Wilkinson Residential Health Care Facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification and abbreviated survey (Case #NY00358788), the facility did not ensure that all allegations of abuse were thoroughly investigated for one (1) (Resident #359) of eight (8) residents reviewed for abuse. Specifically, Resident #359 reported an allegation of verbal/metal abuse and rough treatment during care given on the evening shift of 10/25/2024 by five (5) facility staff during an insertion of an indwelling Foley Catheter. The facility initiated an investigation on 10/28/2024, and did not determine where a bruise of unknown origin occurred and did not investigate the source of the bruise until 10/30/2024.
This is evidenced by:
Cross reference with F-684.
The facility's policy and procedure titled 'Resident Abuse Prevention' dated 5/2023, documented staff shall report any unusual changes in residents' condition promptly so that occurrences, patterns, or trends that constitute abuse can be identified, such as suspicious bruising, change in demeanor, or withdrawal. The abuse policy did not address the process for investigation after an alleged allegation of abuse was made.
Resident #359 was admitted to the facility with diagnoses of status post spinal surgery for a pathological compression fracture (a broken bone caused by underlying disease, diabetes mellitus (a disorder where the body does not produce enough insulin and the person has consistently high blood sugar), and morbid obesity (too much body fat which increases the risk of health problems). The Minimum Data Set (an assessment tool) dated 10/25/2024, documented the resident could be understood, and understand others, and had intact cognition for daily decision making.
Record review demonstrated Resident #359 returned from the hospital on [DATE]. A facility investigation summary documented the following: Investigation was started on 10/28/2024 at 8:00 AM. The report documented Resident #359 reported an allegation of abuse that occurred on 10/25/2024 during the evening shift. Resident #359 alleged 5 staff members held them down to catheterize the resident. The resident reported the incident to Registered Nurse #1 on 10/28/2024 at 7:30 AM. Resident #359 stated staff had been both verbally and physical abusive. Registered Nurse #1 notified Director of Nursing #1 and Director of Social Work #1 who began an investigation and notified the New York State Department of Health reporting division of the alleged abuse per regulation. Investigation on 10/28/2024 did not address bruising on upper left arm with staff until 10/30/2024. The investigation did not address why Licensed Practical Nurse #2 did not call for assistance from Registered Nurse Supervisor #1 or why neither nurse had notified Director of Nursing #1 of the events that occurred on 10/25/2024.
During an interview on 5/23/2025 at 3:00 PM, Director of Nursing #1 stated they were not made aware of the difficulty that occurred during the catheterization of Resident #359 on 10/25/2024 until the morning of 10/28/2024. An investigation was started to determine what had occurred. Director of Nursing #1 stated the investigation was not completed when it was first reported to the Department of Health. Some things were missed during the investigation and the bruise found on the resident arm had not been investigated thoroughly.
During an interview on 5/23/2025 at 3:15 PM, Administrator #1 stated after review of the 'Resident Abuse Policy,' the policy would need to be updated because it did not address the investigation process that should occur when an allegation of abuse was made.
10 New York Code of Rules and Regulations 415.4(b)(2)

Based on observation and staff interview conducted during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, food was not cooled properly, dented cans were with the common stock, and sanitizing solution testing papers were expired.
This is evidenced by:
During observations in the main kitchen on 5/19/2025 at 9:40 AM:
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Cooked pasta in the walk-in refrigerator was 47 degrees Fahrenheit.
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One #10 can of Banana Pudding had a V-shaped dent in the seam which broke the seal of the can (can was in the walk-in refrigerator speed rack).
Director of Food and Nutrition disposed of the pasta and the #10 can of Banana Pudding immediately.
•
The test papers used to check the concentration of the solution for manually sanitizing equipment had an expiration date of 2020.
During an interview on 5/19/2025 at 10:03 AM, Director of Food and Nutrition Services #1 stated that the pasta was cooked yesterday afternoon and should have been cooled to 41 degrees Fahrenheit, the dented can should not have been on the rack with the common stock, and they would order new test papers for checking the sanitizing solution.
New York Codes, Rules, and Regulations Title 10 §415.14(h)
Chapter 1 State Sanitary Code Subpart 14

Based on observation, record review, and interview conducted during a recertification survey, the facility did not ensure control and accountability, determine that drug records were in order, that an account of all controlled drugs was maintained and periodically reconciled. Specifically, (a.) a count was not completed prior to narcotic access keys being handed from one licensed nurse to another; (b.) nursing staff did not document nursing unit narcotics as having been counted by two licensed nurses and signed at the beginning and end of each shift on the facility-provided Controlled Substance Count Sheets for three (3) of three (3) nursing units; and (c.) the facility did not complete periodic reconciliation of controlled substance records.
This is evidenced by:
The facility Policy and Procedure titled Controlled Substance Shift Count, last reviewed 7/2023, documented: Verification of the number of Class II-IV controlled substances on hand would be minimally done at the beginning and end of each shift by the licensed nurse of the outgoing and on-coming shift. Each individual licensed nurse was responsible for counting the controlled substances for the wing that they were assigned to. After the medication was entirely used, all completed sheets would be sent to Nursing Administration. Medication cart keys/controlled substance medication keys were not to be handed off from one shift to the next until the count was complete and accurate. Medication keys were to be on designated medication nurse at all times. Only medication nurse should have access to the keys.
Review of the Controlled Substance Count Sheets (used to document shift to shift narcotic counts) for the month of May 2025, revealed all three (3) facility units had multiple occurrences of missing documentation. Unit 1's sheets were missing 25 nurses' signatures, Unit 2's sheets were missing 10 signatures, and Unit 3's sheets were missing 12 signatures.
During an observation on 5/27/2025 at 9:45 AM, Licensed Practical Nurse #6, the assigned medication nurse was asked by Registered Nurse #2 for the keys to the medication room. Licensed Practical Nurse #6 handed the keys, including keys to access-controlled substances, to Registered Nurse #2. Registered Nurse #2 then accessed the medication room while they had possession of the keys.
During an interview on 5/27/2025 at 9:58 AM, Licensed Practical Nurse #6 stated they had given the keys to Registered Nurse #2 because they needed items from the locked cabinet, but they should have told them no. They stated, when given the keys after shift count the keys should not be exchanged with anyone for any reason unless another count was completed.
During an interview on 5/27/2025 at 10:13 AM, Registered Nurse #3 stated the keys were not to be given to anyone. Registered Nurse #3 stated the nurse that took possession of the keys at the beginning of the shift would count off with the nurse leaving and both would sign the narcotic sheet. They stated they were unaware this was not consistently done, and they did not know who would check the count sheets to ensure this was done.
During an interview on 5/27/2025 at 10:46 AM, Licensed Practical Nurse #7 stated there should be signatures documenting the count was completed for each shift change by nurses. They did not know why it was not done.
During an interview on 5/27/2025 at 10:47 AM, Director of Nursing #1 and Assistant Director of Nursing #1 stated they were unaware that shift to shift signing of narcotic counts was not being done by nurses. They stated an in-service with the staff would be done and the books would be monitored.
On 5/27/2025 at 12:04 PM, in an email response to a request for documents, Administrator #1 stated they had not done any audits of the narcotic sheets.
During an interview on 5/27/2025 at 12:35 PM, Medical Director #1 stated they were surprised that the narcotic count sheets were not being signed off per the policy and regulations. They further stated that facility narcotics processes were updated after the New York State Department of Health Bureau of Narcotic Enforcement visited the facility.
10 New York Code Rules and Regulations 415.18(a)

Based on interview and record review conducted during the recertification survey, the facility did not use the services of a Registered Nurse for at least eight (8) consecutive hours a day, seven (7) days a week. Specifically, a review of staffing revealed a Registered Nurse was not scheduled for eight (8) consecutive hours per day on 1/19/2025 and 3/02/2025.
This is evidenced by:
The facility assessment dated 2024, documented that the staffing plan was based on the resident population and their needs for care and support. The staffing plan documented the following daily staffing needs: one (1) to three (3) Registered Nurses on day shift, zero (0) to two (2) Registered Nurses on evening shift, and zero (0) to one (1) Registered Nurses on night shift.
The facility, Job Title Report, dated 1/01/2025 to 3/31/2025, documented that the facility did not have a Registered Nurse for eight (8) consecutive hours in the facility on the following dates: 1/19/2025 and 3/02/2025.
There was no documented evidence of staffing waivers in place for the facility both before or during the recertification survey.
During an interview on 5/27/2025 at 12:41 PM, Staffing Coordinator #1 stated that they scheduled staff based on resident population and their needs. Staffing Coordinator #1 stated that callouts could impact staff ' s abilities to provide care. Staffing Coordinator #1 stated that they were aware that there needed to be a Registered Nurse working for eight (8) hours per day, every day. They were aware that there were some instances of having less than eight (8) hours of Registered Nurses scheduled a few times last quarter. Staffing Coordinator #1 stated that they believed that the nurse that was scheduled at the time had left early and did not arrange for it in advance.
During an interview on 5/27/2025 at 9:18 AM, Director of Nursing #1 stated that they were aware that the facility had submitted less than eight (8) hours of Registered Nurse care two (2) or three (3) times in the last quarter. Director of Nursing #1 stated that they would not have allowed a schedule that had 7.5 hours of Registered Nurse coverage. Someone had left early but they were not informed about it until after it had already happened. Director of Nursing #1 stated that they explained to the nursing staff the eight (8)-hour requirement the facility was required, and they strived to make sure it would not happen again.
10 New York Code Rules and Regulations 415.13(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification and abbreviated (Case # NY00358788) survey, the facility did not ensure it had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, (a.) the facility did not perform the appropriate competency evaluations for licensed nursing staff to measure the pattern of knowledge, skills, abilities, behaviors and other characteristics that an individual needs to perform work roles or occupational functions successfully; (b) Registered Nurse Supervisor #1 did not document or assess Resident #359 when a procedure was ordered, and mental status changes occurred. Registered Nurse Supervisor #1 did not remain available to assess the resident during an ordered procedure that required assessment, evaluation, and follow up intervention to the medical record and the resident ' s Comprehensive Care Plan. No documentation or report was given to the oncoming Registered Nurse prior to Registered Nurse Supervisor #1 leaving the facility at the end of their shift.
This is evidenced by:
Cross reference to F684.
A facility assessment dated 2024, documented under Part 14 - Staff Training /Education, that training programs applied to all facility staff to include direct care staff, indirect care staff, managers, supervisors, contracted staff, and volunteers, as appropriate. Training programs, as appropriate, were provided as part of their orientation process for new and newly assigned staff, annually, and/or as needed. Training programs contained learning objectives, performance standards, and evaluation criteria.
A review of education records for Licensed Practical Nurse #2 documented that their educations for the following topics expired in [DATE]: Fire Safety, Ethical Behaviors, Emergency Management Plan, Emergency Codes, Electrical Safety, Developing Cultural Competencies in Healthcare, Core Compliance: Fraud, and Abuse, Health Insurance Portability and Accountability Act and Emergency Medical Treatment and Active Labor Act Basics, Active Shooter, and 2022 Health Insurance Portability and Accountability Act.
A review of education records for Certified Nurse Aide #5 documented that their educations for the following topics expired in [DATE]: Fire Safety, Evacuation Plan, Hazard Communication, Emergency Management Plan, Developing Cultural Competencies in Healthcare, Emergency Codes, Electrical Safety, Human Immunodeficiency Virus & Acquired Immunodeficiency Syndrome Confidentiality, Infant and Child Abduction, Patient & Resident Abuse, Patient Rights, Policy on the Rights of Employees to Express Breast Milk in the Workplace, Personal Protective Equipment Refresher, Professional Wellness & Impairment, Sexual Harassment Prevention, Core Compliance: Fraud & Abuse, Health Insurance Portability and Accountability Act and Emergency Medical Treatment and Active Labor Act Basics, Suicide Awareness and Response, and Active Shooter.
