**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the extended Recertification Survey and complaint investigations (#NY00349354, #NY00357725, #NY00362904) from 01/21/2025 to 01/31/2025, the facility failed to ensure residents' right to be free from abuse, mistreatment or neglect for six (6)(Residents #8, #48, #65, #73, #76 and #350) of eight (8) residents reviewed for abuse and neglect. Specifically, Resident #8 and Resident #48 did not receive timely incontinence care. Resident #65 did not receive wound care as ordered by the physician for multiple days and was not assisted with toileting or incontinence care for approximately six hours. Resident #73 was left sitting in their wheelchair in their room for approximately 14 hours without incontinence care despite multiple attempts to alert staff via call light and telephone calls to the nurse's station. Resident #76 waited approximately 21 hours for incontinence care to be provided and wet linens changed. Resident #350 did not receive wound care as ordered by the physician for multiple days. In addition, multiple grievances were filed by the residents related to these issues that were not followed up on by the Administration team. These issues resulted in the likelihood of serious injury, serious harm or death for all 95 residents in the facility, which resulted in Immediate Jeopardy. This is evidenced by the following: 1. Resident #350 had diagnoses that included diabetes (a chronic disease that affects how the body uses sugar for energy), peripheral vascular disease (a condition where arteries and/or veins become narrowed or blocked, reducing blood flow to the limbs), and chronic venous ulcers (wounds caused by reduced blood flow in the limbs). The Minimum Data Set Resident assessment dated [DATE] documented Resident #350 was cognitively intact and had seven (7) venous and/or arterial ulcers (wounds). The Comprehensive Care Plan dated 01/08/2025 included Resident #350 had venous wounds to both legs and to apply treatments per physician orders. Review of the physician orders dated 01/09/2025 revealed 12 different wounds on the resident's left and right lower extremities that required daily dressing changes. The dressing changes included cleansing and drying the wounds and applying different wound treatments (including a wound treatment often used for heavily draining/infected wounds to two of the areas) and dressings to all wounds. During an observation on 01/21/2025 at 10:54 AM, Resident #350 had both legs wrapped in gauze dressings that were undated and heavily soiled with serosanguinous (clear blood-tinged fluid) drainage that had soaked through both dressings, the right sock, and the top and bottom sheets on the bed. In an immediate interview, Resident #350 stated they were supposed to receive dressing changes daily, but it had been several days since they were last changed. As a result of that, their rehabilitation sessions were cut short, and they were unable to attend due to too much drainage from the dressings. Resident #350 said they recently had to wait five hours after their shower with no dressings on any of the wounds because the nurse had been too busy to put the dressings on their legs. Review of Resident #350's Treatment Administration Records dated 01/09/2025 to 01/20/2024 revealed no documented evidence that the resident's dressing changes to both legs were completed on 01/10/2025, 01/12/2025, 01/14/2025, 01/18/2025, 01/19/2025 and 01/20/2025. During an interview on 01/24/2025 at 11:26 AM, Licensed Practical Nurse #2 stated wound dressings should be completed per physician orders, and if missed they should be passed on to the next shift. They stated there are not enough staff to ensure all ordered treatments are completed and they have told the Director of Nursing and Administrator that they are unable to complete all treatments as ordered. During an observation on 01/25/2025 at 1:22 PM Resident #350's dressings to the right and left legs were undated with dried serosanguinous drainage through the outside of the dressing. During an interview on 01/25/2025 at 1:58 PM, Licensed Practical Nurse #2 stated they had not been able to change Resident #350's dressings that day because they were short staffed, and they did not have enough time. 2. Resident #65 had diagnoses that included a right femur fracture (break in the thigh bone on the right side of the body), Parkinson's disease (neurodegenerative disorder that affects movement, balance, and coordination), and malnutrition (lack of sufficient nutrients in the body). The Minimum Data Set Resident assessment dated [DATE] documented Resident #65 was cognitively intact, incontinent of bladder and bowel, and required assistance from staff for transfers and toileting. The resident's Comprehensive Care Plan initiated 12/24/2024 documented Resident #65 had an active skin impairment to the right shin and right thigh and for staff to apply treatments as ordered. Resident #65's [NAME] dated 01/23/2024 documented to check (for incontinence) and change (as needed) every two (2) to four (4) hours and to assist the resident with toileting as needed. Review of physician orders dated 01/03/2025 revealed daily wound care to the right thigh that included