Every finding on record at Alice Hyde Medical Center

Based on observations, interviews and record review during a survey, the facility failed to ensure residents were free from abuse of any type. Specifically, (a) the facility failed to implement care planning interventions to appropriately address Resident #2 who had a documented history of sexually inappropriate behaviors. This resulted in Resident #1 being sexually assaulted by Resident #2. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity Guide, the facility's failure to protect residents from sexual abuse resulted in psychosocial harm to Resident #1 that was not Immediate Jeopardy. (b) Resident #3 had a behavior care plan that documented they demonstrated verbally and physically abusive behavior. On [DATE], a behavior care plan note documented Resident #3 was placed on 15-minute checks for safety due to shoving a staff member and telling other residents to shut up and for pointing at them. On [DATE], the facility failed to implement the care plan intervention of 15-minute checks for Resident #3 from 11:45 AM to 12:30 PM, which placed other residents at risk for abuse. At 1:04 PM, Resident #3 was found having wandered into another resident's room. This is evidenced by: Cross reference F627 The facility policy and procedure titled Abuse Prevention and Reporting, dated 06/2023, documented the purpose was to ensure that all residents of the facility were free from abuse, and that the facility shall not permit verbal, mental, sexual or physical abuse. Immediate action to protect the resident from further alleged abuse shall be taken. The orientation process will include training to ensure that new staff members were fully prepared to recognize instances of potential abuse as well as how to intervene appropriately. Annual in-services as well as ongoing education regarding specific situations would take place with appropriate staff members. The focus would be on identifying what constitutes abuse, as well as reporting of abuse without fear of reprisal. Additional education topics related to resident abuse would be periodically presented to include appropriate interventions to deal with aggressive and potentially dangerous resident behavior. A facility policy titled Safety Intervention at [Facility], dated 05/2024, documented safety interventions will be implemented on a resident centered basis to optimize care and safety for each individual resident while maintaining dignity. Safety interventions will be routinely reviewed for continued use and effectiveness through a collaborative approach with nursing staff, rehabilitation staff, medical staff, and any other staff as appropriate. The policy further documented (A) that the standard types of safety interventions used at the facility included 15 minute checks and observations; that safety measures will be evaluated to ensure the least restrictive interventions were utilized for each resident; and that as with implementation, through an Interdisciplinary Team approach, each individual safety intervention will be assessed routinely and discontinued if found to be ineffective or no longer necessary as resident condition changes. Documentation will be added into the electronic record indicating reason for discontinuation of safety measure, every 15-minute checks/observations will typically be in place for 72 hours depending on what situation or event required them to be initiated. Checks can be extended if felt necessary by the Interdisciplinary Team. Resident #1 Resident #1 was admitted to the facility with diagnoses of Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking and reasoning skills), paralysis on one (1) side of the body, and aphasia following cerebral infarction (a language disorder caused by brain damage, affecting speech, understanding, reading and writing). The Minimum Data Set (a resident assessment tool), dated [DATE], documented the resident was usually able to understand others and made themselves understood but was severely cognitively impaired. The comprehensive care plan dated [DATE], documented the following: Behaviors: Resident #1 had a history of combative, resistant behaviors, weepiness, attempts to self-transfer and ambulate with no ability to recognize their limitations. Goals listed included not being the victim or aggressor daily. Interventions included monitoring behaviors, escalations and intervene and report as needed. Communication Impaired: Resident #1 had an altered ability to communicate related to talking few words only intermittently. The goals listed included caregivers would be able to interpret nonverbal cues/facial expressions and body language when providing care. Interventions listed included observing body language and facial expressions to determine needs. Resident #2 Resident #2 was admitted to the facility with diagnoses of Parkinson's disease with dyskinesia (a neurological disease causing stiffness and movement disorders with jerky movements caused by the medication required to treat the disease), dementia with anxiety (a progressive loss of intellectual functioning, especially impairment of memory and abstract thinking), and heart disease without chest pain. The Minimum Data Set, dated [DATE], documented the resident was usually able to understand others and made themselves understood but was significantly cognitively impaired. The comprehensive care plan for behaviors dated [DATE] documented that Resident #2 had a tendency to be sexually inappropriate, wandering, stayed awake at night and wandered the halls. The goals documented that Resident #2 would not be the aggressor and there would be no sexual talk or touching of staff. The interventions documented were to invite Resident #2 to activities, assess for behaviors, and monitor cognitive status. The care plan was updated on [DATE] to include diversion such as redirection, one-to-one (1:1) supervision (a dedicated staff member assigned to constantly monitor a resident), television, and 15-minute checks. The care plan was updated on [DATE] to again note 15-minute checks. A care plan note dated [DATE] documented that Resident #2 was sexually inappropriate with certified nurse aides on [DATE] while receiving care, Resident #2 asked staff to get into bed with them and touched staff buttocks. Resident #2 Nursing Notes Prior to [DATE] and [DATE] Incidents: A nursing note by Licensed Practical Nurse #1 dated [DATE] at 1:39 PM, documented Resident #2 was sexually inappropriate with staff that shift, making comments to staff such as, You have a nice rear end, I bet you would like if I touched it. Staff educated Resident #2 that comments like that were not appropriate, and they should not say them. The note documented Resident #2 looked the staff up and down and asked them to go to their room with them. Staff documented that they told Resident #2 that it was not appropriate. Additionally, between [DATE] and [DATE], there were 26 documented nursing notes identifying Resident #2 making inappropriate sexual comments and gestures to staff, sexually propositioning staff, and grabbing a staff member's breast. A review of Resident #2's comprehensive care plan for behaviors dated [DATE] indicated between [DATE] and [DATE], there was no documented evidence this care plan was updated to include interventions to reduce sexually inappropriate behaviors or to protect other residents and staff from sexually inappropriate behaviors demonstrated by Resident #2. Resident #2 Physician Notes Prior to [DATE] and [DATE] Incidents: A physician note on [DATE] at 2:40 PM documented Resident #2 was more short tempered than usual during a gradual dose reduction of venlafaxine medication (an antidepressant) and nursing staff reported an increase of sexually inappropriate comments to staff. A physician note on [DATE] at 10:24 AM documented that Resident #2 continued with daily sexual inappropriateness, venlafaxine was noted to be back to 150 milligrams daily on [DATE] and that trazadone would be added at bedtime to help with sleep. A physician note dated [DATE] at 1:36 PM documented that Resident #2 was continuing to have inappropriate sexual comments and agitation. A conversation with Resident #2's family was documented and there was a plan to add trazadone (a prescription antidepressant of the serotonin antagonist and reuptake inhibitor class that is primarily used to treat major depressive disorder, as well as insomnia and anxiety off-label) in the morning and continue the Ativan (a prescription benzodiazepine used short-term to treat anxiety disorders, insomnia, acute seizures, and alcohol withdrawal) as needed. A physician note dated [DATE] at 4:35 PM documented Resident #2 was upset that they and their spouse were being held against their wills, threatened the physician but did not move to do anything, and accused the physician of saying things they did not say. The physician documented the team would try to reduce some of Resident #2's Parkinson's medication and increase trazadone and keep the as needed Ativan. A physician note on [DATE] at 5:00 PM documented Resident #2's family asked to speak to them regarding Resident #2's ongoing anxiety and auditory hallucinations that Resident #2's spouse was talking about them. Also documented was another medication change lowering trazadone because Resident #2 was reporting urinary issues and trying Ativan at bedtime to improve sleep and help lower anxiety during the day. A physician note dated [DATE] at 3:06 PM documented that Resident #2 was having increased sexually inappropriate behaviors with attempts at touching staff. A physician note dated [DATE], documented Resident #2's Ativan (used to treat anxiety disorders, panic attacks, and insomnia) was identified as the possible reason Resident #2 had become more disinhibited and planned to back off the Ativan and trial some Depakote (an anticonvulsant medication also functioning as a mood stabilizer) in the evening. A physician's note from [DATE] documented another medication change, decreasing Ativan and increasing Depakote to minimize Resident #2's mood swings. A physician note dated [DATE] at 4:35 PM documented trying to decrease primidone (an anticonvulsant to control various types of epileptic seizures) and putting valproic acid (a broad-spectrum antiepileptic drug used to treat seizures, bipolar disorder mania, and prevent migraines) on hold as it was the latest medication added. Incident on [DATE] and [DATE]: A nursing note dated [DATE] at 10:38 AM documented Certified Nurse Aide #6 entered the room of Resident #4 at 7:20 AM. The door to this room was closed. Resident #2 was in this room in their wheelchair next to the bed of Resident #4. Resident #4 was sleeping. Resident #2 appeared to be watching Resident #4 sleep. Certified Nurse Aide #6 separated the residents immediately, causing Resident #2 to become very upset insisting the sleeping resident was their spouse. When informing Resident #2's family of the incident, Resident #2's family stated that if we need to medicate them to make them more docile, then that is what I want. Medical doctor aware. A physician's note dated [DATE] at 6:10 PM documented Resident #2's family was very concerned about Resident #2's behavior and gave permission to change the dose of Resident #2's Parkinson's medications with the understanding that the Parkinson symptoms might be more pronounced, but with the hope that the sexual behavior would decrease. A physician's note dated [DATE] at 1:30 PM documented follow up Parkinson's/sexual disinhibition. Resident was alert and up in wheelchair, tells me they are looking for their spouse (deceased ). Now on Sinemet 25/100 (a tablet that contains 25 milligrams of carbidopa and 100 milligrams of levodopa) 1/2 four times a day (Sinemet 25/100 take half four times a day). Will try to watch at this dose through weekend and see if Resident #2 is less likely to be grossly inappropriate physically and verbally with staff. A nursing note dated [DATE] at 1:53 PM documented that Resident #2 had been in and out of bed all shift, intrusively wandering into other rooms, stating residents were their spouse, asked staff if they were married, and was difficult to redirect. As needed Ativan was given at 11:16 AM with little effect. A care plan note for Resident #1 dated [DATE], documented that Staff Member #1 was called to Resident #1's room at approximately 4:35 PM by staff who reported Resident #1's family member came out of Resident #1's room stating someone was in their parent's room. Staff reported upon entering the room, they removed Resident #1 from the bed and placed Resident #1 in a wheelchair. When Staff Member #1 entered the room, Resident #1 was in a wheelchair and Resident #2 was lying on their right side in Resident #1's bed with their pants and brief pulled down to their knees. Resident #1 was wearing a t-shirt and briefs. Resident #1's brief was documented to be intact with no tearing noted. No bruising or injury was noted to Resident #1. Resident #1 was noted to be crying and shaking. They were provided with a blanket and brought to the hallway to be with their family. Resident #1 was unable to communicate what happened. Resident #2 was removed from Resident #1's bed and taken to their room and placed on one-to-one (1:1) care (resident to receive one-to-one (1:1) supervision provided by a staff member). Assistant Director of Nursing #1 and Medical Doctor #1 were called and made aware, New York State Police and Emergency Medical Services were called, and both residents were sent to the hospital for evaluation. Fifteen (15)-minute checks were added to Resident #1's care plan. Per the facility investigation report, on [DATE] at 4:35 PM, Resident #2 was found in bed with Resident #1 by Resident #1's family member (Family Member #1). Family Member #1 immediately asked for help from facility staff to separate the residents. Resident #2 stated multiple times that Resident #1 was their spouse, was documented to be confused and upset that staff were separating them. The facility investigation and hospital documentation indicated that no penetration occurred, however, witness statements documented that Resident #2's pants were pulled down and Resident #1's left breast was exposed when they were found. Resident #1's incontinence brief was intact without signs of having been manipulated. Law enforcement was called, and both residents were sent to the hospital for examination. A care plan note written by Registered Nurse #2 dated [DATE], documented Resident #1's family member reported a bruise to Resident #1's right leg. The bruise was documented as a small faint purple bruise in the middle of their right lower leg. Bruise measured one (1) centimeter by one (1) centimeter. Skin around area intact. Resident showed no signs or symptoms of pain, no pulling away of their leg, no crying or wincing noted. Due to resident's dementia, resident unable to tell Registered Nurse #2 the origin of the bruise. Certified Nurse Aide who toileted resident and transferred resident out of bed prior did not notice the bruise. Registered Nurse #2 updated Medical Doctor #1 via electronic message on [DATE] at 4:45 PM. A care plan note written by Registered Nurse #2 dated [DATE] documented they were called to unit on [DATE] at 5:00 PM. Family Member #1 was visiting Resident #1 and reported the bruise to a licensed practical nurse who reported to writer. Registered Nurse #2 assessed the bruise. Bruise noted to be old in appearance to left lateral thigh measuring two (2) centimeters by two (2) centimeters. Center of bruise was purple and the skin around bruise was a light yellow. Surrounding skin around the bruise was intact. No signs or symptoms of pain when assessed. No guarding, wincing, crying, or pulling away from writer. Resident #1 was unable to tell writer origin of bruise due to dementia. Medical Doctor #1 was made aware via electronic message on [DATE] at 5:08 PM. Information from the facility provided 15 Minute Observation Sheets dated [DATE] revealed the following: Resident #2 was observed every 15 minutes from [DATE] at 7:30 AM until [DATE] at 6:00 PM. During the incident that occurred on [DATE] at 4:35 PM, it was documented that Resident #2 was in their room from 1:00 PM until 4:30 PM.From 4:30 PM until 5:45 PM, it was documented that Resident #2 was in their wheelchair in their room on a one-to-one(1:1) sit. During an interview on [DATE] at 8:39 AM, Certified Nurse Aide #5 stated Resident #2 became behaviorally problematic after their spouse passed away, saying sexually inappropriate things to staff and leering at them. Certified Nurse Aide #5 stated all nursing staff were responsible for 15-minute checks, and they worked together to ensure they were done. During an interview on [DATE] at 11:29 AM, Director of Nursing #1 stated that when Resident #2's spouse became ill and passed away, the resident became verbally and sexually inappropriate with staff. After Resident #2 was found in a resident's room watching them sleep, Resident #2 was put on consistent 15-minute checks. At the time of the incident when Resident #2 was found in bed with Resident #1, it was obvious to staff that Resident #2 believed they were in bed with their spouse and was very upset that staff were forcing them apart. During an interview on [DATE] at 9:43 AM, Certified Nurse Aide #4 stated 15-minute checks were done for falls, some behaviors, and resident-to-resident altercations. They stated there was no training on how to deal with sexually inappropriate behaviors from residents and that the training that was provided was not enough. During an interview on [DATE] at 9:51 AM, Registered Nurse #1 stated when residents say inappropriate things, they tell the resident to stop. If a resident was having inappropriate sexual behaviors, the staff monitored the resident every 15 minutes for 72 hours, notified management, discussed options with the doctor, and made sure the residents were separated. Registered Nurse #1 stated they tried to give Resident #2 same gender care givers because then the behaviors were not as frequent. During an interview on [DATE] at 11:36 AM, Nurse Educator #1 stated there was not really any sexually based behavior training. Dementia training would contain some behaviors, diversion tactics, how to deal with and redirect resistive combative residents and the walk away/reapproach tactics. For sexually based behaviors, diversion would be the main solution taught along with making sure the resident was safe, get another coworker if staff did not feel safe, and raise the alarm to the higher ups (make a supervisor aware of the situation). During an interview on [DATE] at 12:45 PM, Certified Nurse Aide #5 stated that after the incident on [DATE], every once and a while, Resident #1 would cry a little more than they usually did. Certified Nurse Aide #5 also stated Resident #1 was more emotional at night and there were days that they felt Resident #1 was a little more upset. During an interview on [DATE] at 12:46 PM, Licensed Practical Nurse #1 stated Resident #1 was more emotional after the incident, but they did not know if Resident #1 was more emotional because of what happened or because of their disease process. During an interview on [DATE] at 12:53 PM, Director of Nursing #1 stated prior to admission, the social worker did a history of the residents which included if they had behaviors or were an aggressor or a victim. Nurse Educator #1 did abuse training which included how to address sexual behaviors. They talked to the staff about redirecting residents that were problematic. Education was provided through the hospital electronic training program. It taught what to do, how to handle residents, and who to report to. They stated Family Member #1 was hysterical due to the incident between Resident #1 and Resident #2. State Police and Emergency Medical Services were called. Following the incident, Resident #2 was placed on one-to-one (1:1) supervision. They kept a same gender staff member with Resident #2, and a certified nurse aide and licensed practical nurse were with Resident #1. Skin assessments were done. They stated Resident #2 could be quick when they wanted to be, and they could not keep them on a one-to -one (1:1) sit and placing Resident #2 on 15-minute checks failed. They were not able to keep either resident safe. During an interview on [DATE] at 1:30 PM, Administrator #1 stated that the whole thing was a very sad situation. Administrator #1 stated that it made sense that this could be a traumatic event for Resident #1 despite their cognitive status. During an interview on [DATE] at 3:18 PM, Social Worker #1 stated that after the incident on [DATE], Resident #1 had increased weepiness, but Resident #1 was too demented to answer questions. During an interview on [DATE] at 10:16 AM, Nurse Practitioner #1 stated there were multiple medication changes for Resident #2 due to inappropriate sexual behaviors. They attempted to arrange counseling for Resident #2, but this was not documented in their notes and it would have had limited benefit for the resident. During an interview on [DATE] at 3:36 PM, Medical Director #1 stated Resident #2 made a number of comments to female staff, but they were unaware of inappropriate interactions with other residents. They were concerned that medication used to treat Resident #2's Parkinson's disease was contributing to their unwanted sexual behaviors. They could not recall specific interventions that were used to address Resident #2's unwanted sexual behaviors, but the best thing they could have done would have been to teach the staff how to deal with the behaviors. They stated psychological services were not initiated for Resident #2 and it would not have been helpful for this resident. Resident #3 Resident #3 was admitted to the facility with diagnoses of Alzheimer's disease, major depressive disorder (a serious mental health condition characterized by at least two weeks of persistent, severe low mood, sadness, or loss of interest/pleasure in daily activities), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). The Minimum Data Set, dated [DATE] documented the resident was able to make themselves understood, usually understood others and was severely cognitively impaired. A comprehensive care plan for behavior dated [DATE] documented that Resident #3 had wandering behaviors and removed items from other resident rooms, aggressive verbal and physical behaviors and was exit seeking. Goals documented were Resident #3 would be easily redirected and not be the aggressor daily. The documented interventions were: assess for needs, monitor, intervene and report as necessary. On [DATE] the following behaviors were documented on the care plan: Behavior: Behavioral Symptoms: Wandering, Verbally abusive behavior, Physically abusive behavior, Intrusive wandering, Depression/Mood: not answered, Behaviors: Kicking/hitting, Wandering, Abusive language, Threatening behavior, Resists care, Intrusive wandering. Notes: Diversion: 1:1 visits, Bingo, animal visits, walking. Put Boston sports team on television ([NAME], Patriots, Celtics), give stuffed animals, offer space and quiet area (activity room). Liked to do puzzles and was easily redirected with them. A care plan note dated [DATE] documented Resident #3 had an altercation with another resident on the unit at 2:50 PM. Staff intervened and separated the residents. Both residents were placed on 15-minute checks. Additional care plan notes included placing Resident #3 on 15-minute checks as an intervention were documented on [DATE] due to unsafe wandering, [DATE] for striking a resident on the side of their head, [DATE] for shoving a resident on to the floor, [DATE] for kicking a resident, [DATE] for hitting a resident in the chest and face. Notably, of these, a care plan note dated [DATE] at 11:30 AM documented that Resident #3 was noted to be agitated, pushed a staff member, was unable to be redirected or calmed. The medical provider ordered two (2) milligrams of Haldol (antipsychotic medication used to treat acute agitation) to be administered intramuscularly. Resident #3 was placed on 15-minute checks. During observations on the first floor locked unit on [DATE] at 12:00 PM, the 15-minute check list on wall of the nursing station documented Resident #3 was on 15-minute checks. During observations on [DATE] at 12:02 PM, Resident #3 was noted to be in a chair in their room watching television. At 12:13 PM, Registered Nurse #1 checked on Resident #3 in their room and asked if they wanted to have lunch in the unit dining room, to which Resident #3 replied no. During an observation on [DATE] at 1:04 PM, Resident #3 was found in another resident's room. Licensed Practical Nurse #2 and another staff member were able to redirect Resident #3 back to their room. During a record review on [DATE] at 1:08 PM, it was noted the 15-minute check sheets for the residents on these checks, including Resident #3, were not signed from 11:45 AM through 12:30 PM of [DATE]. During an interview on [DATE] at 1:10 PM, Licensed Practical Nurse #2 stated 15-minute checks were done by everyone and whomever laid eyes on the resident were to sign the 15-minute check sheet. Licensed Practical Nurse #2 stated all the residents were having lunch from 11:45 AM until 12:30 PM. They stated, usually, the certified nurse aides would sign the sheets but sometimes they were too busy to sign in real time. No one was able to sign the sheets from 11:45 AM through 12:30 PM on [DATE] because they were assisting with lunch in the dining room. Licensed Practical Nurse #2 then signed all resident's 15-minute check sheets while speaking with the surveyor. When asked what was put for Resident #3 for the missing times, Licensed Practical Nurse #2 stated they documented Resident #3 was wandering in all the time slots because that's what Resident #3 was doing when they found them in another resident's room at 1:04 PM. During general unit observations on [DATE] at 9:45 AM, it was noted Resident #3 was no longer listed to be on 15-minute checks. During an interview on [DATE] at 9:09 AM, Certified Nurse Aide #1 stated that a resident would be put on 15-minute checks because of things like resident-to-resident altercations. During an interview on [DATE] at 9:51 AM, Registered Nurse #1 stated they did not know why Resident #3 was on 15-minute checks. There was no note written as to why Resident #3 was on them, but they figured it was for wandering since Resident #3 was known to wander. The staff had the checks stopped when they could not figure out why Resident #3 was on them. During an interview on [DATE] at 11:36 AM, Nurse Educator #1 stated the 15-minute check policy was taught to staff. The policy covered who was responsible, and what to do if the staff responsible could not do them. Nurse Educator #1 stated if responsible staff were not able to get the checks done, they were supposed to tell someone else on the unit that they were unable to do it so someone else could do the check. During an interview on [DATE] at 12:53 PM, Director of Nursing #1 stated that typically 15-minute checks were put in place for 72 hours and then the situation was reassessed by the nursing staff to determine if the checks were still needed. The need for 15-minute checks should go in the care plan, care card for certified nurse aides, notes should be in the electronic record, and there should be shift to shift messages on why they were in place. All the staff should be checking and filling out the sheets. It was supposed to be a team approach. During an interview on [DATE] at 10:16 AM, Nurse Practitioner #1 stated 15-minute checks were initiated and removed by nursing staff and they were notified when a Resident was placed on or taken off of the 15-minute checks. During an interview on [DATE] at 3:36 PM, Medical Director #1 stated they may request for a resident to be put on 15-minute checks, but it was generally initiated by nursing. They would hear about 15-minute checks being initiated for a resident in morning report. They probably would not get a phone call to notify them if a resident was being put on 15-minute checks. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on record review and interview conducted during the survey, the facility failed to allow one (1) of three (3) residents (Resident #2) to return to the facility to their previous room or immediately upon the first availability of a bed. Specifically, Resident #2, who was on leave at the hospital, was not allowed to return to the facility despite Family Member #2 wanting Resident #2 to return to the facility when they were ready to be discharged from the hospital. Family Member #2 was informed the facility would not accept Resident #2 back and was directed to speak with the social worker/discharge planner at the hospital to assist with arranging an alternative placement. Director of Nursing #1 stated Resident #2 could not be kept on one to one (1:1) supervision after 15-minute checks for safety had failed.This is evidenced by: Cross reference: F600 - Free from Abuse and Neglect The facility policy titled, Transfer and Discharge Rights created 01/2001, released 01/2024, documented its purpose was to ensure transfer and discharges were appropriate to the resident's needs and in accordance with resident's rights. The resident will remain in the nursing home unless transfer or discharge is necessary or requested by the resident. If it was felt that a resident needed to be transferred (other than hospital transfer) or discharged , the Social Worker would consult with the interdisciplinary team as well as the resident and family. Before the transfer or discharge takes place, the resident and family will be notified, preferable 30 days prior to the transfer or discharge. In cases of emergency, this might not be possible. In the case of an involuntary transfer or discharge, a notice will be given which will include a statement that the resident has the right to appeal and will include the telephone numbers of NHSDSS (unknown abbreviation), New York State Department of Health, and the Justice Center, as appropriate, to initiate the appeal. The notice will also include the name and telephone number of the New York State Long-Term Care Ombudsman. In all appeals, the Resident [NAME] of Rights will be respected as well as New York State regulations. The facility policy titled, Transfer to Acute-Hospital (Intra-facility), created 06/2007, released 10/2024, documented the decision to transfer a resident to an acute care hospital was made by a medical provider. The procedure to do so included:Receive an order from provider to send to Emergency Department or direct admission to hospital.Notify family/primary contact if not presentGive verbal report to receiving unit/facilityIf a direct admission to (named Hospital) call admitting and get a bed(Electronic Medical Record) message of transfer to the Interdisciplinary Team. Include name, date, time, and reason of transferRegistered Nurse will write a transfer note to include: where the resident was being transferred, any items that went with the resident, date and time of transfer/discharge, family/primary contact was notified or presentThe Social Worker will inquire about bed hold- payment due Resident #2 was admitted to the facility with the diagnoses of Parkinson's disease with dyskinesia (a neurological disease causing stiffness and movement disorders with jerky movements caused by the medication required to treat the disease), unspecified dementia, unspecified severity, with anxiety (a progressive loss of intellectual functioning, especially impairment of memory and abstract thinking) and atherosclerotic heart disease of native coronary artery without angina pectoris (heart disease without chest pain). The Minimum Data Set ( a resident assessment tool), dated 03/31/2025, documented the resident was usually able to understand others and made themselves understood but was significantly cognitively impaired. Progress note dated 10/10/2025 at 8:58 PM documented Resident #2 was transported to Hospital #1 after being found in Resident #1's room.Resident #2's Comprehensive care plan documented a focus of behavior, with goals that included diversion, redirection, one to one (1:1), television, and 15-minute checks. Effective 04/02/2025.The progress note dated 10/13/2025 at 9:36 AM by Medical Director #1 documented the following: Spoke with Family Member #2 along with Social Worker #1. Family Member #2 is correct that I told them that we could manage Resident #2's behaviors when I spoke with him last, I believe 10/09 [sic]. Unfortunately, the events of 10/10 [sic] have changed the picture considerably and we told Family Member #2 that at least at present, we cannot meet their needs to be discharged from Hospital #1. Family is very much hoping that Resident #2 can be returned to this county at some point.The progress note dated 10/13/2025 at 9:52 AM by Social Worker #1 documented the following: Social Worker #1 let Family Member #2 know that the facility would need to discharge Resident #2 as the facility was unable to meet their needs at this time. Family Member #2 voiced their thoughts on how Resident #2's lack of capacity/ability should be considered in regard to possible future readmission. Family Member #2 asked questions about Resident #2's placement and where they would discharge Resident #2 to from the hospital. Social Worker #1 let Family Member #2 know that the hospital would not be able to discharge Resident #2 unsafely, so directed Family Member #2 to speak with the social worker/discharge planner [at the hospital] to assist in seeking placement. Family Member #2 then asked who they would need to speak to so they could redirect Resident #2's benefits as this facility is their payee. Social Worker #1 provided contact information for the facility biller. Social Worker #1 asked Family Member #2 if they would like to come in and pack Resident #2's belongings or if they would prefer that facility staff complete.During an interview on 12/19/2025 at 11:29 AM, Director of Nursing #1 stated after Resident #2 was found in a resident's room watching them sleep on 10/09/2025, Resident #2 was put on consistent 15-minute checks. During an interview on 01/21/2026 at 10:56 AM, Family Member #2 stated they were informed by the emergency room doctor, who was informed by the facility, that Resident #2 would not be welcomed back to the nursing home facility. Family Member #2 stated the nursing facility staff never met with them regarding discharge from the facility, and they were not provided with options for alternative placements. Family Member #2 stated they were informed that Resident #2 had to go to another hospital (Hospital #2) to wait until there was nursing home placement for them. Family Member #2 stated they would have preferred for Resident #2 to return to the nursing home facility as Resident #2 appeared to like it there and the facility was 20 minutes away from Family Member #2's home. During an interview on 01/22/2026 at 12:53 PM, Director of Nursing #1 stated Resident #2 had to be on a locked unit because of previously well-known exit seeking behaviors. The facility chose not to take Resident #2 back at the time they were cleared for discharge because the facility hadn't concluded their investigation of what happened. Resident #2 could be quick when they wanted to be, and they couldn't keep them on a sit (one (1) to one (1) supervision to ensure safety) and 15 minute checks had failed.During an interview on 01/22/2026 at 1:30 PM, Administrator #1 stated that the whole thing was a very sad situation. There was a unit at another hospital (Hospital #2) where hard to place residents could temporarily stay while placement was found. Usually because of behaviors, placement to nursing homes could be a little harder to do. The unit at the other hospital (Hospital #2) was specifically designed to hold residents with behaviors that were waiting for acceptance at another facility. 10 New York Code Rules and Regulations 415.3(i)