During an interview on [DATE] at 9:05 AM, Assistant Director of Nursing #1 stated that they were responsible for the education records of the nursing staff. Assistant Director of Nursing #1 stated that they did not review the education records as much as they should. They had lost track of the education records of in-house staff due to other responsibilities, and it had been months since they had reviewed any of them. They stated that they would make sure that the person that took on their position as Assistant Director of Nursing would be more diligent about reviewing the records.
During an interview on [DATE] at 9:18 AM, Director of Nursing #1 stated that they were unaware of the lapse in staffing education records. Director of Nursing #1 stated that they would follow up with Assistant Director of Nursing #1.
Resident #359
Resident #359 was admitted to the facility with diagnoses of status post spinal surgery for a pathological compression fracture (a broken bone caused by underlying disease), diabetes mellitus (a disorder where the body does not produce enough insulin and the person has consistently high blood sugar), and morbid obesity (too much body fat which increases the risk of health problems). The Minimum Data Set (an assessment tool) dated [DATE] documented the resident could understand and was understood by others with intact cognition for daily decision making.
During a telephone interview on [DATE] at 1:35 PM, Registered Nurse Supervisor #1 stated they were notified Resident #359 had returned from the hospital on [DATE], had a period of apnea, and was unresponsive. After responding to the unit, 911 was called and the physician was notified. When Emergency Medical Services arrived, Resident #359 was assessed, had become responsive, and refused to go back to the hospital. The physician was notified of the resident ' s refusal, and an order was obtained to bladder scan the resident and catheterize them if urine residual was greater than 400 milliliters. Registered Nurse Supervisor #1 stated that Licensed Practical Nurse #2 was assigned to the resident and was going to perform the catheterization. Registered Nurse Supervisor #1 stated that the resident was stable when they left the unit, and Registered Nurse Supervisor #1 stated they were not aware of anything that had happened until the following day when they returned to the facility. Registered Nurse Supervisor #1 stated that Licensed Practical Nurses could not assess a resident with a change in condition and they needed to notify a Registered Nurse to complete an assessment. Registered Nurse Supervisor #1 stated they were the only Registered Nurse in the building on evenings and had not checked back on the resident ' s condition prior to leaving for the night. No documentation had been placed on the 24-hour report about the resident ' s episode, refusal to go to the hospital, or the events surrounding Resident #359 ' s change in condition and subsequent catheterization. Registered Nurse Supervisor #1 further stated they did not give a shift report to the oncoming nurse and stated that they couldn ' t remember if there was an oncoming nurse at the time.
During a telephone interview on [DATE] at 12:45 PM, Medical Director #1 stated that they were notified on [DATE] that Resident #359 had an episode of unresponsiveness. The physician told the staff to send Resident #359 to the hospital and staff contacted Emergency Medical Services. Medical Director #1 stated that after they were notified, staff called again, and stated the resident had become alert and had refused to go to the hospital. Because Resident #359 had just returned to the facility that day ([DATE]) and there was concern that the hospital had removed their foley prior to their return to the facility, the physician ordered a bladder scan to be done. Medical Director #1 stated that if the results of the bladder scan was greater than 400 millimeters of residual urine, the order was for staff to insert a foley catheter. Medical Director #1 stated that staff did not call to inform them of (a.) the results of the bladder scan - Results of the bladder scan being that Resident #359 had greater than 850 milliliters of urine retention and needed to be catheterized - (b.) the subsequent insertion of the foley catheter, or (c.) the difficulty the staff and resident experienced to carry out the order. Medical Director #1 stated that they did not receive notification of the resident ' s condition until [DATE], 72 hours later when they were informed of Resident #359 ' s condition by Director of Nursing #1. Medical Director #1 stated that the staff should have called and advised them of what had occurred. Medical Director #1 further stated that the Registered Nurse should have reassessed the resident at the time and discussed the situation with them - the physician, so they could have collaboratively decided what would have been the best way to proceed with Resident #359.
During an interview on [DATE] at 3:00 PM, Director of Nursing #1 stated they were not made aware of the issues surrounding the events with Resident #359 on [DATE] until the morning of [DATE]. Director of Nursing #1 stated that Registered Nurse Supervisor #1 had not reported any issues with Resident #359, despite there being many issues at that time, and should have checked with the Licensed Practical Nurses prior to leaving for the night given that Resident #359 had an episode of unresponsiveness and mental status changes. Director of Nursing #1 stated that only a Registered Nurse could assess a resident with a change in condition and because only Licensed Practical Nurses were present at the time of the issues with Resident #359, Registered Nurse Supervisor #1 should have followed up or provided report to the oncoming Registered Nurse. Director of Nursing #1 stated that staff should have been in contact with the Registered Nurse and Physician throughout the whole incident. Director of Nursing #1 stated all staff were reeducated on the policy of notifying the physician when a resident experienced a change in condition. Director of Nursing #1 stated that the situation was not handled per policy, Registered Nurse Supervisor #1 and the other staff did not follow professional standards of care.
10 New York Codes, Rules and Regulations 415.26(c)(1)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that followed professional standards of practice, the resident's care plan, and the resident's choice for three (3) (Resident #'s 44, 63, and 79) of five (5) residents reviewed for oxygen administration. Specifically, (a.) supplemental oxygen flow rate was not ordered by the physician for Resident #'s 44 and 63; (b.) for Resident #79 oxygen therapy was not monitored and physician orders were not followed for cleaning and maintaining respiratory therapy equipment according to professional standards of practice.
This is evidenced by:
A review of the facility policy titled Oxygen Administration and Use, last reviewed 8/2024, documented that oxygen use for residents was per physician orders. It further documented that staff were to verify the liter flow the resident was on as well as the oxygen saturation for residents every two (2) hours and fill out the appropriate check sheet.
Resident #44
Resident #44 was admitted to the facility with left-sided hemiplegia and hemiparesis following cerebral infarct (paralysis and inability to use extremities due to symptoms from having a stroke), chronic respiratory failure with hypoxia (a condition where the lungs struggle to provide enough oxygen to the blood, leading to low oxygen levels in the body), and chronic congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively to meet the body's needs). The Minimum Data Set (an assessment tool) dated 4/14/2025, documented the resident could be understood, usually understand others, and had intact cognition for daily living decisions.
The Comprehensive Care Plan dated 1/16/2025, documented that Resident #44 had diagnoses of congestive heart failure, history of pulmonary vascular congestion, and history of pneumonia. The resident wore supplemental oxygen via a nasal cannula daily to prevent hypoxia. The approaches documented to assess for change in level of consciousness, coherency, break tasks into manageable sub-tasks, encourage activities and self-care as tolerated, encourage fluids daily, monitor and report signs of respiratory distress, monitor closely for respiratory failure, monitor lung sounds, provide medications as ordered, supplemental oxygen as needed to maintain saturations of 88 percent or greater, and check oxygen saturation every shift.
A physician order dated 12/24/2024, by Nurse Practitioner #1 documented, maintain oxygen saturation at 88 percent or greater. There was no documented evidence of flow rate for the oxygen that indicated how many liters per minute were required to maintain oxygen saturation above 88 percent.
During an observation on 5/19/2025 at 12:17 PM, Resident #44 was noted to be on two (2) liters of oxygen via nasal cannula.
During an interview on 5/22/2025 at 10:45 AM, Licensed Practical Nurse #6 stated that nurses set the oxygen flow rate. Licensed Practical Nurse #6 was asked to review the orders for oxygen flow rate per physician order for Resident #44. They stated that they could not find a specific order for the liter flow of oxygen and that the resident to have oxygen saturations to maintain above 88 percent. Licensed Practical Nurse #6 could not state what liter flow the resident should be set to for their saturation to maintain above 88 percent. They stated that the liter flow for oxygen administration should be set per physician order, generally at two to four (2 – 4) liters per minute, if the patient was on a nasal cannula.
Resident #63
Resident #63 was admitted to the facility with diagnoses of hypertensive heart disease with heart failure (a condition where high blood pressure causes the heart to weaken and be unable to pump enough blood to meet the body ' s needs, leading to heart failure), chronic congestive heart failure, and dilated cardiomyopathy (a condition where the heart muscle becomes weakened and enlarged, causing the heart chambers to stretch and thin). The Minimum Data Set, dated [DATE] documented the resident could be understood, could understand others, and was cognitively intact.
The Comprehensive Care Plan for congestive heart failure dated 3/05/2022, documented that Resident #63 had a history of congestive heart failure and associated acute on chronic respiratory failure and risk for altered respiratory function and infection (history of pneumonia) due to immobility and activity intolerance. The approaches documented to assess for change in level of consciousness, coherency, break tasks into manageable sub-tasks, encourage activities and self-care as tolerated, encourage fluids daily, monitor and report signs of respiratory distress, monitor closely for respiratory failure, monitor lung sounds, provide medications as ordered, supplemental oxygen as needed to maintain saturations of 88 percent or greater, and check oxygen saturation every shift.
A physician order dated 1/23/2025, by Nurse Practitioner #1 documented, maintain oxygen saturation at 88 percent or greater. There was no documented flow rate for the oxygen that indicated how many liters per minute were required to maintain an oxygen saturation above 88 percent.
During an observation on 5/20/2025 at 10:17 AM, Resident #63 was noted to be on two (2) liters of oxygen via nasal cannula.
During an interview on 5/21/2025 at 12:22 PM, Nurse Practitioner #1 stated that they did not realize that the order for Resident #63 ' s oxygen was written without a flow rate for the oxygen setting. Nurse Practitioner #1 stated they knew there should have been a flow rate for the oxygen setting.
During an interview on 5/22/2025 at 10:45 AM, Certified Nurse Aide #3 stated that nurses set the oxygen flow rate, but they knew Resident #63 was on two (2) liters of oxygen.
During an interview on 5/27/2025 at 9:18 AM, Director of Nursing #1 stated that oxygen orders should have a flow rate or a flow range. Director of Nursing #1 stated that the staff knew to check the oxygen saturation each shift, and that Licensed Practical Nurses did the flow rate adjustment.
Resident #79
Resident #79 was admitted to the facility with diagnoses of chronic respiratory failure with hypoxia requiring continuous oxygen therapy, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) with recent pneumonia requiring antibiotics, and status post fall with fracture to ribs and left tibia (bone in the lower leg). The Minimum Data Set, dated [DATE], documented that the resident could be understood, understand others, and had intact cognition for daily decision making.
During an observation on 5/20/2025 at 10:51 AM, Resident #79 was observed in their room with oxygen via nasal canula at three and a half (3.5) liters using an oxygen concentrator. The tubing was not dated. The resident had a small-volume nebulizer machine (an electronic breathing device that converts liquid medication into a fine mist, which is inhaled, allowing the medication to reach the airways and lungs) in their room on the end table. The mouthpiece to the machine was lying uncleaned on the end table, was not cleaned after use, and was not in an enclosed bag. The tubing was not dated
During an observation on 5/23/2025 at 11:02 AM, Resident #79 was observed in their room with oxygen via nasal canula at three (3) liters using an oxygen concentrator. The tubing was not dated. The resident had a small-volume nebulizer machine in their room on the end table. The mouthpiece to the machine was lying uncleaned on the end table, was not cleaned after use, and was not in an enclosed bag.
A physician's order dated 4/28/2025, documented budesonide suspension for nebulization, 0.5 milligrams/2 milliliter: amount one (1) vial inhalation. Special instructions: mix with Duo Neb, twice a day for diagnosis of chronic obstructive pulmonary disease: 8:00 AM and 8:00 PM.
A physician ' s order dated 4/28/2025 documented ipratropium-albuterol solution for nebulization: 0.5 milligrams /3 milligrams 3 milliliters; amount to administer one (1) vial per inhalation three times a day, 8:00 AM, 3:00 PM, and 8:00 PM, morning and evening dose to be mixed with budesonide, noon dose to be given alone.
