains stuck to the surface-like a bedsheet) wound. The wound measured 3.2 centimeters (length) by 3.5 centimeters (width) by 0.2 centimeters (depth), the wound base was 60 percent granulation (healing tissue) and 40 percent slough (soft, moist, dead tissue, white, yellow, tan or green in color) with a moderate amount of serosanguineous (mixture of blood and clear or yellow fluid) drainage present. Review of additional Wound Consultant Skin and Wound Notes from 04/02/2026 - 05/28/2026 documented Resident #33 had an open shearing wound to their right buttock with light to moderate serosanguinous drainage was present on assessment.Review of the Order Summary Report dated 06/12/2026 which included all active, completed, and discontinued orders revealed there was no physician order for Enhanced Barrier Precautions until 06/10/2026.During a wound care observation on 06/10/2026 at 10:36 AM, there was no sign observed on Resident #33's doorway indicating they required Enhanced Barrier Precautions. Certified Nurse Aide #2 and Licensed Practical Nurse #5 entered Resident #33's room and set up treatment supplies on a clean barrier next to the resident's bed. Certified Nurse Aide #2 and Licensed Practical Nurse #5 performed hand hygiene, applied gloves and assisted the resident onto their side. Resident #33 was observed to have an open wound to their right buttock; the wound bed was observed to be red and moist with small amount of yellow slough present. Licensed Practical Nurse #5 cleansed Resident #33's right buttock wound with normal saline and patted the wound dry with clean gauze, small amount of bloody drainage was present. Licensed Practical Nurse #5 removed their gloves, performed hand hygiene and applied new gloves, they applied skin prep (topical application that toughens the skin and enhances adherence of dressing) to the wound edges, then applied calcium alginate (a highly absorbent wound dressing) to the wound bed and covered the wound with a dry clean dressing. Licensed Practical Nurse #5 removed their gloves, performed hand hygiene, applied new gloves and assisted Certified Nurse Aide #2 with repositioning Resident #33 in bed. Licensed Practical Nurse #5 and Certified Nurse Aide #2 did not wear a gown during the observation. During an interview on 06/10/2026 at 10:50 AM, Certified Nurse Aide #2 stated they would look for signs posted on resident doorways to identify what residents required enhanced barrier precautions. They stated if a resident required enhanced barrier precautions, they would need to wear a gown and gloves for any physical care provided. Certified Nurse Aide #2 stated Resident #33 was not on enhanced barrier precautions, they stated the sign on the outside of Resident #33's room was labeled B which indicated their roommate was on precautions.During an interview on 06/10/2026 at 11:00 AM, Licensed Practical Nurse #5 stated enhanced barrier precautions were initiated for residents depending on their medical history which included residents that had catheters and certain wounds. Licensed Practical Nurse #5 stated residents that required enhanced barrier precautions would have a physician's order and there would be a little square tag on their doorframe indicating which resident required precautions. Licensed Practical Nurse #5 stated they did not wear a gown while providing wound care to Resident #33 because they were not on enhanced barrier precautions, they stated Resident #33 did not have an order for enhanced barrier precautions and there was no sign indicating they were on precautions. Licensed practical Nurse #5 stated Resident #33 had an open wound but were unsure if they should have been on precautions. They stated the nurse managers and supervisors determined what wounds required enhanced barrier precautions.During an interview on 06/11/2026 at 9:07 AM, Registered Nurse Manager #3 stated any resident with an open wound should be placed on enhanced barrier precautions to prevent the spread of infections. Registered Nurse Manger #3 stated they were responsible to ensure enhanced barrier precautions were in place when needed and expected their staff to utilize the proper protective equipment when providing care. They stated Resident #33 had an open wound and should have been on enhanced barrier precautions, they stated it was overlooked.During an interview on 06/12/2026 at 9:16 AM, Registered Nurse / Infection Preventionist #1 stated enhanced barrier precautions were utilized when a resident had an indwelling device, history of multidrug-resistant organisms, or a chronic wound. They stated that when a resident was on enhanced barrier precautions, they would expect staff to wear gowns and gloves for all direct care activities to protect themselves and the residents from further infection. Registered Nurse / Infection Preventionist #1 stated if Resident #33's wound was open and draining they would have expected that resident to have been on enhanced barrier precautions.During an interview on 06/12/2026 at 10:55 AM, the Director of Nursing stated they would expect any resident with an open wound to be placed on enhanced barrier precautions. They stated the Nurse Managers were responsible to initiate the precautions, obtain a physician order, and ensure a square magnet was placed on the resident's door frame specifying A or B to indicate which resident was on precautions. The Director of Nursing stated they expected staff to wear the appropriate personal protective equipment when providing care to prevent the spread of infection to residents. The Director of Nursing stated Resident #33 had an open wound, they would be at risk for infection and should have been on enhanced barrier precautions.2. Resident #41 had diagnoses which included diabetes mellitus, glaucoma (eye disease that damages the optic nerve), and dry eye syndrome. The Minimum Data Set, dated [DATE] documented Resident #41 usually understands and was usually understood.The comprehensive care plan dated 04/07/2025 documented the resident had impaired visual function related to glaucoma and to monitor symptoms of acute eye problems.The Order Summary Report documented active physician's orders dated 04/01/2025 for Combigan Ophthalmic Solution 0.2-0.5 percent, instill one (1) drop in both eyes two times a day for glaucoma. There was an active physician's order dated 05/02/2025 for artificial tears solution 0.5-0.6 percent, instill one (1) drop in both eyes two times a day for dry eye. During a medication administration observation on 06/11/2026 at 10:04 AM, Licensed Practical Nurse #4 donned (put on) a pair of gloves without performing hand hygiene then removed the cap from the Combigan Ophthalmic Solution bottle and set the cap open end down on the wooden handrail in the hall outside of Resident #41's room. Licensed Practical Nurse #4 instructed Resident #41 to tilt their head back then administered the eye drops into Resident #41's right and left eye by pulling their lower eyelids down with their gloved hand. Licensed Practical Nurse #4 replaced the cap on the bottle of Combigan Ophthalmic Solution without removing their gloves and performing hand hygiene. Then Licensed Practical Nurse #4 removed the cap from the artificial tears solution bottle, set the cap open end down on the wooden handrail and administered the artificial tears solution into Resident #41's right and left eye by pulling their lower eyelids down with their gloved hand. Licensed Practical Nurse #4 replaced the cap on the bottle without removing their gloves or performing hand hygiene. Licensed Practical Nurse #4 then opened the medication cart drawer with their right gloved hand and put the eye drop bottles inside the drawer. Licensed Practical Nurse #4 then removed and disposed of their gloves and sanitized their hands.During an interview on 06/11/2026 at 10:14 AM, Licensed Practical Nurse #4 stated they contaminated both bottles of eye drops by placing the caps on the handrail. The handrails were covered in germs from people touching them. They should have used a clean tissue to set the open end of the caps on. Licensed Practical Nurse #4 stated they should have washed their hands, put gloves on, administered the eye drops in each eye then removed their gloves, performed hand hygiene, put new gloves on then administered the second set of eye drops. Then they should have removed their gloves and performed hand hygiene before cross-contaminating the medication cart.During an interview on 06/12/2026 at 9:33 AM, Registered Nurse /Infection Preventionist #1 stated hand hygiene including washing hands and putting on clean gloves should have been done before and after giving eye drops. Handrails were dirty and not an acceptable place to set the caps. Both bottles of eye drops were contaminated.During an interview on 06/12/2026 at 11:35 AM, Registered Nurse #2 stated hand hygiene should have been done prior to putting on gloves, then again in between the two eye medications. Licensed Practical Nurse #4 should have changed gloves and washed their hands again and was the standard practice for infection control. Registered Nurse #2 stated it was unacceptable to put the caps on the handrail because the rails were dirty and caused an increased risk for infection to Resident #41 and Licensed Practical Nurse #4 should have held the caps in their other hand or set them on a clean barrier.During an interview on 06/12/2026 at 11:44 AM, Director of Nursing #1 stated Licensed Practical Nurse #4 should have used different gloves for each eye, then washed their hands and gave the oral medications in between the eye drops. After administering the oral medications, Licensed Practical Nurse #4 should have repeated the process then removed their gloves, performed hand hygiene before touching the medication cart. Resting the caps on the rails was against infection control practices. 10 New York Codes Rules Regulations 415.19(a)(2)(b)(4)

Based on observation, interview, and record review conducted during survey the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive centered care plan for one (Resident #33) of three residents reviewed. Specifically, a treatment recommendation was made on 04/29/2026 by the Wound Consultant and was not implemented until 06/10/2026 for a resident with an open sheering wound (deep tissues skin damage, internal force where bones and deep tissues move in one direction while skin or external surfaces move in the other, stretching and cutting off blood supply). The findings include: The facility policy and procedure titled Consulting Medical Provider dated 02/20/2025 documented following the consultant appointment, recommendations were forwarded to the Medical Doctor or Nurse Practitioner by the manager or supervisor for approval. If the recommendation was approved, nursing staff will implement said recommendations and appropriate orders from the attending Medical Doctor or Nurse Practitioner. The facility policy and procedure titled Skin Alteration /Ulcer Evaluation/Care Protocol/Documentation dated 02/20/2025 documented it was the facility policy to identify and treat pressure ulcers and other skin alterations by providing care to promote healing and to prevent infection and further skin breakdown. All residents will have an order for wound care consult as needed. The Interdisciplinary Team will meet weekly to review and discuss skin findings. The Unit Coordinator will document in the electronic medical record any recommendations made by the team. Resident #33 had diagnoses that included dementia, unspecified open wound to right buttock, and peripheral vascular disease (poor circulation of the lower extremities). The Minimum Data Set (a resident assessment tool) dated 05/27/2026 documented Resident #33 had moderate cognitive impairment. The Minimum Data Set documented that Resident #33 was dependent on staff for bed mobility and transfers and their risk for pressure ulcer/injury was documented as not assessed. The Comprehensive Care Plan last revised on 03/05/2026 documented Resident #33 had the potential for skin alteration of the buttocks related to fragile skin, incontinence, and decreased mobility. Treatment interventions included to follow facility protocols for treatment of resident's skin breakdown; turn and position every two to four hours and as needed; use a draw sheet or lifting device to move resident; and weekly treatment documentation to include measurement of skin breakdown, type of tissue, drainage, and any other notable changes. Review of the Wound Consultants Skin and Wound Note dated 04/29/2026 revealed Resident #33 had an open wound to their right buttock that was classified as a sheering wound. The skin and wound note documented there was an increased amount of wound drainage present, wound measurements were1.5 centimeters (length) x 1.5 centimeters (width) x 0.1 centimeters (depth); and the wound status was noted to be improving without complications. Treatment recommendations made included cleanse the wound with normal saline, apply calcium alginate (a highly absorbent wound dressing) to base of the wound, secure with bordered gauze to be changed daily and as needed. Review of the Skin/Wound Notes dated 04/29/2026 completed by Registered Nurse Manager #3 documented wound rounds were completed with wound team, Resident #33's skin tear versus sheering wound continued to right lower buttock and was smaller in size. The Skin/Wound note documented per the wound specialist treatment would be changed to calcium alginate and covered with a dressing daily. Review of the Provider note dated 05/27/2026 documented Resident #33 had a slow healing shearing/skin tear wound to their right buttock; they were followed by wound care and current recommendation included applying calcium alginate daily. Review of additional Wound Consultant Skin and Wound Notes dated 05/07/2026, 05/14/2026, 05/21/2026, 05/28/2026, and 06/04/2026 revealed calcium alginate continued to be recommended for Resident #33's wound. Further review of the Wound Consultant Skin and Wound Notes dated 05/07/2026, 05/14/2026, and 05/21/2026 the wound status was documented as being stalled, on 05/28/2026 the wound status documented the wound was improving with delayed closure, and on 06/4/2026 the wound status was documented as worsening and noted increased slough to the wound. The Treatment Administration Record dated 04/01/2026 - 04/30/2026 documented a treatment order with start date 03/17/2026 for Silvadene External Cream (an antibiotic skin cream) 1% (percent) to be applied to Resident #33's right gluteal (buttock) fold topically every shift for skin tear/sheer wound. Further review of the Treatment Administration record revealed there was no order implemented on or after 04/29/2026 for calcium alginate to be applied to Resident #33's wound. The Treatment Administration Record dated 05/01/2026 - 05/31/2026 documented a treatment order with start date 03/17/2026 for Silvadene External Cream (an antibiotic skin cream) 1% (percent) to be applied to Resident #33's right gluteal fold topically every shift for skin tear/sheer wound. Further review of the Treatment Administration record revealed there was no order implemented for Calcium Alginate to be applied to Resident #33's wound. The Treatment Administration Record dated 06/01/2026 - 06/30/2026 revealed Silvadene External Cream 1% (percent) continued to be administered to Resident #33's wound until 06/09/2026 and there was no physician order for calcium alginate to be applied to Resident #33's wound until 06/10/2026. Review of the Skin/Wound Note dated 06/10/2026 completed by Registered Nurse Manager #3 documented Resident #33's treatment order was changed as per the skin specialist. Review of the Order Summary Report dated 06/12/2026 which included all active, completed, and discontinued orders revealed there was no physician order for calcium alginate to reflect the Wound Consultant's recommendation made on 04/29/2026 until 06/10/2026. During a wound care observation and interview on 06/10/2026 at 10:34 AM, Licensed Practical Nurse #5 checked Resident #33's physician orders for wound care and gathered all treatment supplies which included calcium alginate. Licensed Practical Nurse #5 stated Resident #33's treatment had just been changed today, and the new order was to apply calcium alginate to their wound. They stated previously Resident #33's wound was being treated with Silvadene cream. During an interview on 06/11/2026 at 8:29 AM, the Wound Consultant stated they completed wound rounds at the facility weekly with the nurse managers. They stated new recommendations would be communicated first verbally to the nurse manger and additionally were documented in their notes. The Wound Consultant stated the facility typically received a copy of their notes within 24 hours and would expect the nurse manager to implement any changes after receiving the consultation unless the facility medical provider did not agree with the recommendations made. The Wound Consultant stated Resident #33 had an open wound to their right gluteal fold that was classified as a sheering wound with slough (soft, moist, dead tissue white, yellow, tan or green in color) present to the wound bed. They stated they were not aware Resident #33's treatment recommendations from 04/29/2026 were not implemented until 06/10/2026. They stated the treatment was changed due to increased drainage and would have expected their recommendations to be followed. The Wound Consultant stated they could not say if the delay in following their treatment recommendation caused any decline or delayed healing. They stated they had just assessed the wound today, wound status showed improvement, and they had no concerns. During an interview on 06/11/2026 at 8:48 AM, Registered Nurse Manager #3 stated they completed skin rounds with the Wound Consultant weekly, any new recommendations were communicated to them verbally and a copy of the wound consultant report would be emailed to them within a few days. Registered Nurse Manager #3 stated they were responsible for reviewing the wound consults and addressing any new recommendations made with the facility medical provider. They stated if the recommendation made was something critical, they would address it immediately with the medical provider otherwise would wait for the consultant report before changing the order. Registered Nurse Manager #3 stated they changed Resident #33's treatment order to calcium alginate on 06/10/2026 per the Wound Consultant's recommendations made on 06/04/2026. During the interview Registered Nurse Manager #3 reviewed Resident #33's wound consultant notes in the electronic medical record and stated the treatment recommendation for calcium alginate was initially made on 04/29/2026. They stated the recommendation was overlooked, they went by the Wound Consultant verbally stating no changes, did not double check the consultation notes and should have. During an interview on 06/12/2026 at 10:55 AM, the Director of Nursing stated the Wound Consultant notes were automatically uploaded into the electronic medical record within 24-48 hours after the consultation. They stated the nurse mangers were expected to review all consultations, look for recommendations, have them approved by the medical provider, and implement the new orders. The Director of Nursing stated Resident #33's treatment recommendation dated 04/29/2026 should have been reviewed and addressed within one to two days after receiving the consultation. They stated residents were seen by a wound specialist for a reason and it was important to address all recommendations timely to promote wound healing. During an interview on 06/12/2026 at 12:49 PM, the Medical Director stated they would expect the nursing staff to review the wound consultants, look for changes, and notify them or another provider with the recommendations to see if the treatment was appropriate to change. They stated 95 percent of the time they were agreeable with the recommendations made by the wound consultants because they were made for healing purposes. They stated they would expect the wound care recommendation to be reviewed and addressed by the nursing staff within a reasonable amount of time. The Medical Director stated a recommendation made on 04/29/2026 and not implemented until 06/10/2026 would not meet their expectation of a reasonable timeframe. They stated the recommendation made for Resident #33 was made for a reason and should have been addressed sooner. 10 New York Codes, Rules, and Regulations 415.12