Based on observation, record review and interviews during an abbreviated survey (Case #578139, 578179, and 578120), the facility did not ensure residents were free from neglect for three (3) (Resident #s 7, 105, and 119) of seven (7) residents reviewed for neglect. Specifically, for Resident #7, the facility staff did not perform toileting activities every two (2) hours as care planned; for Resident #105, the facility staff did not use two people to transfer the resident despite being care planned for a two person assist transfer; and for Resident #119, facility staff did not put the resident's bed alarm on when they put the resident back to bed. The care plan violations led to all three residents falling. This is evidenced by: The facility policy and procedure titled Abuse Prevention and Reporting, dated 2/2023, documented that all residents of the facility were to be free from abuse, neglect, mistreatment, misappropriation of property, and involuntary seclusion. The facility shall not permit verbal, mental, sexual or physical abuse, including punishment, involuntary seclusion of residents, or misappropriation of resident property. Preventative measures documented included ongoing education; obtain knowledge of resident's history and current behavior; the Social Worker would complete a thorough psychosocial assessment which would include information regarding the resident's mental health history including history of being abused or abusive, as appropriate; and the current potential to be abused or abusive. These findings would be shared with the Interdisciplinary Team and appropriate interventions would be put in place. Documented under assessment: upon admission, readmission, quarterly and if there is a significant change, the Charge Nurse, with input from The Interdisciplinary Team, would assess the resident for potential to be an abuser and assess the resident if they have a potential to be abused. Forms had been developed and are attached to this policy. The residents scores would be tallied, and an appropriate plan of care would be developed to prevent an incident of abuse. Notification of the results of the assessment would be sent to the social worker who would coordinate a plan of care with team. Before admission, prospective residents would be screened to help determine suitable placement within facility. Upon admission and periodically after that, each resident would have a safety and vulnerability assessment completed which identified potential vulnerabilities such as cognitive, physical, and psychosocial and identify these vulnerabilities and interventions on the resident care plan. It would be the responsibility of the Administrator, the Director Nursing, and the Nurse Managers to ensure staff is supervised sufficiently to identify inappropriate behaviors. Strategies to accomplish this included making regular rounds, observations, and discussions with line staff, residents, and families. The facility policy and procedure titled Comprehensive Care Plan, dated 4/2024, documented that the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights including measurable objectives and timeframes to meet resident's medical, nursing, mental, and psychosocial needs that are identified in comprehensive assessment. Each person's care plan would be developed based on their individual treatment plans. Care plans would be monitored and updated quarterly and with any changes in status. A comprehensive person-centered care plan will include the following components: (a) Describe services that are provided to attain or maintain the resident's highest practicable physical, mental, and psychological well-being; (b) Identify residents' ability to make informed decisions regarding care and have the ability to exercise their right to refuse treatment; (c) Describe any specialized services provided regarding Preadmission Screening and Resident Review recommendations; (d) Include the resident's stated and potential for future discharge to include referrals made to local agencies or entities to support the desire; (e) Include any identified problems, resident strengths, and resident wishes regarding care and treatment goals; (f) Identify the professional services that are responsible for each element of care; (g) Aid in preventing/reducing decline in functional status and/or functional levels. Resident #7 Resident #7 was admitted to the facility with the diagnoses of unspecified dementia of unspecified severity with agitation (a condition characterized by a decline in cognitive function without a clearly identified cause. It includes varying severities and can be recorded with or without accompanying behavioral, psychotic, mood, or anxiety disturbances), myocardial infarction (blood flow decreases or stops in one of the arteries of the heart, causing infarction (tissue death) to the heart muscle), and hypertensive heart disease with heart failure ( long-term condition that develops over many years in people who have high blood pressure). The Minimum Data Set (an assessment tool) dated 10/29/2024, documented that the resident was able to be understood and usually understood others with severe cognitive impairment. The comprehensive care plan for dementia with delusions and negative behaviors dated 8/19/2021 documented the resident had both long term and short-term memory loss. The interventions documented included evaluating the pain and medication regimen and evaluating established routines. The comprehensive care plan for falls related to confusion dated 8/19/2021 documented that the resident would be free of falls and injuries related to falls. Interventions documented included investigating the cause of the fall immediately, maintaining a safe environment, and toileting per the resident schedule. A care plan note dated 1/12/2024 documented that the resident was found on the floor of their bathroom. Resident #7 stated they fell near their bed and scooted themselves to the bathroom. The noted documented the resident did not have to use the bathroom and was last toileted around 10:30 AM. There was no documented evidence that the resident was offered toileting opportunities every two hours. The care card for December documented Resident #7 was offered toileting opportunities once a shift, but not every two hours. Care plan titled Urinary Incontinence and Indwelling Catheter effective 4/02/2025 stated resident to be toileted every 2 hours. During an interview on 12/18/2025 at 2:00 PM, Certified Nurse Aide #5 stated Resident #7 took themselves to the bathroom but could sometimes be incontinent. Certified Nurse Aide #5 stated on the morning of 4/19/25, they found a bruise on Resident #7s right forearm and immediately notified Registered Nurse #4 and Licensed Practical Nurse #4 in charge who then checked the bruise. Certified Nurse Aide #5 stated they did not hear back anything about the incident and was later called into Director of Nursing #1s office when they were then given a care plan violation for not toileting the resident every 2 hours along with a verbal toileting education by Director of Nursing #1. Additionally, Certified Nurse Aide #5 stated the resident had not been care planned to be toileted every 2 hours at the time of incident. Certified Nurse Aide #5 met with Director of Nursing #1, and upon returning to their computer, a message for toileting every 2 hours popped up on the electronic health record for Resident #7. During an interview on 12/19/2025 at 11:05 AM, Director of Nursing #1 stated Resident #7 reported to Registered Nurse #4 that they fell outside of the building. Resident #7 was never outside of facility or outside of their unit. Directory of Nursing #1 stated Resident #7 is alert, confused at baseline and can be territorial or sometimes argumentative with other residents. Director of Nursing #1 said the Resident #7 was care planned to be toileted every two hours sometimes around the time of the incident due to the resident becoming incontinent. After the incident occurred, Director of Nursing #1 was notified and educated Certified Nurse Aide #5 on toileting residents every two hours. There was no facility wide education at the time. Additionally, Certified Nurse Aide #5 had never had any complaints regarding resident care by residents or colleagues. Minimum Data Set Coordinator #1 was on call the date of incident who reported to the Department of Health. The facility investigation, dated 4/24/2025, documented that Resident #7 was found to have some bruising that was attributed to a fall that was unwitnessed. Due to Resident #7's incontinence and inability to follow direction, Resident #7 was placed on every 2-hour continence checks. In the investigation of the bruises noted on the resident's arm on 4/19/2025, Certified Nurse Aide #5 admitted that they did not wake Resident #7 up to be toileted as care planned. Resident #105 Resident #105 was admitted to the facility with the diagnoses of vascular dementia, unspecified severity, with agitation (a decline of thinking skills from condition that damage blood vessels), Alzheimer's disease, unspecified (a progressive brain disorder that slowly destroys memory) and ventricular premature depolarization (type of abnormal heart rhythm that originates from the ventricles of the heart). The Minimum Data Set, dated [DATE], documented the resident was usually understood, sometimes understand others and was severely cognitively impaired. The comprehensive care plan for Activities of Daily Living dated 8/06/2024, documented that the resident required assistance with activities of daily living. Interventions include: assistance of two (2) persons, do not leave alone, dependent on care for bathing, bed mobility, dressing and toileting. For transfers, Resident #105 was documented as requiring the assistance of two (2) persons, dependent with gait belt and stand aid. The facility investigation dated 7/06/2024 documented that on 5/31/2024, Resident #105 was transferred to the bathroom by Certified Nurse Aide #6. Resident #105 did not follow directions of Certified Nurse Aide #6, and due to improper body mechanics, Certified Nurse Aide #6 had to lower Resident #105 to the floor. The physical therapy note dated 6/03/2024 at 4:37 PM, documented that the resident had no change in function or signs of abuse after the fall. The resident was care planned for two-person assistance for transfers with mechanical lift, and Certified Nurse Aide #6 did not follow the care plan. Resident #119 Resident #119 was admitted to the facility with the diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations (progressive neurological disorder that primarily affected movement where the patient does not experience involuntary movements (dyskinesia), unspecified dementia, unspecified severity, with agitation (a condition characterized by a decline in cognitive function) and Alzheimer's disease. The Minimum Data Set, dated [DATE], documented that the resident was usually able to be understood but rarely to never understand others with severe cognitive impairment. The comprehensive care plan for Falls, dated 8/05/2021, documented the resident was at high risk for falls related to confusion, weakness, hypertension, Parkinson's and needed assistance with ambulation. Interventions include: maintaining a safe environment by ensuring the floor was free from clutter and lighting was adequate; documented as of 3/08/2024 the use of a bed alarm. A care plan note dated 8/24/2024 at 5:10 AM, documented the resident was found on the floor next to their bed, and a bed alarm was not present on the bed. Certified Nurse Aide #7 did not follow the care plan after putting Resident #119 back to bed by not putting the bed alarm in place. New York Codes, Rules, and Regulations Title 10 S 415.4 (b)(1)(i)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and/or psychosocial needs for four (4) (Resident #'s 81 and 82) of 24 residents reviewed. Specifically, Resident #81's activities care plan was not person centered to meet the resident's activity needs and one to one visits were not provided as care planned; and Resident #82's Comprehensive Care Plan did not include the residents use of a lap belt and how to manage it. This is evidenced by: The policy titled Comprehensive Care Plan dated 4/2024, documented the facility would implement a person-centered care plan for each resident that met their needs; to include nursing, medical, rehabilitation, activities, and social services. Each resident's care plan would be developed based on their individual treatment plans. Care plans would be monitored and updated quarterly and with any changes in status. Care plans included problems, goals, and interventions. Resident #81 Resident #81 was admitted to the facility with unspecified dementia (a group of conditions that cause a progressive decline in cognitive abilities), generalized anxiety disorder (a mental health condition characterized by excessive fear or anxiety that interferes with daily activities), and major depressive disorder (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life). The Minimum Data Set (an assessment tool) dated 10/10/2025, documented the resident made themselves understood, usually understand others, and had significant cognitive impairment. It further documented that the resident had wandering behavior at times, which significantly intruded on the privacy or activities of others. The Comprehensive Care Plan titled Activities: Limited participation dated 7/24/2025, documented Resident #81 had limited participation in recreation programs related to their mood and confusion. They participated in music, one on one visits, and outdoor visits. Resident #81 also had regular family visits and out of the facility trips with family. The interventions documented include: encourage family support/involvement; praise for all efforts made; provide social/emotional support; and communicate with interdisciplinary team any changes in mood and behavior. Resident #81's Comprehensive Care Plan titled Activities: Limited participation, dated 7/24/2025 did not have documented evidence of person- centered diversional activities or interventions to aid with the resident's undesirable behaviors. There was no documented evidence that Resident #81 was provided with one to one visits as indicated in their care plan. During observations on 12/17/2025 and 12/18/2025 between 10:00 AM and 11:00 AM, Resident #81 was sitting in their wheelchair in the hallway of the unit. During an interview on 12/18/2025 at 12:04 PM, Social Worker #1 stated that Resident #81 required diversion to keep them from invading other resident spaces. The Activities department did not provide one to one visits with Resident #81 due to low staffing, but they did have some groups like the men's group, coffee and news groups, and Bingo. During an interview on 12/18/2025 at 10:39 AM, Activity Director #1 stated they did not provide a lot of one to one visits due to lack of staff, but they tried to do them in between scheduled activities. Resident #82 Resident #82 was admitted to the facility with diagnoses of dementia, ventricular tachycardia (a type of abnormal heart rhythm that originates in the heart's lower chambers, causing them to beat rapidly), and anxiety. The Minimum Data Set, dated [DATE], documented the resident was able to make themselves understood, usually understood others, and had severe cognitive impairments. It further documented that the resident used a trunk restraint when in their chair or out of bed daily. Resident #82's Comprehensive Care Plan titled Restraint Use, documented the resident required restraints related to lack of safety awareness. The goals included: safety would be maintained with use of least restrictive device (low bed). Interventions included: skin assessment every shift for skin breakdown, redness, or bruising and low bed, reposition every 2 hours and as needed or toileting and direct care. Resident #82's care plan did not include use of a seat belt and instructions on how to manage or care for a resident that uses a seat belt. During an observation on 12/17/2025 at 3:53 PM, Resident #82 was observed in their wheelchair with a lap belt in place. During an observation on 12/18/2025 at 9:28 AM, Resident #82 was observed in their wheelchair with a lap belt in place. During an observation on 12/18/2025, Certified Nurse Aide #3 asked Resident #82 to remove his lap belt and the resident was not able to remove it. During an interview on 12/18/2024 at 11:04 AM, Certified Nurse Aide #2 stated lap belts were released every two (2) hours and at mealtimes. They stated Certified Nurse Aides documented this in the electronic medical record. During an interview on 12/18/2025 at 11:20 AM, Licensed Practical Nurse #1 stated lap belts should be released every 2 hours and was completed with transfers, bathroom trips, and at mealtimes. During an interview on 12/18/2024 at 11:32 AM, Registered Nurse #2 stated the interdisciplinary team would discuss a resident's potential need for a lap belt after a fall or multiple falls had occurred. They stated a physical therapy evaluation would need to be completed to assess what type of belt, if any was needed. If a lap belt was needed, a care plan should be put into place for the resident. They stated the lap belt should be released every 2 hours and was done with resident transfers, toileting, and at meals. When Registered Nurse #2 was questioned specifically about Resident #82's lap belt, they stated the lap belt was not included in the resident's care plan. During an interview on 12/19/2025 at 8:26 AM, Director of Rehabilitation Services #1 stated therapy completed assessments of residents to see if a restraint was appropriate, such as a lap buddy or a seat belt. They stated after therapy's evaluation was completed; they would discuss their recommendations at their morning interdisciplinary team meeting to make nursing aware. It was verbal and nothing was provided in writing. Director of Rehabilitation Services #1 further stated nursing was responsible for creating a restraint care plan. During an interview on 12/19/2025 at 10:57 AM, Director of Nursing #1 stated some common reasons for a lap belt included trunk strength support, sliding in the wheelchair, and frequent falls. Physical therapy would evaluate a resident to assess the least restrictive option first. They stated if a lap belt was recommended and determined to be a restraint, the resident's care plan would be updated. Director of Nursing #1 further stated, physical therapy would provide their recommendation regarding lap belts verbally and through the electronic medical record messaging to nursing. Nursing would update the care plan/Kardex and place the updated Kardex in the resident's room and the binder on the unit. 10 New York Code, Rules and Regulations 415.11 (c)(1)