The electronic treatment administration record for 5/2025, documented small volume nebulizer tubing and bag, change weekly, once a day on Wednesday, 10:00 PM to 6:00 AM, label tubing with a piece of tape, when initiated, then date and initial, rinse/dry the small volume nebulizer medication holder after each use. Tubing was documented as being changed on 5/7/2025, 5/14/2025, and 5/21/2025, however the tubing was not dated during observations made on 5/20/2025 and 5/23/2025.
During an interview on 5/20/2025 at 11:35 AM, Licensed Practical Nurse #11stated the resident was on 3 liters of oxygen via a nasal cannula. They were not sure why the concentrator was set at 3.5 liters, maybe someone hit the dial. They stated there was no order for it to be checked every shift in the electronic treatment record, but the resident's oxygen saturation was checked periodically.
During an interview on 5/23/2025 at 11:50 AM, Registered Nurse Supervisor #1 stated oxygen tubing was changed every two weeks and should be dated to demonstrate the tubing was changed per policy and the physician's order. Also, the nebulizer mouthpiece and tubing should be cleaned after each use and kept in a plastic bag after it was cleaned and dried. They stated Resident #79 was on droplet precautions and was receiving antibiotics for pneumonia. Registered Nurse Supervisor #1 stated the resident was on 3 liters of oxygen and the concentrator should have been checked every shift. Usually, orders were entered on the electronic record for each shift to check the resident ' s oxygen settings upon admission. Since Resident #79 had pneumonia and was receiving antibiotics, nursing staff should have closely monitored their oxygen saturations every shift. They stated Resident #79 ' s orders would need to be reviewed.
During an interview on 5/22/2025 at 11:17 AM, Nurse Practitioner #1 stated that all residents who received oxygen therapy needed a physician's order. It was considered a medication. The order should specify the parameters and oxygen flow rate, duration of use, and the type of delivery system, such as nasal cannula, and whether to use a concentrator or portable tank. They stated daily monitoring should be done and the equipment should be kept clean.
10 New York Code of Rules and Regulations 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during a recertification and abbreviated (Case #NY00377111) survey , the facility did not ensure that resident environments were as free from accidents or hazards as was possible for three (3) (Resident #s 40, 44, and 358) of five (5) residents reviewed for accidents and hazards. Specifically, (a.) Resident #40, who was at risk for elopement and required supervision, was left alone outside unsupervised for 98 minutes on [DATE], and unable to get back into the building; (b.) an expired ointment medication was left on the Resident #44 ' s bedside table on [DATE], permitting access to the ointment by the resident or anyone that entered the room; and (c.) for Resident #358 - who was documented as someone who wandered with significant risk to themselves – was not adequately monitored when they wandered out of the facility to an adjacent building on [DATE].
This is evidenced by:
The Wandering and Elopement Policy, last reviewed 6/2024, documented the facility was to ensure that systems, tools and processes were in place to prevent unsafe wandering and/or elopement and to ensure that actions were taken quickly and prudently by staff, should either occur. The procedures documented, in part, that an elopement risk assessment would be done on admission, the facility would assure the functionality of alarmed doors, and appropriate care planning implementation and revision.
Resident #40
Resident #40 was admitted to the facility with Alzheimer ' s disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), dementia with behavior disturbances (behavioral and psychological symptoms that accompany dementia, affecting a significant portion of those living with the condition), and hypertension (a condition where the force of your blood against the walls of your arteries is too high). The Minimum Data Set, dated [DATE], documented that Resident #40 usually made themselves understood, sometimes understand by others, and had severe cognitive impairment.
The Comprehensive Care Plan dated [DATE], documented that the resident was at risk for elopement related to impaired cognition and verbalized their desire to leave the facility. Resident #40 had cognitive impairment with poor decision-making skills and/or pertinent diagnoses such as dementia and Alzheimer's. The Comprehensive Care Plan documented the following interventions implemented on [DATE] for safety awareness: the resident would not be left unsupervised when off the unit, including when outside of the building.
The facility ' s Investigative Report dated [DATE] documented that Resident #40 was brought outside by Certified Nurse Aide #7 and left outside the facility's front entrance unattended from 2:12 PM to 3:50 PM on [DATE], at which time they were brought back in by a visitor. A statement in the investigation from Licensed Practical Nurse #10 documented that the resident repeatedly asked to go outside and Certified Nurse Aide #7 offered to take them. Licensed Practical Nurse #10 ' s statement documented that they expected Certified Nurse Aide #7 and Resident #40 to remain outside together but did not see Certified Nurse Aide #7 again because it was the end of the shift. The statement from Certified Nurse Aide #7 documented that they thought there was an activity happening because there were multiple people outside at the time. The resident was assessed upon entrance back into the facility by a Registered Nurse and was found to have no psychological or physical harm.
During an interview on [DATE] at 3:35 PM, Certified Nurse Aide #7 stated that they were asked to bring Resident #40 outside because they expressed interest in getting some fresh air. Certified Nurse Aide #7 stated that upon bringing the resident outside, they noticed a large group of residents gathered and assumed that there was a group activity going on and left the resident with the group, but Certified Nurse Aide #7 did not confirm with any staff present. Certified Nurse Aide #7 stated that they would never have left the resident alone if they knew that there was no activity being done.
During an interview on [DATE] at 10:25 AM, Registered Nurse #3 stated that they remembered the incident. Registered Nurse #3 stated that Certified Nurse Aide #7 was very good at taking care of the residents. Registered Nurse #3 stated that they believed it was a misunderstanding of the circumstances and that Certified Nurse Aide #7 would have never left the resident outside alone if they knew that there was no activity being done. Registered Nurse #3 stated that they have never had any issues with Certified Nurse Aide #7 regarding providing resident care.
During an interview on [DATE] at 11:30 AM, Director of Nursing #1 stated that they were the director at the time of the incident and did remember the incident. Director of Nursing #1 stated that it was the weekend, and a Licensed Practical Nurse asked Certified Nurse Aide #7 to bring Resident #40 outside and the resident was left with a group of residents who were already outside. They stated the Certified Nurse Aide misunderstood and thought there was an activity being performed and left the resident with the group. Director of Nursing #1 stated another resident's family member brought the resident back inside, after they realized the family were outside alone. They stated that the resident was assessed for injuries and none were found. They stated the Certified Nurse Aide #7 was disciplined and reeducated on the policies for taking a resident outside of the facility. Director of Nursing #1 stated there was facility-wide education on the policies of signing residents in and out of the floor, resident head count, wandering and eloping.
Resident #44
Resident #44 was admitted to the facility with left-sided hemiplegia and hemiparesis following cerebral infarct (paralysis and inability to use extremities due to symptoms from having a stroke); chronic respiratory failure with hypoxia (a condition where the lungs struggle to provide enough oxygen to the blood, leading to low oxygen levels in the body); and chronic congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively to meet the body's needs). The Minimum Data Set, dated [DATE], documented that the resident could be understood, usually understand others and had intact cognition for daily living decisions.
During an observation on [DATE] at 12:07 PM, Resident #44 had a medication canister ointment on their bedside table. The label for the medication read MICONAZOLE 1:1:1 OINT, and had an expiration date of [DATE].
During an interview on [DATE] at 12:07 PM, Resident #44 stated that the ointment had been there for quite some time and the nurses applied it to their left buttock area twice a day for a healed bed sore. They stated the nurses left the ointment on the table in their room. They stated that they had used the ointment that morning.
During an interview on [DATE] at 12:33 PM, Registered Nurse #2 was shown the photograph of the medication and stated that it should not have been left at the resident ' s bedside. Registered Nurse #2 stated that the nurse most likely used the medication and forgot to put it away. When informed that Resident #44 stated the medication was always left in their room, Registered Nurse #2 stated that that was probably true, as Resident #44 was alert and oriented When shown the expiration date on the ointment, Registered Nurse #2 stated that it should not have been used. They stated that the resident was approved to self-medicate some medications, but the cream was not one of the medications Resident #44 was approved to self-administer.
During an interview on [DATE] at 2:40 PM, Licensed Practical Nurse #7 was shown the photograph of the medication and stated that it should not have been left at the resident ' s bedside. Licensed Practical Nurse #7 stated that the medication should have been locked up in the medication cabinet. Licensed Practical Nurse #7 stated that since it had expired, it should have been discarded. Licensed Practical Nurse #7 stated that the Resident #44 had a new prescription filled for the ointment medication recently. Licensed Practical Nurse #7 stated that they had seen multiple instances where medications were left at the bedside from the overnight shift, and Licensed Practical Nurse #7 would collect the medications and place them back in the medication cart.
Resident #358
Resident #358 was admitted to the facility with the diagnoses of dementia, chronic kidney disease (kidney dysfunction that does not improve), and Crohn ' s disease (an inflammatory bowel disease causing bloody stool and diarrhea). The Minimum Data Set, dated [DATE], documented the resident was understood and could usually understand others, with severe cognitive impairment. The Minimum Data Set also documented Resident #358 had wandered, wandered at significant risk to themselves, and that the wandering significantly intruded on the privacy and activities of others.
The admission assessment dated [DATE] documented the resident was at high risk for elopement and that the high-risk elopement care plan and wander bracelet needed to be initiated.
The Comprehensive Care Plan for cognitive loss/dementia, wandering related to the diagnosis of dementia, created [DATE], last updated on [DATE], documented the long-term goal was Resident #358 would wander safely within specified boundaries and remain free from injury/harm.
The approaches dated [DATE], included equip resident with a device that alarms when resident wanders and check for proper functioning per facility protocol.
The approaches dated [DATE], documented 30-minute supervisory checks, and diversional activities.
The approaches dated [DATE], documented have door slightly open at night, keep bathroom light on, and place sign outside of resident ' s door to help identify their room.
The evaluation notes dated [DATE], documented Resident #358 utilized a wander guard on their left ankle and right wrist for their safety. The resident continued to desire to find their spouse and was ambulatory throughout the unit.
The Comprehensive Care Plan for behavioral symptoms, risk for elopement related to cognitive impairment with independent ambulation, and known wandering tendencies, created [DATE], last updated [DATE], documented the long-term goals of Resident #358 were that they would not wander out of the facility or off the unit without supervision at any time, Resident #358 would remain safely engaged in activity focused care and have meaningful interventions without making attempts to elope from facility.
The approaches dated [DATE], documented determine peak hours of wandering and provide increased supervision during those periods, check wander guard placement minimally every shift, and check functionality of bracelet daily.
The approaches dated [DATE] documented 15-minute visual checks to ensure resident was in a safe location and additional wander guard was applied to resident ' s right wrist due to elopement on [DATE].
A physician ' s order dated [DATE], documented the placement of a wander guard on the resident ' s left ankle. The wander guard number documented was 996 and had an expiration date of 08/2025.
A physician ' s order dated [DATE], documented the placement of a wander guard on the resident ' s left ankle. The wander guard number documented was 1262 and had an expiration date of 04/2026.
A physician ' s order dated [DATE], documented the placement of a wander guard on the resident ' s right wrist. The wander guard number documented was 996 and had an expiration date of 08/2025.
A physician ' s order dated [DATE], documented to visualize wander guard on resident then utilize secure care tester to ensure wander guard functioning. Left ankle and right wrist once a day.
On [DATE] at 5:45 PM, Resident #358 eloped from Unit 1 to the main lobby of Memorial Campus, a building adjoined by hallways to the nursing home facility. Facility report documentation from the incident documented Resident #358 was looking for their family, had wandered off the unit without triggering the alarm system, was found by a security guard in the main lobby of the adjoined building, and after they were identified as a facility resident, they were returned to the unit by staff.
During an interview on [DATE] at 11:54 AM, Unit Coordinator #1 stated they were not there when the elopement happened but heard about it. Unit Coordinator #1 stated that new doors were installed on the 1st floor after the incident. Additionally, they had a wand on the floor that they used to check the wander guards ' functionality every day. Maintenance checked them too. Registered Nurse #1 joined the conversation and stated that elopement risk assessments were completed by a Registered Nurse upon admission, aides did 15-minute safety checks on high-risk residents, Licensed Practical Nurses helped keep an eye on residents that wandered, and there was a lead Registered Nurse usually posted near the door. If a resident had a wander guard, everyone on the unit was made aware of it and there was a book with each resident's information and picture so that everyone could identify the residents. Registered Nurse #1 stated that a house-wide education was done after the event.