Based on observation, interview, and record review conducted during the Standard survey completed 3/1/24, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtained informed consent prior to the installation of bed rails for two (Resident # 88, and #100) of two residents reviewed for bed rails. Specifically, Residents #88 and #100 were not assessed for risk of entrapment from bed rails, there was no documented evidence the risks and benefits of bed rails were reviewed and that consents were obtained prior to bed rail use. The findings are: The policy and procedure, titled Bed Mobility Assistive Devices dated 9/19//2022 documented to Assess the resident for risk of entrapment from bed mobility assistive device prior to installation, review the risk and benefits with resident and resident representative-assessment will occur quarterly, annually, or a significant change in condition prior to care plan meeting. The bed operations manual dated 09/2014 provided by Clinical Engineer #1 on 2/29/24 at 3:00 PM documented equipment on bed frame were siderails. The operations manual documented a warning that the design of the siderails keep the patient from rolling off the product. The operator must determine the degree on restraint necessary to make sure that the patient is safe. Failure to use the side rails as intended could result in serious injury. 1. Resident #88 had diagnoses that included hemiplegia and hemiparesis (weakness or the inability to move one side of body) affecting their left dominant side, acute kidney failure, and chronic obstructive pulmonary disease. The Minimum Data Set (MDS- a resident assessment tool) dated 1/31/24 documented Resident #88 was understood, cannot recall, and had moderate cognitive impairments. Resident #88's required assist with bed mobility and did not use a bed rail. The comprehensive care plan dated 1/22/24 documented Resident #88 was non-ambulatory and used grab bars in bed. The Kardex (guide used by staff to provide care) dated 2/28/24 documented Resident #88's bed mobility. The resident required the following: lying to sitting on side of bed partial/moderate assist with increased time to assist with grab bars. The Bed Mobility Equipment Assessment Form dated 1/25/24 documented Resident #88 a need for bed mobility assist rail. There was no documented evidence that informed consent was obtained. Additionally, there was no documented evidence entrapment risks and benefits of a bed mobility device were reviewed with the resident or resident representative. During an observation on 2/26/24 at 9:06 AM Resident #88 was lying in bed sleeping, with two 1/2 bed rails in the up position at the head of their bed. During an observation on 2/28/24 at 8:25 AM Resident #88 was lying in bed with two 1/2 bed rails in the up position at head of their bed. During an observation on 2/28/24 at 10:19 AM there were two 1/2 bed rails in the up position at the head of Resident #88's bed. Certified Nurse Assistant #2 stated to the resident that they were going to assist them sit up. Certified Nurse Assistant #2 put both of their arms around Resident # 88 and pulled them up to a sitting position at the edge of bed. Resident # 88 did not use and was not given instructions to use the bed rails to assist them with sitting up. During an observation on 2/29/24 at 8:23 AM and 3/1/24 at 10:00 AM, Resident #88 was lying in bed and had two bed rails in the up position at the head of their bed. During an interview on 2/28/24 at 12:15 PM, Certified Nurse Assistant #2 stated only a few residents had bed rails, and they must be care planned to use them. Additionally, residents must have assessment done by nursing when bed rails were used, and it was important for safety. Certified Nurse Assistant #2 stated Resident #88 siderails were permanently attached to the bed. During and observation and interview on 2/28/24 at 12:20 PM, Licensed Practical Nurse #1 stated they used enablers on the unit, and they were for bed mobility. Licensed Practical Nurse #1 stated a bed mobility equipment assessment would be completed prior to the rails being placed and they would be put on by maintenance if determined appropriate. Licensed Practical Nurse #1 identified and stated Resident #88's bed rails were 1/2 rails and stated would not be considered a restraint. They stated Resident #88 was care planned for bed mobility rails, as they help the resident pull themselves up in bed. During an interview on 2/29/24 at 11:25 AM and 3:15 PM, Registered Nurse #1 Unit Coordinator stated they evaluated the need for the bed mobility devices and documented the assessment on the Bed Mobility Equipment Assessment Form. Bed mobility devices were installed so that residents could turn and position themselves and to promote independence. The Registered Nurse Unit Coordinator #1 stated they do not obtain a written consent for bed rails, and there would be no documentation regarding an evaluation of entrapment risks. 2. Resident #100 had diagnoses that included displaced bimalleolar fracture of lower leg (ankle fracture), Parkinson's Disease, hypothyroidism (thyroid disease). The Minimum Data Set, dated dated dated [DATE] documented Resident #100 was cognitively intact and was usually understood and understands. Resident #100's bed mobility was documented as dependent. The comprehensive care plan dated 2/27/24 documented Resident #100 was non-ambulatory. The Kardex dated 3/1/24 documented Resident #100 was dependent on two staff assist for bed mobility and rolling left and right. The Bed Mobility Equipment Assessment Form dated 3/2023 to 2/2024 documented a need for a bed mobility assist rail. There was no documented evidence that informed consent was obtained, entrapment risks, or benefits of a bed mobility device were reviewed with the resident or resident representative. During an observation on 2/28/24 at 8:55 AM Resident #100 was in bed and had two 1/2 side rails at head of bed in the up position. During an observation on 2/29/24 at 8:04 AM Resident #100 was in bed and had two 1/2 side rails at the head of bed in the up position. During an interview on 2/29/24 at 2:51 PM, Clinical Engineer #1 stated the hospital beds were (formal name) beds and serviced annually. The beds have four side rails. The lower ones get locked in the down position so they cannot be used. The upper side rails were 42 inches long and were permanently fixed to the bed and the mattresses were a standard fit. Additionally, Clinical Engineer #1 stated the other beds have enablers, which may be removed easier. During an interview on 2/29/24 at 3:24 PM, Licensed Practical Nurse #4 Unit Manager stated they use bed mobility devices on Peach unit and call them enablers. Licensed Practical Nurse Unit Manager #4 stated the bed mobility devices promote independence for residents, there was no consent needed and residents were care planned for them. Additionally, Licensed Practical Nurse Unit Manager #4 stated the bed mobility devices would be a restraint if the resident was confined to bed, or unable to use them. Licensed Practical Nurse #4 stated Resident #100 was on a hospital bed with rails, that they came from the Aqua Unit and Resident #100 had a bed mobility assessment done. During an interview on 2/29/24 at 3:49 PM, the Director of Nursing identified in the (formal name) bed manual and stated, that reads side rails. They stated they were not aware that those beds were being used and should have been aware. The Director of Nursing stated they signed the policy in 2022 for bed mobility assist device. The Director of Nursing stated there should be a risk assessment when side rails are were used as a restraint for safety concerns. The Director of Nursing stated they use enablers, which were not a restraint. The Director of Nursing stated they would expect the need to assess for risk of entrapment, measurements, consents to be completed for the residents with side rails and enablers. During an observation and interview on 3/1/24 at 10:21 AM, Clinical Engineer #1 stated Resident #100's bed had permanent rails, in hospital they were referred to as bed rails, in the nursing home there were enablers, the manual refers to them as bed rails. During an interview on 3/1/24 at 9:42 AM, Physical Therapist #1 stated an enabler was used for resident mobility, was not a permanent structure, and they were U shaped. Physical Therapist #1 stated they evaluate the resident's for the use of bed mobility devices. Physical Therapist #1 stated there were other beds in the facility which were hospital beds. The foot rails were not used, and top rails would be enablers. Physical Therapist #1 stated that in hospital, they were referred to as bed rails and were permanent. Over here in the nursing home they were called enablers. Physical therapy #1 stated they do not document any risks or benefits, and not aware of any informed consents. 10 NYCRR 415.12 (h)(1)

Based on interview and record review conducted during a Complaint investigation (#NY00325918) during a Standard survey completed on 3/1/24, the facility did not ensure that a resident has the right to refuse treatment for one (Resident #114) of two residents reviewed for choices. Specifically, Resident #114's Health Care Proxy did not give consent for an influenza vaccine, and the resident received it. The finding is: Review of the policy and procedure titled Influenza and Pneumococcal Vaccination dated 6/28/21 revealed that all residents having capacity to make health care decisions, and all legal representatives of residents lacking capacity to make health care decisions will be educated regarding the risks and benefits of receiving these vaccinations utilizing the What You Need to Know vaccine information sheets from the CDC. (The influenza information sheet is updated yearly.) In the event the resident or legal representative declines these vaccines, a declination form indicating the reason declined will be completed and filed in the permanent record. Resident #114 had diagnoses including dementia, aphasia (a language disorder that affects a person's ability to communicate) and anxiety disorder. Review of the Minimum Data Set (a resident assessment tool) dated 8/1/23 revealed the resident was severely cognitively impaired, usually understood, and usually understands. Review of the Health Care Decision Making Capacity Determination form for Resident #114 dated 1/18/23 revealed the resident lacks any personal medical decision-making capacity caused by severe dementia. Review of the Activating Health Care Proxy/Surrogate Decision Maker form for Resident #114 dated 1/26/23 documented, on 1/26/23 the resident's named health care proxy or guardian was informed of the decision on the resident's medical decision-making capacity and has stated willingness to act on their behalf for medical decision as needed, name of health care proxy notified. Review of the Health Care Proxy form for Resident #114 dated 5/19/23 revealed the Health Care Proxy would go into effect when the resident could not make their own health care decisions. Review of the Influenza Vaccine form dated 9/22/23, revealed Unit Coordinator Licensed Practical Nurse #4 received a verbal declination from Resident #114's Health Care Proxy. The form was signed by Unit Coordinator Licensed Practical Nurse #4 and was not signed by the Health Care Proxy or any witnesses. Review of the Order Review Report dated 10/11/23 for Resident #114 revealed an order for Fluad Quadrivalent (influenza vaccine) Prefilled Syringe 0.5 millimeters, inject one time only for encounter for immunization. The Medication Administration Record dated 10/1/23 - 10/31/23 documented Resident #114 received the Fluad Quadrivalent on 10/12/23 at 9:15 AM, administered by Assistant Director of Nursing Registered Nurse #4. Review of the Clinical-Immunizations form for Resident #114 revealed influenza, consented, and confirmed by Assistant Director of Nursing Registered Nurse #4, immunization administered on 10/12/23. Review of the Medication Incident Report Form dated 10/12/23 revealed Resident #114 received Influenza vaccine in error, Health Care Proxy declined vaccination, but consented to prophylactic treatment. Review of the Grievance / Concern Form dated 10/12/23 for Resident #114 revealed, received message to call Resident #114's Health Care Proxy, stated they were very angry because upon visiting today they were told Resident #114 received the influenza vaccine. Health Care Proxy stated they declined the vaccine for Resident #114, and it shouldn't have been given. Health Care Proxy stated Resident #114 told them they no longer wanted any vaccines last year. Review of the Grievance Resolution Response form dated 10/16/23 for Resident #114 revealed, complaint reviewed by Director of Nursing and Administrator. Consent form reviewed, influenza vaccine administration record reviewed, statements / interviews obtained from staff. It was determined that the influenza vaccine was given in error to Resident #114. Review of consent shows verbal declination was given by Health Care Proxy. Resident #114 being monitored for any adverse reactions. Influenza vaccination consent process will be reviewed prior to next vaccine administration for necessary changed to prevent future errors. During an interview on 2/29/24 at 10:23 AM, Licensed Practical Nurse #4 Unit Supervisor stated Resident #114 did not have capacity and the Health Care Proxy was activated on 1/26/23. Licensed Practical Nurse #4 Unit Supervisor stated they had a verbal discussion with the Health Care Proxy on 9/22/23 and they had verbally declined the influenza vaccination for Resident #114. They had signed and documented it was a verbal declination on the Influenza Vaccine form and forwarded the form to Assistant Director of Nursing Registered Nurse #4 for review. They stated that upon review of the resident's medical record Licensed Practical Nurse #7 entered an order for the influenza vaccine in Resident #114's medical record on 10/11/23. The Assistant Director of Nursing Registered Nurse #4 administered the influenza vaccination on 10/12/23 and Resident #114 should not have received the Influenza vaccine. During an interview on 2/29/24 at 11:07 AM, Licensed Practical Nurse #7 stated the Assistant Director of Nursing Registered Nurse #4 reviewed the Influenza Vaccine form and provided a document on an unidentified list that Resident #114 was to have an Influenza vaccine, therefore they wrote an order for the Influenza vaccine to be administered in Resident #114's medical record. During an interview on 2/29/24 at 11:48 AM, the Assistant Director of Nursing Registered Nurse #4 stated they received a blanket order from Nurse Practitioner #1 to write influenza vaccine orders for residents that had consents to receive the vaccination. They stated they misread Resident #114's Influenza Vaccine form and believed the Health Care Proxy consented for the vaccine. They documented Resident #114 was to receive the influenza vaccination and had the unit write the orders based on their tracking list, that they do not keep. They stated when Resident #114's Health Care Proxy filed a Grievance concerning receiving the influenza vaccine, they reviewed the Influenza Vaccine form again and realized the Health Care Proxy declined the influenza vaccination as indicated in writing as a verbal declination and only consented to treat the resident if they contracted influenza or the facility had an influenza outbreak. They stated Resident #114 should not have received the influenza vaccine and was administered in error. During an interview on 2/29/24 at 12:06 PM, Nurse Practitioner #1 stated they provide a blanket order to the facility for influenza vaccinations and would have expected the facility to have reviewed the Influenza Vaccine form carefully and have honored Resident #114's Health Care Proxy decision to decline the vaccine. During an interview on 2/29/24 at 12:14 PM, the Director of Nursing stated the Assistant Director of Nursing Registered Nurse #4 is responsible to monitor and track influenza vaccination consents and misread Resident #114's Influenza Vaccine form and administered the influenza vaccine in error. The Director of Nursing stated Resident #114's Health Care Proxy provided a verbal declination to the influenza vaccine and the resident should not have received the vaccine. During an interview on 2/29/24 at 12:39 PM, the Administrator stated Resident #114 did not have capacity, the Health Care Proxy had provided a verbal declination to the influenza vaccine and the Assistant Director of Nursing Registered Nurse #4 provided the influenza vaccination in error to the resident and would have expected the influenza declination to have been honored. During an interview on 2/29/24 at 12:57 PM, the Medical Director stated they were aware Resident #114 received the influenza vaccine in error after the Health Care Proxy had provided a verbal declination and would have expected the influenza declination to have been honored. 10 NYCRR 415.3(f)(1)(ii)