cleansing, applying a prescribed wound treatment, and a cover dressing. Review of the resident's Treatment Administration Record dated 01/03/2025 to 01/20/2025 revealed no documented evidence that the right thigh dressing had been changed on 11 of 18 days reviewed with the last date signed off as completed being 01/15/2025 (six days prior). During an observation and interview on 01/21/2025 at 10:27 AM, Resident #65 had an adhesive foam dressing on the inner right thigh dated 1/15. In an immediate interview Resident #65 stated they do not know how often the dressing was supposed to be changed. During an observation on 01/25/2025 at 1:20 PM, Resident #65 was sitting in bed naked with a saturated brief hanging around their knees. There was a strong smell of urine in the room and the resident's thigh dressing was dated 1/23. During an interview on 01/25/2025 at 1:33 PM, Certified Nursing Assistant #4 stated that Resident #65 was on their assignment, and they had changed their incontinence brief last at 7:30 AM (approximately six (6) hours ago). Certified Nursing Assistant #4 stated Resident #65 told them they needed help to go to the bathroom around lunch (12:30 PM) but sometimes the resident took themselves, so they did not assist the resident. During an interview on 01/25/2025 at 1:58 PM, Licensed Practical Nurse #2 stated that they were not sure if Resident #65 had wound treatments ordered, and they had not yet completed all ordered treatments on their assignment due to short staffing. 3. Resident #48 had diagnoses that included a stroke (blood flow to the brain is interrupted), hemiplegia (paralysis on one side of the body) and diabetes. The Minimum Data Set Resident assessment dated [DATE] documented Resident #48 was cognitively intact, was always incontinent of urine and stool, and was dependent on staff for toileting. The Comprehensive Care Plan dated 01/14/2025 and the current [NAME] (care plan used by the Certified Nursing Assistant for daily care needs) dated 01/23/2025 included the resident required a check (for incontinence) and change (as needed) and/or toileting assist every two (2) to four (4) hours. During an observation and interview 01/23/2025 at 12:45 PM, Resident #48's family came to the nursing station and reported to nursing staff Resident #48 was soaking wet and had not received incontinence care for hours. In an immediate interview, Resident #48 stated no one had cleaned them up since breakfast (approximately five hours ago) and they were soaked through. Resident #48's brief was visibly saturated; their gown was wet with multiple dried brown stains on it and there was a strong smell of urine present. During an interview on 01/23/2025 at 12:57 PM, Certified Nursing Assistant #4 stated they had not provided incontinence care to Resident #48 since their first rounds (approximately five hours ago). Certified Nursing Assistant #4 stated residents should be checked and changed for incontinence every two hours. but Resident #48 can call when they need to be changed; they had not called, so Certified Nursing Assistant #4 did not go in their room to check. During an observation and interview on 01/24/2025 at 9:10 AM, Resident #48 stated they had not received incontinence care since last night at 8:00 PM (approximately 13 hours ago). They had put their call bell on this morning and the certified nursing assistant that answered turned the call bell off and had not come back to assist them. Resident #48's incontinence brief, gown, and incontinence pad were saturated and there was a strong odor of urine present. During an interview on 01/24/2025 at 9:13 AM, Certified Nursing Assistant #5 stated Resident #48 was soaked through their incontinence brief, pad, and gown with urine, but they had not changed the resident yet because they were short staffed. They stated nursing leadership and administration knew they needed more help. During an interview on 01/24/2025 at 11:26 AM, Licensed Practical Nurse #2 stated checking and changing for incontinence should happen every two to four hours and as needed if someone was wet. There are not enough staff on the floor to take care of all the residents and they have told the Director of Nursing and Administrator multiple times about their concerns that residents were not getting taken care of. During an interview on 01/24/2025 at 12:10 PM, Registered Nurse Manager #1 stated they were aware of concerns from residents that incontinence care was not being completed timely and wound care was not provided. Registered Nurse Manager #1 said their concerns have been shared with the Director of Nursing and the Administrator. 