During an interview on [DATE] at 3:24 PM, Engineering Supervisor #1 stated that maintenance staff checked the exit door operation of the elopement prevention system utilizing an activated bracelet and verified that the exit door elopement prevention engaged and alarmed.
During an interview on [DATE] at 3:247PM, Director of Nursing #1 stated that the night shift (e.g., third shift) staff checked the bracelet function of the elopement prevention system utilizing a hand-held device to verify that the bracelet was activated.
During an interview on [DATE] at 9:18 AM, Director of Nursing #1 stated that staff had seen Resident #358 roughly 15 minutes before they got off the unit. Director of Nursing #1 stated that it happened and it had not happened since. Once the incident occurred, the facility adjusted the alarm system, educated the staff, and double alarmed Resident #358. Director of Nursing #1 stated it was a tough case because the resident was completely independent and was always trying to get to their family.
10 New York Codes, Rules and Regulations 483.25(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated survey (Case #NY00358788), the facility did not ensure residents received appropriate care and treatment in accordance with professional standards of practice to maintain or improve their physical, mental, and psychosocial well-being for 1 (one) (Resident #359) of 1 (one) resident reviewed. Specifically, for Resident #359, Licensed Practical Nurse #2 did not notify the facility health care practitioner after the resident had a mental status change and became resistant to care during a physician ordered health care procedure on 10/25/2024. Furthermore, a Registered Nurse did not document or assess Resident #359 when a procedure was ordered and mental status change occurred. There was no documented evidence that a Registered Nurse completed a follow up assessment during an ordered procedure that required assessment, nor that a report was given to the oncoming Registered Nurse prior to outgoing Registered Nurse leaving the facility at the end of their shift. The facility did not monitor resident responses to the intervention of the health care procedure or recognize or assess the risk factors placing the resident at risk for psychosocial harm.
This is evidenced by:
Cross reference with F-610, F-726
A review of the policy titled, Change in Condition dated 2/2020 documented that the attending physician would be notified immediately as indicated by the significance of the change and need for medical intervention.
Resident #359
Resident #359 was admitted to the facility with diagnoses of status post spinal surgery for a pathological compression fracture (a broken bone caused by underlying disease), diabetes mellitus (a disorder where the body does not produce enough insulin and the person has consistently high blood sugar), and morbid obesity (too much body fat which increases the risk of health problems). The Minimum Data Set (an assessment tool) dated 10/25/2024, documented the resident could be understood, was able to understand others and was cognitively intact to make daily decisions.
Review of a facility reported incident (Case # NY00358788) received by the New York State Department of Health on 10/29/2025 documented the following intake: On 10/28/2025, Resident #359 voiced concerns to Registered Nurse #1 regarding interactions with staff on date of their readmission from the hospital on [DATE]. Per the resident, five (5) staff members held them down while inserting a catheter. Upon review of nursing notes, resident did have catheter insertion due to bladder scan which revealed 804 cubic centimeters (equivalent to millimeters). Review of 24-hour office report, staff had documented kicking and screaming during foley insertion. The facility's immediate response and plan to prevent recurrence, including any change in policy / procedure and action taken in regard to staff included the social worker to interview the resident to determine resident psychological impact, and two (2) caregivers to be present at all times during care pending outcome of investigation.
A review of the facility investigation report dated 10/28/2024 at 8:30 AM, documented that Resident #359 had returned from the hospital on [DATE] and had an episode of apnea and was unresponsive, physician was notified. A bladder scan was ordered, with placement of a foley catheter if the residual was over 400 milliliters. The resident was intermittently confused and resistive when staff attempted to catheterize them. Resident #359 ' s change of mentation was not reported to the physician to determine if the staff should have attempted further care or if different treatment was necessary. No documentation of the catheterization incident had been completed by Licensed Practical Nurse #2 or Registered Nurse Supervisor #1 until after the resident reported abuse by staff on 10/28/2025.
A review of personal written statement by Certified Nurse Aide #2, located within the facility investigation report dated 10/28/2024, documented that at about 10:00 PM on 10/25/2025, Licensed Practical Nurse #2 asked them to help hold Resident #359 ' s legs so they could insert a catheter. They said yes, went to the room, let the resident know what they were doing; Resident # 359 was very tired still and stated that. Upon trying to complete the catheterization, Resident #359 kicked a few times so they went to get help, and three (3) additional staff came in. Two (2) staff were holding the resident ' s left leg, and two (2) staff (they believe) were holding the resident ' s right leg, while Licensed Practical Nurse #2 was attempting to insert the catheter. Certified Nurse Aide #2 documented that when Licensed Practical Nurse #2 couldn ' t insert the catheter, Licensed Practical Nurse #3 stepped in to help and successfully completed the health care procedure.
A review of personal written statement by Social Worker #1, located within the facility investigation report dated 10/28/2024, documented that Social Worker #1 interviewed Resident #359 on 10/28/2024 at 8:26 AM regarding the resident ' s report. Social Worker #1 wrote that Resident #359 stated the following about the incident: they were ' assaulted by five (5) nursing staff when they told them they were going to put the catheter in and Resident #359 said no because their body just had it; ' that they asked to be woken up and placed on a bed pan; that the staff held Resident #359 down and forcibly put the catheter in; that Resident #359 was ' screaming ' for Registered Nurse Supervisor #1; that there were at least five (5) staff in the room; that Resident #359 was screaming and kicking when a staff member stated ' oh my god you need to stop; ' that Resident #359 felt that ' it was so traumatic, violently because the resident was trying to kick; it was bringing up a lot of childhood trauma; ' that the resident stated ' they could have sat me down and explained--there were so many alternatives that could have happened. ' Social Worker #1 documented that during the incident, when asked where each of the staff were standing and doing, Resident #359 stated that each staffer held a limb and one (1) was leaning over their mid section.
A nursing progress note dated 10/25/2024 at 8:40 PM, written by Registered Nurse Supervisor #1 documented Resident #359 was readmitted today. Had 10 to 15 seconds of apnea with snoring respirations. Vital signs: Temperature 98.7, Pulse 106, Respirations 22, Oxygen saturation 96 percent on room air. Oxygen dropped to 92 percent with apnea. Lungs diminished throughout, oxygen at 2 liters via nasal canula placed on resident due to apnea. Pale in color. Apical Pulse regular but tachycardic (fast heartbeat), blood sugar 110. Physician made aware and order obtained to send to emergency room. Emergency Medical Services notified.
A nursing progress note dated 10/25/2024 at 9:31 PM, written by Registered Nurse Supervisor #1 documented Resident #359 became responsive when Emergency Medical Services arrived. Answering questions appropriately. Still mumbling words. Resident refused medical transport to emergency room even though medical emergency services recommended. Physician made aware of refusal.
A nursing progress note dated 10/25/2024 at 10:19 PM, written by Licensed Practical Nurse #2 documented the resident confused this evening. Refused 9:00 PM medications. Registered Nurse Supervisor #1 administered intravenous medication and resident was not responsive. Vital signs: Temperature 98.7, Pulse 106, Respirations 22, Oxygen saturation 96 percent on room air. Frequent apnea. Physician okayed to sending resident to emergency room. Ambulance arrived and resident decided stay in nursing home; vital signs became stable. Physician ordered bladder scan with anything over 400 milliliters insert foley. Result was 804 millimeters of urine retained. Urine for culture obtained. Resident in bed. Continue plan of care.
There was no documented evidence that the physician was notified of the results from catheterization.
A nursing progress note dated 10/26/2024 at 6:30 AM written by Licensed Practical Nurse #3 documented Resident #359 alert with confusion. Resident had been sleeping in short to moderated intervals. Woke up yelling and confused unaware of where they were. Redirected. No complaints of pain offered Foley catheter output was 1250 milliliters.
There was no documented evidence that the Resident #359 was assessed by a Registered Nurse, or physician notified regarding resident ' s confusion.
A physician order dated 10/28/2024, documented Foley catheter to straight drainage #18 French catheter related to a diagnosis of obstructive uropathy. Special instructions: Change monthly and as needed. There was no documented evidence of physician ' s order for bladder scan or foley on 10/25/2024.
Review of nursing progress notes from 10/25/2024 through 10/31/2025 did not document notification to the physician of difficulty with the ordered catheterization (placement of an indwelling catheter to eliminate urine from the bladder) or continued mental status changes that began on 10/25/2024 when the resident returned to the facility from a hospitalization. There was no documented evidence of vital signs after the procedure on 10/25/2024 through 10/26/2024. No Registered Nurse assessment or addition of a comprehensive care plan for urinary retention was found from 10/25/2024 through 10/26/2024. A comprehensive care plan for mental status changes was not added to the resident ' s care with goals and interventions until 10/28/2025 after abuse allegations were made by Resident #359.
A review of the corrective action report dated 10/28/2024 conducted by Director of Nursing #1 documented that all five (5) staff involved in the catheterization of Resident #359 were educated on the proper way to perform a procedure if a resident was confused or refusing care. It was further noted that the Health Care Provider was never notified of Resident #359 ' s change in mentation after the physician ordered a bladder scan and insertion of the foley catheter. It was also noted that when the resident initially refused the procedure, the physician should have been notified of the difficulty so other options could have been discussed. The Registered Nurse Supervisor #1 should have been notified, and Resident #359 should have been assessed.
During a telephone interview on 5/27/2025 at 2:25 PM, Licensed Practical Nurse #3 stated they had catheterized Resident #359 when they arrived for the night shift. The resident was yelling and another nurse asked for assistance. Licensed Practical Nurse #3 stated they went to help because Licensed Practical Nurse #2 was unable to perform the insertion. Licensed Practical Nurse #3 stated they had not reviewed the order, and staff was trying to calm the resident, so Licensed Practical Nurse #3 took over and inserted the catheter without questioning what had taken place. The resident calmed after the foley was inserted. Licensed Practical Nurse #3 stated they were not aware if the physician was called or if any vital signs were completed after the catheter was inserted. Licensed Practical Nurse #3 stated the Registered Nurse Supervisor #1 had not returned to the floor and no further assessment was done by the Registered Nurse Supervisor that relieved them. Licensed Practical Nurse #3 stated staff was educated after the incident regarding policy and protocol that was not followed and care and treatment should not have been delivered the way it was. Professional standards of care had not been followed. A review of any order should be done before doing a procedure or administration of medication. If a resident was resistive to care or had mental status change, the physician should be notified before proceeding. The resident continued to be confused throughout the rest of the night. The physician was not notified that Licensed Practical Nurse #3 was aware of.
During a telephone interview on 5/27/2025 at 1:35 PM, Registered Nurse Supervisor #1 stated they were notified Resident #359 had returned from the hospital on [DATE], had a period of apnea, and was unresponsive. After responding to the unit staff, 911 was called and the physician was notified. When Emergency Medical Services arrived, the resident was assessed and because they had become responsive by the time Emergency Medical Services arrived, Resident #359 had refused to go back to the hospital. The physician was notified of the resident ' s refusal, and an order was obtained to bladder scan the resident and catheterize them if urine residual was greater than 400 milliliters. Registered Nurse Supervisor #1 stated that Licensed Practical Nurse #2 was assigned to the resident and was going to perform the catheterization. The resident was stable when Registered Nurse Supervisor #1 left the unit, and they were not aware of anything that had happened until the following day when they returned to the facility. The Registered Nurse Supervisor #1 stated Licensed Practical Nurses could not assess and when any change in condition occurred in a resident, they needed to notify the Registered Nurse on duty. Registered Nurse Supervisor #1 stated they were the only Registered Nurse in the building on evenings but had not checked back on the resident ' s condition prior to leaving for the night. They were unaware if any further vital signs were completed, or if any documentation had been placed on the 24-hour report about the resident ' s episode, refusal to go to the hospital, or the events surrounding Resident #359 ' s change in condition and subsequent catheterization. Registered Nurse Supervisor #1 stated they also did not give a shift report to the oncoming nurse and stated that they couldn ' t remember if there was an oncoming nurse at the time.