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that it provided 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, encouraging both independence and interaction in the community for three (3) (Resident #s17, 79 and 81) of three (3) residents reviewed for activities. Specifically, Resident #s 17, 79 and 81 were not provided with activities that met the residents' preferences and cognitive abilities. This is evidenced by: The Policy and Procedure titled; Activity Calendar, dated 1/2024, documented the facility would provide opportunities for residents to use their mental and physical capabilities through participation (on an individual or group basis) in recreational, social, or other meaningful activities. The Policy and Procedure titled; Activity Curriculum for the Cognitively Impaired, dated 1/2024 documented that residents who demonstrated a decline in cognition or who were identified as cognitively impaired would have an opportunity to take part in structured therapeutic recreational activities. The activity would empower them to utilize intact skills based on individual assessments done by the Interdisciplinary Team. Resident #17 Resident #17 was admitted to the facility with the diagnoses of unspecified dementia, unspecified severity, with agitation, Alzheimer's disease with early onset, hypertensive chronic kidney disease (a slow, long-term loss of kidney function where damaged kidneys can't properly filter waste and fluid from the blood). The Minimum Data Set (an assessment tool) dated 9/21/2025, documented the resident was usually understood, was usually understand others and was severely cognitively impaired. During general observations every day between 12/15/2025 and 12/19/2025, Resident #17 was seen ambulating alone on the unit or sitting alone in a common area off to the side. Resident #17 was unresponsive to any communication efforts made by the surveyor. During unit observations on 12/18/2025 at 9:39 AM, the activity schedule in the common area had noodle ball listed as the 9:30 AM activity for the unit. There was no activity observed on the unit at that time. Resident #17 was noted to be pacing the hall alone. The Comprehensive Care Plan titled, Activities: Inability to participate/passive observer/limited, dated 1/02/2025, documented Resident #17 would accept one to one visits and continue to observe activities in their unit to maintain interaction level and leisure awareness. The interventions listed included communicate with interdisciplinary team any changes in mood and behavior; encourage lower-level activity such as reading a book, Television, etc.; evaluate resident likes, dislikes and preferences in activities; provide one to one visits; provide monthly calendars; provide needed supplies for preferred activities of choice; provide stimulation using radio or television. There was no documented evidence of activities being done with Resident #17 in the electronic medical record. Resident #79 Resident #79 was admitted to the facility with the diagnoses of unspecified dementia, severe, without behaviors, Alzheimer's disease with late onset, and fracture of unspecified neck of left femur (a break in the thighbone). The Minimum Data Set, dated [DATE], documented that the resident was rarely or never understood, rarely or never understand others and was severely cognitively impaired. During general observations every day between 12/15/2025 and 12/19/2025, Resident #79 was seen sitting in a wheelchair in the common area of the unit. Resident #79 was unresponsive to any communication efforts made by the surveyor. During unit observations on 12/18/2025 at 9:39 AM, the activity schedule in the common area had noodle ball listed as the 9:30 AM activity for the unit. There was no activity observed on the unit at that time. Resident #79 was noted to be sitting, mumbling to themselves and picking at their lap blanket. The Comprehensive Care Plan titled, Activities: Inability to participate/passive observer/limited, dated 9/25/2025, documented Resident #79 would maintain socialization was evidenced by participating in music events, one to one visits, outdoor visits and spend time in the common area when they got to observe activities on the unit. The interventions documented included communicating with interdisciplinary team any changes in mood and behavior; evaluate resident likes, dislikes and preferences in activities; provide one to one visits; and provide stimulation using radio or television. There was no documented evidence of activities being done with Resident #79 in the electronic medical record. Resident #81 Resident #81 was admitted to the facility with unspecified dementia, moderate, with agitation, generalized anxiety disorder, and major depressive disorder. The Minimum Data Set, dated [DATE], documented the resident was able to be understood and usually understood others with significant cognitive impairment. During observations on 12/17/2025 and 12/18/2025 between 10 and 11 AM, Resident #81 was sitting in their wheelchair in the hallway of the unit. The Comprehensive Care Plan titled, Activities: Limited participation dated 7/24/2025, documented Resident #81 had limited participation in recreation programs related to their mood and confusion. They participated in music, one on one visits, and outdoor visits. Resident #81 also had regular family visits and out of the facility trips with family. The interventions documented included encourage family support/involvement; praise for all efforts made; provide social/emotional support; and communicate with interdisciplinary team any changes in mood and behavior. There was no documented evidence of activities being done with Resident #81 in the electronic medical record. During an interview on 12/18/2025 at 12:04 PM, Social Worker #1 stated that Resident #81 required diversion to keep them from invading other resident spaces. Activities did not do one to one visits with Resident #81 due to low staffing, but they did have some groups like the men's group, coffee and news groups and Bingo. During an interview on 12/18/2025 at 9:30 AM, Licensed Practical Nurse #3 stated that there was a children's choir for the activity the day before. When asked if the residents needed more stimulation or activities, Licensed Practical Nurse #3 stated that the residents did need more to do. Licensed Practical Nurse #3 stated that lack of things to do was one of the reasons that residents would have bad interactions. During an interview on 12/18/2025 at 10:39 AM, Activity Director #1 stated that on the dementia unit specifically, they tried to do activities before lunch so that residents were awake for lunch and in the evening to provide distraction when residents might be starting to sundown. When asked about what kind of activities were done on the dementia unit, Activity Director #1 stated that they did a lot of music and sing along, sometimes manicures and massages as well. In the summer they try to take residents into the enclosed courtyard when there were staff available. Activity Director #1 stated they did not do a lot of one-to-one visits because of lack of staff, but they tried to do them in between scheduled activities. Stated they had two full time activity personnel and that they relied heavily on volunteers. Activity Director #1 stated they had asked for more staff but believed that there was a budgetary issue preventing hiring more people. Activity Director #1 stated they knew which residents were and were not joiners, so they would not try to include residents that did not like group activities to participate. During an interview on 12/19/2025 at 11:29 AM, Director of Nursing #1 stated that they were aware that activities was struggling due to low staffing but stated that they were doing their best to keep the residents occupied. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on observation, record review and interviews conducted during a recertification survey, the facility did not ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms, used for the least amount of time, and did not document ongoing re-evaluation of the need for restraints for one (1) (Resident #82) of three (3) residents reviewed for physical restraints. Specifically, Resident #82 did not have a physician's order for the use of a wheelchair lap belt restraint and there was no evidence of a quarterly assessment/evaluation being completed for its use. The is evidenced by: The facility Policy and Procedure titled Restraints, dated 12/2002 and released 6/2024, documented a physical restraint was defined as any manual, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual could not remove easily and that restricted freedom of movement or normal access to one's body. An example of standard restraints used included and were not limited to, lap belts and seat belts. Some devices could be used to promote safety but were considered a restraint if the resident could not remove it independently and required a Physician order for use. A care plan for a restraint would be created to identify the use of restraint and Certified Nurse Assistant task would be generated to document placement. The use of restraints must be discussed at the Interdisciplinary team meetings and documented in the resident's record. Alternatives to restraints must be tried with the resident's response documented in the resident record. The least restrictive restraint device must be used to achieve the desired care goal of the resident, as assessed by the Interdisciplinary care team. Resident restraints should be released at a minimum of every 2 hours or more frequently as assessed by the Interdisciplinary team. The release of restraints should be documented in the resident medical record. The restraint must be terminated at the earliest possible time. Resident #82 was admitted with a diagnoses of unspecified dementia, unspecified with mood disturbance (describes a group of symptoms affecting memory, thinking and social abilities and mood); hypertensive heart disease with heart failure (heart conditions caused by high blood pressure); and anxiety disorder due to unknown physiological conditions (feelings of anxiety and panic interfere with daily activities, were difficult to control, were out of proportion to the actual danger ). The Minimum Data Set (an assessment tool) dated 10/02/2025, documented Resident #82 was understood and usually understand others with moderate cognitive impairment. Resident #82 required the use of a wheelchair for locomotion, partial to moderate assistance of staff for dressing, and was dependent on staff for transfers, toileting, and bathing. The comprehensive care plan for At High Risk for Falls related to deconditioning, recent fracture, and diagnosis of peripheral vertigo, visual deficits, osteoporosis, confusion, lack of safety awareness. Interventions include: Anticipate resident needs with regard to activities of daily living. Occupational or Physical therapy evaluation and treatment per Physician/Family Nurse Practitioner orders. Education on safety techniques. Maintain safe environment by ensuring that floor is free from clutter, lighting is adequate. Safety Precautions: Elopement Falls Protective Measures: Floor mats, Low bed.; Notes: self-releasing seat belt with front and rear anti-tippers when in wheelchair;. encourage resident to look for items by turning his head to the left; Call bell within reach; appropriate footwear. Care plan for Restraint dated 6/26/2024: use of low bed, related to lack of safety awareness was added to care plan on. During an observation on 12/17/2025 at 11:19 AM, Resident #82 was in their wheelchair with a lap belt/seat belt in place. During an observation on 12/17/2025 at 3:53 PM, Resident #82 was in their wheelchair with a lap belt/seat belt in place. During an observation on 12/18/2025 at 9:28 AM, Resident #82 was in their wheelchair with a lap belt/seat belt in place. During an observation on 12/18/2025 at 11:18 AM, Certified Nurse Aide #3 asked Resident #82 to release lap belt/seat belt, and the resident was unable to do so. During an observation on 12/18/2025 at 12:09 PM, Resident #82 was in their wheelchair at the dining room table with a lap belt/seat belt in place. Registered Nurse #2 asked Resident #82 to release seat belt. Resident #82 was unable to do so. Registered Nurse #2 removed Resident #82 lap belt/seat belt at that time. Physical therapy treatment encounter note dated 1/18/2024 documented that Resident #82 had been care planned for the use of a self-releasing seat belt in wheelchair related to the prevention of falling out of the wheelchair. Resident #82 was documented as able to self-release belt; therefore, the seat belt was not considered a restraint. Certified Nurse Aide documentation records dated November 2025 and December 2025 documented wheelchair restraint/lap belt was in use while Resident #82 was out of bed. Treatment Administration Records dated December 2025. There was no documented evidence of a physician order for Seat belt use. Medication Administration Records dated for December 2025, documented no evidence of physician order for seat belt use. There was no documented evidence of discussions in the Interdisciplinary team meetings for the continued need or use of a seat belt in Resident #82's medical chart. There was no documented evidence of continued assessments of the Resident being able to self-release their seat belt in the medical records. During an interview on 12/18/2025 at 11:18 AM, Certified Nurse Aide #3 stated that lap belts should be released every 2 hours for toileting, transfers, bedtime, and mealtimes. There were different types of lap belts used at the facility. One of the requirements was that the residents were supposed to be able to release lap belt without assistance. During an interview on 12/18/2025 at 11:20 AM, Licensed Practical Nurse #1 stated, lap belts should be released every 2 hours and were released with transfers, bathroom trips or at mealtimes. Residents with lap belts should be able to self-release for them not to require a physician's order, and staff were responsible to check belt placement. Licensed Practical Nurse #1 stated they were not sure how often residents with lap belts were evaluated for self-release. Consent from a resident or health care proxy would need to be obtained for the use of any restraints. During an interview on 12/18/2025 at 11:32 AM, Registered Nurse #2 stated that lap belts could be considered a restraint if a resident was unable to self-release, and the use of restraints was only considered and discussed after a resident had multiple falls. The falls would be discussed at the daily morning Interdisciplinary team meeting and a physical therapy evaluation would be needed to assess the type of belt that was appropriate. If a resident was unable to self-release the belt, there should be a Physician order and care plan in place for that individual. Lap bands/seat belts should be released every 2 hours and was done so with resident transfers, toileting and meals. Re-evaluation for continued use of lap belts should be completed every 3 months by the nursing and physical therapy departments at the interdisciplinary team quarterly meetings. Registered Nurse #2 stated they were not familiar with Resident #82 having a lap belt. After reviewing the medical records, Registered Nurse #2 stated that they did not see a physician order or care plan for a lap belt, only for a low bed. During an interview on 12/19/2025 at 8:26 AM, Rehabilitation Director #1 stated that restraints were considered by the interdisciplinary team after a resident had multiple falls, and less restrictive interventions had not been effective. A Resident would have a physical therapy assessment that was signed by the therapists completing the evaluation. Prior to the implementation of a restraint, there should be a doctor's order and care plan implemented by the nurse manager. The ongoing need of a restraint should be evaluated every 3 months at the care planning meeting. Communication between nursing and physical therapy was conducted typically in person at the daily morning interdisciplinary team meeting or via phone call. There should always be a note in the electronic medical chart regarding resident assessments and doctors' orders. Nursing staff typically would monitor for ongoing need of 'restraint' and discuss at the care planning meeting and communicate with the Resident's family members. During an interview on 12/19/2025 at 10:57 AM, Director of Nursing #1 stated that the facility looked at the risk level of the Resident during interdisciplinary team meetings/care plan meetings at minimum quarterly to assess for the need of a lap belt. A physical therapy evaluation would be needed to assess the resident to determine the appropriate, least restrictive option was used first. The resident should be able to release a lap belt on command, if they were able to release the lap belt, it was not considered a restraint. The physical therapy department evaluated the Resident for self-release ability on a quarterly schedule or with any significant change in health status. A Physician order was needed if the lap belt is considered a restraint (if the Resident is unable to self-release the lap belt), restraint consent was needed from either the Resident or family for use, the Resident care plan would be updated to include a lap belt restraint, and the Kardex would be updated to reflect all changes. All updates should be completed as quickly as possible depending on family response to granting consent. The facility had full coverage with a Physician and Nurse Practitioner on shift during the week and off hour on call coverage for any change in health needs. Director of nursing #1 stated Certified Nurse Aides documented on restraint usage each shift, daily. Documentation included the usage of restraints in and out of bed, release of seat belt and resident skin check. Any concerns would be reported to the Licensed Practical Nurse or Registered Nurse. The nurse manager would complete a referral that would be sent to the physical therapy department with any care interventions or concerns. The physical therapy department communicated its recommendations to the nursing staff via in person 24-hour morning report or daily interdisciplinary care meeting, the Licensed Practical Nurse would give their units report to the nurse manager about the past 24 hours, in which the nurse manager would discuss any concerns/needs at the morning interdisciplinary meeting. The physical therapy department would add the residents' evaluation into the electronic medical record and would add a progress note with detailed interventions or changes and inform nursing. The bedside care card/ Kardex would be updated in the resident room and binder on unit. Changes would be updated/implemented as soon as possible. If the divisional clerk was not available to ensure all changes had been made, the discipline/individual making changes to the resident's care would be responsible to ensure the necessary changes have been made in all the appropriate locations. 10 New York Codes, Rules, and Regulations 415.4(a)(2-7)

Based on observations, interviews, and record review conducted during the recertification and abbreviated survey (Case #578117), the facility did not ensure residents were free from significant medication errors for one (1) (Resident #46) of seven (7) residents reviewed for significant medication errors. Specifically, Resident #46 was administered and received seven (7) medications that were ordered for another resident. This is evidenced by: Resident #46 The policy titled Medication Administration dated 6/2023, documented under supportive data: A.) the medication nurse was personally responsible for every drug they administered; B.) positively identified the resident before administering drugs with instruction to check the resident's identification and ask the resident to state their name and if unable to identify self, ask staff to identify the resident; C.) read the drug label at least 3 times; D.) properly position the resident (if necessary) before administering the drug; E.) provide privacy when administering any injection; F.) before administering any drug, review the following rights: 1.) right resident; 2.) right drug; 3.) right does; 4.) right route; 5.) right time; and 6.) right documentation. G.) check expiration dates prior to administration; and H.) observe the resident take the drug. The policy titled Medication Safety Program dated 6/2023, documented the facility supported safe medication practices and a systems improvement approach to the prevention of medication errors. The facility encouraged the reporting of medication errors, adverse drug events, potential adverse drug events, and potential adverse drug events to assess and improve systems and processes for prescribing, transcribing, dispensing, and administering medications. The goal was to enhance patient safety by decreasing the potential for medication errors. Medication errors were defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication was in control of the health care professional, patient or consumer. Medication errors included, but were not limited to wrong patient, wrong drug, wrong dose, wrong route, wrong frequency, and wrong time. Resident #46 was admitted to the facility with diagnoses of dementia (a group of conditions that cause a progressive decline in cognitive abilities), hyperlipidemia (a condition that causes high levels of lipids, or fats, in your blood), and anxiety (a mental health condition characterized by excessive fear or anxiety that interferes with daily activities). The Minimum Data Set (an assessment tool) dated 4/25/2024, documented the resident made themselves understood, usually understand others, and had severe cognitive impairments. The facility Root Cause Analysis Investigation dated 5/21/2024, documented Licensed Practical Nurse #2 administered seven (7) medications to Resident #46 on 5/14/2025 at 5:30 PM. The medications that Resident #46 received in error included: Simethicone 80 milligrams, Meloxicam 15 milligrams, Protonix 40 milligrams, Risperidone 1 milligram, Melatonin 10 milligram, Buspar 15 milligram, and Amlodipine 10 milligrams. It was further documented, that Licensed Practical Nurse #2 failed to practice safe medication administration by not verifying the correct resident and not passing medications according to the ordered time. They did not perform the five rights of medication administration. During an observation on 12/18/2025 at 1:37 PM, Resident #46 was observed up, groomed, and dressed in the common area on the unit. They were approachable and engaged in conversation. During an interview on 12/18/2025 at 1:37 PM, Resident #46 was able to say their full name when asked what their name was. During an interview on 12/18/2025 at 1:42 PM, Certified Nurse Aide #4 stated that Resident #46 could tell you their name most of the time. During an interview on 12/18/2025 at 1:52 PM, Registered Nurse #3 was asked what the 5 Rights of Medication Administration were. Registered Nurse #3 stated: right patient, route, time, dose, and maybe documentation. They stated they checked the residents name bracelet or their picture in the electronic medical record to identify a resident when passing medications. Registered Nurse #3 further stated that Resident #46 was able to tell you their name if asked what it was. During an interview on 12/18/2025 at 11:32 AM, Registered Nurse #2 stated they completed all the accident and incident reports at the facility. They stated Licensed Practical Nurse #2 gave Resident #46 another resident's medications. It was a significant medication error, and the nurse was terminated. They stated, they tried to complete counseling and education for medication errors, but some errors could not be ignored such as giving medication to the incorrect resident. They did not want their residents harmed there. Registered Nurse #2 further stated the facility provided medication administration education upon hire and annually. During an interview on 12/19/2025 at 10:02 PM, Director of Nursing #1 stated on 5/14/2024 at 5:30 PM, Licensed Practical Nurse #2 popped all of the medications, gave the medications outside the window of time they were ordered, and gave them to the wrong resident. They stated Licensed Practical Nurse #2 was suspended during the investigation and then terminated related to the event on 5/16/2024. Director of Nursing #1 stated once Licensed Practical Nurse #2 realized they had administered the medications to the wrong resident, they immediately reported it to the Registered Nurse, Resident #46 was assessed, and the Medical Provider and family were notified. The Medical Provider gave new orders and Resident #46 was put on 15- minute checks for additional safety. Director of Nursing #1 stated they believed a house wide education on medication administration was completed. They also completed a root cause analysis and reported the medication error to the Chief Nursing Officer who reported it to New York State Board of Education. They further stated medication audits were completed which included the 5 Rights to Medication Administration and the audits were reviewed at the Quality Assurance Performance Improvement Committee. Director of Nursing #1 stated they were still completing medication audits. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: Upon discovery of the medication error, a Registered Nurse assessment was completed immediately. The medication error was reported to the resident's representative and the physician with new orders obtained. The Licensed Practical Nurse who was responsible for the medication error was suspended during the investigation and later terminated. The Board of Education was notified of the nurse's error. The medication error was reported to the New York State Department of Health Medication Administration education was initiated on 7/09/2024 to all nursing staff including Licensed Practical Nurses and Registered Nurses on the Medication Administration policy and procedure, the 6 (six) rights, and documentation. Education was completed on 12/12/2024. For Quality Assurance, medication administration audits were initiated and reviewed monthly. Medication administration audits were still being conducted at time of survey. 10 New York Codes, Rules, and Regulation 415.12(m)(2)

Based on record reviews and interviews during an abbreviated survey (Case #NY00369068), the facility did not ensure 1 (Resident #1) of 3 residents reviewed were free from verbal abuse. Specifically, Resident #1 was not protected from verbal abuse by staff members. This is evidenced by: The policy and procedure titled Abuse Prevention and Reporting, dated 6/2023, documented the facility would not permit verbal, mental, sexual, or physical abuse. Resident #1 was admitted to the facility with the diagnoses of dementia, emphysema (a chronic lung disease that progressively damages the aveoli, or tiny air sac, in the lungs), and atrial fibrillation (irregular heart rate). The Minimum Data Set (an assessment tool) dated 12/02/2024 documented the resident could understand, be understood by others, and was cognitively intact. The Comprehensive Care Plan titled Behavior last revised on 2/28/2024 documented resident was physically aggressive with staff. Intervention included; monitor behavior and intervene and report to Registered Nurse and physician Facility's Investigation Report dated 1/15/2025 documented multiple staff reported Licensed Practical Nurse #1 spoke aggressively towards Resident #1 while yelling at the resident. Multiple Certified Nurse Aides were present in the dining room and overhhead the interaction between Resident #1 and Licensed Practical Nurse #1 A document titled Review Form for Managers documented Licensed Practical Nurse #1 was witnessed speaking loudly and aggressively toward Resident #1. In a written statement dated 1/15/2025, Divisional Clerk #1 stated they witnessed Licensed Practical Nurse #1 mocking the way Resident #1 was speaking. In a written statement dated 1/15/2025, Certified Nurse Aide #2 documented they heard Licensed Practical Nurse #1 and Resident #1 having heated words. In a written statement dated 1/15/2025, Certified Nurse Aide #2 documented they overheard Licensed Practical Nurse #1 yelling at Resident #1. In a written statement dated 1/15/2025, Licensed Practical Nurse #1 documented Resident #1 had raised their voice to them, so they matched Resident #1's voice tone, During an interview on 1/23/2025 at 3:25 PM, Director of Nursing #1 stated when the incidents were reported to them, Licensed Practical Nurse #1 was interviewed. Licensed Practical Nurse #1 denied all allegations of physical abuse and admitted raising their voice was probably not appropriate. They were placed immediately on administrative leave and displayed unprofessional behavior while in the medication room with the assistant director of nursing. Licensed Practical Nurse #1 was informed by Director of Nursing #1 that this incident would be reported to the Department of Health and Office of Professions. Director of Nursing #1 stated the Licensed Practical Nurse had been on a performance improvement plan prior to this incident for professionalism. Licensed Practical Nurse #1 was terminated from employment. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #NY00334727), the facility did not ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency for 1 (Resident #20) of 4 residents reviewed for abuse. Specifically, Resident #20 was left unattended on 2/29/2024 at 12:25 PM, fell , and sustained injury while ambulating. Resident #20's care plan documented the resident required a staff member assist with transfers and ambulation. The incident was not reported to the Department of Health until 3/01/2024 at 2:18 PM. This is evidenced by: Resident #20 was admitted to the facility with diagnoses of Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), unspecified dementia with behavioral disturbance (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and type 2 diabetes (a chronic condition that happens when a person has persistently high blood sugar levels). The Minimum Data Set (an assessment tool) dated 2/18/2024, documented the resident with severe cognition impairment, could be understood and could understand others. Facility Policy and Procedure titled, Fall Assessment, Prevention and Management dated 12/2022 (last updated 1/2024), documented that care plans should include a falls prevention plan as appropriate for the resident. Facility Policy and Procedure titled, Safe Events Reports and Quality Improvement - Nursing Home dated 11/2002 (last updated 4/2022), documented that Safe Events Reports were to be completed and referred to the Administrator, Director of Nursing, and Clinical Nurse Manager. Additionally, the Safe Events Reports should be reviewed with the Interdisciplinary Team at their daily meeting. Facility investigation dated 3/04/2024 documented that the Registered Nurse on duty at the time of the fall did not know that the Certified Nurse Aide who was assigned to provide care to Resident #20 had allowed a care plan violation to occur when Resident #20 was left to ambulate independently. The Certified Nurse Aide did not know that Resident #20 was care planned to have a one person assist when ambulating. Additionally, the facility investigation documented that both staff members were reeducated on care plans and their responsibilities regarding resident care and reporting of incidents. Record review of Resident #20's progress notes on 2/29/2024 revealed they were left unattended on 2/29/2024 at 12:25 PM, fell , and sustained injury to their head while ambulating. Resident progress notes from 2/29/2024 to 3/01/2024 documented that the resident fell , and assessments were completed post fall. Resident comprehensive care plan for Activities of daily Living dated 9/29/2023 documented the resident required touching assistance with transfers and when ambulating. Record review of the New York State Department of Health ASPEN Complaint Tracking System revealed the 2/29/2024 fall event was reported to the Department of Health on 3/01/2024 at 2:18 PM. During an interview on 3/19/2024 at 10:45 AM, Administrator #1 stated every accusation against staff was taken seriously, with the resident protected, and the accusations investigated. They stated they report all allegations of abuse, mistreatment, misappropriation, and injuries of unknown origin to the New York State Department of Health. 10 New York Codes, Rules, and Regulations 415.4 (b)

Based on observations, record review and interviews during an abbreviated survey (Case #s NY00301319, NY00313776, NY00318247, NY00318964, and #NY00324492) dated 3/18/2024 through 3/29/2024, the facility did not ensure the facility implemented a comprehensive person-centered care plan for each resident for 5 (Residents #6, 15, 19, 23, and 24) of 25 residents reviewed for comprehensive care plans. Specifically, for Residents #6, 15, and 19, 15-minute safety checks were not completed; Resident #23's bed was not in a low position and appropriate footwear was on the resident on 8/26/2022; and Resident #24's, bed alarm was not in place before the resident was put to bed on 6/11/2023 as per resident care plans. This is evidenced as follows: The Policy and Procedure titled, Fall Assessment, Prevention and Management, dated 1/2024, indicated the prevention tools available to use in the prevention of a fall included 15-minute observation sheet and alarms (bed mat, chair mat and personal alarm). Resident #6 Resident #6 was admitted to the facility with the diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, and rheumatoid arthritis. The Minimum Data Set (an assessment tool) dated 2/19/2023 documented the resident was understood by others and able to understand others. The Brief Interview for Mental Status documented the resident was cognitively intact. During record review, Resident #6's comprehensive care plan titled, Falls initiated on 2/10/2021 and revised on 6/12/2023, was reviewed and indicated the interventions included 15-minute safety checks to be completed by the Certified Nurse Aide. Record review for Resident #6 indicated a document titled, Resident Nursing Instructions dated 3/1/2023-3/31/2023, listed 15-minute check was initiated on 1/26/2023. Resident #6's record review of a document titled, 15-minute Observation Sheet initiated on 1/26/2023, indicated no documentation of 15-minute checks being done from 2:00 AM to 6:00 AM on 3/30/2023. A progress notes for Resident #6, dated 3/30/2023 at 6:50 AM, was reviewed and indicated the resident was found at 5:45 AM after an unwitnessed fall. The resident had a minor injury and did not need to be sent to the hospital for evaluation. Resident #23 Resident #23 was admitted to the facility with diagnoses of Parkinson's disease with dyskinesia, hyperlipidemia, gastroesophageal reflux disease. The Minimum Data Set, dated dated dated [DATE], documented Resident #23 could be understood and could understand others with a Brief Interview of Mental Status indicating of no cognitive impairment. During record review, Resident #23's comprehensive care plan titled, Behaviors, initiated 9/16/2020, was reviewed. It indicated Resident #23 exhibited behaviors including self-ambulation, refusing care and being resistive to care at times with an intervention of safety checks every 15 minutes. Resident #23's comprehensive care plan titled, Falls, initiated 9/17/2020, was reviewed and indicated an intervention of safety checks every 15 minutes. Resident #23's document titled, Resident Nursing Instructions, for the period of 8/1/2022 through 8/31/2022 was reviewed and indicated 15-minute safety checks were to be completed and documented for the resident. Resident #23's document titled, 15 Minute Observation Sheet, was reviewed and indicated no documentation for 15-minute safety checks between 2:00 PM and 7:00 PM on 8/26/2022. During record review, Resident #23's progress note dated 8/26/2022 at 8:11 PM indicated Resident #23 had been found at 7:20 PM after an unwitnessed fall. The progress note indicated Resident #6 was transferred to the hospital for evaluation. Resident #24 Resident #24 was admitted to the facility with the diagnoses of dementia with agitation, chronic obstructive pulmonary disease, and vascular parkinsonism. The Minimum Data Set, dated dated dated [DATE], documented Resident #24 could usually be understood and could sometimes understand others with a Brief Interview of Mental Status indicating severe cognitive impairment. During record review, Resident #24's comprehensive care plan titled, Falls, initiated 8/19/2021, listed a bed alarm as an intervention. Resident #24's document titled, Resident Nursing Instructions, for the period of 6/1/2023 through 6/30/2023 was reviewed and indicated a bed alarm was to be applied to Resident #24's bed when the resident was in bed. Resident #24's progress note dated 6/11/2023 at 8:10 PM, was reviewed and indicated resident had been found on the floor after an unwitnessed fall at 7:40 PM. Further review indicated the progress note documented a bed alarm was not in use on Resident #24's bed. The progress note indicated Resident #24 had a skin tear but no major injury and did not require transfer to a hospital for evaluation. General interviews: During an interview on 3/28/2024 at 12:10 PM, Licensed Practical Nurse #2 stated that the nurse, either a licensed practical nurse or registered nurse, would check over the certified nursing aide paperwork at the end of the shift and will go to the assigned certified nursing aide if there were blanks or discrepancies. They stated that if a 15-minute safety check sheet was not completed, it would be a care plan violation. During an interview on 3/28/2024 at 12:15 PM, Certified Nurse Aide #7 stated the 15-minute safety check sheet was to be completed. If they were to go on lunch or know they would be in another resident's room for an extended amount of time, they would go to the nurse or another certified nursing aide to help complete the checks for them. They stated that not completing the 15-minute safety check sheet was a care plan violation. 10 New York Codes, Rules, and Regulations 415.11 (c)(1)