Based on observation, interview, and record review conducted during a Standard survey completed on 3/1/24, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for two (Residents #22 and #88) of four residents reviewed. Specifically, Resident #22 had thick dark debris under their fingernails and was observed on multiple occasions to eat their meals with their fingers; Resident #88 had long, jagged fingernails with dark debris underneath. Additionally, staff did not provide nail care for Resident #88 when they requested it. The findings are: The policy and procedure titled Bath Routine dated 5/27/2021 documented the bath routine included a shampoo, body cleansing and nail care. 1. Resident #22 had diagnoses that included dementia, fibromyalgia (a chronic disorder that causes pain throughout the body), and depression. The Minimum Data Set ( a resident assessment tool) dated 12/27/23 documented the resident was usually understood, usually understands, and had severe cognitive impairment. The Minimum Data Set documented resident #22 did not exhibit rejection of care and required substantial/maximal assistance for personal hygiene. The comprehensive care plan dated 11/8/23 documented Resident #22 had an activity of daily living self-care performance deficit related to dementia. Interventions included substantial/maximal assistance for personal hygiene. The treatment administration record dated 2/1/24-2/29/24 documented Resident #22's nails were observed on their shower days on 2/5/24, 2/12/24, 2/20/24 and 2/26/24. The nursing progress notes dated 2/6/24-2/29/24 revealed no documented refusals of care for Resident #22. During an observation on 2/26/24 from 12:33 PM until 12:46 PM, Resident #22's fingernails were long with dark debris under them; the fingernail on the right middle finger was jagged. Resident #22 was eating carrots and spaghetti using their fingers and at times their fingers entered their mouth when feeding themselves. During an observation on 2/27/24 at 7:54 AM, Resident #22's fingernails were long and had dark debris underneath them. Resident #22 was in the dining room eating toast with their fingers. During an observation on 2/28/24 from 7:53 AM until 8:04 AM, Resident #22's fingernails were long and had dark debris underneath them. Resident #22 was eating toast and scrambled eggs with their fingers. Resident #22's index and middle fingers entered their mouth when they were feeding themselves. During an observation and interview on 2/29/24 at 10:33 AM, Certified Nurse Aide #3 observed Resident #22's nails and stated Resident #22's nails were dirty and needed to be cleaned. Certified Nurse Aide #3 stated it was the responsibility of the staff who gave the shower on 2/26/24 to complete nail care. Certified Nurse Aide #3 stated if they noticed dirty nails, they would clean them, but they did not check Resident #22's nails on 2/29/24. Certified Nurse Aide #3 stated Resident #22's nails should have been cleaned whenever they were dirty; not only on their shower day. During an observation and interview on 2/29/24 at 10:54 AM, Licensed Practical Nurse #5 observed Resident #22's nails and stated Resident #22's nails absolutely need to be cleaned and trimmed. Licensed Practical Nurse #5 stated normally nail care was done with showers but could have been done any day and any shift. Licensed Practical Nurse #5 stated it looked like Resident #22 needed to have their nails soaked in warm water to get them clean. Licensed Practical Nurse #5 stated, at times, Resident #22 could be resistive with care, but staff should have reapproached Resident #22 when that happened. Licensed Practical Nurse #5 stated Resident #22 should have had their nails cleaned before they ate their meals because they used their fingers to pick up their food. Licensed Practical Nurse #5 stated there was a risk for germs and bacteria to enter Resident #22's mouth. Licensed Practical Nurse #5 stated they were not sure what was under Resident #22's fingernails; it could have been food, feces, or something else. Licensed Practical Nurse #5 stated it was the responsibility of all staff to make sure all of the residents' nails were cleaned and trimmed. Licensed Practical Nurse #5 stated they signed off the treatment administration record for nail care on 2/26/24 without looking at Resident #22's fingernails because they thought the certified nurse aide completed nail care. During an interview on 2/29/24 at 12:49 PM, Licensed Practical Nurse #6 stated it was expected nail care was completed on shower days. Licensed Practical Nurse #6 stated Resident #22 should have had their nails cleaned prior to meals because Resident #22 did not always use utensils to eat their food and Resident #22 had a history of playing with their bowel movement. Licensed Practical Nurse #6 stated all nursing staff was responsible to ensure the residents had clean nails and hands. During an interview on 2/29/24 at 3:07 PM, Director of Nursing stated nails were supposed to be clipped and filed weekly on shower days, at a minimum, and checked every day for cleanliness. Director of Nursing stated it was expected that nails and hands were cleaned prior to meals because it was both a dignity concern and an infection control problem. Director of Nursing stated the nurses and certified nurse aides should have documented in the nursing notes if a resident refused care. 2. Resident #88 had diagnoses that included hemiplegia and hemiparesis (weakness or the inability to move one side of body) following unspecified cerebrovascular disease (brain attack, interruption of blood flow to the cells of the brain) affecting left dominant side, acute kidney failure, and chronic obstructive pulmonary disease. The Minimum Data Set, dated dated dated [DATE] documented Resident #88 had moderately impaired cognition, no rejection of care, and required supervision touch assist with hygiene. The comprehensive care plan dated 1/5/24 documented the resident had an activity of daily living self- care performance deficit related to musculoskeletal impairment and required supervision/touch assist with personal hygiene and substantial/ maximal assist to shower/bathe self. There was no documentation the resident had a history of refusing care. The treatment administration record dated 2/1/24- 2/29/24 documented Resident #88's skin and nails were observed on 2/25/24. During an observation and interview on 2/26/24 at 12:41 PM, Resident #88's fingernails were long, had jagged edges with brown debris under all nails on both hands. Resident #88 stated their left thumb nail was long, and poking into my skin on my left hand. Resident #88's left thumb nail was observed to be long and thick. Resident #88 stated that they requested a therapist to trim their nails on Friday (2/23/24), and it had not been completed. During an observation on 2/27/24 at 3:50 PM, the fingernails on Resident #88's left hand were long, had jagged edges, with brown debris present. During an observation on 2/28/24 at 8:25 AM, Resident #88 was in bed eating breakfast. The resident's left hand fingernails were long, jagged, with brown debris present. During a telephone interview on 2/28/24 at 10:17 AM, Licensed Practical Nurse #3 stated they signed the treatment record that Resident #88's skin and nails were checked, but they did not recall what the resident's nails looked like. License Practical Nurse #3 stated they may have signed the treatment administration record in error. During an interview on 2/28/24 at 11:00 AM, Certified Nurse Aide #1 stated they gave Resident #88 a shower on Monday 2/26/24. They noticed Resident #88's nails were dirty, and stated Resident #88 refused to have their nails trimmed. They stated when residents refused, they would tell a nurse, but they weren't sure if they told a nurse about this resident's refusal on 2/26/24. Certified Nurse Aide #1 stated that nail care was important for sanitary reasons, would cause infection and injury prevention. During an interview on 2/28/24 at 11:06 AM, Licensed Practical Nurse #1 stated residents got their nails trimmed on shower days and as needed. Licensed Practical Nurse #1 stated if residents refused nail care, the Certified Nurse Aide should notify the nurse, so they can document it in the treatment administration record or progress notes. Licensed Practical Nurse #1 stated nail care was important because it was part of hygiene and to prevent injury to the skin from pressure applied by long fingernails. During an observation and interview on 2/28/24 at 11:13 AM, Licensed Practical Nurse #2 stated Resident #88's fingernails should be checked on shower days and as needed. Licensed Practical Nurse #2 observed Resident #22's fingernails and stated that Resident # 88 nails had gunk on both of their hands, their fingernails were dirty and long. They would expect the aides to tell them when the resident refused, so they could document the refusal. Nail care was important for good hygiene, and to prevent infection. During an interview on 2/28/24 at 11:27 AM, Physical Therapy Assistant #1 stated Resident #88 requested their nails to be trimmed a couple days ago as their left thumb nail was poking into their left hand. The Physical Therapy Assistant #1 stated they reported it to unknown nursing staff at the nurses' station. Physical Therapy Assistant #1 stated Resident #88's nails were thick and long, and they were told they weren't allowed to trim residents' nails. During an interview on 2/28/24 at 11:35 AM, Registered Nurse Unit Coordinator #1 stated they expected nursing staff to look at resident's nails daily for overall health. Registered Nurse Unit Coordinator #1 stated Certified Nurse Aides were responsible for nail care on shower days, and as needed. Registered Nurse Unit Coordinator #1 stated if a resident refused their nails to be trimmed, they expected the nursing staff to reapproach and document if it was not done. During an interview on 3/1/24 at 8:51 AM, the Director of Nursing stated they expected nail care to be done at a minimum on resident's shower day and as needed for dignity and infection control. The Director of Nursing stated if a resident requested their nails to be trimmed, they would expect the nursing staff to complete in a timely manner. The Director of Nursing stated if a resident refused nail care, they expected the nurses to document it in the progress notes. The Director of Nursing stated if residents refused frequently, they would expect the resident's care plan to be updated to reflect a refusal of care. 10 NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted during a Standard survey completed on 3/1/24, the facility did not ensure that appropriate treatment and services were provided to prevent urinary tract infection (UTI) for a resident with a suprapubic urinary catheter (a tube inserted into the bladder, through the abdomen, to drain urine) for one (Resident #40) of one resident reviewed. Specifically, Resident #40 had a history of urinary tract infections and was observed on several occasions with the urinary catheter drainage bag, catheter drainage port, and catheter tubing lying directly on the floor in the resident's room. The finding is: The policy and procedure titled Catheter Care - Foley/Suprapubic Urinary Drainage Bag - Emptying dated 1/13/22 documented catheter care is performed with am/pm care and as needed to prevent potential complications that can arise from the presence of an indwelling catheter; Providing regular perineal (the area between the anus and genitalia), preventing catheter related trauma are important interventions to reduce risk of catheter associated urinary tract infection; Drainage bags are to be placed below the level to avoid backflow of urine into the bladder; Never place the drainage bag on the floor. Resident #40 had diagnoses which included benign prostatic hyperplasia (BPH - enlargement of the prostate), neuromuscular dysfunction of bladder (bladder with diminished sensation), and history of urinary tract infections. The Minimum Data Set (MDS - a resident assessment tool) dated 1/31/24 documented Resident #40 had severe cognitively impairment, had an indwelling urinary catheter, and had a urinary tract infection in the past 30 days. The Comprehensive Care Plan documented that Resident #40 had a suprapubic catheter related to benign prostatic hyperplasia (date initiated 5/19/21) and staff were to provide incontinent care every 2 to 4 hours and as needed. The Certified Nursing Assistant (CNA) care plan dated 3/1/24 did not include interventions for catheter care. The physician Order Listing Report, dated 3/1/24, included Foley (indwelling urinary catheter) Care per protocol. The Physician Progress Note, dated and signed by Nurse Practitioner #1 on 1/23/24, documented urinalysis (urine test to detect urinary tract infection, kidney disease, and diabetes) performed 1/23/24 was highly suspicious for infectious process and an antibiotic was initiated. During observations on 2/26/24 at 9:25 AM; on 2/29/24 at 12:45 PM and 3:34 PM; and on 3/1/24 at 7:48 AM, Resident #40's urinary catheter drainage bag, catheter drainage port, and catheter tubing were observed lying directly on the floor in the resident's room. During an interview on 3/1/24 at 7:53 AM, Certified Nursing Assistant #4, stated the urinary drainage bag, drainage port, and tubing should not touch the floor, as germs from the floor can migrate up the tubing causing contamination. During an interview on 3/1/24 at 7:56 AM, Licensed Practical Nurse #8 stated the urinary drainage bag, drainage port, and tubing should not be lying directly on the floor secondary to infection control. During an interview on 3/1/24 at 8:00 AM, Licensed Practical Nurse #4, Unit Manager, stated Resident #40 had a history of urinary tract infections. Additionally, the urinary drainage bag, drainage port, and tubing were contaminated from lying directly on the floor and bacteria can travel up the tubing into the bladder causing a urinary tract infection. During an interview on 3/1/24 at 8:51 AM, the Director of Nursing stated they expected catheter care to be performed at a minimum of daily as it is part of daily hygiene for dignity and infection control. The Director of Nursing stated catheter bags and tubing should not be touching the floor due to infection control; that there could be a potential for a resident to develop a urinary tract infection if touching the floor. The Director of Nursing stated that catheter bags have hooks present and privacy bags can be used to secure to equipment to prevent catheter bags from touching the floor. The Director of Nursing stated they expected catheter equipment that has touched the ground to be cleansed with alcohol, or the catheter bag be changed for infection control. 10NYCRR 415.12(d)(1)