During an interview on 5/21/2025 at 2:52 PM, Registered Nurse #1 stated Resident #359 reported an accusation of verbal and physical abuse on 10/28/2024 when Registered Nurse #1 went in their room to perform a procedure. Registered Nurse #1 stated they notified Director of Nursing #1 and the Social Worker on 10/28/2025, and an investigation was started. They further stated that it was determined that no abuse occurred, however, the handling of the insertion of the catheter was not done per policy. If a resident was confused and refusing care, staff should have stopped and called the physician and the Registered Nurse on duty. That was not done. Registered Nurse Supervisor #1 did not notify the physician and did not return to the unit to ensure Resident #359 had been successfully catheterized. They stated no documentation was found on the 24-hour report. Registered Nurse #1 stated they were unaware there had been a concern with Resident #359 until they were told by the resident on 10/28/2024 at 7:30 AM. No evidence or documentation could be produced that Licensed Practical Nurse #2 had documented the events that occurred on 10/25/2024, or that the physician was contacted to report the difficulty that had occurred with the resident. They stated that staff were reeducated on proper ways to care for residents who were resistive to care and confused.
During a telephone interview on 5/27/2025 at 12:45 PM, Medical Director #1 stated that they were notified on 10/25/2024 that Resident #359 was having an episode of unresponsiveness. The physician told the staff to send them out to the hospital. Staff contacted Emergency Medical Services to take the resident to the hospital. Medical Director #1 stated that after they were originally notified, staff called again, and stated the resident had become alert and had refused to go back to the hospital. Because the resident had just returned to the facility that day, and there was concern that the hospital had removed their foley prior to returning Resident #359 to the facility, the physician ordered a bladder scan to be done and if the results of the bladder scan was greater than 400 millimeters of residual urine, the staff would insert a foley catheter. The results of the bladder scan demonstrated Resident #359 had greater than 850 milliliters of urine and needed to be catheterized. The staff did not call the physician to inform them of the results of the bladder scan, the subsequent insertion of the foley catheter, or the difficulty the staff and resident experienced to carry out the order. Medical Director #1 stated that they did not receive notification of the resident ' s condition until 10/28/2024, 72 hours later when Director of Nursing #1 made them aware of the complications that had occurred. Medical Director #1 stated that the staff should have called and advised them of what had gone on. Registered Nurse Supervisor #1 should have reassessed the resident at the time and discussed the situation with them, so they could have collaboratively decided what would have been the best way to proceed with Resident #359 care and further interventions.
During an interview on 5/22/2025 at 10:46 AM, Physician Assistant #1 stated they were notified on 10/28/2025 by Director of Nursing #1 of the allegation of abuse made by Resident #359. Physician Assistant #1 stated that resident was very sick and had experienced mental status changes on the day they returned from the hospital. When Physician Assistant #1 interviewed the resident, they did not remember the events of the day. Physician Assistant #1 stated that the physician should have been notified, and further assessment should have been completed when the resident was refusing to be catheterized. They stated that closer monitoring should have been done with vital signs and behavior monitoring over the weekend, so the provider could have made sure that the care and treatment for the resident could have been adjusted if it was required.
During an interview on 5/23/2025 at 3:00 PM, Director of Nursing #1 stated Registered Nurse Supervisor #1 had not reported any issue with Resident #359 and should have checked with the Licensed Practical Nurses prior to leaving for the night, given the fact the resident had an episode of unresponsiveness and mental status change. Director of Nursing #1 stated that a Registered Nurse was the only person that could assess residents, and Registered Nurse Supervisor #1 should have followed up or reported off to the oncoming Registered Nurse any concerns that occurred, especially with a resident who had been readmitted . Director of Nursing #1 stated that staff should have been in contact with the Registered Nurse #1 and the health care Provider throughout the whole event on 10/25/2024, given the difficulty during catheterization The allegation of abuse was unfounded, but all staff were reeducated on the policy of notifying the physician when a resident became resistive to care or confused or had any change of condition. They stated the situation was not handled per policy and the Registered Nurse, and the other staff did not follow professional standards of care.
Multiple attempts (from 5/22/2025 to 5/28/2025) to interview Licensed Practical Nurse #2 were unsuccessful.
10 New York Codes and Rules and Regulations 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification and abbreviated survey (Case #s NY00343349, NY00344172, NY00345225, and NY00379263), the facility did not ensure the resident's right to be free from abuse and neglect for three (3) (Resident #s 40, 44, and 53) of eight (8) residents reviewed for abuse and neglect. Specifically, (a.) on 6/02/2024, Resident #40 was left unattended outside of the facility by Certified Nurse Aide #7 for an extended period of time; (b.) on 6/12/2024, Certified Nurse Aide #8 did not follow Resident #44's care plan to use a mechanical lift which resulted in an injury to the residents foot; (c) on 5/27/2025, Certified Nurse Aides #'s 5 and 6 did not provide personal care to Resident #53 the way the resident preferred, causing Resident #53 to fight against the care, sustaining a bruise to their hand.
This is evidenced by:
The facility policy titled, 'Resident Abuse Prevention,' dated 5/2023, documented that the purpose was to provide residents, families, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution. The policy documented that the facility shall identify, correct, and intervene in situations in which abuse, neglect, mistreatment, or misappropriation of property may be more likely to occur. Procedures documented included, but were not limited to, supervision of staff shall include identification of inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, or directing residents in need of toileting to urinate or defecate in their beds or briefs, and counseled when performance is not acceptable.
Resident #40
Resident #40 was admitted to the facility with Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), dementia with behavior disturbances (behavioral and psychological symptoms that accompany dementia, affecting a significant portion of those living with the condition), and hypertension (a condition where the force of your blood against the walls of your arteries is too high). The Minimum Data Set, dated [DATE], documented that Resident #40 usually made themselves understood, sometimes understand others, and had severe cognitive impairment.
The Comprehensive Care Plan, dated 11/20/2023, documented that the resident was at risk for elopement related to impaired cognition and verbalized their desire to leave the facility. Resident #40 had cognitive impairment with poor decision-making skills and/or pertinent diagnoses such as dementia and Alzheimer's. The Comprehensive Care Plan documented the following interventions implemented on 6/03/2024 for safety awareness: the resident would not be left unsupervised when off the unit, including when outside of the building.
The facility's Investigative Report dated 6/05/2024 documented that Resident #40 was brought outside by Certified Nurse Aide #7 and was left outside the facility's front entrance unattended from 2:12 PM to 3:50 PM on 6/02/2024, at which time they were brought back in by a visitor. A statement in the investigation from Licensed Practical Nurse #10 documented that the resident repeatedly asked to go outside and Certified Nurse Aide #7 offered to take them. Licensed Practical Nurse #10's statement documented that they expected them to remain outside together, but did not see t Certified Nurse Aide #7 again because it was the end of the shift. The statement from Certified Nurse Aide #7 documented that they thought there was an activity happening because there were multiple people outside at the time. The resident was assessed upon entrance back into the facility by a Registered Nurse and was found to have no psychological or physical harm.
During an interview on 5/22/2025 at 3:35 PM, Certified Nurse Aide #7 stated that they were asked to bring Resident #40 outside as they expressed interest in getting some fresh air. They stated that upon bringing the resident outside, they noticed a large group of residents and assumed that there was a group activity going on, and left the resident with the group. Certified Nurse Aide #7 stated that they would never have left the resident alone if they knew that there was no activity being done.
During an interview on 5/23/2025 at 10:25 AM, Registered Nurse #3 stated that they remembered the incident. They stated that Certified Nurse Aide #7 was very good at taking care of the residents. They stated that they believed it was a misunderstanding of the circumstances and that they would have never left the resident outside alone if they knew that there was no activity being done. They stated that they have never had any issues with Certified Nurse Aide #7 in providing resident care.
During an interview on 5/23/2025 at 11:30 AM, Director of Nursing #1 stated that they were the director at the time of the incident and did remember the incident. They stated that it was the weekend, and a Licensed Practical Nurse # 10 asked Certified Nurse Aide #7 to bring the resident outside and the resident was left with a group of residents who were already outside. They stated the Certified Nurse Aide #7 misunderstood that there was an activity being performed and left the resident with the group. They stated another resident's family member brought the resident back inside, realizing they were outside alone. They stated that the resident was assessed for injuries, and none were found. They stated the Certified Nurse Aide was disciplined and reeducated on the policies for taking a resident outside of the facility. Director of Nursing #1 stated there was facility-wide education on the policies of signing residents in and out of the floor, resident head count, and wandering and eloping.
Resident #44
Resident #44 was admitted to the facility with left-sided hemiplegia and hemiparesis following cerebral infarct (paralysis and inability to use extremities due to symptoms from having a stroke), chronic respiratory failure with hypoxia (a condition where the lungs struggle to provide enough oxygen to the blood, leading to low oxygen levels in the body); and chronic congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively to meet the body's needs). The Minimum Data Set, dated [DATE], documented that the resident could be understood, usually understand others, and had intact cognition for daily living decisions.
A review of progress notes dated 6/13/2024 at 9:25 AM, documented Registered Nurse #2 witnessed the resident sitting on the edge of their bed, eating breakfast, complaining of pain in their left ankle/foot. They documented that the resident's foot was red, warm, and swollen. They also documented a bruise on the outside of their foot from mid-foot to heel. Registered Nurse #2 documented that the Medical Director #1 ordered an X-ray for the resident.
A review of the Facility Reported Incident dated 6/17/2024, documented that the resident was injured when Certified Nurse Aide #8, who was caring for them, did not use the required mechanical lift as directed in the resident's care plan and care card.
During an interview on 5/19/2025 at 12:07 PM, Resident #40 stated that they remembered the incident and stated that the Certified Nurse Aide who took care of them did not use the mechanical lift they were supposed to, and their foot got caught under the bed. They stated they only had the Certified Nurse Aide a couple of times and that they never used the lift, but all the other aides did.
During an interview on 5/21/2025 at 11:45 AM, Registered Nurse #2 stated that they remembered the incident. They stated Certified Nurse Aide #8 did not use the lift when they transferred Resident #44 into bed. They stated that the resident's care card documented to use an Mechanical-1 lift device when transferring the resident. They stated that during the facility incident investigation, Certified Nurse Aide #8 admitted that they did not follow the resident's care card and transferred the resident by themselves. The Certified Nurse Aide thought they were able to transfer the resident by themselves and did not get the lift. Registered Nurse #2 stated that the aide was terminated that day for not following the care card, which resulted in injury to the resident. Registered Nurse #2 stated they interviewed other residents regarding the Certified Nurse Aide and there were no other reports made that the staff were not using the appropriate devices for transferring. They stated that care plans should reflect the resident's needs.
During an interview on 5/23/2025 at 11:30 AM, Director of Nursing #1 stated that they were the director at the time of the incident and did remember the incident. They stated the Certified Nurse Aide at the time of care did not follow the care card for the resident, which resulted in injury. They stated that the Certified Nurse Aide was from an agency and was terminated from employment after the incident due to not following the resident's care plan. They stated that there was no facility-wide education as there were no other incidents, and the Certified Nurse Aide was terminated that same day.
Resident #53
Resident #53 was admitted to the facility with the diagnoses of hypertensive heart disease (high blood pressure), chronic kidney disease with heart failure (chronic kidney damage due to uncontrolled high blood pressure), and type 2 diabetes mellitus (an endocrine dysfunction causing issues with insulin production). The Minimum Data Set, dated [DATE], documented that the resident could usually be understood, usually understand others, and was slightly cognitively compromised.
The Comprehensive Care Plan for behaviors initiated 10/09/2023 documented that the resident had socially inappropriate/disruptive behavioral symptoms as evidenced by yelling at staff and refusal of medications/treatments. Approaches documented included allowing the resident to have control over situations, if possible.