Based on record review and interviews during an abbreviated survey (Case #NY00324492), the facility did not ensure the resident's environment remained as free of accident hazards as was possible for 1 (Resident #15) of 5 residents reviewed for accidents. Specifically, Resident #15 was found on the floor on 9/19/2023, bed was not in a low position, call light not within reach, and resident had no socks on. This is evidenced as follows: Resident #15 Resident #15 was admitted to the facility with diagnoses of heart failure, type 2 diabetes mellitus, and end stage renal disease. The Minimum Data Set (an assessment tool) dated 9/22/2023, documented the resident could be understood and could usually understand others with a Brief Interview of Mental Status indicated moderate cognition impairment. The Policy and Procedure titled, Fall Assessment, Prevention and Management, dated 1/2024 documented the prevention tools available to use in the prevention of a fall included 15-minute observation sheet and alarms (bed mat, chair mat and personal alarm). The Comprehensive Care Plan titled, Falls, initiated 9/26/2022 documented interventions included a low bed and appropriate footwear. The Resident Nursing Instructions for care from 9/1/2023 through 9/30/2023 documented a low bed as a safety instruction. A progress note dated 9/19/2023 at 10:34 PM documented the Resident had an unwitnessed fall. The resident was found on the floor, the bed was not in the low position, the call light was not in reach, and the resident did not have socks on. The Facility Investigation completed 9/20/2023 documented the Certified Nurse Aide did not follow the care plan. The Certified Nurse Aide did not place a bed alarm on the resident's bed prior to placing the resident in bed. The resident also did not have non-skid socks on, and the call light was not in reach. During an interview on 3/20/2024 at 12:40 PM, Human Resource Director #1 confirmed Certified Nurse Aide #2 was still actively employed by the facility. Certified Nurse Aide #2 was provided with education regarding following a resident's care plan to prevent falls and injuries. During an interview on 3/21/2024 at 10:00 AM, Clinical Educator #1 stated if the incident involved only one resident and one staff member, that staff member would be individually counseled. They stated they were a member of the Quality Assurance and Performance Improvement committee and that falls were discussed not only in morning report but at the quarterly meetings. If a systemic issue was found to be at the root of an incident, they would hold education for all employees. During an interview on 3/21/2024 at 11:56 AM, Certified Nurse Aide #2 stated they knew the care plan should be followed to made sure residents do not become injured. They stated they should have checked the care instructions and known to put a bed alarm on the resident's bed. They stated they should have made sure the call light was in reach and the resident had non-skid socks on. They stated they were given education regarding following a care plan after the incident. They stated they received abuse, neglect, and mistreatment education when they were hired and then again after they had been at the facility for about a year. They stated if they had any questions about a policy or procedure, they felt comfortable asking the nurse manager or going to the clinical specialist. During an interview on 3/28/2024 at 12:15 PM, Certified Nurse Aide #7 stated the 15-minute safety check sheet should have been completed. If they were to go on lunch or know they would be in another resident's room for an extended amount of time, they would go to the nurse or another certified nurse aide to help complete the checks for them. They stated that not completing the 15-minute safety check sheet was a care plan violation. They stated that safety instructions like making sure the bed was in the lowest position before leaving the room and applying non-skid socks to residents' feet were also important to help prevent falls. 10 New York Codes, Rules, and Regulations 415.12(h)(1)

Based on record review and interviews during an abbreviated survey (Case #s NY00302427, NY00303564, NY00312507, and #NY00313484), the facility did not ensure that in response to allegations of abuse, the facility must ensure all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Specifically, the facility did not ensure abuse was reported to the Department of Health (DOH) or reported within 2 hours if the events that cause the allegation involve abuse or result in serious bodily injury, for 5 (Resident #s 1, 2, 3, 4, and 5) of 7 residents reviewed for abuse. For Resident #1, the facility did not report an incident of alleged sexual abuse until 4 hours after the resident reported the incident, for Resident #2, the facility did not report an incident of alleged sexual abuse until 5 hours after the resident reported the incident. For Resident #s 3 and 4, the facility did not report an allegation of sexual abuse made by Resident #4 against Resident #3 to DOH. For Resident #s 4 and 5, the facility did not report an alleged resident-to-resident altercation between the 2 residents to DOH. This was evidenced by: The Policy and Procedure dated 10/2019 titled, Abuse Prevention and Reporting documented by regulation the facility was responsible to report alleged violations of abuse to the Director of Nurses (DON), and the Administrator in accordance with State law, to DOH as soon as possible, but not to exceed 24 hours after the discovery of the alleged abuse. Resident #1 Resident #1 was admitted to the facility with diagnoses of dementia with psychotic disturbance (hallucinations, delusions, confused, and disturbed thoughts), Alzheimer's disease, and schizoaffective disorder, bipolar type. The Minimum Data Set (MDS- an assessment tool) dated 2/28/2023, documented the resident had severe cognitive impairment, could be understood, and could understand others. The undated and untimed Nursing Home Investigative Report submitted to DOH documented the incident occurred on 3/27/2023 at 8:00 AM. An email from Survey Builder at DOH, documented the Nursing Home Incident Report was submitted on 3/27/2023 at 12:11 PM. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated abuse needed to be reported within 2 hours if bodily harm occurred and 24 hours if no injury occurred. During an interview on 4/5/2023 at 1:41 PM, the DON stated abuse needed to be reported within 2 hours if injury occurred and within 24 hours if no injury. The DON stated they would report abuse as soon as they found out about an incident. Resident #4 Resident #4 was admitted to the facility with diagnoses of dementia, psychotic disorder, and diabetes. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could usually understand others. A Nursing Note dated 3/26/2023 at 10:20 AM, documented Resident #4 was in their wheelchair in Resident #5's doorway. Resident #5 asked Resident #4 to move. Resident #4 would not move, and they hit Resident #5 on top of their left thigh 2-3 times with a closed fist. There was no documentation that the incident was reported to DOH. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated they did not know why the incident was not reported to DOH. Abuse needed to be reported within 2 hours if bodily harm occurred and 24 hours if no injury occurred. During an interview on 4/5/2023 at 1:41 PM, the DON stated both Resident #s 4 and 5 had behaviors. The DON stated the incident probably should have been reported. They stated abuse needed to be reported within 2 hours if injury occurred and within 24 hours if no injury. The DON stated they would report abuse as soon as they found out about an incident. Resident #5 Resident #5 was admitted to the facility with diagnoses of diabetes, seizure disorder, and coronary artery disease. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could understand others. A Nursing Note dated 3/26/2023 at 10:24 AM, documented Resident #5 was in their wheelchair in the hallway attempting to enter their room. Resident #4 was in their wheelchair in the doorway of Resident #5's room. Resident #5 asked them to move, and when Resident #4 would not, Resident #5 attempted to move Resident #4's wheelchair with their foot. Resident #4 then hit Resident #5 on the left thigh with a closed fist 2-3 times. There was no documentation that the incident was reported to DOH. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated they did not know why the incident was not reported to DOH. They stated abuse needed to be reported within 2 hours if bodily harm occurred and 24 hours if no injury occurred. During an interview on 4/5/2023 at 1:41 PM, the DON stated both Resident #s 4 and 5 had behaviors. The DON stated the incident probably should have been reported. They stated abuse needed to be reported within 2 hours if injury occurred and within 24 hours if no injury. The DON stated they would report abuse as soon as they found out about an incident. 10 NYCRR 415.4(b)(3)

Based on record review and interviews during an abbreviated survey (Case #s NY00302427, NY00303564, NY00312507, and NY00313484), the facility did not ensure in response to allegations of abuse and neglect the facility must have evidence that all alleged violations are thoroughly investigated for 4 (Resident #s 4, 5, 6, and 7) of 7 residents reviewed for abuse and neglect investigations. Specifically, incidents that involved Resident #s 4, 5, 6, and 7's did not include investigative summaries, or the summaries that were included were not thorough. This was evidenced by: The Policy and Procedure dated 10/2019 titled, Abuse Prevention and Reporting documented the Administrator will ensure that a complete investigation is conducted. The Director of Nursing (DON) or designee shall coordinate all investigations including but not limited to the following tasks: conducting interviews with staff and resident, writing a summary and conclusion, and what corrective steps were taken. Resident #4 Resident #4 was admitted to the facility with diagnoses of dementia, psychotic disorder, and diabetes. The Minimum Data Set (MDS- an assessment tool) dated 1/17/2023, documented the resident had moderate cognitive impairment, could be understood, and could usually understand others. A Nursing Note dated 3/26/2023 at 10:20 AM, documented Resident #4 was in their wheelchair in Resident #5's doorway. Resident #5 asked Resident #4 to move. Resident #4 would not move, and they hit Resident #5 on top of their left thigh 2-3 times with a closed fist. There was no documentation of the facility's investigation summary of the incident. Resident #5: Resident #5 was admitted to the facility with diagnoses of diabetes, seizure disorder, and coronary artery disease. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could understand others. A Nursing Note dated 3/26/2023 at 10:24 AM, documented Resident #5 was in their wheelchair in the hallway attempting to enter their room. Resident #4 was in their wheelchair in the doorway of Resident #5's room. Resident #5 asked them to move, and when Resident #4 would not, Resident #5 attempted to move Resident #4's wheelchair with their foot. Resident #4 then hit Resident #5 on the left thigh with a closed fist 2-3 times. There was no documentation of facility's investigation summary of the incident. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated an investigation would be started immediately upon report of an incident and consisted of interventions to ensure the resident(s) was/were safe, witness statements, resident statement(s), the care plan was updated as necessary, an assessment would be done on the resident, and corrective action(s) implemented to ensure an incident did not recur. During an interview on 4/5/2023 at 1:41 PM, the DON stated an investigation was not completed for the resident-to-resident incident between Resident #s 4 and 5. The DON stated an investigation was not done due to the residents' behavioral issues. They stated both Resident #s 4 and 5 had behaviors. Resident #6 Resident #6 was admitted to the facility with diagnoses of dementia, diabetes, and anxiety disorder. The MDS dated [DATE] documented the resident had severe cognitive impairment, could be understood, and could sometimes understand others. The facility investigation did not include interventions to prevent a recurrence of the care plan violation that involved Resident #6's lap buddy use. The investigation included one staff interview. A Nurse's Note dated 10/9/2022 at 10:56 AM, documented Registered Nurse Supervisor (RNS) #1 was called to the unit. Resident #6 was on the floor bleeding from their left eye socket from a laceration, a head laceration on their left temporal area. The resident's nose was bleeding. 911 called and the on-call MD was notified. During an interview on 4/5/2023 at 1:13 PM, the Administrator stated an investigation would be started immediately upon report of an incident and consisted of interventions to ensure the resident(s) was/were safe, witness statements, resident statement(s), the care plan was updated as necessary, an assessment would be done on the resident, and corrective action(s) implemented to ensure an incident did not recur. During an interview on 4/6/2023 at 9:17 AM, the DON stated an investigation consisted of staff interviews, including staff who were in the area even if they had not witnessed anything. The resident would be interviewed. An investigation summary would include a history about resident, resident records, what was done about the incident (interventions to prevent recurrence.), and a synopsis of the interviews. The DON stated an investigation must be completed within 5 days. The DON stated for this incident, CNA #6 was not interviewed because they were sent home. 10 NYCRR 415.4(b)(3)

The facility did not ensure that its residents were free of any significant medication error during an abbreviated survey (Case #s NY00302427, NY00303564, NY00312507, NY00313484, and NY00316282) for 3 residents (Resident #s 9, 10, and #11) of 4 residents reviewed for significant medication errors. Specifically, for Resident #9, the facility did not ensure licensed staff did not administer a medication used to treat anxiety (diazepam-a controlled substance) that was on hold from 12/9- 12/13/2022 on 2 occasions (12/10/2023 and 12/12/2023), for Resident #10, the facility did not ensure that facility staff administered the correct doseage of a controlled substance to treat anxiety (clonazepam) after the doseage of clonazepam was reduced by the Medical Doctor (MD) on 4/19/2023 from clonazepam 0.50 mg to clonazapam 0.25 mg and for Resident #11, the facility did not ensure that the physician order for a narcotic pain medication (Percocet) for 5/325 mg, 2 tablets twice a day as needed was followed on 1 occasion, when only 1 tablet was administered. This was evidenced by: The Policy and Procedure titled, Medication Administration Safety Program documented a medication error is any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional. A medication error can also be defined as a mistake with one of the 6 rights that includes right medication, right time, and right dose. Resident #9 Resident #9 was admitted to the facility with diagnoses of Alzheimer's disease, dementia, and anxiety disorder. The Minimum Data Set (MDS- an assessment tool) dated 11/21/2022, documented the resident had severe cognitive impairment, could sometimes be understood, and could sometimes understand others. The Comprehensive Care Plan (CCP) dated 4/28/2022 for Psychotropic Drug Use: Behavior Problems, documented to administer medications as ordered. An MD (medical doctor) order dated 12/9/2022 at 6:58 PM, documented diazepam 5 (mg), 1 tablet once daily; hold from 12/9/2022 at 7:00 PM- 12/13/2022 at 12:00 PM. The 12/14/2022 facility event report, documented Licensed Practical Nurse (LPN) #2 administered Resident #9's diazepam 5 mg in error on 12/14/2022 at 10:30 AM thinking they were administering lorazepam. The error actually occurred on 12/12/2022 during the timeframe diazepam was on hold. LPN #6 also administered Resident #9 diazepam at 8:00 PM on 12/10/2022 while the medication was on hold. There was no facility medication error report regarding the incident. The 12/2022 Medication Administration Record (MAR) documented diazepam 5 mg tablet, 1 tablet once daily at 7:00 PM. It was documented as held from 12/9/2023-12/13/2023. The Controlled Medication Utilization Record dated 12/5/2022 for diazepam 5 mg daily documented LPN #6 administered diazepam 5 mg at 8:00 PM to Resident #9 on 12/10/2022. The Controlled Medication Utilization Record dated 12/5/2022 for diazepam 5 mg daily documented LPN #2 administered Diazepam 5 mg at 10:30 AM to Resident #9 on 12/12/2022. During an interview on 5/16/2023 at 1:35 PM, the Director of Nursing (DON) stated LPN #2 administered Resident #9 diazepam instead of lorazepam. The resident had a number of medication changes when LPN #2 made the medication error on 12/12/2022. Resident #10 Resident #10 was admitted to the facility with diagnoses of seizure disorder, chronic obstructive pulmonary disease (COPD), and anxiety disorder. The MDS dated [DATE], documented the resident was cognitively intact, could be understood, and could understand others. The CCP for Psychotropic Drug Use dated 3/16/2023, documented to administer medication as ordered. An MD order dated 4/19/2023 at 11:19 AM, documented clonazepam 0.25 mg (give 1/2 of a 0.5 mg tablet) once daily. The April 2023 MAR documented clonazepam 0.5mg tablet give 1/2 tablet (0.25 mg) once daily at 2:30 PM. The 3/30/2023 pharmacy label on the Controlled Medication Utilization Record, documented clonazepam 0.5 mg by mouth 3 times a day; DIRECTIONS CHANGED, REFER TO CHART. It documented on 4/20/2023, unknown LPN #5 (unable to decipher signature) administered 0.50 mg at 3:30 PM. On 4/24/2023, LPN #2 documented they administered 0.5 mg at 2:00 PM. The Controlled Medication Utilization Record dated 4/19/2023 for medication received from pharmacy, did not document clonazepam 0.25 mg was administered at 2:30 PM on 4/20/23 or 4/24/2023. The undated Event Report for the medication error that occurred on 4/24/2023 documented LPN #2 reported at 3:45 PM they had administered Resident #10 the wrong dose of clonazepam at 2:30 PM. They reported they administered 0.50 mg instead of 0.25 mg as ordered. A Nursing Note dated 4/24/2023 at 4:14 PM, documented LPN #2 notified Registered Nurse #4 (RN) that they administered Resident #10 the wrong dose of clonazepam at 2:30 PM. The LPN administered 0.5 mg instead of 0.25 mg as ordered. The resident had a current gradual dose reduction of clonazepam in progress. Resident #10 did not exhibit and signs or symptoms of fatigue or sedation. The Administrator on call, the medical provider, and the resident's representative were notified. During an interview on 5/16/2023 at 1:35 PM, the DON stated LPN #2 administered Resident #10, 0.50 mg of clonazepam on 4/24/2023. The MD had decreased the dose a few days prior to 0.25 mg. During an interview on 5/22/2023 at 1:07 PM, Registered Nurse Manager #1 (RNM) stated Resident #10's Clonazepam 0.50 mg three times a day was discontinued and changed to 0.25 mg once a day at 2:30 PM and 0.5 mg twice a day at 8:30 AM and 8:30 PM. During an interview on 5/22/2023 at 1:17 PM, the Interim DON, stated when there were changes to controlled substance orders, stickers were put on the pharmacy label of the Controlled Medication Utilization Record to alert the nurses there was a change and to look at the resident's chart. They stated they were unable to identify who unknown LPN #5 was. Resident #11 Resident #11 was admitted to the facility with diagnoses of Alzheimer's disease, COPD, and diabetes. The MDS dated [DATE], documented the resident had severe cognitive impairment, could be understood, and could sometimes understand others. The CCP Alteration in Comfort (Pain), documented to administer medications as ordered by the physician or nurse practitioner. The MD order for Percocet 5 mg-325 mg ordered on 6/3/2022, documented to administer 2 tablets by mouth every 3 days for chronic pain at 2:00 PM. A documented titled, Event Report dated 5/8/2023, documented on 5/7/2023 at 2:00 PM, LPN #2 administered Resident #11 one Percocet 5 mg-325 mg tablet. The order was for the resident to receive 2 tablets. The May 2023 MAR documented LPN #2 administered Resident #11's Percocet on 5/7/2023. The Controlled Medication Utilization Record dated 5/2/2023 for Percocet 5-325mg, documented on 5/7/2023, the number of remaining tablets was 18 after LPN #2 administered the Percocet at 2:00 PM. The remaining should have been 17 on the date the resident was supposed to receive 2 tablets due to their fentanyl patch being changed. On 5/8/2023 before a PRN (as needed) dose was administered, and the number of remaining tablets was 17. A Nurse's Note dated 5/8/2023 at 1:11 AM, documented an unnamed LPN notified RN #4 of the medication error that had occurred on the prior shift on 5/7/2023. Resident #11 was to receive 2 tablets of Percocet 5-325 mg on Fentanyl (a narcotic pain medication) patch change days. The resident only received 1 tablet on 5/7/2023. The resident was noted to be resting comfortably in bed at this time. The resident was not showing any signs of pain. During an interview on 5/16/2023 at 9:46 AM, the Registered Nurse Educator (RNE) stated they had been in their position just a little over a year and was unsure how often nursing competencies were conducted. The RNE stated the DON was following up on the incidents. They stated upon hire, the nurses were given a medication exam. During an interview on 5/16/2023 at 11:59 AM, Registered Nurse Manager (RNM) #1 stated they were aware of the medication errors made by LPN #2 but did not know what remediation had taken place. RNM #1 stated that LPN #2 should have been given a written exam and they should have demonstrated medication administration while supervised by licensed staff. During an interview on 5/16/2023 at 1:35 PM, the DON stated Resident #11 was prescribed 2 Percocet tablets for pain and LPN #2 only administered one on 5/7/2023. The resident did not have an increase in their pain level from being underdosed. The DON stated LPN #2 was educated following each incident. 10 NYCRR 415.12(m)(2)