Based on interview and record review conducted during an Abbreviated survey (Complaint # NY00311282) completed on 6/14/23, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the appropriate officials (including the State Survey Agency) for two (Resident #1 and 2) of 3 residents reviewed. Specifically, Residents #1 reported alleged resident-to-resident abuse and it was not reported timely to the New_York State (NYS) Department of Health (DOH) as required. This finding is: The policy and procedure (P&P) titled Abuse Prohibition and Reporting Protocol, dated 10/4/22, documented, Reporting / Response - Administration will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation. Ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source are reported immediately to NYS DOH but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or results in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and other officials in accordance with the State Law through established procedures. 1. Resident #1 had diagnosis including schizoaffective disorder, anxiety disorder and depression. The Minimum Data Set (MDS - a resident assessment tool) dated 12/24/22 documented Resident #1 was cognitively intact, understands, and was understood. Additionally, exhibited no behaviors. Resident #1's comprehensive care plan (CCP), dated 2/18/22, documented physical aggression received, complains of soreness in chest. Interventions included follow facility protocols for treatment of injury should resident develop one. Resident #2 had diagnosis including dementia with agitation, diabetes mellitus type 2, and hypertension. The MDS dated [DATE] documented Resident #2 had severe cognitive impairment and wandering behaviors. The undated CCP documented Resident #2 was an elopement risk/wanderer related to disoriented to place, impaired safety awareness, wanders aimlessly, and significantly intrudes on the privacy or activities (dated 11/30/22). Interventions included anticipate needs, distract from wandering by offering diversions, structured activities, food, conversation, television, books, intervene as necessary to protect the rights and safety or others, divert attention, speak in calm manner, remove from situation and wander-guard in place. During an interview on 6/13/23 at 1:32 PM, Resident #1 stated Resident #2 picked up their wheelchair (w/c) three times and threw it at them. Resident #1 stated the w/c hit them in the chest. Resident #1 stated they reported the incident to the staff at the nurse's station. Resident #1 stated at the time their chest hurt, but there was no visible injury until days later when staff noticed a bruise where the chair hit them. Resident #1 stated they were afraid of Resident #2. Resident #1's Progress Notes dated 2/18/23 through 2/24/23 included the following: - 2/18/23 12:29 PM, Licensed Practical Nurse (LPN) #1 documented, Resident alert with confusion at times, resident came out to nurses' station and stated that a resident just wandered into their room and picked up their w/c and smashed it into their chest multiple times, resident had complaints of (c/o) pain on their chest from the hits, supervisor notified. - 2/18/23 3:59 PM, Nursing Supervisor Registered Nurse (RN) #1 documented, Resident came out to nurses' desk and self-reported that co-resident had come into their room while they were sleeping, and without provocation, picked up this resident's w/c and threw it at him three times. Resident endorses some soreness in their chest, no physical signs, or symptoms (s/s) injury. Residents separated; this resident's door was closed. Writer notified Nurse Practitioner (NP) #1, updated resident's brother, notified Administrator, Director of Nursing (DON), and Social Worker (SW) #1 Department Director. - 2/20/23 2:24 PM, Social Worker (SW) #1 documented, met with resident to discuss report of a co-resident wandering in his room and throwing a w/c at him. Resident described the situation as such, stating they were in their bed and co-resident picked up the w/c and threw it at them 3 times, hitting them in the chest. The resident stated they feel nervous it will happen again and stop sign mesh gate for doorway offered and agreed. - 2/21/23 10:29 AM, RN #2 documented, bruise noted right upper chest above nipple faint greenish/purple in color, measured 1.5 centimeters (cm) by 3 cm. Denies any c/o pain or discomfort upon palpitation. NP into see new order for chest x-ray. - 2/21/23 4:17 PM, NP #1 documented, Acute Visit. Resident to Resident. Seen today for evaluation after a resident to resident, according to the resident they were sitting in their room when another resident wandered in, became angry, lifted the w/c above their head and threw it at their chest. Resident states it happened 2 more times. On examination there is a small area of ecchymosis (bruising) to the right anterior chest just above the nipple. There is associate tenderness to palpation in this region. Facility incident report #1805 Physical dated 2/18/23 at 12:05 PM Nursing Supervisor RN #1 documented resident (#1) came out to nurse's desk and self-reported that co-resident had come into their room while they were sleeping and without provocation, picked up this resident's w/c and threw it at them three times, resident (#1) endorses some soreness in their chest. No physical s/s of injury. Mental Status documented, oriented to person, place, situation, and time; no witnesses found; family notified 2/18/23 at 12:15 PM and NP #1 notified on 2/18/23 at 3:58 PM. Facility Event Form dated 2/18/23 documented, Summary of Event 'Resident reported to staff that co-resident came into their room, picked up their w/c and threw it at them three times unprovoked. Resident sustained no injury, endorses some chest soreness'. Conclusion 'Reportable investigation completed per NYS DOH guideline. Signatures identified as the Director of Nursing (DON) and Administrator. An e-mail dated 2/21/23 at 4:32 PM, provided by Administrator, documented Nursing Home Facility Incident Report Successfully Submitted 2/21/23 at 4:31 PM; documented Resident #1 stated 'They threw a w/c at me and hit me in the chest three times.' RN assessment revealed no noted injuries or re- marks to resident #1 chest area, resident offered no complaints of pain at that time. On February 21, 2023, it was noted that Resident #1 had a noted / faded 1.5 cm x 3.5 cm greenish discoloration to right upper chest above the nipple line. After interview of Resident #1 who was involved in the resident contact, it was determined that Resident #1's discoloration of the upper chest area may have been a result of w/c handle being pushed into Resident #1's chest by co-resident (Resident #2) during the February 18th incident. During an interview on 6/14/23 at 11:50 AM, LPN #1 stated Resident #1 reported Resident #2 threw a w/c at them 3 times. LPN #1 stated the incident was a resident-to-resident allegation of abuse, and the facility had to report the allegation to the DOH but was uncertain of the time frames. During an interview on 6/14/23 at 12:21 PM, Nursing Supervisor RN #1 stated they considered the incident between Resident #1 and #2 to be a resident-to-resident allegation of abuse and completed the incident report. RN #1 stated they do not have access for reporting facility incidents to the DOH, therefore they would have expected either the DON or Administrator to have reported the allegation of abuse to the DOH. RN #1 stated the facility was to report any allegations of abuse within 2 hours of the allegation. RN #1 stated the incident occurred on 2/18/23 and if the facility did not report the allegation until 2/21/23 then it was a delay in reporting the allegation of abuse to the DOH. During an interview on 6/14/23 at 1:15 PM, the DON reviewed the P&P Abuse Prohibition and Reporting Protocol dated 10/4/22 and stated when Resident #1 voiced the allegation of abuse it should have been reported within 2 hours because it was an allegation of abuse. Therefore, the facility failed to report the allegation of abuse within 2 hours per the regulation. During an interview on 6/14/23 at 1:35 PM, the Administrator stated allegations of abuse were to be reported to the DOH within 2 hours of the reported allegation of abuse. The Administrator stated the incident was not reported to the DOH until 2/21/23 when they realized the incident reported to them on 2/18/23 was a resident-to resident allegation of abuse. 10 NYCRR 415.4 (b)(4)

Based on interview and record review during the Standard survey completed on 3/11/22, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified 16 (one Agency Registered Nurse (RN#4), seven Agency Licensed Practical Nurses (LPNs #4, 8, 9,10,11,12,13), and eight Agency Certified Nurse Aides (CNAs #7,8,9,10,11,12,13,14,15) of 16 agency employees that worked in the facility and were subject to the New York State Nurse Aide Registry had been screened through the New York State Nurse Aide Registry prior to their first date worked at the facility. The finding is: According to the facility policy and procedure titled, Abuse Prohibition and Reporting Protocol, dated 2/24/21, all employees, volunteers, and consultants will be checked through the Nurse Aide Registry for any findings of abuse and/or neglect. Review of a list of agency staff members who actively worked at the facility revealed the list contained 16 names: one RN, seven LPNs and eight CNAs. According to the list, the start dates for these 16 active agency staff members ranged from 3/15/21 to 1/31/22. The facility provided Nurse Aide Registry verification sheets on 3/9/22 and 3/10/22 for the 16 active agency staff members. Review of the Nurse Aide Registry verification sheets reveled they were all dated 3/9/22 and 3/10/22. During an interview on 3/9/22 at 3:00 PM, the Director of Nursing (DON) stated the facility did not have Nurse Aide Registry verification sheets for any of the active agency staff members before today. The DON further stated the facility utilized agency staff from multiple staffing agencies and the staffing agencies provided the Nurse Aide Registry verification sheet when a CNA started, but the staffing agencies did not provide Nurse Aide Registry verification sheets for licensed employees. The DON additionally stated the facility began using a new staffing agency recently and that staffing agency had not supplied any Nurse Aide Registry verification sheets. The DON stated the facility currently had eight active agency CNAs and they were all from the new staffing agency. The DON sated the Nurse Aide Registry checks should be done prior to start of work at the facility. They stated for facility employees, the Nurse Aide Registry is checked and a verification sheet is printed prior to the start of each new facility employee, including licensed and unlicensed individuals, and this is done by the facility's Human Resources department. During an interview on 3/9/22 at 3:30 PM, the Administrator stated exclusion checks are performed prior to the start of each new agency staff member. At this time, the Administrator provided documentation of exclusion checks performed for two active agency CNAs and two active agency LPNs. Review of the exclusion checks revealed they indicated whether or not an individual's name appeared on the Office of Inspector General's List of Excluded Individuals/Entities. During an interview on 3/10/22 at 2:45 PM, the DON stated the facility had been using agency staff on and off for several years, and agency staff are used on all four resident units and are used on both shifts, which are 6:30 AM to 7:00 PM and 6:30 PM to 7:00 AM. During an interview on 3/10/22 at 4:07 PM, the Administrator stated the facility had no policies and procedures related to the use of agency staff. Additionally, at this same time, the DON stated Nurse Aide Registry checks are the responsibility of the facility's Human Resource department for new facility staff and they are the responsibility of the staffing agency for new agency staff. The DON stated the Acting Scheduler reviews the paperwork that the staffing agencies send to the facility regarding new agency employees. During an interview on 3/10/22 at 4:20 PM, the Acting Scheduler stated they had been working in the role of Scheduler on and off since September 2020 and one of their duties was to check incoming paperwork for new agency employees. The Acting Scheduler stated there was no checklist to use when reviewing the paperwork, but there were several documents that they routinely looked for, including identification, proof of certification/license, and exclusion check, but not a Nurse Aide Registry sheet. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview, and record review during the Standard survey completed on 3/11/22, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, one (Resident # 37) of one resident observed for position/ mobility did not have their feet supported by the foot plate of the chair, or a positioning device, while sitting in a broda (positioning chair that prevents skin breakdown) chair and the resident had a decline in measurements/ range of motion (ROM). The finding is: Facility policy and procedure titled Therapy Consults dated 10/2012 documented a guideline for therapy consult would include wheelchair positioning and/or questions regarding whether the wheelchair is properly fitted to the resident. Once a potential problem is identified an initiation of the consult can be performed by any interdisciplinary (IDT) staff member. 1. Resident #37 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 12/21/22 documented Resident #37 had severe cognitive impairment. Additionally, it documented the resident was extensive assist to total dependence of two staff for activities of daily living (ADLs) with functional limitation in range of motion (ROM) with impairment of both lower extremities. There was no decline in functional ROM with prior MDS. Review of Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan (CCP) documented the following: Date initiated 9/2/20-limited physical mobility related to (r/t) Alzheimer's with intervention: Non-ambulatory; Date initiated 7/21/21- dependent in broda geri-chair. Date initiated 9/9/20-ADL self-care performance deficit r/t Alzheimer's with intervention: transfer full mechanical lift with two staff assist on medium sling. Date initiated 9/14/20-Actual fall without injury r/t poor communication/comprehension, unsteady gait with intervention: Physical Therapy (PT) consult for strength and mobility. Date initiated 12/16/21-OT evaluation for chair positioning as needed. Review of the Care Card for CNA (certified nurse aide-guide used by staff to provide care) last updated 3/11/22 documented under Equipment: Chair that resident uses broda with chair cushion. Ambulation/ROM: documented the resident was non ambulatory. Therapy Services documented Physical, Occupational and Speech Therapy as needed (PRN). Review of Annual Physical Therapy (PT) Review dated 11/24/21, signed by the Physical Therapist, documented the following: Left knee flexion (bending) 125, extension (straightening) 0. Left ankle dorsiflexion (DF-backward bending toward the body) -10. Left ankle plantar flexion (PF- bending downward away from the body) within functional limit (WFL). Right knee flexion 122, extension 0. Right ankle DF 12, PF WFL. Goal documented resident will not develop further complications of immobility. Review of OT Evaluation and Plan of Treatment dated 12/1/21-12/7/21, signed by the Occupational Therapist, documented the following: Trial use of broda chair, secondary to poor positioning in w/c, for improved posture/ability for staff to provide pressure relief when out of bed (OOB). Review of OT Treatment Encounter Notes documented the following: -12/2/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Issued broda w/c with staff education regarding use. Demonstrates improved posture/midline positioning and appears more comfortable. Monitored multiple times during day for positioning. Demonstrates improved posture in newly issued chair. Staff education on use of broda chair for positioning. -12/3/21 Continues to demonstrate improved posture in newly issued broda w/c. -12/6/21 Monitored in broda chair, demonstrates improved posture, tolerates midline position for greater than three hours. -12/7/21 Continue to monitor in newly issued broda chair. Demonstrates ability to maintain midline position. Review of OT Discharge Summary dated 12/7/21 documented issued broda chair for trial with significant improvement in posture and appearance of comfort. Staff compliant with positioning in broda chair. Intermittent observations from 3/7/22 through 3/11/22 revealed the following: -3/7/22 at 11:35 AM Resident in common area/TV lounge sitting in broda chair with bilateral lower extremities (BLE) resting on straps of chair, feet dangling and unsupported by footplate/footrest of chair. Resident wearing non -skid socks. -3/08/22 08:24 AM Resident at table in dining room for breakfast, sitting in broda chair BLE resting on straps of chair with feet dangling unsupported by footplate of chair. Resident wearing non-skid socks. -3/08/22 12:00 PM Resident being transported from TV lounge to dining room in broda chair. BLE resting on straps of chair with feet dangling unsupported by footplate of chair. Resident wearing non-skid socks. -3/08/22 2:54 PM Resident observed in bedroom, resting in broda chair. Chair slightly reclined. BLE resting on straps of chair with feet dangling unsupported by footplate of chair. Resident wearing non-skid socks. -3/09/22 10:08 AM Resident sitting in hallway near nurses' station, in broda chair. BLE resting on straps of chair with feet dangling unsupported by footplate of chair. Resident wearing non-skid socks. -3/09/22 10:20 AM CNA #1 transporting resident, in broda chair, to music activity. BLE resting on straps of chair with feet dangling unsupported by footplate of chair. Resident wearing non-skid socks. -3/09/22 11:57 AM Resident observed in common area/tv lounge with peers. Resident sitting in broda chair. BLE resting on straps of chair with feet dangling unsupported by footplate of chair. Resident wearing non-skid socks. -3/10/22 08:38 AM Resident in common area in broda chair. BLE resting on straps of chair with feet dangling unsupported by footplate of chair. Resident wearing non-skid socks. -3/11/22 09:49 AM Resident sitting in broda chair in common lounge. BLE resting on straps of chair with feet dangling unsupported by footplate of chair. Resident wearing non-skid socks. During an interview on 3/11/22 at 10:14 AM, the PT stated the resident was transitioned from the w/c to broda chair in December 2021 due to gradual medical decline, positioning, and safety. The PT stated broda chairs have foot plates at the base of the chair that are adjustable, can be pulled up, and feet should be supported on the foot plate for multiple reasons, including comfort and to prevent contractures. During an interview on 3/11/22 at 10:21 AM, the OT stated they had worked with the resident when the resident was transitioned to the broda chair. The OT stated broda chairs have adjustable foot plates and feet should be supported in the chair on the foot plate for comfort and to allow an opportunity for the resident to reposition themselves, if able. Additionally, the OT stated resident #37 is full mechanical lift so we would want their feet supported to prevent contractures. At 10:35 AM, the OT stated ideally, I would like the aides to notice and notify the nurse or therapy, but they may not always notice positioning issues. It looks like a pressure reduction cushion was added to the broda chair seat and that may have caused the resident's feet to not reach the foot plate as it did initially. This foot plate is adjusted all the way up to the shortest position, the resident may need a positioning device for their feet to be supported. During an observation and interview on 3/11/22 at 10:42 AM, CNA #1 assigned to resident #37, stated the resident had been in the broda chair for a couple of months. CNA #1 stated, their (resident #37) feet aren't touching the footrest (plate) and should definitely be supported. I did not notice before, but I should tell the charge nurse and they would put in a therapy referral for therapy consult. During observation and interview on 3/11/22 at 10:47 AM, Licensed Practical Nurse (LPN) #1 Unit Coordinator observed the resident and stated, I would expect staff to notify me, so the resident's feet don't drop. The resident will need something like a bolster or build up to support their feet. I will call therapy and put in a referral. During an interview on 3/11/22 at 11:06 PM, the Director of Reimbursement/Quality/SNF Rehab, with the Administrator, stated a cushion should not be used in a broda chair and feet should be supported by the foot plate on the chair. We will have to do education regarding broda chairs and positioning. If staff think a resident needs a pressure reduction cushion they should refer to therapy. During an interview on 3/11/22 at 12:47 PM, the Director of Nursing (DON) stated resident's feet should be supported for many reasons. Pain, [CONDITION(S)], pressure relief. I would expect staff to follow therapy recommendations to nursing for positioning. Review of PT Review dated 3/11/22 documented the following: Left knee flexion 115, extension -31; resistive to motion into extension-draws left knee up into flexion. Left ankle dorsiflexion -18. Left ankle plantar flexion 61, WFL. Right knee flexion 115, extension -50; resistive to attempts to move into extension draw right knee into flexion. Right ankle DF 3, PF 50 WFL. During interview on 3/11/22 at 1:37 PM, the PT stated the knee resistance and decline could be expected from [CONDITION(S)], but the ankle decline could be positional, from the feet not being supported in the broda chair. 415.12(e)(2)