An evaluation note dated 5/28/2024, documented the incident with Certified Nurse Aides #5 and #6, and that Resident #53 would see psychology and social work for several weeks, but was not showing negative psychological signs from the event.
The Facility Investigation dated 5/27/2024 documented Resident #53 reported that Certified Nurse Aide #5 and Certified Nurse Aide #6 did not provide personal care to Resident #53 the way the resident preferred, which caused Resident #53 to fight against the care, and sustained a bruise to their hand. Resident #53 stated that the Certified Nurse Aides flipped the resident around in the bed and shoved them. Both Certified Nurse Aides were suspended while the investigation was performed. Follow up to the investigation documented that the Certified Nurse Aides had not given Resident #53 their evening care in the manner they preferred. This caused the resident to act out/fight during care and the resident hit their hand on the side rail.
During an interview on 5/22/2025 at 10:45 AM, Certified Nurse Aide #3 stated that if a new injury was discovered, they would tell the Licensed Practical Nurse or Registered Nurse on the unit. They were supposed to look at the injury, write statements, assess the injury, and determine how it happened. Certified Nurse Aide #3 stated they would report any abuse or mistreatment they saw or heard about.
During an interview on 5/27/2025 at 9:18 AM, Director of Nursing #1 stated that the Resident #53 was very particular about their care and was very verbally abusive with the staff at times. Certified Nurse Aides #s 5 and 6 were spoken to about the incident when it occurred. Director of Nursing #1 stated that they had not heard of Resident #53 having any problems for a while, so they believed the resident was settling in and things were good.
10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on record review and interview during the recertification survey dated 8/3/2022 through 8/9/2022, the facility did not ensure it developed a policy and procedure for the medication regimen review (MRR) that included timeframes for the different steps in the process. Specifically, the facility's Drug Regimen Review policy did not include timeframes for the physician and/or facility staff to complete the review of reported irregularities requiring immediate or urgent action that were identified by the consultant pharmacist. This is evidenced by:
The Policy and Procedure (P&P) titled Consultant Pharmacist Drug Regimen Review dated 2/18, documented when the consultant pharmacist identified an irregularity that required immediate or urgent action, the pharmacist would notify the physician and/or the Director of Nursing (DON) or designee at the time the irregularity was identified. The P&P did not include timeframes for the physician and/or facility staff to complete the review of reported irregularities requiring immediate or urgent action that were identified by the consultant pharmacist.
During an interview on 8/09/2022 at 11:12 AM, the DON stated all pharmacy recommendations were discussed with the medical providers. The DON did not know why a timeframe for action by the medical provider was not included in the policy and procedure.
10 NYCRR 415.18 (c)(2)

Based on observation, record review, and interviews during a recertification survey dated 08/03/2022 through 08/09/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for 5 (Resident #'s 9, 43, 71, 74, and #83) of 24 residents reviewed. Specifically, for Resident #9, whose primary language is Spanish and whose English proficiency is limited, the facility did not ensure their comprehensive care plan included a plan for the resident to communicate effectively, for Resident #43, the facility did not ensure the CCP for a suprapubic catheter included monthly changes of the suprapubic catheter with the use of Diazepam and did not ensure the CCP for mood included personalized interventions, for Resident #71, the facility did not ensure the CCP included a care plan to address the routine care and maintenance of the resident's enteral feeding tube, for Resident #74, the facility did not ensure that the resident's dialysis care plan was updated to reflect the monitoring needs of their current dialysis access site and for Resident #83, the facility did not ensure the CCP for Mood state included personalized interventions for their diagnoses of anxiety and depression.
This was evidenced by:
The policy & procedure titled Care Planning and Care Conference and dated 1/2019 documented, the interdisciplinary plan of care included: identified needs, strengths, and problems of the resident; identified goals that are realistic and measurable; the interdisciplinary team (IDT) reviews the initial/revised care plan and makes changes as necessary; care plans are reviewed by IDT to ensure that it reflects the resident's individual needs.
The policy and procedure (P&P) title Language/Communication Assistance last revised 6/2020 documented the facility is committed to provide appropriate communication assistance to all patients and residents with limited English proficiency and/or limited communication proficiency/communication differences. The facility will provide a variety of assistive modalities that are available to all staff to utilize in order to provide accurate and increased communication assistance and effectiveness.
Resident #9:
Resident #9, was admitted to the facility with diagnoses of hypertension, diabetes mellitus, and depression. The Minimum Data Set (MDS- an assessment tool) dated 5/9/2022 documented the resident was cognitively intact, could usually understand others and could usually make self-understood.
The comprehensive care plan (CCP) did not include a care plan to address the communication needs of the resident whose primary language is Spanish and whose English proficiency is limited.
On 8/3/2022 at 11:04 AM, Resident #9 declined an interview stating No English, No English.
On 8/8/2022 at 10:28 AM, Certified Nurse Assistant (CNA) #2 said it was hard to communicate with Resident #9 because they did not understand Spanish. CNA #2 stated there were some staff members who understood and were able to translate but they were not always available. CNA #2 stated they were not aware of how to access translator services.
On 8/8/2022 at 11:31 AM, Activities Aide (AA) #1 said live face to face translator services were downloaded to the units iPad. The iPad was stored in the observation room on the unit and was available to all staff and residents as needed. The nursing supervisor would have the key to access the room on the off shifts. AA #1 stated the instructions about how to access to the translator services using the iPad should be listed in the resident's care plan.
On 8/8/2022 at 11:49 AM, Licensed Practical Nurse (LPN) #3 stated they were aware that there were translator services available at the facility but did not know how to access them. LPN #3 said they could usually figure out what the resident needed or would find another staff member to translate.
On 8/8/2022 at 12:17 PM, Registered Nurse Unit Manager (RNUM) #2 stated there was not a communication care plan for Resident #9 whose primary language is Spanish. The care plan should include specific interventions to improve communication such as how to access translator services and use of a picture board. RNUM #2 said they were responsible to ensure the care plan was initiated.
On 8/8/2022 at 2:51 PM, Social Worker (SW) #1 stated there is a communication line and a user-friendly iPad on wheels that staff use to assist residents communicate when English is not their primary language. SW #1 said a care plan to address the resident's communication needs should have been initiated upon admission, within 48 hours and then revised as needed.
On 8/9/2022 at 10:32 AM, the Director of Nursing (DON) stated Resident #9 was able to communicate their needs and had also used the translator services on their own cell phone. However, a care plan to address their communication needs and specific approaches should have been initiated. The DON said that RNUM #2 initiated a communication care plan dated 8/8/2022.
Resident #43
Resident #43 was admitted to the facility with the diagnoses of neuromuscular dysfunction of bladder, major depressive disorder, and anxiety. The Minimum Data Set (MDS-an assessment tool) dated 06/06/2022 documented the resident could sometimes make self understood or understand others and had severe cognitive impairment.
The comprehensive care plan (CCP) titled Elimination, resident requires a suprapubic catheter dated 12/29/2021. The interventions did not include a monthly catheter change and/or the use of Diazepam with the catheter change.
The CCP titled Mood state, resident has diagnosis of mental health issues specifically, depression and anxiety dated 03/25/2022. There were no personalized interventions documented for staff to utilize when caring for the resident.
The physician order dated 9/27/21 documented Clonazepam (sedative, can treat seizures, panic disorder, and anxiety) 0.25 mg every day at bedtime for anxiety.
The physician order dated 9/27/21 documented Escitalopram (can treat depression and generalized anxiety disorder) 20 mg every day at bedtime for depression.
The physician order dated 9/29/22 documented Diazepam (anxiolytic and sedative) 5mg (milligram)/1 ml (milliliter) intramuscular, every month prior to supra-pubic catheter (catheter is inserted through a hole in your abdomen) and then directly into your bladder) change.
The Nurse Practitioner progress note dated 06/30/2022 documented; resident required Diazepam dosing prior to suprapubic catheter changes every 4 weeks. Major depressive disorder, recurrent and moderate, Escitalopram 20 mg daily. Diagnosis anxiety, received Clonazepam 0.25 mg daily at bedtime.
During an interview on 08/09/2022 at 09:04 AM, the MDS Coordinator (MDSC) stated the care plans are developed by the nurse managers, although sometimes the MDSC does the care plans. When a CAAS (care area assessment summary) are triggered the MDSC would make sure there were care plans for those areas. Most of the care plans are templates and were supposed to be customized to the resident, sometimes they were not customized. The care plan templates were generic and needed to be personalized to the resident. The suprapubic monthly changes and Valium (diazepam) given prior to the change should be in the care plan. The Mood State Care Plan was generic and should have been personalized for the resident.
During an interview on 08/09/2022 at 10:05 AM, the Assistant Director of Nursing (ADON) stated that in morning report while reviewing incident reports they had found the care plans needed to have interventions added.
During an interview on 08/09/2022 at 10:05 AM, the Director of Nursing (DON) stated, we are looking to work with our computer program company to optimize the care plan process. We will be having people come in to do some additional training. The care plan has to flow to the CNA program, and we know we have to look at the interventions so personalized interventions flow to the CNA care plan.
Resident #71
Resident #71 was admitted to the facility with diagnoses of dysphagia (difficullty swallowing), protein calorie malnutrition, and gastrostomy (a surgical opening in the stomach made for the introduction of food). The Minimum Data Set (MDS - an assessment tool) dated 6/27/2022, documented the resident was rarely/never able to make themselves understood or understand others, and was severely cognitively impaired.
The policy and procedure (P&P) titled Enteral Nutrition Tube Feeding, reviewed 8/2021, documented evaluation, assessment, and ongoing care planning by the multidisciplinary team was required for all residents with enteral feeding devices.
Physician orders dated 6/20/2022 documented to cleanse the skin under the gastrostomy tube (G-tube) with normal saline, pat dry, apply bacitracin, and cover with a drainage sponge daily.
The CCP, revised 6/30/2022, did not address the routine care and maintenance of the resident's G-tube.
During an interview on 8/8/2022 at 1:40 PM, Licensed Practical Nurse (LPN) #2 stated that when residents had a G-tube inserted, a care plan would be initiated immediately that provided information regarding the care and maintenance of the tube. They started working at the facility near the beginning of this year, and Resident #71 already had a G-tube in place at that point.
During an interview on 8/9/2022 at 10:15 AM, Registered Nurse (RN) #2 stated that following the placement of a G-tube, residents needed to have a care plan developed that addressed the routine care and maintenance of the tube. Resident #71 had their feeding tube placed a few years ago and did not have a care plan developed addressing the routine care and maintenance of the tube, and should have been developed.
During an interview on 8/9/2022 at 10:42 AM, the Director of Nursing (DON) stated that after placement of any enteral (through the intestine) feeding tube, residents would have a care plan created that addressed the routine care and maintenance of the tube. Resident #71 had a G-tube in place but did not have a care plan developed that addressed the routine care and maintenance of the tube, this should have been created.
10NYCRR 415.11(c)(1)

Based on record review and interviews during a recertification survey from 8/3/2022 - 8/9/2022, the facility did not ensure that a resident who required dialysis received such services, consistent with professional standards of practice, for 1 (Resident #74) of 1 resident reviewed for dialysis. Specifically, for Resident #74, the facility did not ensure that there was ongoing communication from the facility to the dialysis center regarding dialysis care and services and nursing home staff did not provide immediate monitoring and documentation of the status of the resident's access site upon return from dialysis treatment. This is evidenced by:
Resident #74
Resident #74 was admitted with diagnoses of chronic kidney disease, end stage renal disease, and anemia. The Minimum data Set (MDS - an assessment tool) dated 7/4/2022, documented the resident was able to make themselves understood, could understand others, and was cognitively intact. The MDS documented the resident received dialysis.
The policy and procedure (P&P) titled Hemodialysis, reviewed 3/2022, documented to maintain communication with the dialysis facility via telephone, and upon return to the facility, the nurse would review the dialysis communication book for any pertinent information and convey this information to the physician and staff. Monitoring of the hemodialysis access site was performed daily, and any unusual findings would be reported to the physician.