4. Resident #8 had diagnoses including morbid obesity, dementia, and a history of Extended Spectrum Beta Lactamase (ESBL) Resistance (infection resistant to antibiotics) in the urine. The Minimum Data Set Resident assessment dated [DATE] documented the resident had moderately impaired cognition and was frequently incontinent of bowel and bladder. Review of Resident #8's undated Comprehensive Care Plan revealed the resident was incontinent. Interventions included to check the resident every two (2) hours, assist with toileting as needed and to provide a bedpan/bedside commode. Review of Resident #8's current [NAME] revealed the resident required two staff assist for toileting, using a bed pan or urinal every two hours and offer to take the resident to the toilet at around the same time each day. During an observation and interview on 01/21/2025 at 11:51, AM Resident #8 was incontinent of stool and stated that they had been waiting since they woke up (approximately four hours prior) to be changed but had no response to their call light. At this time Resident #8's lunch tray was delivered and they requested to be changed before eating lunch. When checked Resident #8's call light was not working. In an interview on 01/23/2025 at 12:35 PM, Resident #8 stated staff never come to help, and they have to urinate on themselves sometimes when their urinal is full, or they have to dump it out the window. The resident's room had an overwhelming odor of urine. In a telephone call placed to the New York State Department of Health complaint line on 01/21/2025 at 5:01 PM, Resident #8 stated they had gone to the bathroom that morning and were still waiting to be cleaned up, as they were sitting there with stool all over them. Resident #8 reported sometimes they have to wait all night to get cleaned up and they are sick of it. They said they had to eat their lunch like this, and they (the facility) are not taking care of them and should know it is not nice to do this to a veteran. In an interview on 01/24/2025 at 12:24 PM, Licensed Practical Nurse Manager #1 stated Resident #8 can use a urinal, is sometimes incontinent of urine, and always incontinent of stool. Staff do the best they can, sometimes the Certified Nursing Assistants don't have time to empty urinals, and the nurses try to help. 5. Resident #73 had diagnoses that included a stroke with right-sided weakness, expressive aphasia (partial loss of the ability to speak), and left side below the knee amputation. The Minimum Data Set Resident Assessment, dated 10/14/2024, documented the resident had no behaviors, and was dependent on two (2) or more staff for transfers and toileting. A Social Work Assessment and Documentation Form dated 01/08/2025 documented the resident was cognitively intact. Review of Resident #73's current Comprehensive Care Plan revealed the resident required assistance with all activities of daily living for toileting, two (2) staff assistance with a mechanical lift for transfers, and frequent repositioning (initiated 10/31/2022). The care plan also included the resident was at risk for impaired skin integrity and pressure ulcer development with interventions to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing and sheets; turn and reposition every two (2) to four (4) hours as needed (initiated 10/12/2022). During an observation and interview on 01/21/2025 at 3:12 PM, Resident #73 was sitting in their room in their wheelchair. There was no call light accessible. Resident #73 was unable to provide a full verbal interview but was able to nod yes and no when interviewed and was able to relay that when they do not have their call light nearby, they need their roommate to call for help for them. During an interview on 01/21/2025 at 3:24 PM, Resident #73's roommate (Resident #299), identified by the facility as alert and oriented, stated staff had gotten Resident #73 up at 10:00 AM on Sunday (two days prior) and they remained in their wheelchair until 1:00 AM Monday morning (15 hours later). Resident #299 stated they had used their call light and tried to reach the front desk multiple times to get help for Resident #73 but received no response. During an interview on 01/24/2025 at 3:06 PM, Certified Nursing Assistant #1 stated they put Resident #73 to bed on 01/20/2025 between 12:00 AM and 12:30 AM, due to short staffing. Certified Nursing Assistant #1 stated it is hard to check on residents every two (2) hours and to get help for a two-person assist when there are only two (2) or three (3) people on the whole floor (census 48). 6. Resident #76 had diagnoses that included bilateral below-the-knee amputations, history of deep vein thrombosis (blood clot), and anxiety. The Minimum Data Set Resident Assessment, dated 12/10/2024, documented the resident was cognitively intact and required moderate assistance with toileting . Review of Resident #76's current Comprehensive Care Plan, initiated 09/06/2023, revealed the resident required assistance of staff with all activities of daily living, and was at risk for pressure ulcers. Interventions included to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing and sheets as needed; turn and reposition every two (2) to four (4) hours as needed. Review of Resident #76's [NAME] dated 01/30/2025 revealed to check the resident every two (2) to four (4) hours as tolerated during waking hours and assist with toileting as needed. During an interview on 01/21/2025 at 12:10 PM, Resident #76 stated they were concerned with not being changed on 01/19/2025 from 8:30 AM until 01/20/2025 at 5:30 AM (21 hours). The resident said they had been so soaked- their sheets were soiled and wet and they had put their call light on numerous times, but it was turned off by staff who stated they knew the resident needed assistance, but they were short staffed. Resident #76 stated they had to urinate and