Based on interview and record review conducted during the Standard survey (Complaint #NY 011), completed on 3/11/22, the facility did not ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately, but not later than 2-hours after the allegation if the events that cause the allegation involve abuse or result in serious bodily injury to other officials (including to the State Survey Agency) for two (Resident #102 and Resident #39) of two residents reviewed for abuse. Specifically, the facility did not report an allegation of sexual abuse between Resident #102 and Resident #39 on 9/9/21 at 11:30 PM to the New York State Department of Health (NYS DOH) as required. The findings are: The facility policy and procedure (P&P) titled Abuse Prohibition and Reporting Protocol revised 2/24/21 documented all information obtained will be reviewed by Administration, to determine if there is sufficient evidence for a prudent person to believe that physical abuse, mistreatment, or neglect has occurred in the facility. If determined reportable the facility must report the results of the investigation to the DOH at that time, whether or not the interval investigation is complete. Reporting/Response- Administration will report all alleged violations and all substantiated incidents to the state agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigation. 1. Resident #102 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-resident assessment tool) dated 9/8/21 documented Resident #102 was cognitively intact, usually understood and understands. 2. Resident #39 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #39 had severe cognitive impairment, sometimes understood, and understands. Disorganized thinking continuously present. Review of the ACTS (Aspen Complaint/Incidents Tracking System) Complaint/Incident Investigation Report completed by the Director of Nursing (DON) documented date/time of occurrence as 9/9/2021 at 11:30 PM. Submitted by the facility as 9/10/2021 at 4:05 PM. Review of Social Work (SW) statement documented on 9/10/21 at 1:15 PM they were approached by the Physical Therapist (PT) regarding an allegation of sexual abuse Resident #102 reported. Review of the statement signed by Certified Nurse Aide (CNA) #2 regarding an allegation of sexual abuse Resident #102 reported, documented a date of 9/10/21 at 1:00 PM. During an interview on 3/10/22 at 1:32 PM, CNA #2 stated they believed Resident #102 reported an allegation of sexual abuse on the day shift and they reported it to the nurse. Follow up interview on 3/11/22 at 11:44 AM, CNA #2 stated Resident #102 had a visitor in their room and it was Resident #102's visitor who reported allegation to them first. Resident #102 then reported the allegation of sexual abuse to them. CNA #2 stated that once Resident #102 reported the allegation of sexual abuse to them they reported it to RN #1. RN #1 then had me write a statement. CNA #2 further stated that they wrote statement shortly after reporting it to RN #1, late morning. CNA #2 believed visitor was in Resident #102's room before lunch. During an interview on 3/10/22 at 1:49 PM, the SW stated they were unable to recall whom reported the sexual abuse allegation to them. They came in the morning of 9/10/21 to a voicemail message on the phone stating Resident #102 claimed their roommate Resident #39 had touched them. SW stated they did not recall the date or time the voice message was left. SW further stated that they believed it was early morning when they first saw Resident #102, they wanted to make sure Resident #102 felt safe. SW also stated they know they talked to the unit manager of their findings related to the sexual abuse allegation. During an interview on 3/10/22 at 5:07 PM, the DON stated they were not notified until the day after the allegation of sexual abuse was made. The DON could not recall when the incident date and time was reported to DOH, stating they would not have just picked that date and time to report. On 3/11/22 at 12:45 PM, the DON stated they had 24 hours to report allegations of sexual abuse to the state. During an interview on 3/11/22 at 11:50 AM, RN #1 stated they did not recall initiating an incident report, nor why they didn't initiate a report. RN #1 stated they should have documented on both Resident #102 and Resident #39 in their chart and completed an incident/accident report. RN #1 further stated they were not aware of the time the sexual abuse allegation was made by Resident #102. During an interview on 3/11/22 at 1:00 PM, the Administrator stated allegations of abuse should be reported within 24 hours to the state. Stated they did not know what time the allegation of sexual abuse occurred but that it was reported to the state within 2 hours of them being notified. 415.4(b)(4)

Based on observation, interview and record review during the COVID-19 Infection Control Focused Survey completed on 1/29/21, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, for 2 of 2 residents reviewed the facility did not protect a COVID-19 negative resident who resided in the same room with a resident who was positive for COVID-19 (Residents #1 and 2). The finding is: The Centers for Disease Control and Prevention (CDC) guidance titled, Responding to Coronavirus (COVID-19) in Nursing Homes, updated April 30, 2020 documented: Ensure the resident (with new-onset suspected or confirmed COVID-19) is isolated and cared for using all recommended COVID-19 PPE (Personal Protective Equipment); and If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). The CDC guidance titled Preparing for COVID-19 in Nursing Homes, updated November 20, 2020, provided: Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility with dedicated HCP. This guidance further documented: As roommates of residents with COVID-19 might already be exposed, it is generally not recommended to place them with another roommate until 14 days after their exposure, assuming they have not developed symptoms or had a positive test. The New York State Department of Health DAL (Dear Administrator Letter), dated April 29, 2020, documents the following: As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: . Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful(ly) separate out patients in individual facilities. Review of the facility policy and procedure (P&P) titled COVID-19, dated 1/4/21 documented all residents will be COVID-19 tested per CDC/Department of Health (DOH) guidelines. In the event of a positive notification, the facility will follow the guidance as directed by the CDC/DOH. All positive residents will be located on one unit in closest proximity possible. Discontinuation of precautions with test-based strategy require negative results of an authorized COVID-19 molecular assay for detection of COVID-19, from at least two consecutive tests collected greater than or equal to 24 hours apart. For residents who were asymptomatic at the time of their first test and remain asymptomatic, testing for release from isolation may begin a minimum of seven days from the first positive test. During an entrance interview on 1/29/21 at 9:15 AM, the facility Administrator, in the presence of the Director of Nursing (DON), stated the facility currently had 10 COVID-19 positive residents and 11 staff on quarantine. She stated the Aqua and Blue Units were the facility hot zones, designated COVID-19 Units where residents were on airborne (infectious particles that are transmitted from one person to another in the air) precautions and were cohorted behind plastic barrier walls and/or double fire doors. Plum and Peach Units had no COVID-19 confirmed residents and the facility was testing residents every seven days due to a COVID-19 outbreak in the building. Review of an untitled facility document identified by the Administrator as the facility COVID-19 positive residents list, documented Resident #1 tested COVID-19 positive on 1/18/21. The form documented if the resident remained asymptomatic, they could be removed from isolation (14-20 days from test date) on 2/1/21. Resident #1 resided on the Plum Unit with roommate Resident #2. Per Department review of records described below, Resident #1 was moved to the COVID-19 positive Aqua unit on 1/18/21, and Resident #2 was moved into Resident #1's room on the Aqua unit on the same date, 1/18/21. Resident #1's COVID-19 lab result dated 1/18/21 documented positive for COVID-19. Review of Resident #1's subsequent COVID-19 lab result dated 1/25/21 documented a negative result for COVID-19. Review of nursing Progress Note dated 1/18/21 at 2:56 PM documented: Resident #1 had a positive COVID-19 test result and resident would be moved to the COVID-19 Unit for 14 day isolation. The nursing Progress Note dated 1/28/21 at 4:27 PM documented Resident #1 returned to the Plum Unit at approximately 1:00 PM. Resident #2 resided on the Plum Unit with roommate Resident #1. Resident #2's COVID-19 lab results dated 1/18/21 and 1/25/21 documented a negative result for COVID-19 for both dates. Review of a nursing Progress Note dated 1/19/21 at 4:36 PM documented Resident #2 was moved to the Aqua Unit with roommate due to COVID-19 exposure. The nursing Progress Note dated 1/28/21 at 4:26 PM documented Resident #2 returned to the Plum Unit at 1:00 PM. An observation on 1/29/21 at 10:21 AM revealed Residents #1 and #2 resided in the same room on the Plum Unit. An airborne precaution (indicating anyone entering the room should wear full PPE) sign was posted on the doorframe. During an interview on 1/29/21 at 10:40 AM, Registered Nurse (RN) #1 stated Resident #1 and #2 were on contact/airborne isolation due to Resident #1 having a positive COVID-19 test, Resident #2 had a negative test and both residents were moved to the same room on the Aqua Unit, a COVID-19 isolation unit (hot zone) on 1/18/21. They were both moved back to their room on the Plum Unit on 1/28/21 and were being kept on airborne precautions for 14 days until 2/1/21. The RN #1 further stated they stay in their room with the door shut. During an interview on 1/29/21 at 1:30 PM, the Administrator reviewed the line list of COVID-19 positive residents and stated Resident #1 was currently on the Plum Unit. The resident had a positive COVID-19 test on 1/18/21 and was moved to the COVID-19 isolation unit hot zone. Resident #1 was retested on [DATE], when they tested the whole house and the test result was negative, so the resident was moved back to the Plum Unit. Resident #1 should not have been taken out of the hot zone because the 14- day precautions would not have ended until 2/1/21. During an interview on 1/29/21 at 3:30 PM, Infection Preventionist (IP) #1, in the presence of IP #2, stated if a resident tested positive for COVID-19, the facility Administrator was responsible for making the decision to transfer the resident(s) to the COVID-19 hot zone Unit. If a resident that tests positive for COVID-19 had a roommate that tests negative for COVID-19, the COVID-19 positive resident would be moved to the hot zone and the COVID-19 negative resident would stay in place and should be placed on airborne precautions for 14 days due to potential exposure to a COVID-19 positive resident. Resident #1 tested COVID-19 positive on 1/18/21 and had a roommate (Resident #2) that tested COVID-19 negative on the same day. Resident #1 and #2 should not have been moved together into the hot zone. Only confirmed COVID-19 positive residents should go into the hot zone. Both IP's stated they were not aware both residents were moved together into the hot zone. Resident #1 should have remained in the hot zone for 14 days (until 2/1/21) and Resident #2 should not have been moved to the COVID-19 Unit hot zone. During an interview on 1/29/21 at 4:25 PM, the Administrator, stated she and the IP's get the COVID-19 test results. Resident #1 had a roommate (Resident #2) that was exposed to COVID-19 due to Resident #1's positive test result. The Plum Unit did not have any COVID-19 confirmed residents, therefore she decided to move both residents together to the COVID-19 Unit hot zone. The Administrator stated she did not feel it would increase exposure for Resident #2 because they were still sharing a room on the hot zone and that moving them together was the smartest thing to do and she felt it was the safest move to make. Resident #1 should not have been tested within the 90-day window of first testing COVID-19 positive but was tested by accident. The result was negative, so she moved both Resident #1 and #2 back on the Plum Unit where they originally were. The Administrator stated she was aware of the cohorting guidance and stated, I stand by my decision. 415.19(a)(2),(b)(1);400.2

Based on observations, interviews, and record review, conducted during the Recertification Survey, it was determined that for one (Resident #100) of seven residents reviewed for accidents, the facility did not ensure that the resident's environment remained as free of accident hazards as possible. The issues involved the lack of a smoking assessment for safety and the lack of a resident specific care plan for smoking. This is evidenced by the following: Resident#100 was admitted to the facility on [DATE] for rehabilitation with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/13/19, revealed the resident had moderately impaired cognition. The Smoking Regulations and Safety form, dated 1/4/19 and signed by the resident and a Social Worker (SW), includes all residents will be deemed to be supervised until a smoking assessment is completed by the team and care planned accordingly. A smoking blanket/apron is provided and should be used by residents when smoking. The blanket/apron is placed on the resident's lap and against the chest or abdomen to prevent live ashes from burning their clothing and/or causing other injury. There was no documentation that a smoking assessment had been completed. The Comprehensive Care Plan (CCP) for smoking, dated 1/14/19, included to monitor the resident during smoking for safety needs, assist to and from the smoking room, and that the resident needs to abide by the facility smoking rules. The Certified Nursing Assistant (CNA) Care Card, updated 2/6/19, does not include smoking. A review of nursing progress notes, from 12/30/18 through 1/27/19, included a note, dated 1/26/19, that revealed the resident dropped her cigarette on her shirt. The staff reported that the resident had a smoking apron on at that time. During an observation on 2/11/19 at 11:06 a.m., Licensed Practical Nurse (LPN) #2 was wheeling the resident back to her room after smoking. There were several clumps of white cigarette ashes visible on the resident's black pants. When interviewed at that time, LPN #2 said that is why the resident needs to wear the smoking apron. LPN #2 said she had taken the resident to the smoking room. At 1:35 p.m., the resident was in the smoking room and was not wearing a smoking apron. A family member was outside the smoking room, talking on a cell phone. When interviewed on 2/7/19 at 10:59 a.m., the resident said she smokes three to four times a day and she is not supervised when smoking. The resident said that the nurse holds on to her smoking supplies. She said that she does not wear a smoking apron because she is not careless when smoking. Interviews conducted on 2/11/19 included the following: a. At 10:15 a.m., LPN #1 said that SW is responsible for performing the smoking assessment. b. At 10:44 a.m., a SW said she could not find that a physical smoking assessment had been completed but she would keep looking. c. At 10:54 a.m., a Registered Nurse Manager (RNM) said that a physician order [REDACTED]. d. At 11:05 a.m., CNA #1 said there was nothing regarding smoking on the CNA Care Card and there should be. e. At 11:11 a.m., LPN #2 said information on resident smoking should be included on the CNA care card as staff need to know. (10 