The physician orders did not include orders for monitoring of the resident's dialysis access site.
During a record review from 6/1/2022 - 7/29/2022, the medical record did not include documentation that:
- A nurse consistently inspected the hemodialysis access site in accordance with facility policy. There was no documentation that the resident's dialysis site was being monitored by nursing for bleeding or other complications.
- A consistent record of ongoing communication between the facility and dialysis center had been established. The Dialysis Communication Book contained documentation of pre and post dialysis vital signs and weights while at the dialysis center. On 6/10/2022, there was no documentation from the dialysis facility of the resident's pre-dialysis vital signs and weight, and on 7/20/2022 only one set of vital signs and weight was documented by the dialysis facility. There was no documentation by the facility in the Dialysis Communication Book.
The Dialysis Communication Book did not contain consistent documentation from the nursing home to the dialysis center. Upon return from dialysis, there was no documentation of monitoring of the resident's dialysis access site for bleeding or other complications.
During an interview on 8/8/2022 at 1:50 PM, Licensed Practical Nurse (LPN) #3 stated that facility staff do not document in the dialysis communication book, the only documentation in this book was from the dialysis center. The resident dialysis communication book was kept by the resident, and the staff were responsible for reviewing it when they returned from dialysis. When the dialysis communication book was reviewed, staff did not document this anywhere. The dialysis center received no documented communication from the facility on days when the resident went to dialysis unless they specifically called and requested it.
During an interview on 8/9/2022 at 10:15 AM, Registered Nurse (RN) #2 stated that when residents have a dialysis access site, staff were responsible for visually inspecting the access site for any abnormal presentation, and there would normally be a physician order for this. RN #2 stated that Resident #74 had a non-tunneled dialysis catheter inserted in their right chest in February. The resident's current physician orders were reviewed; there were no orders for monitoring of the dialysis access site, and there was no documentation that the site was being consistently monitored. On dialysis days, RN #2 stated the dialysis communication book was only documented in by the dialysis center, who typically documented the resident's pre and post treatment vital signs, weight, and how they tolerated the treatment. Staff were responsible for reviewing the book when the resident returned to the facility; there was no consistent documentation of this. Staff communicated with the dialysis center via telephone, typically only when they called with a question or a concern. It was common for the resident to have dialysis treatment days where there was no communication between the facility and the dialysis center.
During an interview on 8/9/2022 at 10:43 AM, the Director of Nursing (DON) stated that when residents had a dialysis access device, the access site must be inspected daily and documented in the treatment administration record; this was not done for Resident #74. Staff were responsible for reviewing the dialysis communication book each time the resident returned form dialysis; there was no documentation to support that this was occurring consistently. The dialysis communication book for Resident #74 was reviewed, there was no consistent documentation between the facility and the dialysis center. The DON stated that staff do not communicate with the dialysis center every time the resident goes to dialysis, and there were days where no communication occurred between the two facilities.
10 NYCRR 415.12

Based on observation, record review, and interviews during the recertification survey dated 08/03/22 through 08/09/22, the facility did not ensure food was stored, prepared, distributed, or served food in accordance with professional standards for food service safety in the main kitchen. Food preparation equipment and serving areas are to be kept clean and in good repair, and a test kit is to be available to measure the parts per million (ppm) concentration of the solution used to sanitize equipment. Specifically, four (4) rubber spatulas for cooking had splits and cracks on the edges and were not cleanable; the can opener holders, stove, fire extinguishers, floor under cooking equipment, and floor in corners and next to walls were soiled with food particles or a black build-up; and a test kit to measure the concentration of chemical sanitizer used to manually sanitize food contract equipment was not provided. This is evidenced as follows:
During observations of the main kitchen on 08/03/22 at 9:50 AM, 4 rubber spatulas for cooking had splits and cracks on the edges and were not cleanable; and the can opener holders, stove, fire extinguishers, floor under cooking equipment, and floor in corners and next to walls were soiled with food particles or a black build-up.
During an interview on 08/03/22 at 9:50 AM, the Assistant Director of Food Service presented the test kit the facility utilizes to measure the parts per million (ppm) concentration of the solution used to sanitize equipment.
The test kit label document titled QT-10 Hydrion was printed with an expiration date of 09/15/21; 10 months and 18 days from survey review.
During interviews on 08/03/22 at 10:31 AM and 08/08/22 at 11:12 AM, the Assistant Director of Food Service stated that a new test kit will be purchased, the rubber spatulas have been discarded, and the kitchen will be deep cleaned.
During an interview on 08/08/22 at 3:41 PM, the Director of Nursing stated that the Assistant Food Services Director has been spoken with and is in the process of correcting the items found in the kitchen.
10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.90, 14-1.110, 14-1.112(c), 14-1.170

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during a recertification survey the facility did not ensure each resident who used psychotropic drugs received gradual dose reductions (GDRs) unless clinically contraindicated, in an effort to discontinue the drugs and the documentation did not include adequate indications for the use of psychotropic medications for 3 (Residents (#'s 2, 81, and 91) of 5 residents reviewed for psychotropic medications. Specifically, for Resident #2, the facility did not attempt a gradual dose reduction (GDR) for Xanax (an anti-anxiety medication) twice within the first year after initiation of the psychotropic medication; for Resident #81, the facility did not ensure that the resident's behaviors were monitored and documented to justify an increase in Seroquel (an anti-psychotic medication); for Resident #91, the facility did not ensure that the resident's behaviors were monitored and documented to justify an increase in Risperdal (an antipsychotic medication) and did not attempt a GDR for Lexapro (an anti-depressant medication). This is evidenced by:
The Policy & Procedure (P&P) titled Psychotropic Medications dated 5/2018 documents, Residents who receive psychotropic medications will receive gradual dose reductions and behavioral interventions unless clinically contraindicated with the intention to decrease or discontinue the use of psychotropic medications whenever safe or possible.
Resident #2
The resident was admitted to the facility with diagnoses of major depressive disorder, heart failure, and dependence on renal (kidney) dialysis. The Minimum Data Set (MDS) dated [DATE], documented the resident was cognitively intact, could usually understand others, and could usually make self understood.
The Comprehensive Care Plan for Mood last updated 12/28/19, documented the resident would be maintained on the lowest effective psychotropic medication dose, and the facility was to attempt a GDR when and if appropriate.
A pharmacy recommendation dated 12/12/19, documented the resident had received Xanax 0.25mg at bedtime since 9/4/18 without a dose reduction while in facility.
A review of physician orders did not include documentation of a Xanax dose reduction between 9/4/18 and 9/4/19.
A review of the resident's medical record did not include documentation of a clinical contraindication to gradually dose reduce the resident's Xanax.
A pharmacy recommendation dated 12/12/19 documented the resident had received Xanax 0.25mg at bedtime since 9/4/18 without a dose reduction while in facility.
During an interview on 2/03/20 at 11:56 AM, the Director of Nursing (DON) stated she was not aware the resident's Xanax had not been dose reduced twice within the first year it was prescribed in the facility. The DON stated the physician and interdisciplinary team oversaw the GDR process.
Resident #81
The resident was admitted to the facility with diagnoses of anxiety with agitated behaviors and dementia with behavioral disturbance. The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition, could usually understand others, and usually able to make self understood.
A physician order dated 12/31/19, documented the resident was to receive Seroquel 25mg once daily at 1:00 PM.
Behavior monthly flow records dated 12/16/19 - 12/31/19, documented the resident did not have any episodes of sadness, weepiness, or yelling out.
A review of progress notes dated 12/16 - 12/31/19, did not include documentation of behaviors.
A progress note dated 12/31/19, documented the physician was aware of reported increased behaviors and new orders were received.
During an interview on 1/31/20 at 2:45 PM, the Director of Nursing (DON) stated she was unable to find documentation of increased behaviors in the medical record to justify the increase in Seroquel order on 12/31/19. The DON stated behaviors should also be documented on the 24-hour report, and he/she was unable to find documentation of increased behaviors on the 24-hour reports.
Resident #91:
The resident was admitted to the facility with the diagnoses of Dementia, depression and diabetes mellitus. The Minimum Data Set (MDS - an assessment tool) dated 12/16/19. documented the resident had moderately impaired cognition.
Finding #1:
The current Medication Administration Record (MAR) dated 5/20/2019, documented the resident was to receive Risperdal 0.5 mg twice daily.
The physician's orders dated 6/9/19 documented to increase Risperdal to 0.5 mg once per day.
The Behavior Monthly Flow Records dated May and June 2019 did not include documentation of resident behaviors.
The Monthly Physician Progress Notes for the months of May, June and July 2019 did not include documentation to support the increase in Risperdal on 6/9/19.
During an interview on 2/3/20 at 11:35 AM, RN #1 stated the resident had an increase in Risperdal on 6/9/19, and there were no behaviors documented on the behavior tracking sheets when the Risperdal was increased.
During an interview on 02/03/20 at 1:21 PM, the Physician stated the nurses were supposed to document on the front of the monthly physician note to give him the information he needs to be aware of and what needed to be reviewed. The Physician stated the behavioral tracking information should have been written on the front of the monthly physician notes.
Finding #2:
A physician order dated 12/27/18, documented the resident was to receive Lexapro 10 mg daily, and the medical record did not include documentation of Lexapro order changes between 12/2018 and 1/20/20.
The Monthly Physician Progress Notes for the months of December 2019 and January 2020 did not include documentation to support GDR was contraindicated.
During an interview on 2/3/20 at 11:35 AM, RN #1 stated the resident had a gradual dose reduction of Lexapro in 12/2018, and there had been no other changes to the Lexapro since then. RN #1 reviewed the Monthly Physician Notes dated 5/2019, 6/2019, 7/2019, 12/2019 and 1/2020 and stated the physician did not document on the psychotropic medications.
During an interview on 02/03/20 at 1:21 PM, the physician stated the pharmacy usually tracks the GDR's and notifies the facility when one is due. The Physician stated the pharmacy consult sheet did not leave enough room on the form for documentation, and he/she did not document regarding the Lexapro GDR in his/her notes. The Physician stated the nurses were supposed to document on the front of the monthly physician note to give him the information he needs to be aware of and what needed to be reviewed.
10 NYCRR415.12(1)(2)(i)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one (Resident #40) of three residents reviewed for pressure ulcers. Specifically, for Resident #40, the facility did not ensure that when bleeding was noted to an area of a previous pressure Ulcer (PU), that the the area was assessed, the MD notified, the care plan updated, and a new treatment started. This is evidenced by:
A policy on Pressure Ulcers, Prediction and Prevention, last revised in 1/2008, documented this protocol utilized an interdisciplinary approach in the prevention of pressure ulcers, identifies at-risk residents and defines early interventions for the prevention of pressure ulcers; it would develop a comprehensive interdisciplinary care plan that is consistent with the resident's specific conditions, risks, and needs; preventative skin care shall be provided for resident with identified risks and may include establishing an individualized plan of care to address the specific needs and risk factors of each resident and to notify the Medical Doctor (MD) of new skin problems and need for change in approaches
Resident #40:
The resident was admitted with diagnoses of dementia, chronic kidney disease, and HTN. The Minimum Data Set (MDS-an assessment tool) dated 10/29/19, assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was sometimes understood by others. The resident had previously developed a stage 2 PU to the right hand between the thumb and index finger on 10/23/10 that was documented as healed on 12/11/19.
A Braden Scale (a prediction of Pressure Ulcer (PU) Risk) dated 8/20/19, documented that the resident scored a 13, indicating a moderate risk for a pressure sore.
During an observation on 01/31/20 09:22 AM, the resident was noted with an open area between the right thumb and index finger. The wound bed was light pink and the tendon was exposed. There was a deeper area in the center and a small amount of purulent drainage noted on the old dressing.