Based on record review and interviews during an abbreviated survey (Case #s NY00302427, NY00303564, NY00312507, and NY00313484), the facility did not ensure the resident has the right to be free from neglect for 1 (Resident #6) of 7 residents reviewed for neglect. Specifically, for Resident #6, the facility did not ensure facility staff followed the resident's Kardex (care plan) that documented that the resident was to have a lap buddy (a soft tray-like device with slots that fit around the arm rests of a wheelchair to prevent a fall out of a wheelchair) when in their wheelchair. On 10/9/2022, Certified Nurse Aide did not place the lap buddy on the resident's wheelchair and subsequently the resident fell out of their wheelchair, was transferred immediately to the emergency department (ED), and diagnosed with a swollen, bruised left eye and fractured nose. This was evidenced by: The Policy and Procedure (P&P) titled, Abuse Prevention and Reporting dated 10/2019, documented the purpose of the P&P was to ensure that all residents of the facility were free from neglect. Resident #6 Resident #6 was admitted to the facility with diagnoses of dementia, diabetes, and anxiety disorder. The Minimum Data Set (MDS- an assessment tool) dated 8/29/2022 documented the resident had severe cognitive impairment, could be understood, and could sometimes understand others. The Comprehensive Care Plan (CCP) for Behavior dated 8/1/2019, documented the resident had a history of self-transferring. The CCP for Restraint Use-Frequent Falls dated 8/29/2019, documented the resident required restraint use due to risk for injury from frequent falls. The resident was to have a lap buddy applied when in their wheelchair. The CNA Kardex (undated) documented the resident was to have a lap buddy for lack of safety awareness when in their chair and released every 2 hours for repositioning. The MDS dated [DATE], documented the resident had a trunk restraint that was used daily. A Medical Doctor (MD) order dated 11/26/2019, documented a lap buddy to be used while Resident #6 was in their wheelchair for positioning and lack of safety awareness. Release every 2 hours for 15 minutes. A Nurse's Note dated 10/9/2022 at 10:56 AM, documented Registered Nurse Supervisor #1 (RNS) was called to the unit. Resident #6 was on the floor bleeding from a head laceration on their left temple area, and their nose was bleeding. 911 was called and the on-call MD was notified. A Nurse's Note dated 10/9/2022 at 12:14 PM, documented the nurse at the ED reported Resident #6 was returning to the facility with a fractured nose and a swollen bruised left eye. The MD was notified. The ED Provider Notes dated 10/9/2022 at 11:15 AM, documented the resident had a nondisplaced nasal bone fracture. No further intervention necessary. Will discharge with Tylenol. During an interview on 4/6/2023 at 10:53 AM, the Medical Director stated Resident #6 had a lap buddy in place when in their wheelchair due to poor judgement and they did not have very good trunk support. Unfortunately, the lack of the lap buddy's use contributed to the resident's fall. The Medical Director stated a fracture nose was not a serious injury as long as the resident did not have difficulty breathing or developed a fever (that could indicate a possible infection). It was more a question of managing the pain from the injury. During an interview on 4/6/2023 at 11:18 AM, the Director of Nursing (DON) stated they realized the staff assigned to the resident did not follow the resident's care plan. The resident's lap buddy was found on the floor of their room. The DON stated RNS #1 was witness to the fact the resident did not have the lap buddy in place at time they assessed the resident. The resident had facial injuries as a result of their fall. They stated the resident had bilateral black eyes and a fractured nose. The DON stated the resident would not have fallen if the lap buddy had been in place. It was an intervention that worked very well for them. They stated the resident would slide out of their wheelchair and it was in place to keep them safe from sliding out. The DON stated the CNAs were supposed to be looking at the residents' Kardex daily. There was a binder at the nurses' stations and in the electronic medical record where the CNAs documented the care provided. A message was sent through electronic messaging if a change in a resident's Kardex occurred. During an interview on 5/2/2023 at 1:13 PM, RNS #1 stated they were called about 9:56 AM (on 10/9/2022) to Resident #6's unit. They found the resident lying on the floor of the common area with bleeding from their nose, a laceration to the temple of their head and bleeding from their eye socket from a laceration. RNS #1 stated they did not feel comfortable moving Resident #6, so they called 911 and then the medical provider. The RNS stated the resident had been in their wheelchair but did not witness the fall. The resident was supposed to have a lap buddy, and the lap buddy was not in place. RNS #1 stated they searched for it and the lap buddy was found in the resident's room by the side of their dresser. The RNS stated the resident would not have been able to remove it and place it where it was found in their room. Attempts to contact CNA #6 were unsuccessful. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during the recertification survey dated 08/14/22 through 08/18/2022, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for two (2) of 3 resident's reviewed. Specifically, the facility did not ensure that Residents #470 and #60, who received Medicare Part A services, received timely notification (2-day notification) of the termination of services with the required form Notice of Medicare Non-Coverage, Form CMS -NOMNC. This is evidenced as follows: The document titled Notice of Medicare Non-Coverage, Form CMS -NOMNC (NOMNC) and dated 12/31/2011, documents that resident #470 last received rehabilitative services on 04/27/2022 and was provided the NOMNC to inform the resident of their right to an expedited review of service termination on 04/27/2022 (date signed), the same day as the termination of services. The document titled Notice of Medicare Non-Coverage, Form CMS -NOMNC and dated 12/31/2011, documents that Resident #60 last received rehabilitative services on 08/04/2022, but does not document the date when the NOMNC was provided to the resident. During an interview on 08/17/2022 at 1:48 PM, the Administrator stated that the facility will conduct trainings to ensure residents receiving Medicare Part A will receive a 2-day notification as the end of services approach and that all NOMNCs are signed and dated. 10 NYCRR 415.3 (g)

Based on observation and interviews during the recertification survey dated 08/14/22 through 08/18/22, the facility did not ensure food was prepared in accordance with professional standards for food service safety in the main kitchen, one (1) of 3 Country Kitchens, and 4 of 6 Activities Kitchens (unit kitchens). Food preparation and serving areas and equipment are to be kept clean, product thermometers are to be calibrated, and kitchen equipment is to be kept in good repair. Specifically, in the main kitchen, one food product thermometer was not in calibration; on the second floor County Kitchen, the electronic thermometer display on the [NAME] dishwashing machine was not functioning; and the refrigerators and floors in the 1-East, 1-West, 2-East, and 2-West Activities Kitchens required cleaning. This is evidenced as follows: During observations on 08/14/22 at 12:24 PM, in the main kitchen, one food product thermometer read 20 degrees Fahrenheit (F) when checked for calibration in an ice bath (32 F is the calibrated temperature); on the second floor County Kitchen, while the machine was in use, the electronic thermometer display on the [NAME] dishwashing machine was not functioning; and the refrigerators, drawers, and/or floors in the 1-East, 1-West, 2-East, and 2-West Activities Kitchens were soiled food particles or dirt. During an interview on 08/14/22 at 1:04 PM, Dietary Aide #1 stated that the [NAME] dishwashing machine is utilized to wash tableware, and maintenance has been notified that the display on this dishwashing machine works only intermittently. During an interview on 08/14/22 at 1:34 PM, the Director of Support Services stated that the 2nd floor [NAME] dishwashing machine should have been tagged as being out of service; the activity kitchens are used to stock snacks and food from outside for the residents; the refrigerators, drawers, and floors noted will be cleaned; and the thermometer should have been in calibration. During an interview on 08/17/22 at 1:45 PM, the Administrator stated that the 2nd floor Country Kitchen [NAME] dishwashing machine should have been tagged as being out of service; the activity kitchens are used to stock snacks and food; the refrigerators, drawers, and floors noted will be cleaned; and the thermometer should have been in calibration. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.85, 14-1.110, 14-1.113, 14-1.170

Resident #1 Based on observation, interviews and record review during an abbreviated survey (Case #NY 051), the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed. Specifically, when exit doors alarmed on 3/3/3033, staff did not check outside to see if a resident may have gone outside. Additionally, the door alarm system did not identify doors with an identifier which confused staff as to where to go when a door alarm sounded. Subsequently, Resident #1 left the facility undetected by staff and was located outside. This is evidenced by: Resident #1 was admitted to the facility with diagnoses of stroke, diabetes, dementia with behavioral disturbance. The Minimum Data System (MDS-an Assessment Tool) dated 12/12/2021 documented the resident had moderately impaired cognition and could make themself understood and could understand others. The Policy and Procedure (P&P) for Unsafe Wandering and Elopement dated 6/2005, and last reviewed in 3/2022 documented that when a resident was missing an immediate head count was to be completed. Staff were to initiate a search of all resident rooms, common areas, offices, closets, bathrooms etc. If the resident was not found within 5 minutes, the Missing Resident Protocol would be implemented. If a staff member needed to leave the building in search of a resident, they were to notify other staff on duty. Two staff members were to go outside to search. When a resident was located, staff were to complete a head count. An Elopement Risk Assessment Report dated 12/22/2021 documented Resident #1 was cognitively impaired and was independently mobile and scored to be at low risk for elopement. A Risk Management Report dated 3/3/2022 at 5:25 AM by RN #1 documented in an unsafe Wandering /Elopement Note that they were notified at 4:20 AM they were notified by the lab technician that Resident #1 was not in their room. A unit search was done, and the resident was found outside. The resident stated they were trying to get to their truck to go home. The resident was transported to the hospital at 5:05 AM for evaluation. During an observation and interview on 3/10/2022 at 4:07 PM the Administrator (ADM) stated the 1 West double door led to an area in the building which did not have a name and was referred to as no man's land. The ADM stated that some doors and areas did not have an identifier which made it confusing when trying to reference a location or door. During an interview on 3/11/2022 at 9:22 AM CNA #1 stated that on 3/3/2022 at about 3:30 AM they heard the alarm on their pager that showed the 1 East double door had been opened and they went to check those doors. CNA #1 stated they did not look outside to ensure there was no resident out there, instead they cleared the alarm and went back to search rooms and do a head count on the residents. While they were doing the head count, the Supervisor asked if they had seen Resident #1. CNA #1 stated they did not check the exterior door and instead they shut the alarm off and went back to East unit to do the head count. CNA #1 had not checked with the West unit to see if they were missing a resident. CNA #1 stated they had no idea it was a West unit resident because it came across on the pager as One East. During an interview on 3/11/2022 at 1:41 PM Registered Nurse (RN) #2 stated that on 3/3/2022 they noticed Resident #1 missing when the Lab Technician informed them that the resident was not in their room. They started looking for the resident and circled back towards the resident's room. They went by a window and saw the resident outside. Resident #1 was sent to the hospital and there was no harm identified. During an interview on 3/11/22 at 10:20 AM CNA #2 stated that, when a door alarm sounded, staff were supposed to open the door to check, to see if they anyone had exited the building. If a resident was not located during a head count of the residents, the building was locked down and everyone searched for a missing resident. A door alarm was only to be turned off after a resident was found. During an observation and interview on 3/11/2022 at 1:13 PM with the Director of Maintenance (DM) and RN #3 and the DM demonstrated the alarm operations of the alarmed egress doors that were in between the East and West units. The DM set off the alarm which showed on the pager: 1 East double door elopement. This also set off call bell system on the desk at the nurse's station. RN #3 stated that the alarm was set off for alarmed exit doors, but the pager notification indicated it was the 1 East double door which was confusing. During an interview on 3/11/2022 at 2:45 PM the ADM stated the exit doors were not labeled with an identifier and the alarm system had no reference to signal staff as to which doors had been opened. During an interview on 3/10/2022 at 3:15 PM the Director of Nursing (DON) stated they were notified on 3/3/2022 at 4:20 AM by RN #1 that Resident #1 had been found outside. The facility investigation determined the CNA did not look through the exterior doors to check for any missing resident. During an interview on 3/10/2022 at 3:15 PM the ADM stated Resident #1 on 1 West unit which was not a secured unit. On admission to the facility, Resident #1 was assessed as not a high risk for elopement and had no history of exiting seeking. The resident's room was next to the double doors he exited through. On 3/3/3033, Resident #1 pushed on the door, and it opened after 15 seconds, and the resident was able to get through the next set of alarmed doors and exited the exterior door off the West and East units. The ADM also stated the door was operating correctly, but during the investigation the facility realized that the doors had not been labelled as East or West. 10 NYCRR 415.12(h)(1)

Based on record review, and interviews during an abbreviated survey (Case #s NY 539 and NY 511), the facility did not ensure the resident environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #s 1 and 4) of 4 residents reviewed. Specifically, while transferring Resident #4 using a sit-to-stand lift, two staff did not fasten the leg strap around the resident's legs, and the resident's legs buckled. Subsequently, the resident complained of pain, and was admitted to the hospital with a spiral fracture of the upper bone in the right leg. Additionally, Resident #1, who had a physician order for a pureed diet, was served a whole sandwich and choked while eating it, requiring mechanical suctioning. This resulted in actual harm that was not immediate jeopardy for Resident #4. This was evidenced by: Resident #4: Resident #4 was admitted to the facility with diagnoses of dementia, [CONDITION(S)], and chronic pain syndrome. The 5/29/2020 Minimum Data Set (MDS - an assessment tool) documented the resident had severe cognitive impairment, could be understood, and could understand others. The Policy and Procedure titled, Mechanical Lifts dated 6/2021, documented that training of staff in the safe use of mechanical lifts, including the sit-to-stand lift, was completed upon hire and as needed. The sit-to-stand lift was to be used on residents that were able to bear weight, but not able to support their weight independently. A resident's lifting/transfer needs were documented on their Comprehensive Care Plan (CCP) and the resident's care card. All staff were to follow the care plan. The Manufacturer's User Manual for the sit-to-stand lift, revised in 7/2014, documented the lower leg straps were used to ensure the lower parts of the resident's legs stayed close to the knee support. To fasten, the strap was clicked into its socket, like with a seatbelt. Staff were to ensure the straps were firm but comfortable for the resident. The Comprehensive Care Plan (CCP) for Activities of Daily Living dated 4/19/2020, documented the resident needed a sit to stand lift for transfers. The Resident Nursing Instructions, (the care card - used by Certified Nurse Aides (CNA) to know what care the resident required) dated 5/24/2020, documented Resident #4 was to have a 2-person physical assist using a sit-to-stand lift for all transfers. A Nurse's Note dated 8/29/2020 at 4:08 AM, written by Registered Nurse Charge Nurse (RNCN) #4 documented that at 3:45 AM, two staff members were transferring Resident #4 to a recliner when the resident's knees buckled and the resident was lowered to the floor. The resident had no complaints of pain, vital signs were stable, no visible injury noted, and the resident's range of motion (ROM) was normal. The physician (MD) was notified. A Nurse's Note dated 8/29/2020 at 12:41 PM written by RNCN #5 documented that at 5:00 AM, Resident #4 complained of pain. Scheduled pain medication and a pain-relieving cream were administered with no relief. At 11:50 AM, RNCN #5 was called to the resident's room to assess Resident #4's uncontrolled pain. Upon assessment, there was tenderness at the right hip joint with external rotation and the right knee was bent. The resident was unable to tolerate an assessment of their ROM due to the pain. The MD was notified, and an order was obtained to send Resident #4 to the emergency room for evaluation. A Radiology Report dated 8/29/2020 at 1:58 PM, documented there was a spiral fracture (a bone broken by a twisting motion) of the lower part of the right femur (the large bone in the upper portion of the leg). A Nurse's Note dated 8/29/2020 at 7:06 PM, written by RN #6 documented Resident #4 was admitted to the hospital with a right femoral fracture. The facility Investigation Summary dated 8/31/2020, written by the Director of Nursing (DON), documented that on 8/29/2020 at approximately 3:00 PM, the DON was notified that Resident #4 had been lowered to the floor on 8/29/2020 at 3:45 AM. The resident was subsequently sent to the emergency room at 12:15 PM for uncontrolled pain. Resident #4 was diagnosed with a spiral fracture to the right femur. An investigation found that there were 2 staff present for the transfer that led to the fall, but the equipment had not been appropriately used. Staff had not used the provided straps on the equipment to secure Resident #4's legs, which may have contributed to the twisting of the resident's leg while being lowered to the floor. During an interview on 6/28/2021 at 8:31 AM, CNA #4 stated the 8/29/2020 incident occurred when LPN #2 and CNA #4 were trying to get Resident #4 up and ready for the day. They were using the sit-to-stand lift, and when they attempted to raise Resident #4 with the lift, the resident started to slide. At that time, they lowered the resident to the floor and Resident #4 complained that their leg hurt. CNA #4 stated they called the Supervisor who came to assess the resident. CNA #4 described the proper use of straps for the sit-to-stand lift then stated they could not recall if the leg strap was fastened when they transferred Resident #4 on 8/29/2020. CNA #4 stated they were given a Performance Improvement Plan (a documented corrective action) because the leg strap was not buckled at the time of Resident #4's fall on 8/29/2020. During an interview on 6/28/2021 at 2:26 PM, LPN #2 stated that on 8/29/2020 they helped CNA #4 put Resident #4 on the sit-to-stand lift to transfer them from the bed to their recliner. While they were transferring the resident, the resident let go of the handlebars and started sliding down. The resident's feet had come off the foot pads and when the resident was lowered to the floor, Resident #4 sat down with their right leg caught under the resident. The sit-to-stand lift had a sling that went around the resident's abdomen, and a buckle that was supposed to be around the lower legs. The purpose of the buckle around the lower legs was to prevent a resident's feet from slipping off the foot pads. LPN #2 stated they did not hook the lower leg buckle around Resident #4's lower legs on 8/29/2020 because they did not think of it at the time. During an interview on 6/25/2021 at 2:08 PM, RNCN #4 stated they were called to the unit, and when entering Resident #4's room, saw Resident #4 sitting on the floor in front a recliner. Licensed Practical Nurse (LPN) #2 and CNA #4 stated they had attempted to transfer Resident #4, and when the resident's knees buckled, they needed to lower the resident to the floor. RNCN #4 assessed the resident who complained of pain in the right leg but had no visible injuries. RNCN #4 stated that, at the time of the incident, they were not aware the staff had not used the leg straps to secure the resident in the sit-to-stand lift when they attempted to transfer the resident. During an interview on 6/30/2021 at 10:25 AM, the DON stated what caused that the outcome of the 8/29/2020 incident, was that Resident #4's legs were not strapped into the lift with the leg strap. Resident #4 became weak and the resident slipped out of the lift. If the leg strap had been used, the resident would have fallen straight back and would not have twisted their leg. The DON stated the leg strap should have been fastened prior to transferring the resident. During an interview on 6/30/2021 at 12:54 PM, the Orthopedic Physician's Assistant (PA) who saw the resident for the right femur fracture sustained on 8/29/2020, stated the 8/29/2020 x-ray of Resident #4's right femur documented the resident had osteopenia (reduced bone mass of lesser severity than osteoporosis) that contributed to the fracture. Resident #4's fracture was definitely the result of the combination of not strapping the resident into the lift properly and the resident's osteopenia. The PA stated the staff should have had the resident strapped into the lift with the leg strap, and that landing on top of their right leg would have caused the spiral fracture. During an interview on 7/7/2021 at 1:54 PM, Resident #4's primary MD at the facility stated the staff should have followed the protocol for the use of the sit-to-stand lift, or for any equipment used in resident care. The MD stated processes were in place to maintain resident safety and should always be followed. During an interview on 7/1/2021 at 11:29 AM, the Medical Director stated the improper use of the sit-to-stand lift certainly contributed to the resident's fall with the fracture and there was no way the Medical Director could say the fracture was not related to improper lift use. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, difficulty swallowing, and chronic lung disease. The MDS dated [DATE] documented the resident had severe cognitive impairment, could usually be understood, and could usually understand others. The Policy and Procedure (P&P) dated 6/2021 titled, Resident Dining, documented nursing staff were to review the resident's menu and tray for accuracy, paying particular attention to any consistency modifications, sign it, and take it to the table with the resident's tray. The menus were to stay with the resident until the end of the meal and then would be collected and turned in to the DON. The Comprehensive Care Plan (CCP) for Nutrition-Potential for Loss/Gain Weight related to Dysphagia (difficulty swallowing) dated 8/5/2019, documented that per MD orders, the resident's diet consistency was for pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) and nectar thick liquids (liquids made to be thicker than water). The Resident Nursing Instructions (the Care card) updated on 5/4/2021 at 2:10 PM, documented the resident was to have the supervision of one person at meals. The MD orders dated 5/4/2021, documented Resident #1 was to have a diet of nectar thick liquids and pureed food. Resident #1's meal ticket for supper dated 5/20/2021, documented the resident's food was to be pureed and liquids be nectar thick. A Speech Therapy (ST) Note dated 5/20/2021 at 3:03 PM, written by Speech Language Pathologist (SLP) #1, documented Resident #1 was seen at the request of nursing for a coughing incident during a meal. The resident demonstrated safe tolerance of a pureed diet. There were no signs/symptoms of aspiration/obstruction during the screening. A Nurse's Note dated 5/20/2021 at 6:47 PM, written by RN #1, documented being called to the dining room where Resident #1 was in a chair coughing. It appeared Resident #1 was choking and RN #1 suctioned the resident 4 times. The resident was on a pureed diet, but there was half of a turkey sandwich on the resident's dinner plate. The resident's lungs had expiratory rhonchi (abnormal sounds) in both lung bases with wheezing in both upper lobes. The MD was notified, examined the resident, and ordered nebulizer treatments (medication inhaled to help open airways), every 4 hours for 24 hours, and one dose of [MEDICATION(S)] (used to reduce inflammation). An History and Physical Note dated 5/20/2021, written by the MD, documented the MD was called to see Resident #1 for choking. Resident #1 had received a sandwich that was not pureed. Upon the MD's arrival, the resident was being suctioned resulting in tan mucous that contained some food chunks in it. Resident #1 was in mild respiratory distress, coughing, and was able to speak in sentences. The resident's breath sounds were diminished throughout their lungs, no rhonchi were heard and there was a slight wheeze after the resident coughed. The resident was able to swallow several spoonfuls of their pureed entrée without difficulty. The MD documented the incident as a witnessed aspiration (breathing in a foreign object/substance) and prescribed [MEDICATION(S)] and nebulizer treatments. An ST note dated 5/21/2021 at 10:10 AM, written by SLP #1, documented Resident #1 was seen for a choking episode. SLP #1 also documented the resident should only be provided with puree solids and nectar thickened liquids as all other solids or liquids put the resident at risk for aspiration /obstruction. During an interview on 6/16/2021 at 3:32 PM, CNA #3 stated they believed they served Resident #1, but could not recall what was on Resident #1's supper tray on 5/20/2021. When Resident #1 started choking, the nurse got a suction machine and suctioned the resident and the RN was called. CNA #3 stated the resident's tablemate was also on a pureed diet so there should not have been a sandwich on the table. During an interview on 6/16/2021 at 4:01 PM, LPN #1 stated that at supper time on 5/20/2021, LPN #1 heard Resident #1 coughing, so they went to check on the resident. Someone grabbed the suction machine for LPN #1 who then suctioned the resident. RNCN #1 came to the dining room and took over and suctioned the resident again. At that time, there was a sandwich on Resident #1's tray, and LPN #1 immediately removed it. LPN #1 stated Resident #1's tablemate was on a pureed diet as well as the residents at the table next to Resident #1, so there should not have been a sandwich on the table. During an interview on 6/16/2021 at 1:01 PM, SLP #1 stated Resident #1 was provided the wrong consistency diet at dinner on 5/20/21. The resident choked and nursing had to intervene by suctioning the resident. During an interview on 6/16/2021 at 1:35 PM Registered Dietician #1 (RD) stated they were informed that nutritional services and nursing staff gave Resident #1 a whole sandwich on their supper tray. Resident #1 was on a pureed diet and never should have been given a whole sandwich. During an interview on 6/16/2021 at 3:16 PM, RNCN #1 stated they were called to the dining room on Resident #1's unit on 5/20/21 during supper. When entering the dining room, LPN #1 had the suction machine set up and was with Resident #1. RNCN #1 could tell that the resident was choking and RNCN #1 grabbed the suction catheter and suctioned the resident 3 times. A moderate amount of chewed up sandwich pieces were removed from the resident's mouth during suctioning. As soon as Resident #1 was stable, RNCN #1 started an investigation but found nobody that would admit they had put the sandwich on Resident #1's tray. RNCN #1 stated the sandwiches came wrapped and someone would have had to unwrap it for the resident. During an interview on 6/16/2021 at 4:15 PM, the DON stated the facility's investigation could not determine who gave a sandwich to Resident #1. The DON also stated staff were supposed to have been checking the meal tickets against the food on the residents' trays. 10NYCRR 415.12(h)(1)