NYCRR 415.12(h)(1-2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #92) of three residents reviewed for pressure ulcer care, the facility did not provide care using appropriate infection control technique. Specifically, a staff member did not follow standard infection control practices in multiple areas related to dressing changes. This is evidenced by the following: The facility procedure for dressings, located in the Mosby's Skills and Procedure Manual, included after donning gloves and removing the dressing, dispose of the gloves and soiled dressing, and perform hand hygiene. Cleanse the wound, perform hand hygiene, blot dry, dispose of gloves, and perform hand hygiene. Apply clean gloves and apply dressing as ordered. Resident #92 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/27/18, revealed the resident had severely impaired cognition, requited the extensive assistance of staff for care, and had three pressuer ulcers, one Stage I (intact, nonblanchable redness), one Stage II (partial thickness skin loss), and one Stage III (full thickness skin loss). Physician orders, dated 1/17/19, included to cleanse the right and left ischium (lower buttocks) wounds with pressurized normal saline, pat dry, pack wounds with 4 x 4 gauze, and cover with mesh overlay four times a day. Also, cleanse the area around the nephrostomy tube with warm soapy water, apply triple antibiotic ointment, and cover the site with a split dressing once a day. During an observation of care on 2/12/19 at 10:05 a.m., the Licensed Practical Nurse (LPN) removed the gauze packing from the two ischial wounds. The LPN changed her gloves and proceeded to cleanse the left ischial wound and then the right ischial wound. She changed her gloves, packed the two wounds with saline gauze, and applied barrier cream to the surrounding tissue of the open wounds. The gauze fell out of the wounds and onto the bed. The LPN picked the gauze up and placed it back into the wounds. The LPN removed her soiled gloves and applied clean ones. While the LPN was trying to apply the resident's mesh underwear the gauze pads fell out onto the bed again. The LPN picked them up and placed them back in the wounds. The LPN covered both wounds, applied the mesh underwear, and then proceeded to remove the suprapubic dressing. She cleansed the area around the tube, applied a dressing, and then removed her gloves and washed her hands. When interviewed at that time, the LPN said she usually washes her hands after the treatments are completed. Interviews conducted on 2/12/19 included the following: a. At 10:28 a.m., the Registered Nurse (RN) Unit Coordinator stated that staff should wash their hands between each treatment. She said if the packings fall out of the wound, she would expect the nurse to start the treatment again. b. At 11:59 a.m., the infection prevention RN said that the nurses should perform hand hygiene before starting a dressing change and after removing the soiled dressings. She said the nurse should have removed her gloves and washed her hands before applying the new dressing. She said the nurses should wash their hands and apply new gloves between each treatment. She said if the packing falls out of the wound, the treatment should be started again. (10 NYCRR 415.19(b)(4))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for three of three residents reviewed for tube feedings, the facility did not have a mechanism in place to ensure that the administration of enteral nutrition and additional water ordered for flushes was consistent with and followed physician orders [REDACTED].#49), and the amount of bolus tube feeding was not accurately measured (Resident #103). This is evidenced by the following: 1. Resident #49 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS)Assessment, dated 12/10/18, revealed the resident had unplanned weight loss, required the use of a feeding tube, received 50 percent or greater of calories through the tube feeding, and 501 cubic centimeters (cc) of fluid or more per day via tube feeding. The Comprehensive Care Plan (CCP) for Feeding Tubes, dated 11/19/18, directs the use of the feeding tube for all nutritional and medication intake. Approaches include to check for residual contents prior to each feeding, monitor intake and output and record, and report any significant fluid balance discrepancy to the physician. Physician orders, dated 12/28/18, included Vital AF (a peptide-based therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding with ingredients to help manage inflammation, impaired gastrointestinal (GI) function, and/or GI intolerance) 1.2 calories per milliliter (ml) at 130 ml/hour, start at 7:00 p.m. and end at 7:00 a.m. to provide 1,560 ml per day and provide 100 ml water flush every six hours via j-tube. Additionally, may have 2 ounces of ice chips as requested and one 4-ounce pureed item or pudding thick liquid at lunch and afternoon snack with supervision. Review of the (MONTH) 2019 Treatment Administration Record (TAR) revealed that the resident should receive Vital AF 1.2 at 130 ml/hour for 12 hours, start at 7:00 p.m. and end at 7:00 a.m., and give 100 ml water flush every six hours at 4:00 a.m., 10:00 a.m., 4:00 p.m., and 10:00 p.m. The actual (total) volume of tube feeding and water flushes administered were not documented. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Observations and interviews conducted on 2/7/19 included the following: a. At 9:09 a.m., the resident said his usual weight is 205 pounds (lbs), and he has lost 50 lbs in the last nine months. b. At 9:21 a.m., the tube feeding pump had been turned off. There was a bag of tube feeding nutrient, (capacity approximately 500 ml), about 1/2 full, hanging from the intravenous pole. The label was dated 2/6/19, and it was documented that the feeding was hung at 9:30 p.m., and the rate was 130 ml per hour. There was no other information on the label. Observations and interviews conducted on 2/11/19 included the following: a. At 8:55 a.m., the tube feeding pump was turned off. There was a bag of tube feeding nutrient hung which was almost half full (approximately 250 ml). The label on the bag was entirely blank. b. At 10:07 a.m., Licensed Practical Nurse (LPN) #1 said the feeding pump is turned off at 7:00 a.m. She said the resident occasionally asks for it to be turned off in the early morning. At that time, the resident was resting in bed. He said if he feels full, depending on what he ate during the day, he will ask staff to stop the feeding. LPN #1 turned the pump on and read the display. The resident received 200 ml of water and 2,174 ml of tube feeding. She said the rate was set to 130 ml per hour. LPN #1 said she was told at morning report that the tube feeding had been stopped at the resident's request in the early morning. LPN #1 said the volume of water flush and tube feeding delivered per the pump was wrong. She said per the orders, he should be getting 400 ml water flush and only 1,560 ml tube feeding daily. Both the resident and LPN #1 said they did not know if anyone was evaluating the resident's request to stop the tube feeding. c. At 1:41 p.m., a Registered Dietitian (RD) said the resident has a history of weight loss but has started to show a positive weight gain trend. She said the current tube feeding order delivers 1,560 ml tube feeding in 12 hours and flushes are given 100 ml every six hours. The RD said she knew that the tube feeding was being turned off, but staff had not met yet to determine what to do. When interviewed on 2/12/19 at 9:42 a.m., the RNM said the team was aware of the resident's request to stop the tube feeding at night, but there has not been any discussion or change in care yet. She said LPN #1 told her that the pump display was inconsistent with the physician order. The RNM said the nurses sign for the starting and stopping of the tube feeding but do not verify the actual amount given. 2. Resident #30 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/12/19, revealed the resident had severely impaired cognition, use of a feeding tube, received 50 percent or greater of calories through the tube feeding and 501 cc fluid or more per day via tube feeding. Physician orders, dated 2/11/19, directed [MEDICATION NAME] (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 1.5 at 80 ml/hour to run continuously from 4:00 p.m. to 9:00 a.m. to provide1,360 ml and give 100 ml water flush every four hours. The current CCP for Feeding Tubes includes approaches to check for gastric residuals and administer feedings per physician orders. Review of the (MONTH) 2019 TAR revealed that the resident should receive [MEDICATION NAME] 1.5 at 80 ml/hour continuously from 4:00 p.m. to 9:00 p.m. and to give 100 ml water flush every four hours at 12 midnight, 4:00 a.m., 8:00 a.m., 12 noon, 4:00 p.m., and 8:00 p.m. The actual volume of tube feeding and water flushes administered are not documented. A review of the (MONTH) 2019 MAR indicated [REDACTED]. Observations and interviews conducted on 2/8/19 included the following: a. At 9:01 a.m., LPN #2 said she takes the tube feeding down at 9:00 a.m. and discards it. At that time, the resident was in bed and the tube feeding was still running. The bag of tube feeding was labeled with the resident's name and dated 2/7/19, 4:00 p.m. start. LPN #2 read the pump display and said the rate was set at 80 ml/hour and flush to give 100 ml every four hours. She said the resident had received 3,359 ml tube feeding and 1,004 ml of water flushes. b. At 9:13 a.m., LPN #2 said she had stopped the pump and the display read 3,387 ml of tube feeding was given. LPN #2 said the resident's pump runs for 16 hours at 237 ml per hour. c. At 9:41 a.m., LPN #2 said the resident gets 100 ml water every four hours and she gives an additional 50 ml water before and after each med pass. LPN #2 said the resident gets Juven (a modular powder used to promote wound healing) which she mixes with 8 ounces of water. LPN #2 mixed and administered the Juven at that time. Observations and interviews conducted on 2/11/19 included the following: a. At 8:51 a.m., the tube feeding pump was running, and the display read 80 ml/hour, 501 ml water flush given, and 1,753 ml tube feeding was given. There was no labeling of any kind on the bag. b. At 9:36 a.m., LPN #1 said she had turned the pump off at around 9:00 a.m. She said she had not cleared the feeding pump but when she starts the feeding again at 4:00 p.m., she will enter that amount in the chart. LPN #1 said each 12-hour shift is responsible to monitor the amount of tube feeding and water given on that shift. LPN #1 said she does not think that anyone is responsible to monitor the total amounts given in 24 hours. c. At 9:57 a.m., LPN #1 was asked by the surveyor to turn the pump on. The display read that the resident received 301 ml of water flush and 927 ml of tube feeding. LPN #1 said the label was blank so how could she know what tube feeding nutrient was hung or when. 3. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/14/19, revealed the resident was cognitively intact, used a feeding tube, received 50 percent or greater of calories through the tube feeding and 501 cc fluid or more per day via tube feeding. Physician orders, dated 12/18/18, directed to give [MEDICATION NAME] 1.2 calorie, 355 ml bolus (single dose given all at once) at 6:00 a.m., 10:00 a.m., 1:00 p.m. and 4:00 p.m., and give 40 ml water flush before and after each feed. An additional order, dated 12/18/18, directs to give [MEDICATION NAME] 1.2 237 ml bolus but no time was specified. Review of the (MONTH) 2019 MAR indicated [REDACTED].m The 9:00 p.m. feeding was discontinued on 2/5/19. There was no (MONTH) 2019 TAR for the tube feeding administration. During an observation on 2/8/19 at 1:35 p.m., LPN #2 said she had assembled two containers, 8 ounces each, of [MEDICATION NAME] 1.2 to give via bolus. She said the resident gets 355 mls of tube feeding at 10:00 a.m., 1:00 p.m., and 4:00 p.m. with 40 mls flush before and after each time, then gets 237 mls at 9:00 p.m. LPN #2 administered one full container of the tube feeding and then said she knows to give about 3/4 of the remaining container. LPN #2 said that she does not measure. LPN #2 said she has talked with dietary to evaluate to change to two full containers but that has not happened. The label on each container of [MEDICATION NAME] 1.2 reads 237 mls (237 x 0.75 = 178; 237 + 178 = 415 mls given). When interviewed on 2/12/19 at about 9:42 a.m., the RNM said nurses are expected to measure out and administer the tube feeding per physician order. (10 NYCRR 415.12(g)(2))

Based on interviews and record review conducted during the Recertification Survey and complaint investigation (#NY 654), it was determined for one (Resident #54) of one resident reviewed for notification, the facility did not ensure that the resident and/or responsible party was informed, in advance, by the physician, Nurse Practitioner, or professional of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option that he or she preferred. Specifically, the resident was prescribed and administered a narcotic medication without the resident and/or responsible party being informed. This is evidenced by the following: Resident #54 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/24/18, revealed that the resident was cognitively intact. A progress note, dated 2/11/18, revealed that the Social Worker had completed a Brief Interview of Mental Status with the resident who scored a 6 out of 15 (severely impaired cognition). The Nurse Practitioner (NP) note, dated 1/25/19, revealed that the resident reported increased shortness of breath at rest. The NP notes documented next to Review of Systems limited due to resident's cognitive limitations. The plan included to add [MEDICATION NAME] 5 milligrams (mg) by mouth/sublingual (SL - under tongue) every 12 hours for reports of increased shortness of breath at rest. There was no documentation that the resident and/or responsible party had been informed of the plan to add [MEDICATION NAME] or made aware of the risks and benefits and afforded the right to choose preferred treatment. A physician order, dated 1/29/19, included to administer [MEDICATION NAME] 20 mg/milliliter (ml), give 5 mg (0.25 ml) SL every 12 hours for [DIAGNOSES REDACTED]. A second physician's orders [REDACTED]. A review of the nursing progress notes, from 1/28/19 through 2/3/19, did not include any documentation that the resident and or family member was notified that the resident was ordered [MEDICATION NAME] and of the risks and benefits of the medication prior to administration on 1/29/19 or prior to the increase of the [MEDICATION NAME] dosage on 2/1/19. A nursing progress note, dated 2/5/19, revealed that the Health Care Proxy (HCP) shared concerns about the resident and does not want the resident to continue with [MEDICATION NAME]. A NP note, last amended 2/7/19, revealed that the NP had a lengthy discussion with the HCP on 2/6/19 regarding the resident being on [MEDICATION NAME]. The resident's progressive decline since the death of his wife, as well as his complaint of air hunger occurring at night which has notably improved since 1/28/19 when the routine [MEDICATION NAME] was initiated. Family members believe that the [MEDICATION NAME] was doing more harm than good and requested that it be stopped. The [MEDICATION NAME] was discontinued per family request. When interviewed on 2/11/19 at 1:30 p.m., the Registered Nurse (RN) Unit Coordinator said that after reviewing the electronic medical record, she was unable to find any documentation that the resident's HCP was notified prior to the resident starting [MEDICATION NAME]. She said she remembers speaking to the HCP about the [MEDICATION NAME] but she was not sure if it was prior to the resident beginning the [MEDICATION NAME] or when exactly it was. She stated that she had spoken to the family in-depth about the resident being on [MEDICATION NAME] and the benefits for air hunger, but the family was not willing to listen and requested the [MEDICATION NAME] be discontinued. When interviewed on 2/12/19 at 8:44 a.m., the family member said that she was not the HCP but would be the second person notified and that the family members are in constant communication. The family member stated that none of the family were notified before the resident was placed on [MEDICATION NAME]. The family member stated that the longer the resident was on the [MEDICATION NAME], the more confused he got and that is why the HCP requested that he not take any more. During an interview with the Director of Nursing (DON) on 2/11/19 at 11:15 a.m., the DON reviewed the electronic medical record and said she was unable to find documentation that the responsible party was notified prior to the resident starting [MEDICATION NAME]. (10 NYCRR 415.3(e)(1))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 9 (Residents #47, #49, #96, #100, #103, #115, #123, #225, and #227) of 11 residents reviewed for Baseline Care Plans, the facility did not consistently develop a thorough Baseline Care Plan within 48 hours of admission that included instructions needed to provide effective person-centered care. This is evidenced by, but not limited to, the following: Review of the facility policy, Comprehensive Assessment Minimum Data Set (MDS) Assessment 3.0/Care Plans, dated 6/28/17, revealed a Baseline Care Plan will be developed within 48 hours. 1. Resident #227 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/12/19, revealed the resident was cognitively intact. An Individual Resident Care Plan Develop within 48 hours of Admission form, dated 1/11/19, was signed as completed on 1/18/19. Sections that were blank included: Social Work, Initial Goals determined by the Resident/Resident Representative, resident specific Occupational and Physical Therapy goals, and a section for Problems with Goals and Approaches. The medical orders were not attached to the form and there were no staff signatures for participation in the development of the Baseline Care Plan. When interviewed on 2/11/19 at 9:06 a.m. and 10:55 a.m., the Registered Nurse Manager (RNM) said she could not find a Baseline Care Plan for the resident. The RNM said the only care plan she could find was dated 1/18/19. 