A CCP for Skin dated 11/18/19, documented to assure proper fitting clothing and shoes, avoid sheering and friction to skin, weekly skin inspection, and report any signs of skin breakdown (sore, tender, red, or broken areas), and provide skin interventions per profile card.
A Certified Nursing Assistant (CNA) Profile card (a guide for CNAs as to what care to provide) documented on 12/30/19, apply geri sleeves every morning after being lotioned; remove the geri sleeves at night and apply lotion; night shift to apply lotion as well.
MD orders documented the following:
-12/7/19 - Cetaphil lotion to upper and lower extremities every shift.
-12/11/19 - Documented to apply skin prep twice daily between the right thumb and index finger.
Progress notes documented the following:
-1/21/19 - The right hand between the index finger and thumb started bleeding when the geri sleeve was removed and a bandaid was applied. Geri sleeves were re-applied, to be kept loose at the bottom, continue treatment.
-1/25/19 - Called to assess area between right thumb and index finger. A moderate amount of serosanguinous drainage was noted on geri sleeve that was in place. The sleeve was removed to reveal a now stage 4 area measuring 3.6 cm x 2 cm x 0.2 cm with approximately 1 cm of tendon exposed, foul odor, warmth, redness, swelling, and obvious discomfort with range of motion (ROM).
The 24-hour report on 1/21/20, did not include an entry about the area on the resident's hand.
The medical record did not include any further documentation about the appearance of the area or the bandaid that was applied on 1/21/19, that the MD was notified and that the CCP was changed to address this area.
A wound note dated 1/25/19, documented the presence of a stage 4 PU measuring 3.6 cm x 2 cm x 0.2 cm; there was a moderate amount of foul-smelling serosanguinous drainage and erythema (redness); the wound edges were irregular and there was a 1 cm length of tendon exposed. This was an area of prior concern; A weekly assessment on 1/2/19 indicated bleeding was present but no alteration in the treatment was done. The plan of care included geri sleeves and a new pair was applied at the time as the previous pair was heavily soiled with wound drainage.
During an interview on 01/31/20 at 10:50 AM, Licensed Practical Nurse (LPN) #2 stated she would initial the Treatment Administration Record that a weekly skin assessment was done but did not document any skin issues there; if she noticed any abnormal findings, she would report it to the Registered Nurse (RN). As far as she could recall, the area looked fine on 1/24/20.
During an interview on 01/31/20 at 11:13 AM, the Director of Nursing (DON) stated the area should have been assessed on 1/21/20, when the nurse noted bleeding to the area and a bandaid was applied. There should have been follow up documentation regarding the bandaid and the area.
During an interview on 01/31/20 at 12:52 PM, the Medical Doctor (MD) stated the resident has had an issue with this area in the past. He was not aware that the wound was bleeding on 1/21/19. Hewould have expected an assessment of the area on 1/21/20 and notification that the area opened back up. If they notified him, he would have discussed holding the geri sleeve.
During an interview on 02/03/20 at 09:13 AM, Registered Nurse Manager #3 stated there should have been an assessment with measurements, notification to the MD, and a treatment change when bleeding was noted on 1/21/20. In hindsight they should have switched from the geri sleeves to the derma sleeves after the stage 2 noted to the area in 10/2019, and it was probably not realistic to think that the skin prep was done on the evening and night shift prior, considering the condition of the wound in the morning. The system breakdown occurred on 1/21/20; it should have been put on the 24-hour report and identified as a new area so it could have been looked at by the wound team, as 1/21/20 was a wound round day.
During an interview on 02/03/20 at 11:47 AM, Certified Nursing Assistant (CNA) #5 stated she had the resident on 1/25/20 and noticed blood on the geri sleeve between the thumb and index finger. She did not feel comfortable taking the sleeve off so reported to the nurse. She was not sure if there was a bandaid in place on the area as she did not want to touch it.
10NYCRR 415.12(c)(1-2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it provided, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for one (Resident #40) of one resident reviewed for activities. Specifically, the facility did not ensure that activities were provided to the resident based on his/her abilities and preferences. This is evidenced by:
Resident #40:
The resident was admitted with the diagnoses of Alzheimer's dementia, chronic kidney disease, and HTN. The Minimum Data Set (MDS-an assessment tool) dated 10/29/19 assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was sometimes understood by others.
The following observations were made of the resident:
-01/28/20 at 09:39 AM -10:20 AM, 01:34 PM, the resident was sitting in a scoot chair pushed up to a table in the hall. There was a television (TV) in the hall but the resident was not engaged.
-01/29/20 at 1:54 PM, the resident was brought from the dining room and placed in the hall across from the TV. The resident moved his/her self a couple feet toward the center of the hall and a staff member moved the resident back against the wall to take another resident to an activity program, but did not offer the activity to Resident #40.
-01/29/20 at 02:10 PM, the resident was put to bed.
-01/30/20 at 08:35 AM, the resident was sitting in scoot chair across the hall from the TV which was off.
-01/30/20 from 09:14 AM to 10:30 AM, and 10:43 AM- 11:13 AM the resident was at the table in front of TV that was on, but the resident was not engaged with it.
-01/30/20 at 02:19 PM, the resident was sitting in his/her chair in the common area TV room while there was a group music activity going on just a short distance away; the resident was brought into the activity at 02:43 PM.
-01/31/20 9:32 AM, the resident was in the day room with TV on and at 10:48 AM, in the hall in front of the TV; she was not engaging with the TV.
The MDS dated [DATE], documented that it was very important to the resident to go outside and to participate in religious services, and somewhat important to listen to music.
The Comprehensive Care Plan for Activities dated 3/4/19, documented to consider the resident's past and present interests when inviting to program (the resident was a volunteer and enjoyed bowling and painting); Invite and assist to programs such as Catholic mass/communion, Protestant chapel, music-related activities especially piano music and meaningful music group, outdoor activities and church related activities and provide verbal/tactile/visual cues as needed to perform Activities.
The residents Activity Census Calendar dated from 1/12/10 - 1/30/20, documented that the resident had 23 activities. They were as follows:
-12 were Daily Chronical (an activity person standing in the dining room while meals are being served and speaking to the entire dining room about current and past events usually lasting approximately 15 minutes);
-6 were exercise activities
-1 tranquility time
-1 pet therapy
-1 meal time visit
-1 music program that the resident was not brought into until approximately ½ hour after it started
-there were no 1:1 activities.
During an interview on 01/31/20 at 02:20 PM, the Activities Manager (AM) stated the residents Her CCP documented that the resident followed the Catholic faith, and they would provide 1:1 activities. He/she attended group 5-6 times a week including Daily Chronical) which she thought was a meaningful activity for residents with dementia. When the surveyor asked about all the commotion going on in the dining room during this activity, the AM agreed that it would be better if staff spoke directly to the resident. They used to have a separate calendar for dementia activities, but they had a staff member out on medical leave; they could do better with the resident, and he/she would benefit from 1:1 activities.
10NYCRR 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey, the facility did not ensure within 14 days after the facility completed resident assessments that the assessments were electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Center for Medicare and Medicaid Services (CMS) System for 2 (Resident #'s 1 and 2) of 2 residents reviewed for resident assessment. Specifically, the facility did not ensure the required quarterly Minimum Data Sets (MDS's) were completed and transmitted as required to CMS. This is evidenced by:
Resident #1
The resident's quarterly MDS dated [DATE], documented the assessment was not completed until 12/26/19. The facility did not provide documentation of the MDS transmission date.
During an interview on 1/30/20 at 1:58 PM, the MDS Coordinator stated the resident's MDS dated [DATE], was not submitted or finalized at the time of interview. The MDS Coordinator stated someone should have identified that the MDS was not completed or transmitted.
Resident #2
The resident's quarterly MDS dated [DATE], documented the assessment was not completed until 10/28/19. The facility did not provide documentation of the MDS transmission date.
The resident's quarterly MDS dated [DATE], documented the assessment was not completed until 1/27/20. The facility did not provide documentation of the MDS transmission date.
During an interview on 1/31/20 at 2:32 PM, Registered Nurse #3 stated the late submission dates were due to the MDS Coordinator being in multiple roles. RN #3 stated staffing changes were made and the MDS submissions should be timely.
During an interview on 2/03/20 at 11:54 AM, the Director of Nursing stated he/she was not aware the MDS's were not completed and transmitted within 14 days. The DON stated the facility process is the lead MDS coordinator would send emails to any discipline that did not complete the MDS, and the Assistant Director of Nursing would utilize the [NAME] reports (an accounting of a facilities CMS reporting history) to oversee the time frames for submission.

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy included a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. This is evidenced by:
A Policy and Procedure (P&P) titled Food Safety Requirements and Use and Storage of Food and Beverage Brought in for Residents dated 4/2018, did not include documentation of a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own.
During an interview on 1/31/20 at 2:51 PM, the Food Service Director (FSD) stated the policy did not include documentation of a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own.
10 NYCRR 415.14(h)

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Foods time/temperature controlled for safety (TCS foods) are to be cooled to 41 degrees Fahrenheit (F) within 6 hours provided the food is cooled from 135F to 70F within the first two hours of cooling. Food contact surfaces and floors must be kept clean. Specifically, TCS foods were not cooled safety, food contact surfaces were not clean, and there was a build-up of grease on the floor in the main kitchen. This is evidenced as follows.
The main kitchen was inspected on 01/28/2020 at 09:00 AM. The temperature of the pasta salad in the produce walk-in cooler which was prepared on 01/27/2020 was 46 degrees Fahrenheit (F). Four cutting boards on the clean equipment storage rack in the main kitchen were covered in food debris, and the floor under the fryers and oven were covered in grease.
The Director of Food Service stated in an interview on 01/28/2020 at 10:15 AM, that she will in-service staff on safe food cooling procedures, and have staff clean the cutting boards and grease off the floor.
10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.40(b), 14-1.113

Based on observation and interviews during the recertification survey, the facility did not ensure residents received drinks consistent with their preferences on 1 of 3 units. Specifically, the facility did not ensure resident's received coffee. This is evidenced by:
The Policy and Procedure (P&P) titled Hydration dated 6/16, documented residents were to receive coffee at breakfast, lunch, and dinner. The P&P documented bevereage preferences would be obtained from the resident and/or family and the daily pattern would be adjusted based on preferences.
During an lunch dining room observation on 1/28/20 at 12:01 PM, a resident asked when they would be getting some coffee.
During an interview on 1/29/20 at 8:41 AM, Resident #70 stated he/she did not get coffee this morning, and did not ask for it because it was on her ticket.
Resident #70's breakfast meal ticket dated 12/29/19, documented the resident was to receive 8 ounces of decaffeinated coffee.
During an interview on 1/29/20 at 1:25 PM, Licensed Practical Nurse (LPN) #2 stated there was an issue with residents getting coffee because of the cities water last week. LPN #2 stated the coffee machine on the unit broke a week ago.
During an interview on 1/29/20 at 1:26 PM, Certified Nursing Assistant (CNA) #2 stated the coffee machine on the unit was broken and the one the kitchen sent up was also broken.
During an interview on 1/29/20 at 1:28 PM, CNA #3 stated the staff asked the kitchen for coffee and nothing was sent up to the unit.
During an interview on 1/30/20 at 11:20 AM, the Director of Social Work (DSW) stated she was not aware that residents could not get coffee, and she discussed it yesterday with the Food Service Director (FSD) who said they are looking into it.
During an interview on 1/31/20 at 1:55 PM, the FSD stated the third floor coffee machine was still not working, and carafes of coffee were being sent to the unit until the machine was fixed. The FSD stated he/she was not aware residents weren't getting the coffee. The FSD stated the kitchen staff usually pours the beverges, including coffee, and sends them up to the units with the trays. The FSD stated a phone call was made to communicate the temporary change in nursing serving the coffee on the unit. The FSD stated once the trays leave the kitchen, nursing is responsible.
During an interview on 2/03/20 at 12:02 PM, the Director of Nursing (DON) stated he/she would expect residents to be served the beverages they preferred.
10NYCRR415.14(d)(4)