Based on observation, interview and record review during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections determined for 3 (Resident #'s 50, 63 and #223) of 3 residents reviewed on the third floor. Specifically, for Resident #50, the facility did not ensure standard precautions were maintained during a dressing change, for Resident #'s 50 and 63, the facility did not prevent the development of facility acquired pseudomonas infections (type of germ that can cause infections in humans) in their wounds and for Resident #223, standard precautions were not followed during administration of an intravenous medication. Additionally, the facility did not ensure that a basin filled with wound care supplies was not carried from room to room. This was evidenced by: Resident #50: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 12/3/19, documented the resident was cognitively intact, was able to understand others and was able to be understood by others. Resident resides on the 3rd floor of the nursing home. Pressure Ulcer-Assessment, Prevention, Treatment and Wound care with a revision date of 03/2017, documented the following for dressings; always cleanse the wound before new dressing is applied, use clean technique to apply dressing after cleansing wound, change dressing when soiling is apparent regardless of timeframe and loosely fill all wound cavities with dressing material, and do not pack wound tightly. A Wound Care Tool dated 12/30/19, documented an unstageable wound to the resident's coccyx measuring 11.1 cm x 13.5 cm x 0.1 cm. tunneling at 6:00. Moderate purulent drainage. 70% necrotic (dead tissue), 30% slough (layer of dead tissue seperated from living tissue), 70% eschar (dead tissue) intact, 30% eschar unstable/mushy-boggy. Necrotic tissue is present in wounds as eschar and slough. Eschar presents as dry, thick, leathery tissue that is often tan, brown or black. Slough is characterized as being yellow, tan, green or brown in color and may be moist, loose and stringy in appearance. Wound Care Tool dated 01/20/20, documented a Stage IV wound to resident's coccyx measuring 11.2 cm x 12.2 cm x 3 cm with undermining (a pocket beneath the skin at the wound's edge) 8 cm at 9:00. Wound Care Tool dated 01/30/20, documented stage IV midline coccyx. which was debrided at the Wound Center one week ago. Packing removed from wound (6 4 x 4's) for a large amount of serous drainage. Wound measurements are 11.0 cm x 10.1 cm x 4.2 cm. Resident denied pain during the procedure. Edges of the wound are distinct. Large area of undermining 1.0 cm to the edge between 10:00 to 5:00. Small amount of soft black eschar at the base of the wound (less than 25%). Skin color surrounding wound is dark red/purple and non-blanchable. Pink granulation tissue covers approximately 25% of the wound with no epithelization (wound healing). Faint foul odor from the wound. Finding #1: During an observation of a dressing change to the resident's stage IV wound to the coccyx on 01/30/20 at 9:50 AM: - Registered Nurse (RN) #1 placed a barrier on resident's bedside table without first wiping the table. There were numerous personal items left on the sides of the table. - RN #1 held the package of cotton tipped applicators, opened the package and pulled out an applicator and placed it on the barrier. She did not remove her gloves and wash her hands after touching the outside of the package. - Wearing the same gloves, she packed the wound with 4 x 4 gauzes using the cotton tipped applicator. -Wearing the same gloves, she placed an ABD pad on the wound. During an interview on 01/30/20 at 02:40 PM, RN #1 stated she was not aware she should not have touched the outside of the dressing packages and touch the dressing contents without first removing her gloves, washing her hands and putting on another pair of gloves. There are monthly in services and during orientation she performed dressing changes but did not remember when she should change her gloves. During an interview on 01/30/20 at 03:42 PM, the Registered Nurse Manager (RNM) #2 stated RN #1 did not receive a specific in-service on dressing changes when she was hired. She should know how to do a dressing change since she had recently became an RN and would have learned it in school. During an interview on 01/30/20 at 03:48 PM, the Infection Control Nurse/Staff Education Nurse #2 stated she had not held a dressing change in-service since she was hired approximately one year ago. The nurses have not been in serviced to do dressing changes. During an interview on 01/30/20 at 04:16 PM, the Director of Nursing (DON) stated RN #1 is a new nurse coming recently from school. She should have known not to touch the outside of the dressing packages without first washing her hands. Finding #2: Wound Care Tool dated 01/30/20, documented stage IV midline coccyx. which was debrided at Wound Center one week ago. Packing removed from wound (6 4 x 4's) for a large amount of serous drainage. Wound measurements are 11.0 cm x 10.1 cm x 4.2 cm. Resident denied pain during the procedure. Edges of the wound are distinct. Large area of undermining 1.0 cm to the edge between 10 to 5:00. Small amount of soft black eschar at the base of the wound (less than 25%). Skin color surrounding wound is dark red/purple and non-blanchable. Pink granulation tissue covers approximately 25% of the wound with no epithelization. Faint foul odor from the wound. Progress Notes 12/14/19 at 10:06 PM, dressing change to buttock. Old dressing removed with moderate amount of thick yellow/green drainage and small amount of blood present. Laboratory report dated 12/16/19, culture to buttock wound result dated 12/20/19-pseudomonas aeruginosa. Per physician order, resident started on [MEDICATION NAME] 250 mg qd. During an interview on 01/30/20 at 03:48 PM, Infection Control Coordinator stated she was aware that this resident and Resident #63 both resided on the Third Floor of the nursing home and both contracted pseudomonas in their wounds that required dressing changes. Wound cultures were sent, and the resident was placed on contact isolation. Education was done on proper hand hygiene, the donning and offing of personal protective equipment and how to properly throw away any linen. The residents are on opposite sides of Unit 3. She is tracking and monitoring the spread of the infection. During an interview on 01/30/20 at 4:16 PM, the DON stated the pseudomonas infection had been discussed many times with the Interdisciplinary Team (IDT). No common denominator could be found to pin the infection to. Resident #63 The resident was admitted with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact, was able to understand others and was able to be understood. Resident resides on the 3rd floor of the nursing home. MD Admission assessment dated [DATE], documented resident underwent [REDACTED]. Progress Note dated 1/04/20 at 10:08 AM, documented dressing removed from stump. Wound bed red/pink with moderate amount green drainage. Physician order [REDACTED]. Laboratory report dated 01/06/20, culture ordered for wound drainage. Result dated 01/07/20 -pseudomonas species. Per physician order, resident started [MEDICATION NAME] mg twice a day for 10 days. Progress Note dated 01/27/20, documented resident developed a scab on her left amputation site and developed an infection on her stump while in the nursing home. She was diagnosed with [REDACTED]. During an interview on 01/31/20 at 09:25 AM, Infection Control Coordinator #3 stated she was aware of the 2 residents with pseudomonas in their wounds on the third floor. Wound care education is in the works to start very shortly. For wound rounds, the nurses will be educated on how to set up treatment carts appropriately. During an interview on 01/31/20 at 09:25 AM, the Infection Control Coordinator stated she did not have a listing of reportable diseases. She stated she reported to epidemiology if a resident has [MEDICAL CONDITION]. She stated she has heard about the list of reportable diseases list but did not seem to have a copy. Resident #223 Resident #223 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was cognitively intact, was able to understand others and was able to be understood by others. The Facility Policy for Infection Prevention/Control on hand hygiene dated December 2002 and last updated in June 2009, documented the following: Centers for Disease Control (CDC) - How to use hand washing (soap and water): 1. Turn on water and wet hands. 2. Apply 2 squirts of antimicrobial soap: 3. Thoroughly wash all surfaces of hands (palms, backs), fingers (all 4 sides, with special attention to knuckle and fingernails), and wrists for at least 20 seconds. 4. Rinse and dry hands thoroughly with paper towel. A physician order [REDACTED]. During an observation of an intravenous (IV) medication on 1/30/2020 at 9:30, RN #1 placed a bag of [MEDICATION NAME] on the residents overbed table. Sanitation of the bedside table was not done, and a barrier was not placed on the surface before placing the antibiotic there. RN #1 washed her hands less than 5 seconds with soap and water, applied gloves, picked up the bag of antibiotic off the overbed table and attached the IV tubing to the antibiotic solution. During the transfer of the IV tubing RN #1 gloved hand touched the spike of the tubing as it was seperated from the used bag. While reinserting the spike into the antibiotic solution, RN #1 was observed to hold the bag against her/his uniform top touching the spike of the IV tubing with the thumb of her right gloved hand. RN #1 then removed the end of the IV tubing from a port on the used IV tubing and without cleansing the tip of the tubing, inserted it into the resident's valve adapter on the PICC line. A sterile cap had not been placed on the tip of the IV extension set after the IV tubing was used last. During an interview on 1/30/2020 at 10:15 AM, RN #1 stated I wasn't aware I touched the IV spike with my glove. I should have changed my gloves and washed my hands after mixing the antibiotic before attaching the tubing. The person that discontinued the antibiotic must have forgotten to put a cap on the end of the IV, but I didn't realize you couldn't put the end in the injection port. I want to learn the right way. During an interview on 1/30/2020 at 11:56 AM, the Nurse Practitioner stated when reusing IV tubing a sterile cap should be placed on the end of the tubing after disconnecting it from the hub of the PICC line. Placing it inside a port hanging from the IV tubing contaminates the tubing and they should not reuse it. Failure to place a sterile cap on the end of a reusable intravenous administration set that has been removed from an IV catheter hub leaves the resident at risk for infection. The tip of the IV set is exposed to potential contaminants if not cleaned properly when connecting and disconnecting from the PICC line. Facility During an observation on 1/29/20 at 10:01 AM, Registered Nurse #5 (RN) entered room [ROOM NUMBER]-101-B to perform wound care on the resident with a basin full of dressings and wound supplies. RN #5 placed the basin on the overbed table without cleaning the table or placing a barrier underneath the basin. When RN #5 was finished performing wound care for the resident, hands were washed with an alcohol-based sanitizer, the bucket with supplies was picked up and carried by RN #5 under the nurses' arm and against the nurses' uniform to room [ROOM NUMBER] A. RN #5 placed the bucket on the bedside table in the second room without cleaning the basin or the bedside table. Hand washing was not performed before placing the basin in the room. A barrier was not placed under the basin. RN #5 was stopped before performing wound care by this writer to address the possibility of cross contamination. During an interview on 1/29/2020 at 10:17 AM, RN 5 stated I should not have brought the basin of dressings and wound supplies into the resident's room. They are taught to use the wound cart, to clean the bedside trays, and to use a barrier on the surface where supplies are placed in the resident's room. RN #5 stated using the basin was easier than dragging the treatment cart around. During an interview on 1/29/2020 at 10:21 AM, the Registered Nurse Unit Manager (RNUM #4), stated the nurses should be using the treatment cart for wound care. It was unacceptable for RN #5 to carry a basin full of supplies into one residents' room and then bring in into another resident's room. Once supplies are brought into a resident's room they should be left in that room. This was an infection control policy and RN #5 did not follow the facility policy. RN #5 would need to be reeducated. During an interview on 1/29/2020 at 10:33 AM, the Infection Control Registered Nurse #3(ICRN) examined the basin RN #5 had brought into the room. The ICRN #3 stated none of the dressings and multiple use ointments in the basin should have been brought from one residents' room to another resident's room. All items in the basin were now contaminated and would need to be discarded. ICRN #3 stated the nurses had not been given in-servicing on wound care practices in over a year, but all should be aware of the proper infection control procedures. The most important way of preventing cross contamination from one resident to another was maintaining infection control procedures and handwashing with care between residents. During an interview on 01/30/20 at 09:52 AM, the Nurse Manager for Quality Assurance #7 and lead Registered Nurse for wound rounds stated on 1/29/2020 she was aware RN #5 should not have been using a basin to transport wound supplies from room to room during the daily wound rounds. It is an infection control issue that I have addressed since I started this job. I knew you had identified this during observation, so I did not stop RN #5 because I though you would and then it would be addressed and corrected. 10NYCRR415.19(a) (1-3)

Based on observation, medical record review and staff interviews during an abbreviated survey (Case #'s NY 042 & NY 499) it was determined that the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, for two (Resident #'s 1 & 2) of three residents reviewed the facility did not identify that both resident's behaviors in the dining room had the potential for risk of injury, did not implement interventions to prevent the risk for injury and did not implement behavior care planned interventions of intervening and notifying the medical doctor for escalation in behaviors resulting in second degree burns from spilled hot liquids that were not served at safe temperatures. This is evidenced by the following: Resident #1: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have severely impaired cognition. The Comprehensive Care Plan (CCP) titled Behaviors initiated 5/7/15, documented the resident has physical and verbal abuse towards others, yells profanity at staff and agitation towards other residents. Interventions include: invite to activities; monitor for escalation; intervene and report to physician. A review of the progress notes dated 1/2/16 at 2:24 pm, documented the resident was very agitated, throwing food and drink at staff, yelling and swearing at staff and residents and was taken out of the dining room. A review of progress notes dated 1/25/16 at 2:35 pm, documented the resident was throwing her food and drinks at other residents who were sitting at the table, swearing and yelling at staff, refused to eat any lunch and was removed from the dining room. A review of the progress notes dated 2/6/16 at 10:24 am, documented complaints from the resident of right shoulder pain. Staff state the resident has not been able to lift her left arm well for some time. A review of the progress notes dated 2/8/16 at 10:31 pm, documented that the resident was verbally abusive during supper and needed to be removed from dining room. A review of the progress noted dated 2/10/16 at 3:02 pm, included documentation that the resident was very upset after lunch complaining of back pain, and was yelling and screaming. A review of the progress note dated 2/14/16 at 11:10 am, documented that the resident was yelling and swearing prior to breakfast and was removed from the dining area. A review of the progress notes dated 3/12/16 at 2:24 pm, documented the resident was agitated at lunch, she started throwing things and swearing, yelling and was taken out of the dining room. A review of the progress notes dated 3/22/16, documented that the resident was very agitated after supper, yelling at staff and other residents. A review of the progress notes dated 4/6/16 at 2:48 pm, documented that the resident didn't eat breakfast as she was agitated, spitting her food out and throwing her milk on the floor. A review of the progress notes dated 4/7/16 at 7:00 pm, documented that at 5:25 pm the resident was in her chair in the dining room yelling racial slurs towards staff. Another resident approached her and told her what she was saying was wrong. The resident then became agitated and reached out towards the other resident, when the other resident back handed Resident #1. There was no documented evidence of changes made to the resident's care plan related to her behaviors during meals. The progress notes dated 4/8/16 at 6:15 pm, documented that at 5:35 pm, the staff heard the resident yell out and noted her soup was spilled on her lap. Both inner thighs were reddened with fluid filled blisters on each inner thigh. The resident stated the area hurts. The resident was sent to the emergency room and treated for [REDACTED]. A review of a facility form titled Risk Management Report dated 4/8/16, documented that at 5:35 pm staff heard the resident yell out. They noted at that time that her soup was spilled in her lap. The resident's pants were removed and the inner and outer thighs were noted to be red with blisters. Cold compress was applied; the left thigh blister was red and measured 7 by 3 centimeters (cm); the right thigh blister was red and measured 9 by 4 cm. The resident stated her legs burned. The resident was sent to the emergency room for an evaluation and treatment of [REDACTED]. The form also documented that staff will be more attentive to resident during meals. A review of the facility's form titled Line Temperatures for 4/8/16 (supper/Unit 1) documented that the temperature of the soup was 180 degrees. Review of an article from The Burn Foundation (www.burnfoundation.org) regarding burn prevention, documents that when tap water reaches 140 degrees, it can cause a third degree burn in five seconds. A review of a progress note dated 4/11/16 at 1:09 pm, written by an OTR (occupational therapist registered), documented that the resident was screened when eating lunch d/t burns on left thigh from spilled soup. Resident is able to feed self with set up assistance and was utilizing a tray table at the time of observation. Staff stated that the lunch shift uses the tray table in order to prevent spilling d/t positioning in scoop chair. This writer recommends using the tray table at all meals. She would also benefit from utilizing a piece of dycem underneath her plates and bowls to prevent movement and spillage. CNA (certified nursing assistant) assignments have been updated to reflect this change. During an interview with the Dietary Manager (DM) on 5/4/16 at 11:00 am, the DM stated that there were no changes made to temperatures of served food. The DM stated that the residents were asked if the soup was too hot and there were no complaints. During an interview with the OTR on 5/4/16 at 2:20 pm, the OTR stated the resident was assessed after the burn and made recommendations that were communicated to the nurse manager via email and written in the communication book. The care plan was updated to include a tray table with dycem under plates and bowls to be used at all times. During an interview with the physician (MD) on 6/1/16 at 1:50 pm the MD stated no new issues were reported about the resident's behaviors, but she would expect to be notified especially if they are repetitive behaviors. Observation of the resident on 5/4/16, during the noon time meal revealed the resident sitting at the table without a tray table in place. Resident #2: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have severe cognitive impairment. The Comprehensive Care Plan (CCP) titled Behaviors initiated 6/11/15 and renewed on 1/7/16, documented that the resident yells out and calls staff names, very impatient, combative with care and throws food items. Listed as interventions: invite to activities; assess for possible bowel needs; intervene and report to the physician; assess resident's comfort; and psych consult as needed. A review of progress notes dated 4/18/16 at 2:09 pm, documented that the resident knocked soup off the tray table and it landed on his lower legs. Noted to have first degree burns on the left lower shin and inner left shin measuring 6 by 7.5 centimeters (cm) on the top lower left shin and the inner shin measures 7 by 3 cm. A review of the progress notes dated 4/18/16 at 3:46 pm, by the nurse practitioner documented bilateral lower extremity burn noted to left anterior shin and right lateral shin area. These areas are shiny with blistering. A review of the progress notes dated 4/19/16 at 10:18 am, written by the OTR, documented that the resident was being assessed due to soup spill related to the resident having behaviors at lunch time, which is the resident's norm. The resident knocked his soup bowl onto his legs and sustained burns to bilateral lower extremities. Trial new seating options and until the equipment is determined, it was recommended that the resident does not eat hot soup due to safety risks as behaviors are this resident's norm. An additional note documented on 4/19/16 at 3:53 pm, by the Physical Therapist (PT) that the resident was placed in a scoop tilt chair, because the resident had difficulty maintaining midline alignment while in a recliner. The resident is known to voluntarily spill food and drinks to get attention. A note documented on 4/22/16 at 12:07 pm, written by the OTR, documented that the resident was assessed due to the risk of spilling a bowl of soup. The resident was noted to have confusion and some behavioral issues at breakfast time. The resident dropped food frequently, and would risk spilling of soup. A review of the facility's form titled Line Temperatures for 4/18/16 (lunch/Unit 2) documented that the temperature of the soup was 180 degrees. During an interview on 5/4/16 at 3:45 pm, with a certified nursing assistant (CNA) who takes care of the resident frequently, stated the resident always throws food and drinks during his meals. During interview on 6/2/16 at 10:35 am with the physician, he stated he was not made aware that the resident continually had behaviors during meals, and would expect to be made aware. 10 NYCRR 415.12(h)(1)