2. Resident #49 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/15/18, revealed the resident was cognitively intact. The Individual Resident Care Plan Develop within 48 hours of Admission form, dated 10/8/18, was signed as completed on 10/8/18. The sections of the form which were incomplete included: Discharge Plans, Therapy Services, and Social Work. Additionally, sections that were blank included Initial Goals determined by the Resident/Resident Representative and Problems, Goals, and Interim Approaches. A list of medications were not attached to the form. When interviewed on 2/11/19 at 9:06 a.m., the RNM said the Baseline Care Plan did not include initial goals or dietary information other than nothing by mouth. 3. Resident #47 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/10/18, revealed that the resident had moderately impaired cognition and received antipsychotic and antidepressant medications. The Individual Resident Care Plan Develop within 48 hours of Admission form, dated 12/3/18 and 12/4/18, was not completed for therapy services, admission list of medications, and initial goals. When interviewed on 2/8/19 at 2:07 p.m., the RN Unit Coordinator stated the admitting coordinator or supervisor are responsible for developing the Baseline Care Plan. She stated she developed the Certified Nursing Assistant (CNA) Care Card. During an interview on 2/8/19 at 1:09 p.m., the RN Director of Education stated the CNA Care Card is the Baseline Care Plan which is developed within 48 hours.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of seven residents reviewed for unnecessary medications and one of three residents reviewed for tube feedings, the facility did not develop a comprehensive person-centered care plan for each resident that addressed the resident's medical, physical, mental, and psychosocial needs. The issues involved the lack of development of a care plan for the use of an antipsychotic medication (Resident # 47), and the lack of a care plan for a resident's non-complaince with their diet order (Resident #49). This is evidenced by the following: 1. Resident #47 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/10/18, revealed that the resident had moderately impaired cognition, no behaviors or wandering, and received antipsychotic and antidepressant medications. The admission physician orders, dated 12/3/18, included [MEDICATION NAME] (an antipsychotic) and [MEDICATION NAME] (an antidepressant) for depression. The Comprehensive Care Plan (CCP), dated 12/3/18, revealed that the resident was at risk for depression and received an antidepressant medication. The CCP did not include the use of an antipsychotic medication. The admission history and physical, dated 12/4/18, documented the resident had increased agitation at home due to a chronic and progressive disease. Medications prior to admission included [MEDICATION NAME] and [MEDICATION NAME] which would be continued. The resident will be monitored for increased signs of depression. During observations conducted from 2/7/19 through 2/12/19 between 9:00 a.m. and 3:00 p.m., the resident was sitting in the dining room reading, visiting, or looking out the window. When interviewed on 2/8/19 at 1:23 p.m. and on 2/12/19 at 9:38 a.m., the Registered Nurse (RN) Unit Coordinator stated that the resident did not have any behaviors. She stated the resident was on [MEDICATION NAME] but she did not know what target symptoms the medication was intended to address. After review of the physician orders, she stated that the antipsychotic medication was being used for depression. The RN Unit Coordinator stated she did not know what depressive symptoms the resident exhibited. She said she was responsible for developing the CCP, and it should address the use of the [MEDICAL CONDITION] medications including the non-pharmacological interventions and the target symptoms. 2. Resident #49 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] with a jejunostomy feeding tube (J-tube, a permanent feeding tube placed in the small intestine). The MDS Assessment, dated 11/1/18, revealed that the resident was cognitively intact. The MDS Assessment, dated 12/10/18, revealed that the resident required the use of a feeding tube, received 50 percent or greater of calories through the tube feeding and 501 cubic centimeters (cc) of fluid or more per day via tube feeding. The CCP for nutrition, dated 10/19/18, revealed that the resident may have 2 ounces of ice chips as ordered and one 4-ounce pudding thick liquid or pureed item at the noon meal and for an afternoon snack with supervision. There was no CCP in place for non-compliance with the diet order. Physician orders, dated 12/28/18, revealed that the resident may have 2 ounces of ice chips as requested and one 4-ounce pureed item or pudding thick liquid at lunch and for an afternoon snack with supervision. Observations and interviews conducted on 2/8/19 included the following: a. At 12:45 p.m., the resident was wheeling himself to the gift shop on the ground floor (he lives on the first floor). The resident said they have stuff in there that he cannot get elsewhere. About ten minutes later, the resident was observed sitting outside of the ground floor conference room eating a donut. The surveyor notified the Director of Nursing (DON). The DON said she would take care of it as the resident needs to be supervised when eating. She said that she believed the resident was on a pureed diet. b. At 2:00 p.m., a Registered Nurse Manager (RNM) said the resident had told staff that he was going off the unit to get something he could not get elsewhere but staff did not know it was going to be a donut. The RNM said that the resident's non-compliance with his diet has been discussed before but he just continues to do what he wants. When interviewed on 2/12/19 at 9:42 a.m., the RNM said the resident's CCP lacks a problem for non-compliance with his diet and there should be a problem for safety issues related to his non-compliance. (10 NYCRR 415.11(c)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for pressure ulcers, and one of one resident reviewed for dental, the facility did not ensure the Comprehensive Care Plan were revised to reflect the current status of each resident. The issues involved the lack of care plan revision for actual pressure ulcers (Resident # 92), and the lack of care plan revisions for the use of dentures (Resident #66). This is evidenced by the following: The facility policy, Comprehensive Assessment and Care Plans, dated 6/28/17, revealed that care plans will be reviewed at least every three months and updated as needed. The resident's Comprehensive Care Plan (CCP) shall be reviewed and updated by each responsible discipline as needed to ensure appropriate problem, goals, and interventions are in place. 1. Resident #92 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/27/18, revealed that the resident had severely impaired cognition, required the extensive assistance of staff for care, and had three pressure ulcers - one Stage I (intact-non-blanchable redness), one Stage II (partial thickness skin loss), and one Stage III (full thickness skin loss). The CCP, dated 7/10/15, revealed that the resident was at risk for an alteration in skin integrity as the resident has a history of healed Stage II and Stage III pressure ulcers. The CCP, dated 12/17/15, revealed the resident had a deep tissue injury. The physician note, dated 6/6/18, documented that the resident had a history of [REDACTED]. The Nurse Practitioner (NP) note, dated 10/19/18, documented that the staff reported that the resident's buttock pressure ulcer was improving. The Registered Nurse (RN) note, dated 1/17/19, revealed that the resident had a pressure ulcer on the left buttock, right buttock, and right hip. In a readmission note, dated 1/18/19, the NP documented that the resident had a sacral wound. During an observation of pressure ulcer care on 2/12/19 at 10:05 a.m., the resident had two pressure ulcers (one on the left ischium and one on the right ischium). When interviewed on 2/12/19 at 10:28 a.m., the Registered Nurse (RN) Unit Coordinator stated she was responsible for the development and revision of the CCP. She stated that the resident had two healing Stage III pressure ulcers on his right and left lower buttocks (ischial area). The RN Unit Coordinator stated that the areas heal and then reopen. She stated that the CCP does not reflect the resident's current skin status and should be revised to reflect the resident's current pressure ulcers. 2. Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/18/19, revealed that the resident was cognitively intact. The Dental Progress Note, dated 8/31/18, revealed that the resident was edentulous (no natural teeth) and had full upper and lower dentures. The Individualized Resident Care Plan, dated 1/30/19, and the current CCP, revealed that the resident has her own teeth and needs assistance with oral care twice daily. Observations conducted from 2/6/19 through 2/12/19 between the hours of 9:00 a.m. and 3:00 p.m., revealed that the resident was edentulous and was not wearing dentures. Interviews conducted on 2/8/19 included the following: a. At 11:55 a.m., the Certified Nursing Assistant (CNA) said that the resident does not have her own teeth. She said she would inform the Nurse Manager so that the resident's care card could be updated. b. At 12:25 p.m., the Licensed Practical Nurse (LPN) stated she completes the quarterly MDS Assessments for the unit, and she talked to the resident when she completed her assessments. She said that on 12/6/18 she documented that the resident had her own teeth, and on 1/14/19, she documented that the resident wears dentures. The LPN said that the resident's Care Card and CCP need to be updated to include the use of dentures. (10 NYCRR 415.11(c)(2)(iii))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #29) of one resident reviewed for abuse, the facility did not ensure that the resident received treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and the resident's choices. The issue involved the lack of administration of bowel medications. This is evidenced by the following: The facility policy, Bowel Protocol, dated effective 2/13/17, revealed that when it is noted that the resident has not had a sufficient bowel movement in two days, the evening nurse will initiate Milk of Magnesia (MOM) 30 milliliters (ml) as needed times one based on admission standing orders. If the resident does not have results following the MOM, a [MEDICATION NAME] Suppository is to be administered on day three by the night nurse based on admission standing orders. If the resident again does not have results, a Travad (ready for use enema) is to be administered by the day nurse on day four based on admission standing orders. If no results, notify physician as needed. Resident #29 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/20/18, revealed the resident was unable to complete the interview for cognitive status and required the extensive assistance of one for toileting. The MDS Assessment, dated 9/17/18, revealed that the resident had severely impaired cognition. The current Comprehensive Care Plan revealed to monitor bowel elimination and utilize bowel protocol per physician order. The (MONTH) 2019 physician's orders [REDACTED]. A review of the Bowel Movement and Size Roster, from 12/29/18 through 1/5/19, revealed that the resident was without a bowel movement from 12/29/18 until 1/3/19. A review of the Electronic Medication Administration Records (EMAR) for (MONTH) (YEAR) and (MONTH) 2019 revealed that the resident had not received as needed bowel medications on 12/31/18, 1/1/19, and 1/2/19 per physician's orders [REDACTED]. The nursing progress notes, from 12/29/18 through 1/3/19, did not include documentation of the resident having a bowel movement, receiving any of the prescribed bowel medications, or of the physician being contacted on day five with no bowel movement. A nursing progress note, dated 1/3/19, revealed that the resident had been administered an enema due to no bowel movement in five days. A second progress note documented that the enema had been effective. When interviewed on 2/12/19 at 10:35 a.m., the Registered Nurse Unit Coordinator stated that the resident's bowel movements are documented in the computer. She said the night nurse waits until after midnight, reviews the bowel movement report for the unit, and administers medications as needed. During an interview on 2/12/19 at 11:41 a.m., the Director of Nursing (DON) said that if a resident does not have a bowel movement, she would expect the nurses to follow the bowel protocol. She said if the resident refused the medications, she would expect staff to reapproach the resident more than once on the same day. The DON reviewed the Bowel Movement Report for the resident and then said the resident had not had a bowel movement for five days. The DON stated that per the Bowel Protocol the resident should not have received the enema on day five without the physician being called first. (10 NYCRR 415.12)

Based on interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #33) of three residents reviewed for abuse, the facility did not investigate a resident's allegations in order to rule out abuse, neglect, or mistreatment. Specifically, the resident complained about staff treatment. This is evidenced by the following: Resident #33 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/18/17, revealed that the resident had clear speech, was understood by others and able to understand others (clear comprehension). A Brief Interview of Mental Status revealed that the resident had severe impairment of cognitive function. The current Comprehensive Care Plan (CCP) included that the resident had weepy episodes that appeared to be pain related and had a history of [REDACTED]. The CCP did not include behaviors or any history of the resident making false accusations. Review of a Nursing Progress Note, dated 8/17/17 and signed by the Licensed Practical Nurse (LPN), revealed that the resident reported that staff were being mean to her, threw her in bed and just left her, and refused to give her pain medication. Review of the resident's Incidents/Accident Reports and grievances for the past six months revealed one investigation, dated 8/30/17, related to bruising from her wheelchair. When interviewed on 9/26/17 at 3:35 p.m., the Certified Nursing Assistant said that the resident does not have any behaviors other than crying sometimes. She said the crying stops if staff sit with the resident. Interviews conducted on 9/28/17 included the following: a. At 8:18 a.m., the LPN stated the resident told her that staff were being mean, threw her in bed and left her there. The LPN said she passed the resident's complaints on to the next shift during report. b. At 10:50 a.m., the Social Worker (SW) said that she was not aware that the resident complained of staff being mean to her. She said that if it was reported to her, she would have completed a grievance form, started an investigation, talked to the resident, and discussed the concern with the Director of Nursing (DON). c. At 11:26 a.m., the Registered Nurse Unit Coordinator stated that she was aware of the resident's allegations, adding that the resident says things like that a lot. She said she did not speak to the resident about it but should have attempted to find out about the issue. She said she should have informed the SW. d. At 1:30 p.m., the DON stated that she would expect something like this to be reported and investigated to see if the allegation could be validated. (10 NYCRR 415.4(b)(3))