defecate several times in their brief; this was not the first time they had to wait long hours to be changed when soiled and they felt very neglected. During an interview on 01/24/2025 at 10:36 AM, Certified Nursing Assistant #3 stated that when they arrived to work on 01/20/2025 at 6:00 AM, Resident #76 was very soiled, and the resident and their roommate had stated they had not been changed at all during the night. Certified Nursing Assistant #3 stated sometimes there were only two (2) Certified Nursing Assistants on the third floor (census 48) for the 6:00 AM to 2:00 PM shift and it was hard to provide care timely, especially when residents required the assistance of two (2) staff. The facility was very understaffed and many of the residents required two staff for assistance. During an interview on 01/27/2025 at 11:05 AM, the Director of Nursing stated the assigned nurse is responsible for completing wound care as ordered. The nurse manager is responsible for completing audits to ensure treatments are being completed and following up with staff when they are not documented as complete. The Director of Nursing stated nurses should notify their Nurse Manager, the Assistant Director of Nursing, or Director of Nursing if wound care cannot be completed. The Director of Nursing said residents should be toileted or checked and changed per their care plan. They have received grievances related to lack of wound care, assistance with toileting, and incontinence care not being completed due to short staffing. The Director of Nursing said they and their Assistant Director of Nursing have assisted on the units to help when staff call in. They have terminated some staff and attempted to re-educate staff regarding these ongoing issues. During an interview on 01/27/2025 at 1:47 PM, the Administrator stated they had received grievances related to wound care, toileting assistance, and incontinence care not being provided. They stated the Director of Nursing should be following up on these concerns but was unsure if they had. During an interview on 01/31/2025 at 11:25 AM, the Medical Director stated not getting incontinence care, not answering call bells, and not helping with activities of daily living could be considered neglect. This could cause feelings of anxiousness, frustration, or being upset that could then affect residents mentally and psychologically and have a negative impact on their physical health. On 01/28/2025, the New York State Department of Health survey team identified and declared Immediate Jeopardy. The facility Administrator was notified at 4:56 PM. On 01/29/2025 at 4:30 PM, the New York State Department of Health survey team declared the Immediate Jeopardy was removed based on the following corrective actions taken by the facility: -A QAPI meeting was held on 1/28/2025 at 5:30 PM with all members present, to discuss Immediate Jeopardy issues. -100% of staff working the previous three (3) shifts, including staff on-site at the time of Immediate Jeopardy removal, received education on Abuse, Neglect, Mistreatment; Call Bells; Activities of Daily Living Care and Support; Grievances; Skin and Pressure Injury Prevention; and a newly implemented shift-to-shift report. -Interviews completed with multiple staff, including direct care staff and licensed nursing staff on two (2) of two (2) resident care units, revealed appropriate knowledge of the Abuse, Neglect and Mistreatment; call light response and accessibility; incontinence care; wound prevention and wound care; shift-to-shift report; and grievance process. -Observations of random call bells on two (2) of two (2) units revealed call bells in working order. Two (2) resident call bells on Unit 3 were not in reach of the resident. Observations of the two (2) rooms were made with Administration present. Both residents will be evaluated by therapy for ability to use call bell and call bell placement. -Approximately 30/40 total active nursing staff, including licensed nurses and Certified Nursing Assistants, were educated on Abuse, Neglect, and Mistreatment; call light response; Activities of Daily Living Care and Support; Grievances; Skin and Pressure Injury Prevention; and a newly implemented shift-to-shift report. -Five (5) per diem staff members and four (4) staff members who are on vacation and/or sick leave have been notified and will be educated prior to their next scheduled shift. -Four (4) of four (4) leadership staff, including Administrator, Director of Nursing, Assistant Director of Nursing and Director of Social Work, were educated on the grievance process. -A weekly on-call rotation for clinical leadership was implemented. -A full house skin sweep audit was completed, newly identified wounds had treatments ordered and were scheduled for wound rounds to be completed 01/29/2025. -Full house treatment completion audit conducted with no wound care treatments identified as missing or incomplete. -Full house call bell audit completed with three (3) call bells replaced. -Full house incontinence rounding completed with incontinence care provided as needed. -Audits to be continued each shift for wound treatment completion, call light accessibility and function, and incontinence care. 10 NYCRR 415.4 (b)(1)(i)