Based on observation ,record review and interview during the extended recertification survey it was determined that the facility failed to have an effective system in place to ensure physician orders would be obtained, transcribed and administered as ordered by the physician and that medication omissions, errors in transcription and administration were investigated and action was taken to prevent recurrence. Lack of an effective system resulted in significant medication errors for 10 (#s- 4, 19, 25, 33, 41, 44, 48, 57, 60 and 73) of 28 residents reviewed. Specifically, the facility failed to ensure that staff followed acceptable standards of practice and transcribed Physician Orders (MD) orders accurately and administered medications according to the written orders. The facility failed to identify medication errors , therefore failed to ensure Medication Variance reports were filed. Additionally, the facility failed to ensure that a resident did not receive a medication which they were allergic to, that a diuretic ( used to remove excessive fluid from the body) medication ordered for a resident with an acute respiratory condition was transcribed and administered by the route and frequency ordered by the physician. The facility's system did not include multiple levels of reconciliation of orders received by the physician to ensure accuracy of transcription and administration of medications. This in no actual harm with the potential to cause serious harm that is IMMEDIATE JEOPARDY to the health and safety of the residents and SUBSTANDARD OF CARE of all 74 residents that reside in the facility. This is a repeat deficiency from a partial abbreviated survey 10/21/13. This is evidenced by the following : Resident # 4 The resident missed 8 consecutive days of [MEDICATION NAME] which was ordered for early [MEDICAL CONDITION] ( fluid accumulation around the heart muscle causing the heart to pump ineffectively) and did not receive a newly order medication, [MEDICATION NAME], for three days after being ordered. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE] documented that the resident scored a 1/15 on the Brief Interview for Mental Status (BIMS) indicating that the resident had severe cognitive impairment for daily decision making, sometimes understood and sometimes understands. During an observation on 11/22/13 at 12:20 pm, the resident was noted in bed positioned on his back with the head of bed ( HOB) elevated approximately 30 degrees. Oxygen ( O2) was being administered at 2 liters/ minute (l/m) by way of ( via) nasal cannula. The resident was restless, moaning and was noted to have generalized [MEDICAL CONDITION] ( build up of fluid in the body). The Physician 's Order, dated 9/17/13, documented an order for [REDACTED]. The Physician's order dated 10/30/13 at 6:25 pm , documented orders for a Stat ( right away) chest x-ray (CXR) and to call physician with results, and Albuteral with Atrovent ( used to open and relax airway tubes in lungs) one vial by way of nebulizer ( delivers medication in mist form) every 4 hours for 24 hours due to shortness of breath (SOB) and low oxygen levels. The Physician's order dated 10/30/13 at 8:40 pm, documented an order for [REDACTED]. The telephone Physician's order , dated 10/31/13 at 10:00 pm, documented an order for [REDACTED]. The computerized generated monthly Physician Orders for November 2013, and reviewed by the RN on 10/22/13 prior to physician review documented a handwritten order dated 10/31/13 " switch [MEDICATION NAME] to 20 mg IM daily" . These orders were signed by the physician on 11/20/13 . The Medication Administration Record (MAR) dated 10/31/13, documented an order for [REDACTED]. The MAR dated 11/1/13 documented [MEDICATION NAME] 20 mg IM daily and was set up to be given on the odd days. The MAR documented that [MEDICATION NAME] 20 mg was administered IM in the left arm. The order on the MAR was documented as being discontinued on 11/2/13. A nursing progress noted dated 11/1/13 at 2:14 am, written by a Licensed Practical Nurse (LPN) documented that the resident refused his [MEDICATION NAME] 20 mg po. The next nursing progress note, dated 11/1/13 at 7:45 am, documented that a new physician's order was received to change the [MEDICATION NAME] from by mouth to IM. The order for [MEDICATION NAME] IM was not found in the medical record. The orders written on 11/1/13 at 2:20 pm, documented to discontinue [MEDICATION NAME], measure urinary output and for blood work. The Physician's order dated 11/2/13 at 11:25 am, documented an order for [REDACTED]. The same order included directions to give the [MEDICATION NAME] IM if the resident does not take it by mouth. The Medication Administration Record (MAR) for November 2013, documented the resident received 20 mg of [MEDICATION NAME] daily on 11/2/13- 11/7/13 and did not include the route in which it was administered. The Physician's order , dated 11/7/13 at 6:30 am documented an order for [REDACTED]. The Physician's orders dated 11/7/13 at 12:55 pm, documented an order for [REDACTED]. The MAR dated 11/7/13, documented [MEDICATION NAME] 20 mg IM now and was signed as being administered at 12:55 pm in the left arm . The order for [MEDICATION NAME] 20 mg daily po or IM was documented on the MAR as discontinued. There were no physician's order found to indicate the daily dose of [MEDICATION NAME] IM or by mouth were to be discontinued . The resident was seen on 11/7/13 at 6:30 pm by the physician. Orders were written for [MEDICATION NAME] 40 mg IM now , and [MEDICATION NAME] 2 mg subcutaneous (sc) every 2 hours as needed for anxiety and respirations. The MAR date 11/7/13 documented " [MEDICATION NAME] 40 mg IM x 1 now" and was signed as being administered at 6:35 pm. The MAR dated 11/8/13 through 11/16/13 did not document the order for [MEDICATION NAME] 20 mg IM daily as written by the Physician on 11/7/13. The nursing Progress notes, dated 11/8/13 - 11/16/13, documented that the resident was experiencing restlessness and agitation and continued to be medicated with [MEDICATION NAME]. The resident had not received any form of [MEDICATION NAME] from 11/8/13 -11/16/13. There was no documented evidence that the physician was made aware that the [MEDICATION NAME] po and IM were both discontinued for administration on 11/7/13 per the documentation on the MAR. The Physician's Order, dated 11/17/13 documented an order for [REDACTED]. The nursing progress note for 11/22/13 documented the physician ordered an additional [MEDICATION NAME] 20 mg IM for SOB (shortness of breath) and congestion, and a [MEDICATION NAME] (medication to dry secretions) every 72 hours. The MAR dated 11/22/13 - 11/25/13 documented an order for [REDACTED]. The MAR documented that on 11/22/13-11/25/13 the patch was not applied. A physician order dated 11/22/13 at 11:15 pm documented orders to discontinue all future laboratory test, apply [MEDICATION NAME] every 72 hours, and give [MEDICATION NAME] 20 mg IM twice a day (BID) prn (as needed) for SOB/Congestion. During an interview on 11/24/13 at 7:40 am, the RN Charge Nurse (RNCN) #2 stated that when an Licensed Practical Nurse (LPN) transcribes an order it is signed off as verified by the RN. If an RN transcribes an order it does not need to be checked by another nurse. During an interview on 11/25/13 at 8:00 am, the RNCN #1 stated that when the physician writes orders, the RN will check them and sign off. The RN will then give the orders to the LPN to transcribe. Once that is done the RN will sign off the MAR that the order was checked and correct. The LPN will then fax pharmacy, and gives the medication. During an interview on 11/25/13 at 8:30 am, the LPN #2 stated that she had not looked at the resident's MAR in a while so she does not know about the [MEDICATION NAME]. She later stated that there was no [MEDICATION NAME]es on the cart and she could not find a copy of the fax and order. During an interview on 11/25/13 at 10:00 am the RN Clinical Nurse Manager (RNCNM) stated that the RN or LPN should have faxed the order for the [MEDICATION NAME] to the pharmacy and then made a call to make sure the fax was received. Staff then should have made a copy of the order and stapled it to the confirmation page. During an interview on 11/25/13 at 8:30 am, the LPN #2 stated that she had not looked at the resident's MAR in a while so she does not know about the [MEDICATION NAME]. She later stated that there was no [MEDICATION NAME]es on the cart and she could not find a copy of the fax and order. During an interview on 11/25/13 at 10:00 am the RN Clinical Nurse Manager (RNCNM) stated that the RN or LPN should have faxed the order for the [MEDICATION NAME] to the pharmacy and then made a call to make sure the fax was received. Staff then should have made a copy of the order and stapled it to the confirmation page. If the medication did not arrive The progress note for 11/22/13 documented the physician ordered [MEDICATION NAME] 20 mg IM for SOB and congestion, and a [MEDICATION NAME] (medication to dry secretions) every 72 hours. During an interview on 11/25/13 at 8:00 am, the RNCN #1 stated that when the physician writes orders, the RN will check them and sign off. The RN will then give the orders to the LPN to transcribe. Once that is done the RN will sign off the MAR that the order was checked and correct. The LPN will then fax pharmacy, and gives the medication. During an interview on 11/25/13 at 9:40am the RN #1 stated that if the MD wrote an order to discontinue po medications the [MEDICATION NAME] would have been discontinued but that she probably should have contacted the doctor because the medication was for po (by mouth) or IM. The primary physician was not available for in person or telephone interview ( was out of the country). Resident #33 The facility failed to ensure [MEDICATION NAME] was correctly administered according to physician orders for this resident with shortness of breath on exertion. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS ,dated 9/16/13, ( 14 day admission assessment), assessed the resident as understood and able to understand with moderate cognitive impairment. The resident was also assessed as having received a diuretic for seven times in the seven days prior to the assessment. A nursing progress note dated 11/11/13 at 5:26 am documented the RN was notified the resident was short of breath on exertion. It was noted that the RN assessed the resident and the resident's Saturated Peripheral Oxygen (SPO2, used to measure oxygen level in blood) ) was 94 percent ( 95- 100% are acceptable range for elderly) on room air. It noted the resident's lungs were with occasional wheezing, and that her breathing was slightly labored after exertion. It noted that the resident was not cyanotic ( bluish skin coloring due to lack of oxygen in the blood), her breathing was non-labored after lying down and resting, and her lower legs were with [MEDICAL CONDITION] ( fluid build up under the skin). Her vital signs were noted with her blood pressure at 189/79, her pulse at 71, respirations at 20, and temperature at 96.5 degrees. A nursing progress note dated 11/11/13 at 8:21 am documented that the Medical Director (MD) was notified of the resident having intermittent SOB with exertion. It was documented that the physician ordered a chest x-ray, and a BNP blood test (used to detect heart failure and worsening heart failure). A physician order dated 11/11/13 at 7:40 pm documented to give the resident [MEDICATION NAME] 40 mg po tonight and daily at night for two days along with [MEDICATION NAME] 60 milligrams po given daily in the morning for early [MEDICAL CONDITION]. The MAR for November 2013 had the order for 11/11/13 handwritten onto the MAR and documented [MEDICATION NAME] 40 mg tonight and daily at night 11/12/13 for two days along with the [MEDICATION NAME] 60 milligrams po given in the morning. Beside this order on the MAR, the 40 milligrams of [MEDICATION NAME] was signed as having been administered on 11/10/13, but then crossed out in error, and signed as having been administered on the evening of 11/11/13 at 8:00 pm. Below this the [MEDICATION NAME] was again handwritten on the MAR with notation that the [MEDICATION NAME] 40 milligrams be administered for two doses on 11/11/13 and 11/12/13. Beside this notation, the 40 milligrams of [MEDICATION NAME] was then signed as having been administered on 11/12/13. There was no documented evidence on the MAR that the [MEDICATION NAME] 40 milligrams was again administered to the resident on 11/13/13 as it should have been according to how the order was written in the interim physicians order on 11/11/13. A facility Risk Management Report for a medication error that occurred with this resident with an event date of 11/11/13 was completed and signed on 11/13/13 by the Clinical Nurse Manager, the Director of Nursing, and the Assessment Nurse Manager. The event was coded as a transcription error. It noted that the medication involved was [MEDICATION NAME]. It was documented that on 11/11/13, an order was received for [MEDICATION NAME] 40 mg that night and daily at night for two days. It was then noted that on 11/12/13 an LPN recognized that the order had been transcribed incorrectly on the MAR. It documented that an arrow was drawn over to 11/10/13 and was signed for by the LPN on that date and was left blank on 11/11/13. It documented that the order had been co-signed on the MAR by the 3:00 pm to 11:00 pm Registered Nurse (RN). The corrective action noted was to review the event with the staff involved and provide education on 11/13/13. It also noted that it would be reviewed at the monthly medication meeting. During an interview on 11/21/13, the Director of Nursing stated she was aware that they were having some issues with medication errors. She stated that it was not an excuse but felt it had to do with some of the staff having little experience. She stated that the Clinical Nurse Manager had been in charge of working on this. She stated that they had hired five to six new LPNs, some of which they have had to let go because there had been a lot of errors, primarily with process errors in transcription. She stated that the RNs at the facility had been placed with the responsibility of monitoring the LPNs for orders having been written and not transcribed timely. She stated that the Plan of Correction for Significant Medication Errors for 10/13 would not have been helpful in identifying these issues. During an interview on 11/23/13 at 10:10 am, the LPN stated that she had noticed on the MAR on 11/12/13 the [MEDICATION NAME] was signed out as being given on 11/10/13, but knew that was an error as the order was received on 11/11/13. The LPN stated she wrote the order over on the next line for the [MEDICATION NAME] to be given again on 11/12/13. The LPN stated the [MEDICATION NAME] should have been given for 2 days. When she read the order to the surveyor she stated " Oh, I see now it should have been for a total of 3 days extra." Resident #60 The facility failed to ensure that an order for [REDACTED].e. antianxiety and narcotic pain medications) were administered to the resident at the times they were supposed to be administered according to physician orders. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as understood and sometimes able to understand with moderately impaired cognition. She was noted to have received an antianxiety medication seven times in the seven days prior to the assessment. Finding # 1 A physician's progress note dated 7/31/13 documented that the resident was showing some mental deterioration. It was noted that her mental status was not as good as it had been and that she became a little more confused rather easily than as she had in the past. The physician noted that because of this and with possibility that the resident was developing a senile dementia, they would go ahead and start her on a low dose of [MEDICATION NAME] and see how she responded to this over the next few weeks. It was noted that she would probably need the medication adjusted within a month. An interim physician order dated 7/31/13 unsigned by a nurse and signed by the physician on 8/28/13 documented an order for [REDACTED]. There was no documented evidence of the [MEDICATION NAME] having been transcribed to the MAR until 8/20/13. A nursing progress note dated 8/20/13 at 11:44 am, documented that on 7/31/13 an order was written for [MEDICATION NAME], but that the order was never transcribed to the MAR. It noted that this was found today and corrected. It also noted that the physician and the resident were notified. A facility Risk Management Report for a medication error that occurred with this resident with an event date of 7/31/13 was completed and signed on 8/21/13 by the Assessment Nurse Manager, on 9/13/13 by the Director of Nursing and the Clinical Nurse Manager and on 9/20/13 by the nursing home Administrator. The event was coded as a medication omission and documented that the event occurred during transcription. It noted that an order for [REDACTED]. The corrective action noted that the event was reviewed with the staff involved and that the event would be reviewed at the monthly medication meeting. It documented that Registered Nurse Education was completed to follow the process put into place by the facility so as to prevent these types of errors. This event was noted on this report to not be reportable. Finding # 2 Monthly physician's orders dated 6/30/13, 7/31/13, and 9/29/13 documented orders for the resident to receive [MEDICATION NAME] 50 mg po every four hours as needed, [MEDICATION NAME] 0.25 mg three times a day, and APAP (Tylenol) with [MEDICATION NAME] 30 mg BID, and [MEDICATION NAME] 50 mg BID. On the MAR for August 2013, [MEDICATION NAME] was signed as having been administered on 8/8/13 at 12:00 pm. A nursing progress note dated 8/8/13 at 10:28 pm documented that the resident received [MEDICATION NAME] at 12:00 pm instead of [MEDICATION NAME]. A facility Risk Management Report for a medication error that occurred with this resident with an event date of 8/8/13 was completed and signed on 8/9/13 by the Assessment Nurse Manager, on 8/12/13 by the Clinical Nurse Manager, on 8/16/13 by the Director of Nursing, on 9/9/13 by the nursing home Administrator, and on 10/10/13 by the Pharmacy Director. The event was coded as the wrong medication administered. It noted that the resident was give [MEDICATION NAME] at 12:00 pm instead of [MEDICATION NAME] in error and that no ill effects were noted to the resident. The corrective action noted that the incident was reviewed with the LPN, that education was completed, and that the event would be reviewed at the monthly medication meeting. This event was noted on this report to not be reportable. On the MAR for September 2013, APAP/[MEDICATION NAME] was signed as having been administered on 9/12/13 at 8:00 am and 12:00 pm and [MEDICATION NAME] 50 milligrams was also signed as having been administered on 9/12/13 at 8:00 am and 12:00 pm. A nursing progress note dated 9/12/13 at 3:28 pm documented that while preparing the resident's medications at 7:30 pm, the Licensed Practical Nurse (LPN) noted that APAP/[MEDICATION NAME] was not removed from the medication card but was signed out on the narcotic count sheet. It documented that it was also noted that one extra dose of [MEDICATION NAME] was missing from the medication card but was not signed our on the count sheet. It documented that it appeared the LPN gave an extra dose of [MEDICATION NAME] and no dose of APAP/[MEDICATION NAME] at 8:00am. It documented that a fax was sent to the attending physician about this. A facility Risk Management Report for a medication error that occurred with this resident with an event date of 9/12/13 was completed and signed on 9/13/13 by the Assessment Nurse Manager, on 9/13/13 by the Director of Nursing, on 9/17/13 by the Clinical Nurse Manager, on 10/7/13 by the nursing home Administrator, and on 10/10/13 by the Pharmacy Director. The event was coded as the narcotic count having been off. It documented that while preparing the resident's medications at 7:30 pm, the LPN noted that no APAP/[MEDICATION NAME] had been removed from the medication card, but one was signed out on the card. It documented that it was also noted that one extra dose of [MEDICATION NAME] was missing but not signed out. It documented that it appeared the 7:00 am to 3:00 pm LPN gave [MEDICATION NAME] at 8:00 am instead of the APAP/[MEDICATION NAME]. The corrective action noted was that the event was reviewed with the staff involved and would be reviewed at the monthly medication meeting. It was not identified on this report if the event had been reportable. During an interview on 11/25/13 at 9:40 am, the Administrator stated that she would have expected the Pharmacy Consultant to have identified the problems with transcription and medication administration errors. During interview on 11/25/13 at 10:15 am in the presence of both the Administrator and Director of Nursing (DON) , the DON stated she did not realize the abundance of medication errors that were occurring. She stated the she would have expected a lesser number as the licensed staff had just received education in-service form an outside consultant. The DON did state that the current QA program and corrective actions in place would not have identified the current issues with medications. 10 NYCRR 415.12 (m)(2)

Based on record review and staff interview the facility was not administered in a manner that enabled it to use resources effectively and to attain or maintain the highest practical physical , mental, and psychosocial well-being of each resident during the extended recertification survey. Specifically, for 8 residents ( #s- 4, 16, 25, 33, 44, 48, 57 and 60) of 28 residents reviewed the Administration failed to ensure that residents were free of significant medication errors. Additionally, the Administration failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents. The Administration failed to provide monitoring of the care and treatment to prevent the development and/or worsening of pressure ulcers for Resident #'s 12, 25 and 49. This resulted in the potential for serious harm that is IMMEDIATE JEOPARDY to the health and safety of all residents. This is evidenced by the following: Refer to Quality of Care -F 333, Residents are Free of Significant Medication Errors, Scope and Severity L Refer to Quality of Care - F 314, Pressure Sores- Do Not Develop, Receives Treatment, Scope and Severity H Refer to Administration - F 501, Medical Director Scope and Severity L Refer to Administration - F 520, Quality Assessment & Assurance Scope and Severity L During an interview on 11/24/13 at 1:00 pm, the Administrator stated she was not aware of the medication errors being identified. She stated medications errors identified by the staff are discussed and reviewed by the Medical Director weekly. She stated she was not fully aware of that reconciliation of orders were not being conducted by multiple staff. She stated that the facility did recently revise the Medication Policy for reconciliation of orders. She stated that the Policy was revised on 9/19/13. She further stated that she thought the policy and procedure for pressure ulcer prevention and care was working. She stated the facility was aware of pressure ulcer concerns with the Certified Nursing Assistants (CNA) applying ointments awhile back, but was not aware of that the CNAs were continuing to apply non-medicated ointments to Stage 2 open areas ( open areas that involve the loss of the first layer of skin). During the interview she stated that the Medical Director is also the primary physician for 52 of the 74 residents residing in the facility and could see how things could easily be missed or overlooked . During an interview on 11/24/13 at 1:15 pm, the Director of Nursing ( DON) stated that the revision of the Medication Policy on 9/19/13 would not have been helpful to identify the current medication errors being identified by the surveyors. 10NYCRR 415.26

Based on medical records and staff interviews during the extended recertification survey the facility failed to ensure that the Medical Director effectively coordinated medical care and implemented effective policies for resident care for 28 ( #'s 3, 4, 10, 12, 16, 19, 24, 25, 27, 32, 33, 38, 39, 41, 44, 46, 48, 56, 57, 60, 62, 67, 68, 73, 75 and 76) of 28 residents reviewed. Specifically, the Medical Director failed to effectively address issues related to the significant medication errors and assist the facility to meet its regulatory requirements to implement, review and revise policies related to medications, pressure ulcers. This had the potential to effect all 74 residents residing in the facility. This resulted in no actual harm but had the potential for serious harm that is Immediate Jeopardy for the health and safety of all residents. This is evidenced by the following: Finding # 1 Refer to F- 333 - Quality of Care - Significant Medication Errors- Scope and Severity- L Refer to F-314- Quality of Care-Pressure Ulcers-Scope and Severity- H The Medical Director failed to implement, assist the facility or review facility policies for medication administration and reconciliation. Additionally, failed to implement, revise and review facility policies related to physician and medication orders. The facility policy titled Medication Administration with a revision date of 9/19/13, did not include documentation in a process to be used to reconcile new or renewed physician orders. During review of medical records during the survey process, significant medication errors were identified by the surveyors. These errors were related to the omission of new physician orders [REDACTED]. The Medical Director was not available for interview by telephone or in person ( was out of the country). During an interview on 11/24/13 at 1:00 pm, the Administrator stated she was not aware of the medication errors being identified. She stated medications errors identified by the staff are discussed and reviewed by the Medical Director weekly. She stated she did not believe the Medical Director would have been aware of issues related to reconciliation and transcribing of orders. She stated that the Policy revised on 9/19/13, was not reviewed by the Medical Director. Finding # 2 The Medical Director failed to ensure that an effective plan was reviewed and revised for the prevention, treatment of [REDACTED]. The facility policy titled Pressure Ulcers, revised 9/13 and signed by the Medical Director on 9/17/13, documented under Medical Director or designee documented the Medical Director and the Wound Care Certified Nurse (WCCN) will perform monthly rounds on any resident with a Stage 3 ( full thickness of skin loss, exposing the more than top layer of skin , may appear as shallow crater) or above and /or non healing Stage 2 pressure ulcers( opening of top layers of skin). During an interview on 11/21/13 at 4:00 pm, the Medical Director stated she had little involvement with pressure ulcers as she was not trained in wound care. She stated she relies on the expertise of the WCCN for advisement. 10NYCRR 415.15(a)

Based on record review and interview, the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents during the extended standard recertification survey. Specifically, for 28 ( #'s 3, 4, 10, 12, 16, 19, 24, 25, 27, 32, 33, 38, 39, 41, 44, 46, 48, 49, 56, 57, 60, 62, 67, 68, 73, 75 and 76) of 28 residents reviewed, the QA program failed to identify the system failure of staff not following acceptable standards of practice in the areas of transcribing physician orders [REDACTED]. Additionally, the facility failed to ensure those residents with allergies [REDACTED]. Additionally, the QA program failed to provide monitoring of the care and treatment to prevent the development and/or worsening of pressure ulcers for Resident #'s 12, 25 and 49 that resulted in actual harm and Standard Quality of Care. This resulted in no actual harm with the potential for serious harm that is IMMEDIATE JEOPARDY for all residents. This is evidenced by the following : Refer to F- 333 - Quality of Care - Significant Medication Errors- Scope and Severity- L During an interview on 11/24/13 at 1:00 pm, the Administrator stated she was not aware of the medication errors being identified. She stated medications errors are discussed during monthly QA meetings, but she was not aware of the number of issues related to reconciliation and transcribing of orders. She further stated that medication errors identified by the staff are reviewed but there is no monitoring or audits being conducted in relation to chart review of physician orders. She stated there were audits being conducted for admission and re-admissions orders, but was not sure if a multiple check of these orders was taking place. During an interview on 11/24/13 at 1:30 pm, the Director of Nursing (DON), stated there was currently no facility procedure in place for reconciliation of transcribed orders to ensure accuracy. The DON stated the current QA monitoring the facility is using would not have identified the medication errors being identified during the survey process. Medical Director was not available for interview by telephone or in person. Refer to F-314- Quality of Care-Pressure Ulcers-Scope and Severity- H During an interview on 11/22/13 at 11:30 am , the Wound Care Registered Nurse (WCRN) stated the facility had a very high number of pressure ulcers and there was very little involvement from the physicians. She stated that the physician relies on her heavily for pressure ulcer treatment. During an interview on 11/22/13 at 12:00 pm, the Administrator stated that there was no current QA monitoring for pressure ulcers. She stated the usual monitoring with the Wound Care team is conducted weekly, but there is no QA specifics being done. During an interview on 11/22/13 at 12:30 pm, the DON stated that it was identified several months back that the Certified Nursing Assistant's (CNA) were applying Sensicare ( a zinc based barrier cream) ointment to Stage 2 ( opening of the first layer of skin) areas, but was not aware it was still occurring. Refer to 501- Medical Director-Scope and Severity- L The QA failed to ensure that the Medical Director failed to effectively address issues related to the significant medication errors and assist the facility to meet its regulatory requirements to implement, review and revise policies related to medications. The Medical Director was not available for interview by telephone or in person ( was out of the country). During an interview on 11/25/13 at 9:30 am, the Administrator stated that the Medical Director is also the primary care physician for 52 of 74 residents residing in the facility. She stated that the physician was very involved with the care of the resident's , but maybe she has taken on to much for the responsibilities involved as the Medical Director. 10NYCRR 415.27(a-c)

Based on record review and interviews the facility did not ensure that residents were free from any significant medication errorsfor 2 (#s-89, 90) of 9 residents reviewed during a post survey revisit. Specifically for resident #90 the facility did not ensure that a time specified medication was discontinued as ordered by the physician, and for resident # 87 the facility did not ensure that the resident's pain medication was increased from once a day to twice a day per physician order. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This is evidenced by: Resident # 90 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) documented that the resident scored an 11/15 on the brief interview for mental status indicating that the resident had moderate cognitive impairment for daily decision making. It documented that she is usually understood and usually understands. A physician order [REDACTED]. A Medication Administration Record (MAR) dated January 2014 documented on 1/10/14; [MEDICATION NAME] oral suspension 500mg by mouth three times daily for 7 days. It was documented to be given at 9:00am, 2:00pm, and 9:00pm and the administration boxes had lines through them from 1/1/14 through 1/10/14 at 2:00pm. The medication dosing was not counted out on the MAR or "x's" marked in the boxes after the 7th day of administration. The last dose should have been given on 1/17/14 at 2:00pm. The MAR documented initials in the boxes for 1/17/14 at 9:00pm, on 1/18/14 it documented initials in the boxes for 9:00am, 2:00pm, and 9:00pm, and on 1/19/14 it documented initails in the boxes for 9:00am and 2:00pm. During an interview 1/23/14 at 2:30pm the Director of Nurses (DON) stated that the numbers that were written in on the MAR and TAR counting off the days was written in after the error was discovered. Resident # 87 The resident was admitted to the nursing home on 2/16/05 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) documented that the resident scored 15/15 on the brief interview for mental status indicating that the resident had intact cognitive skills for daily decision making. It documented that he is usually understood and usually understands. A physician order [REDACTED]. There was no documented evidence that the 2nd or 3rd nurse check was completed on the order. A Medication Administration Record (MAR) for January 2014 documented [MEDICATION NAME] 15mg extended release by mouth every night for 7 days. The 7 days( 1/8/14 - 1/17/14) were counted out on the MAR and an x and line were documented from day 8 through the rest of the month. The next box down documented [MEDICATION NAME] 15mg by mouth twice daily and times for 9:00am and 9:00pm were written in. The spaces for 1/1/14 - 1/14/14 were crossed out on the MAR. The 9:00 am boxes for 1/15 and 1/16/14 were blank. A narcotic sheet for the resident's [MEDICATION NAME] ER 15mg had no documented evidence of a dose signed out at 9:00am on 1/15 or 1/16/14. During an interview on 1/23/14 at 11:40am the resident stated that he had pain mostly in his wrists and did not recall having increased pain on the 1/15 and 1/16/14 because it takes a while for the [MEDICATION NAME] to start working for him. During an interview on 1/24/14 at approximately 2:00pm the DON stated that she was aware that there was a problem with the medications with a time limit and that they had a policy to address marking out the a time block for these medications but was unable to produce the policy. The DON further stated that the order probably should have been written as two separate orders. 10NYCRR415.12(m)(2)