Based on observation, interview, and record review during the Extended Survey completed on 7/12/16, the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Two (Aqua, Plum) of four resident units observed for a safe environment had an issue involving missing safety stops on sliding windows that allowed the windows to open fully and there was no ongoing process in place to identify accident hazards relating to windows in the skilled nursing facility. Twenty-one residents resided on the Aqua Unit and 37 residents resided on the Plum Unit at the time of the survey. Residents #23, 49, 142, 177, and 178 were involved. This resulted in no actual harm that is IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on 7/11/16, prior to completion of the survey. The findings are: 1. a.) Observation of the First Floor, during the initial tour of the Plum Unit in the hospital based skilled nursing facility, on 7/5/16 at approximately 9:45 AM, revealed the window at the end of the corridor outside of resident room #C1246 had a keyed window stopper that was not engaged and was positioned at the far end of the window track, allowing the window to be fully opened. Further observation at this time revealed the window was not equipped with a screen. Further observation of the corridor window located outside of resident room #C1246 on the Plum Unit on 7/5/16 at approximately 3:30 PM revealed the following concerns: - The window measured 58 inches high by 54 inches wide and the width when fully opened was 24 inches wide. - The window sill was approximately 38 inches above the floor's surface. - A heating/cooling unit was located directly below the window, and an approximate eleven inch high piece of wood was secured to the heating/cooling unit, approximately two inches in front of it. - On the exterior of the building, the vertical distance from the window sill to the ground below was approximately 15 to 20 feet onto a small area of grass, a concrete sidewalk, and a metal guardrail. Interview with two Certified Nurse Aides (CNAs #4 and 5) on 7/5/16 at approximately 3:00 PM revealed they were not aware of any windows or window locks that were broken and if they were aware they would call maintenance to repair the issues. They also stated that there weren't any maintenance logs to log any issues with residents' rooms. Interview with three Licensed Practical Nurses (LPNs #3, 4, and 5) on 7/5/16 at approximately 3:00 PM revealed they were not aware of any issues with window locks being broken. Interview with a Maintenance Worker on 7/5/16 at approximately 3:30 PM revealed he was not aware that the keyed window stopper on the Plum Unit corridor window was not engaged and it appeared to have been pried off. Further interview with the Maintenance Worker revealed only the maintenance staff members have the key to the stopper and without the key, someone would have needed a screwdriver or wrench to pry it off. Additionally, the Maintenance Worker stated that the keyed window stoppers have been on all of the resident-access windows for at least [AGE] years and the maintenance department does not perform any audits on the windows. Interview with a Registered Nurse (RN#1) on the Plum Unit on 7/5/16 at approximately 3:50 PM revealed that she was not aware that the corridor window opens 22 inches or if there were any restrictions of openings of the windows, and she would not expect the window to fully open. Interview with the Director of Nursing (DON) on 7/5/16 at approximately 5:00 PM revealed that she was not aware of the window issue right at this moment. The DON stated that she does know that they do EOC (environment of care) rounds and they look at windows for holes in screens or cracked windows. The DON stated that the team that does the EOC rounds (for the hospital campus) is comprised of different people and it can be maintenance, housekeeping, or nursing. The DON also stated that she knows that they also do safety rounds and infection control rounds. When asked if they (the hospital campus team) look at windows for stoppers or whether the windows can be opened, the DON stated I couldn't tell you that, there's a formatted list that they use and honestly I don't know everything they look at. During the interview, the DON stated she would expect maintenance to be routinely monitoring the windows, It's environmental, not a nursing responsibility. The DON further stated she wouldn't see staff noticing if the stoppers weren't there because they are not supposed to be opening the windows. The DON further stated she thought they may check the windows at change of season - checking for holes in screens and she's not on the EOC team. Interview with the Administrator on 7/5/16 at approximately 5:00 PM revealed that environmental rounds are done throughout the facility (hospital campus) and they look at everything including windows. The Administrator also stated that she would not expect a window to open 24 inches because someone could get through it and that it would be insane to check every window in the facility to see if it locks. The Administrator stated she was not aware of a problem with the windows and staff had not alerted her. The Administrator stated that the last time she looked at the window (outside of resident room #C1246) a couple of months ago, it had a stopper in it and she has spoken to Maintenance about that window in the past. Interview with LPN #3 on the Plum Unit on 7/5/16 at approximately 6:10 PM revealed there were 37 who currently reside on the unit including five residents who wander, ten residents who ambulate independently, and 22 residents who self propel in wheelchairs. Resident #177 resides on the Plum Unit and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 2/16/16 revealed the resident is moderately cognitively impaired, understands, and is understood. The Mood section of the MDS documented that the resident stated that he felt like he was better off dead or hurting himself on 12 to 14 days out of 14 days and was moderately depressed. Resident #49 resides on the Plum Unit and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/25/16 revealed the resident is moderately cognitively impaired, usually understands, and is usually understood. The Mood section of the MDS documented that the resident stated that he felt like he was better off dead or hurting himself on two to six days out of 14 days and was moderately depressed. Resident #178 resides on the Plum Unit and has [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed that the resident is severely cognitively impaired and exhibited wandering behavior on one to three days out of seven. Resident #142 resides on the Plum Unit and has [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed that the resident is severely cognitively impaired and exhibited wandering behaviors on one to three days out of seven. Resident #23 resides on the Plum Unit and has [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed that the resident is severely cognitively impaired and exhibited wandering behavior on four to six days out of seven. b.) Observation of the Aqua Unit, located on the First Floor, on 7/5/16 at approximately 5:25 PM revealed the window in resident room #B1142 had no window stopper, allowing the window to be fully opened. Further observation at this time revealed the window was not equipped with a screen. This window was observed to slide open from left to right approximately 26 inches wide and from right to left approximately 30.5 inches wide. Continued observation revealed the vertical distance on the exterior of the building from the window sill to the ground below was approximately 15 to 20 feet onto grass. Further observation of the Aqua Unit on 7/5/16 at approximately 5:30 PM revealed the window in resident room #B1144 had no window stopper, allowing the window to be fully opened. Further observation at this time revealed the window was not equipped with a screen. This window was observed to slide open from left to right approximately 26 inches wide and from right to left approximately 30.5 inches wide. Continued observation revealed the vertical distance on the exterior of the building from the window sill to the ground below was approximately 15 to 20 feet onto grass. Interview with RN #4 on the Aqua Unit on 7/5/16 at approximately 5:40 PM revealed that the windows in those resident rooms (B1142 and B1144) should not open all the way and she would get someone to fix them right away. The RN also stated that the drop from the window to the ground was approximately 15 feet. Interview with RN #4 on 7/5/16 at approximately 6:00 PM revealed that 21 residents currently reside on the Aqua Unit and that seven of the 21 residents ambulate independently. c.) On 7/5/16 at approximately 6:00 PM, the DON provided a policy and procedure (P&P) entitled Life Safety Environmental Tours effective March 2013. The Purpose of the P&P documented that the hospital system will perform monthly environmental tours to promote the detection and correction of safety related hazards. Review of the Environment Tour Form revealed that criteria #5 under the Safety section documented: Are window safety blocks installed and working properly. Interview with a Maintenance Worker on 7/5/16 at approximately 6:35 PM revealed he is currently replacing all loose window stoppers throughout the facility with safety screws and all resident-access windows should open six to eight inches wide. During the interview, the Maintenance Worker was observed installing a window stopper and was installing an approximately two inch safety screw (screws unable to be removed by a regular screwdriver) into the window tracks of the window in the Plum Unit corridor, outside of resident room #C1246. Observation on 7/5/16 at approximately 6:55 PM revealed that safety screws were installed in the right and left hand side window tracks of residents' rooms #B1142 and #B1144. The windows were not able to be opened more than approximately six inches from either the right or left side. Observation of the window outside of resident room #C1246 on the Plum Unit on 7/6/16 at approximately 8:45 AM revealed that the newly installed window stopper was very loose and able to be partially lifted off the window track. The observation revealed that the screw that was installed into the track to prevent the window from opening did not penetrate the bottom of the window and the screw was able to be removed from the hole completely. d.) Interview with the Maintenance Supervisor on 7/6/16 at approximately 11:10 AM revealed that Environment of Care audits of the hospital campus are completed two times per year by the Maintenance Supervisor, Laundry/Housekeeping Supervisor, and the Infection Control Nurse. The Maintenance Supervisor stated that each department (including the skilled nursing facility) is responsible for performing Environment of Care Audits on their own departments quarterly. Review of Environment of Care Audit documentation revealed there was no documented evidence that departmental quarterly Environment of Care audits were done in the skilled nursing facility from July 2015 to July 2016. The most recent semi-annual Environment of Care Audit, performed by the Maintenance Supervisor, Laundry/Housekeeping Supervisor, and the Infection Control Nurse in the skilled nursing facility was on 2/9/16. Review of the Environment of Care Audit form for 2/9/16 revealed that windows were not addressed in these audits. Interview with the Maintenance Supervisor on 7/6/16 at approximately 1:30 PM revealed he had no further Environment of Care Audit documentation to submit. The interview revealed that a form entitled Life Safety Environmental Tours was developed 3/2013 by a previous Administrator and included questions about window stoppers, but it was never used. 2. Review of a letter from the Administrator dated 7/11/16 and undated documents describing the Environment of Care Rounds Process, Weekly Window Audits, and Education for all Staff Members revealed the Administrator documented that the Immediate Jeopardy situation in the nursing home, related to the openable windows that lacked stoppers, was removed on 7/11/16. Additional review of the letter revealed the following: - All windows in the skilled nursing facility were repaired by the maintenance department, to include stops to prevent windows opening greater than six inches. - All of the Unit Coordinators, Clinical Coordinators, and Nursing Supervisors were educated regarding a plan to conduct ongoing Environment of Care Rounds and Weekly Window Audits to verify that stops are in place on all windows. - Eighty-four percent of nursing services staff (including Activities and Social Work) and seventy-eight percent of Therapy, Maintenance, Housekeeping, and Dietary staff were inserviced that all windows in the nursing facility must have a stop in place to prevent opening greater than six inches. - A plan was put in place to educate all remaining staff (on vacation or on disability) through the scheduling office, prior to their first day of work. Observations of the Aqua and Plum Units on 7/11/16 and 7/12/16, between the hours of 8:00 AM and 12:00 PM, revealed the following: - The windows in resident rooms B1142 and B1144 had screws securely placed into the window tracks and the windows were not able to be opened more than six to eight inches. - The corridor window outside of resident room C1246 had a lock mechanism engaged so the window could not be opened at all. Interviews conducted on 7/11/16 and 7/12/16, between the hours of 8:00 AM and 12:00 PM, revealed: - Four RN Unit Coordinators were aware of the EOC Rounds they were to conduct and the auditing tool to use during the rounds. The RN Unit Coordinators stated that they received recent inservice education regarding the windows - Two 2 RN Supervisors, who work the day and evening shifts, were aware of the window audits that they were going to complete weekly and stated they received recent education regarding the windows - Six LPNs who work the day and evening shifts were aware that windows were supposed to have stoppers and were not to open more than six inches. If the windows open more than six inches and didn't have a stopper in place, staff are to report it to a supervisor. The LPN stated they received recent inservice education regarding windows - Eight CNAs, including agency staff, were aware that windows were supposed to have stoppers and not to open more than six inches, and to report it to their supervisor if they saw a window without a stopper. The CNAs stated they received recent inservice education regarding windows - Four Housekeepers, working on the four resident units were aware that windows are supposed to have stoppers and not open more than six inches. The Housekeepers stated that they received recent inservice education regarding windows - One Physical Therapist was aware that windows are supposed to have stoppers, not open more than 6 inches, and the Physical Therapist received recent inservice education regarding windows - One Maintenance Worker was aware that windows were supposed to have stoppers, not open more than 6 inches, and the Maintenance Worker received recent inservice education regarding windows 415.12(h)(1)

Based on observation, interview, and record review conducted during an Extended Survey completed 7/12/16, it was determined that the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to ensure that systems were in place to ensure a safe environment was maintained for residents. Specifically, there was no process in place to identify openable windows that lacked [MEDICATION NAME] and the windows opened 24 to 30 inches wide. This was a pattern with no actual harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on 7/11/16, prior to the completion of survey. REFER TO: F323 - Free of Accident Hazards/Supervision/Devices - S/S=K The finding is: 1.) Observation of the First Floor, during the initial tour of the Plum Unit in the hospital based skilled nursing facility, on 7/5/16 at approximately 9:45 AM, revealed the window at the end of the corridor outside of resident room #C1246 had a keyed window [MEDICATION NAME] that was not engaged and the [MEDICATION NAME] was positioned at the far end of the window track, allowing the window to be fully opened. Further observation at this time revealed the window was not equipped with a screen. Interview with a Maintenance Worker on 7/5/16 at approximately 3:30 PM revealed he was not aware that the keyed window [MEDICATION NAME] on the Plum Unit corridor window was not engaged and it appeared to have been pried off. Further interview with the Maintenance Worker revealed only the maintenance staff members have the key to the [MEDICATION NAME] and without the key, someone would have needed a screwdriver or wrench to pry it off. Additionally, the Maintenance Worker stated that the keyed window [MEDICATION NAME] have been on all of the resident-access windows for at least [AGE] years and the maintenance department does not perform any audits on the windows. Interview with the Director of Nursing (DON) on 7/5/16 at approximately 5:00 PM revealed that she was not aware of the window issue right at this moment. The DON stated that she does know that they do EOC (environment of care) rounds and they look at windows for holes in screens or cracked windows. The DON stated that the team that does the EOC rounds for (the hospital campus) is comprised of different people and it can be maintenance, housekeeping, or nursing. The DON also stated that she knows that they also do safety rounds and infection control rounds. When asked if they look at windows for [MEDICATION NAME] or whether the windows can be opened, the DON stated I couldn't tell you that, there's a formatted list that they use and honestly I don't know everything they look at. During the interview, the DON stated she would expect maintenance to be routinely monitoring the windows, It's environmental, not a nursing responsibility. The DON further stated she wouldn't see staff noticing if the [MEDICATION NAME] weren't there because they are not supposed to be opening the windows. The DON further stated she thought they may check the windows at change of season - checking for holes in screens and she's not on the EOC team. Interview with the Administrator on 7/5/16 at approximately 5:00 PM revealed that environmental rounds are done throughout the facility (hospital campus) and they look at everything including windows. The Administrator also stated that she would not expect a window to open 24 inches because someone could get through it and that it would be insane to check every window in the facility to see if it locks. The Administrator stated that the last time she looked at the window (outside of resident room #C1246) a couple of months ago, it had a [MEDICATION NAME] in it and she has spoken to Maintenance about that window in the past. On 7/5/16 at approximately 6:00 PM the DON provided a policy and procedure (P&P) entitled Life Safety Environmental Tours effective 3/2013. The P&P documented that the Maintenance Supervisor and Nursing Facility Administrator or designee will complete monthly environmental tour and record findings on the life safety environmental tour form (see attached). Review of the attached Environmental Tour Form revealed criteria #5 included Are window safety blocks ([MEDICATION NAME]) installed and working properly. Interview with the Maintenance Supervisor on 7/6/16 at approximately 1:30 PM revealed he had no further Environment of Care Audit documentation to submit. Continued interview revealed a form called Life Safety Environmental Tours was developed 3/2013 by a previous Administrator, it included questions about window [MEDICATION NAME], but it was never used. During an interview on 7/12/16 at 10:25 AM, the Administrator stated there was a policy for Life Safety Environmental Tours developed 3/2013 but it wasn't implemented, maintenance still did Environment of Care Rounds, but windows were not listed on the EOC (Environment of Care) checklist. 415.26