Based on observation, record review and staff interview it was determined during an extended recertification survey the facility did not ensure a resident who entered the facility without pressure sores did not develop pressure sores after admission and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent worsening and new sores from developing for 7 ( #s- 4, 12, 16, 25, 41, 49, 73 ) of 14 residents reviewed for pressure sores. Specifically, the facility did not ensure that Stage 2 areas were monitored and assessed by the Registered Nurse , to prevent the worsening of a Stage 2 pressure ulcer located on the buttock area. A Roho ( specialized air flow cushion ) cushion was ordered and took 17 days to acquire was not available after the intervention/recommendation was made. The facility was treating Stage 2 pressure ulcers with Sensicare ( a zinc based ointment), which was being applied by the Certified Nursing Assistants (CNA). Additionally, the facility failed to identify a recurring Stage 2 pressure ulcer to the right buttock and failed to implement effective offloading to heal and prevent further breakdown. This is a pattern that resulted in actual harm to Residents # 12, # 25 and # 49 and had the potential for more than minimal harm for Residents # 4,16,61 and 73 which resulted in Substandard Quality of Care that is not immediate jeopardy. This is evidenced by the following: Resident # 12 The facility did not ensure that Stage 2 areas were monitored and assessed by the Registered Nurse , to prevent the worsening of a Stage 2 pressure ulcer located on the buttock area. A Roho ( specialized air flow cushion ) cushion was recommended and added to the Comprehensive Care Plan (CCP). The Roho was not available for 17 days after the intervention/recommendation were made. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], assessed the resident was not able to be interviewed for the Brief Interview for Mental Status (BIMS) and not able to be understood and not able to understand. The MDS further assessed the resident was at risk for pressure sores and the resident had Stage 2 pressures ulcers with dimensions of 8.0 cm(centimeters) long and 2.4 cm wide. The facility Standard of Care ( universal interventions used for all residents) for Pressure Ulcers, documented; reposition resident at least every 2 hours when in bed, if repositioning is required more often it would be identified in the residents' individualized care plan. Use pillows, foam wedges or assistive devices to keep bony prominence from direct pressure, totally relieve pressure on heels with pillows that lift heels off surface of the bed or chair and that selected residents with existing skin issues are placed on specialty mattresses's per Interdisciplinary Team (IDT). The current Braden Scale was dated 9/26/13. This document assessed the resident as having a risk score of 13 /23, indicating a moderate risk for the development of pressure sores. The CCP, 11/21/13, documented under problem section, "11/18/13- purple /blue area right buttock. Scattered areas of ecchymosis and Stage 2 at right and left coccyx and sacrum; worsening but not indurated. Under the problem section of the same CCP, documented " 11/21/13- area merged with left gluteal fold areas , see new problem . " The new CCP, dated 11/21/2013 for Actual Skin Impairment, documented two separate pressure areas in the gluteal fold. A second notation, dated 11/21/13 , documented " area merged with right buttock, see new problem". The goal was documented as the resident's skin will heal by 2/5/14. The approach section documented a cushion will be used for the resident's back, the physician will be notified of changes in the resident's condition, and the resident will be repositioned every 2 hours, off-loading, and positioning devices per occupational therapy (OT)/ physical therapy (PT). The CCP further documented a weekly pain assessment, treatment as per protocol, diet to promote healing, encourage adequate fluids, and supplements as the physician orders. There were no specific type of cushion or off loading device documented in the CCP. Observation of the pressure sore on 11/23/13 at 8:20 am, the pressure area located on the sacral area measured approximately 7 cm wide by 11.2 cm long, with an irregular shape. The base of the area was pink with darkening purplish color surrounding the outer area. The Weekly Wound/ Pressure Ulcer Healing Assessment, documented a pressure sore with a date of onset as 11/5/13 to the proximal left gluteal fold area. The wound description section documented the wound was a Stage 2 with measurements of 0.8 centimeters by 0.5 centimeters, the color was red, and surrounding skin area was normal. The progress note documented on dated 11/5/13 by the Registered Dietician (RD), documented the resident had two new Stage 2 pressure ulcers in gluteal fold and diet/intake would be reviewed for need of changes. The progress note, dated 11/5/13, written by the Registered Nurse (RN) , documented the resident slides down in the chair when self propelling in wheel chair. The resident had a gel cushion in place for pressure relief, however despite this the resident shears her bottom when she slides in the chair. Physical Therapist (PT) stated that this was the appropriate chair for the resident to maintain her out of bed independence. On 11/6/13 a hammock ( sling type ) cushion was added to chair and the gel cushion was placed on top of hammock cushion to attempt to decrease sliding in chair. The Weekly Wound/ Pressure Ulcer Healing Assessment, dated 11/8/13, assessed by the RN Wound Care Nurse (RNWCN) , documented a non- opened area on the right buttock, measuring 1 cm by 0.5 cm, blue purple in color and surrounding skin to be purple in color. The progress note dated 11/8/13 , written by the RN, documented " resident has a new pressure ulcer on the right buttock which is blue /purple in color and measures 1 cm by 0.5 cm . The progress note , dated 11/8/13, written by the Occupational Therapist (OT), documented " the resident now has a Stage 2 area on the coccyx. New cushion will be assessed and ordered early next week ( need administrator approval). Hard base removed from under gel cushion to decrease/prevent sacral sitting. The OT note, dated 11/8/13, documented the resident will receive a RoHo ( a specialized air flow cushion used to relieve pressure) cushion . The progress note and Weekly Wound/ Pressure Ulcer Healing Assessment, dated 11/14/13, documented the resident was seen for wound rounds. "The pressure ulcer on the right buttock is now a Stage 2. Wound bed measures 0.8 cm by 0.7 cm , red in color with small amount of clear bloody drainage. The surrounding tissue is dark red/purple and very fragile. The area on the distal left buttock measures 1.4 cm by 0.8 cm , wound bed is red with a small amount of clear bloody drainage. the surrounding tissue is dark red/purple. The proximal aspect of the left buttock including the coccyx is unstageable measuring 8 cm by 2.4 cm with red and black eschar ( dying tissue) with a small amount of clear bloody drainage. The surrounding tissue is dark red/purple. The progress note , dated 11/19/13, written by the RN, documented the physician wanted another cushion as the anti- hammock ( sling type device ) cushion was to hard. A new soft anti- hammock was provided. The physician additionally ordered a surgical consult. The Weekly Wound/ Pressure Ulcer Healing Assessment, dated 11/21/13, documented that the pressure areas on the right and left buttocks had merged. The progress note, dated 11/21/13, written by the RN to support this assessment, documented "the pressure ulcers on the right buttock, proximal and distal left gluteal fold have all merged into one area. The area is Stage 2 measuring 7 cm by 11.2 cm , wound bed is red and most with scant clear bloody drainage. The surrounding skin is dark purple/red ". During interviews with several Certified Nursing Assistants ( CNAs ) on 11/21/13 -11/23/13, the CNAs stated that they apply the Sensicare to open areas unless told differently. They stated that if it was a doctor ordered treatment, then the area would be cared for by the Registered Nurse (RN). The Cans stated that they would report any worsening of the areas to the nurses. The CNA that was the primary care giver for this resident stated that Sensicare was being used after each time the resident was changed, and that the resident stays in bed most of day getting up for meals only. The CNA stated that the increase of time in bed started after the areas got larger and started to turn black. During interviews with the Licensed Practical Nurse's (LPN) from 11/21/13 -11/23/13, the LPNs stated that they go with the CNAs once a week to look at the areas receiving Sensicare. The LPNs stated that they do not always get to do this. Additionally, the LPNs stated that the CNAs apply the ointment but they sign in the Treatment Administration Record (TAR), that the ointment was applied. The LPN stated that the CNAs report any changes in the pressure areas to the floor RN or the RNWCN. During an interview on 11/21/13 at 7:30 am, the RNWCC stated that she uses Sensicare on all Stage 2 pressure areas and will individualize treatments for Stage 3 and/or Stage 4 areas. She stated she would only notify the MD of Stage 3 and Stage 4 areas, and would only report stage 2 pressure areas if they were not healing. She stated she suggested treatments to the physician and would write an order and the doctor signed them. She stated that the facility only owned three high flow pressure relieving air mattresses and therefore the resident with the most severe pressure sores would be given the mattress. During interview on 11/23/13 at 9:00 am, the RNWCC stated she doesn't necessarily assess pressure ulcers at Stage 2 level unless other areas are identified or if the CNAs or LPNs report a worsening of the areas. She stated that the resident had issues with shearing when out of bed in the chair, but the CCP was not changed to increase time in bed to relieve pressure until after the area had worsened. During interview on 11/23/13 at 12:20 pm, the Director of Nursing (DON) stated that she was aware of problem with the CNAs applying ointments to open areas, but the policy was revised a few months ago and she was not aware the practice was still happening. She stated the LPNs are suppose to be doing a weekly skin check with the CNA's. Additionally, she stated that the resident had not received the Roho cushion for out of bed seating because it is a special order item and takes 3-4 weeks to arrive. She further stated that the facility only owns three speciality air flow mattresses and are used for the resident's with the worst areas. She stated all other residents are on low pressure relieving mattresses ( the standard mattress used in long term care facilities). Resident # 25 The facility failed to identify a Stage 2 pressure ulcer to the right buttock until 13 days after the developement of the pressure area. The area was documented as developing on 11/8/13 and monitoring and treatment was note implimented until 11/21/13. The resident was admitted to the facility on 4/19/11 with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented that the resident scored a 10/15 on BIMS indicating that the resident had moderate cognitive impairment for daily decision making and was always understood and usually understands. The same MDS documented the resident had one Stage 2 area and one Stage 4 area and utilized pressure relieving devices in and out of bed. A CCP for skin integrity, impaired, actual, dated 6/24/13 , documented actual skin impairment evidenced by a Stage 2 area on the coccyx. The goal was for the area to heal by 12/24/13 . The approaches documented reposition every 2 hours, offloading, positioning devices per OT/PT and for skin assessment /wound rounds weekly. There were no other skin impairments documented on this CCP under the problem section. During an observation on 11/20/13 at approximately 9:30 am, an open area was noted on the right buttock measuring approximately 1.5 cm x 1 cm in size with an approximately 0.1 cm area of slough ( thick grayish or yellowish tissue) in the proximal aspect of the wound. Two CNAs were providing care and applied Sensicare to the open area on the right buttock. A second observation at 1:00 pm, the resident was transferred back to bed and had been incontinent of a large amount of stool. The CNA cleaned the resident and applied Sensicare to the open area on the buttock. During an observation of wound rounds on 11/21/13 at 7:40 am, the RNWCN measured what she described as" a new area to the right buttock" but did not remove the Sensicare that was on the wound and peri wound. prior to measuring it. The area was measured as being 0.2 cm x 0.2 cm. On the same date at 9:35 am, the RNWCN re-measured the wound after the Sensicare was removed. The area measured to be 1.4 cm x 1 cm in size. During an observation of care on 11/21/13 at 6:30 pm, the resident was noted in a reclining Geri chair. The resident was sitting on a thin foam cushion ( which is provided for all residents and used when out of bed for comfort) . During an observation on 11/22/13 at 7:00 am, the resident was in bed positioned on her back, heels were not off loaded off bed. At 9:00 am, the resident was again observed in bed positioned on her back with her left heel positioned on a pillow. The Wound/Pressure Ulcer Assessment sheet,( used to document the treatment and care of pressure ulcers), dated 10/13, documented " apply Sensicare to coccyx until healed ". The Weekly Wound/Pressure Ulcer Healing Assessment, documented the coccyx area as being healed from 11/1/13 - 11/21/13. The Weekly Skin and Pain Flow sheet, a flow sheet that is completed weekly by a CNA and a LPN to focus on the prevention and early detection of skin and pain issues. The form dated 10/19/13, documented " new open area on buttocks, see treatment sheet". The physician's orders [REDACTED]. A Task Manager Sheet ( a document used to sign that care was provided) by CNAs, dated 11/19/13, documented to float heels on a pillow when in bed, and Sensicare for days, evenings, and nights, but did not specify where to put the Sensicare. It documented to reposition the resident when out of bed at 10:00 am, 4:00 pm and 7:00 pm. A Resident Care Card (RCC) , dated 11/20/13, documented under mobility that the resident had a gel foam cushion in the chair when out of bed. The Weekly Wound/Pressure Ulcer Healing Assessment, documented a Stage 2 area located on the right buttock measuring 1.4 cm by 1 cm. with the onset date of 11/21/13. A RN treatment record for November 2013, documented an order dated 11/21/13, to start Sensicare to right buttock every shift and as needed with hygiene care. During an interview on 11/20/13 at 3:55 pm, the CNA #7 stated that he has done weekly skin checks on the resident and if no issues were found he would let the nurse know and they would sign off on the skin check. The CNA further stated that the RN showed him how to do a skin assessment and to apply Sensicare to open areas. He further stated that he would know an area was not new if he saw Sensicare around the area. During an interview on 11/21/13 at 7:10 am, the CNA #4 stated that the weekly skin check is supposed to be done with an LPN or RN but that it is not always done with a nurse. During an interview on 11/21/13 at 9:05 am, CNA #2 stated that she noted the open area when she was covering on that floor. The CNA stated that she notified the RNCN # 1 for the unit and that the RNCN came down checked the wound, and said that it was not new and to just apply Sensicare. During an interview on 11/21/13 at 9:50 am, LPN #1 stated that she thought the right buttock pressure area was an area that a CNA reported to her on 10/19/13. LPN #1 was not sure that she saw the area on the 19th or if she just documented what the CNA reported it to her. LPN # 1 further stated that CNAs apply the Sensicare to the open areas and the RN checks it weekly on wound rounds. LPN#1 further stated that she was not sure if the area was reported to the RN at the time but that they are supposed to check the skin at rounds. The LPN further stated she is not aware of the process used to report new or worsening skin issues. During an interview on 11/21/13 at 10:22 am, the RNCN #1 stated that she was not aware of the area to the resident's right buttock prior to wound care rounds today. She further stated that the area to the right buttock was new that day and that she had not seen that before. She stated that she left the Sensicare on the wound when she measured it because the skin surrounding the open areas is sensitive. Resident #49 The facility failed to prevent development and worsening of a pressure ulcer on the buttock as a result of not receiving alteration in interventions to promote off-loading of the area, provision of physician oversight with facility pressure ulcer management, provision of licensed clinical nursing assessments during treatments to the area. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], assessed the resident as understood and able to understand with moderately impaired cognition. It also assessed the resident as being at risk for pressure ulcers and as having one or more unhealed pressure ulcers at Stage 1 or higher. It noted the resident to have one unstageable pressure ulcer (known, but not stageable due to coverage of wound bed by slough or eschar) and measured 0.7 centimeters (cm) in length, 0.7 cm in width, and 0 cm in depth. The most severe tissue type was noted as necrotic (eschar) tissue that was black, brown or tan tissue adhered firmly to the wound bed or ulcer edges. It noted that pressure ulcers were present on the prior assessment and that the resident had pressure reducing devices for the chair and the bed, was receiving pressure ulcer care and application of ointments/medication to other than the feet. A CCP, dated 11/11/13, documented that the resident had "Actual Impaired Skin Integrity" as evidenced by two pressure areas on the right buttock that measured 0.5 centimeters (cm) by 0.5 cm and 0.5 cm by 1.0 cm. The goal was for the skin to heal by 2/14/14. Interventions included: a back cushion, notification of the physician with changes in the resident condition, repositioning every two hours, off-loading (unspecified), positioning devices per PT and OT (unspecified), weekly skin assessments/wound rounds, treatment per protocol, provision of a diet to promote healing with two different interventions dated 11/11/13 with one stating approximately 100 grams of protein and 1750 to 1900 calories per day with encouragement for intake and the second one stating 85 to 95 grams of protein and 2100 to 2500 calories per day , education of importance of nutrition in healing/prevention of pressure ulcers, provision of fortified foods at all meals and gelatin with lunch, and provision of supplements at all meals (unspecified). There was no documented evidence of revision or evaluation of the interventions on the care plan. The Resident Care Card, last updated on 8/9/13, and documented that the resident required two person physical assist for bed mobility and total dependence with locomotion on the unit. It documented that the resident had a gel foam cushion in the chair and a foot buddy cushion with pillows under her calves to relieve pressure. It noted the resident to have a pressure ulcer on the right ischium that was facility acquired and that the preventative measure was back to bed (there was no identified time frames for this or guidance to turning an positioning). A Weekly Wound/Pressure Ulcer Healing Assessment with an onset date of 11/11/13 documented that the resident had a Stage 2 pressure ulcer on the right buttocks that measured 0.5 cm by 0.5 cm. On 11/17/13 it was again noted as a Stage 2, but was measured larger in size at 4.3 cm by 2 cm. On 11/21/13, it was then identified as unstageable and measuring 1.8 cm by 4.8 cm with black color. A Weekly Wound/Pressure Ulcer Healing Assessment with an onset date of 11/11/13 documented that the resident had a Stage 2 pressure ulcer on the left buttock that measured 0.5 cm by 1.0 cm. On 11/14/13, it was again noted as a Stage 2 then measuring 0.2 cm by 0.5 cm. On 11/21/13, it was noted again as a Stage 2 pressure ulcer measuring 1.2 cm by 0.8 cm. A Wound/Pressure Ulcer Assessment Report (forms where treatment of [REDACTED]. It noted the area as having been debrided ( removal of dead tissue), date unknown. It noted that the original off-loading device of a pillow behind the resident's back and turning and repositioning every two hours was discontinued on 11/22/13 along with application of Sensicare every shift and with hygiene care. Documented on this same form dated 11/22/13, was a treatment order change due to the debridement of the area. The new treatment/dressing order was changed to Santyl ( an medicated ointment used to remove dead/dying tissue) cream to the area, covered with Versicare dressing beginning on 11/23/13 and a new intervention of turning and repositioning side to side every hour along with implementation of an alternating air mattress. A Nutritional Services progress note dated 11/11/13 written by the RD, documented that the resident had 2 new pressure ulcers to the right buttocks. It was noted that the plan of care had been updated and that diet/menus were reviewed/modified to provide adequate calories and protein for wound healing for the pressure areas that developed on 11/11/13. A Nutritional Services progress note dated 11/12/13 written by the RD documented that an intake study was completed due to new pressure areas. It noted that the resident consumed 75 percent of her calorie needs and 87 percent of her protein needs. It noted that the resident was educated on her dietary needs for wound healing with good understanding noted. It documented that she did consume supplements per the same and that her wound status would be followed. There was no other information or documented evidence of full dietary assessments related to the resident's calorie and protein needs having been completed at the time of pressure ulcer development and worsening of the pressure ulcer along with evaluation of the interventions that were implemented over time. A physician progress notes [REDACTED]. A nursing progress note, dated 11/22/13 at 5:33 pm, was documented by the RNWCN and noted as a late entry. It noted that the resident was seen for wound rounds at 2:50 pm and that the pressure ulcer on her buttocks remained a Stage 2 area measuring 1.2 cm by 0.8 cm with surrounding tissue as pink. It then noted that the pressure ulcer on the right buttocks was now unstageable a with wound bed measuring 1.8 cm by 4.8 cm and documented that it was observed to be dry black eschar with wound edges attached and surrounding tissue pink. It was documented that the Physician was notified and ordered a stat surgical consult. A physician order [REDACTED]. It noted that the surgeon was in and debrided ( using sharp debridement by use of surgical blade) the area with the resident having tolerated it well. It noted that a tissue sample was sent to the lab for pathology and new orders were received for Santyl ( an ointment used to removed dead tissue ) cream to the area and cover with an absorbent dressing to start on 11/23/13. A handwritten surgical consult, dated 11/22/13, documented that the surgeon was called to evaluate a right gluteal decubiti ulcer that was unstageable due to necrotic tissue. It noted that the patient had been a long term nursing home resident with multiple medical comorbidities who was noted to have an unstageable ulcer. It documented a [DIAGNOSES REDACTED]. It noted that the area was prepped with [MEDICATION NAME] and sharply debrided until healing tissue was noted. The recommendations were to apply Santyl dressing daily and to implement an air flow mattress or constant change in position to prevent decubiti. . During an interview on 11/21/13 at 3:30 pm, the DON stated that pressure ulcers were looked at weekly by the Registered Charge Nurse and the facility's RNWCC. She stated this information was completed and then sent to the physician log if there was anything different from week to week. She stated the facility had a protocol of treatments for different stages of pressure ulcers that was signed off by the medical director. She stated there was no specific orders written by the physicians for pressure ulcer treatments. She stated that they used Sensicare with stage 2 pressure ulcers, which is a barrier used in relief of pressure. She stated the LPNs should be doing application of Sensicare to open areas and that CNAs should only be applying this to closed areas. During an interview on 11/21/13 at 4:15 pm, the Medical Director stated she received a facility pressure ulcer log one to two times per month, sometimes every three weeks. She stated that they had developed a form for this because they realized there was a problem with identifying the root cause of pressure ulcers and also to increase communication about pressure ulcers. She stated that when the physicians came into the facility, this information was not readily available and the main thing was to see that everything that needed to be done for pressure ulcers was being done. She stated if a wound was not healing and difficult, the physicians may come in to see the area but they also may defer to the Wound Care Clinic or to surgeons for debridement in dealing with resident wounds because they themselves were not proficient specifically in wound care. She stated that with this resident they may think twice before sending her out to wound care due to the length of the trip out of the building. She stated she just found out a few days ago about this resident's pressure ulcer worsening and that it may be good to send her out Wound Care at this time. She stated she left it up to the facility to determine appropriate off loading interventions. She stated she knew the facility used Sensicare to treat areas and expected the RNs to be applying this treatment to open areas. She stated the nurses should be eye balling open areas every day if they were a Stage 2 or greater. She stated treatments should be done by an RN and not CNAs so they can be monitored by an RN for effectiveness of the treatment. During an interview on 11/22/13 at 9:15 am, the RD stated that intake studies were usually done before they decided on which supplements to add. She stated they knew the resident's intake of supplements only at the time intake studies were completed for one day, otherwise supplement intake was just added into the overall total meal consumption. She stated she did not complete full nutritional assessments at the time of pressure ulcer notifications and that they only completed nutritional assessments on admission and annually. She stated that the specific supplements that the resident was provided is not specifically documented on the care plan. She stated that there was presently no way to track nutritional supplements in between the one day intake studies that were completed. During an interview on 11/22/13 at 11:30 am, the RNC #2 stated that she was aware that the resident had a surgical debridement last evening to her buttocks and that the Santyl that was ordered by the surgeon had not yet arrived from pharmacy, but that she knew it was due to be done. She stated that she had not seen the wound yet because the resident was already out of bed when she got here at 7:00 am, but that she assumed there was a dry dressing on it. During an observation on 11/22/13 at 1:00 PM the resident was in her room her reclining wheelchair with legs elevated and heels positioned directly on a pillow. Staff entered and transferred the resident with two person physical assistance and a Hoyer ( a mechanical lift) lift to bed and was positioned on her left side. There was a 4 x 4 dressing noted to the right buttock, and an approximate 2 cm x 2 cm red area noted to the right trochanter area. During an observation on 11/22/13 at 1:30 pm, the RNWCC removed the 4 x 4 dressing covering the wound and the wound measured approximately 2 cm x 0.7 cm deep with 0.6 cm tunneling at 1:00 position. The nurse covered the area again with a dry 4 x 4 dressing. The RN saw and touched the red area to the trochanter. During an interview on 11/23/13 at 9:40 am, the RNWCC stated she was not aware until today that the treatment was not done to the resident ' s buttock or that the RNC #1 told the pharmacy that the medication could be delivered the next day. She further stated that the MD should be contacted as soon as the nurse knows that a treatment is not available. She stated the RN charge nurse should check that offloading is being done, but then stated that she did not know where staff was signing for any special offloading cushions. She stated that to offload the heels a pillow needs to be placed under the calves so that the heels are floating off the bed. She stated that it was not appropriate for a resident with a Stage 3 pressure ulcer to the buttocks to be out of bed routinely in her chair for extended periods of time, and stated that she did not know that this had occurred with the resident. During an interview on 11/23/13 at 11:45 am, a 6:30 am to 2:30 pm CNA stated that the resident was got out of bed for meals and usually wants to lay down afterwards, but not always and with that, they typically just do what she wants to do. He stated that they turned and positioned the resident in bed using pillows to prop her up and try to off-load her buttocks. He stated they used pillows under her calves to off load her heels in bed and in the chair. He stated she had a cushion in her chair. The resident was then observed by the surveyor to be up sitting in her geri-recliner chair with a cushion underneath her buttock and a pillow under her calves with her heels in direct contact of the pillow. During an interview on 11/23/13 at 1:00 pm the pharmacy representative stated that they received the fax from the facility for the Santyl at 4:15 pm on 11/21/13. One of the pharmacy technicians contacted the nursing home at 5:14 pm to see if they had to make arrangements to get Santyl and was told by RNC #1 that it was ok to send the Santyl with the next day delivery that would arrive between 3:30 pm and 4:00 pm due to it being the weekend. During an interview on 11/24/13 at 9:00 am, the RNC #2 stated that she had signed for Sensicare having been applied to the resident's buttock on the Pressure Ulcer Assessment Report when that was the treatment for [REDACTED]. She stated that Santyl was to start on 11/23/13 but she was not sure if it was completed because it had not been signed for on the MAR. 10NYCRR 415.12 (c)(1)

Based on medical record review and staff interview during a complaint investigation (Case # NY 109) the facility did not ensure that each resident received adequate treatment and care for respiratory srvices. Specifically, for one ( Resident # 1) of five residents reviewed the facility did not assess a severely decompensated resident's respiratory status prior to and after giving the resident breathing treatments, and placing her on bilevel positive airway pressure ([MEDICAL CONDITION], pressure controlled ventilation in a system allowing unrestricted spontaneous breathing) machine as ordered by the physician. Additionally, an order on readmission for overnight oximetry reading was not done and the physician was not notified and previous orders to monitor oxygen saturations (Oxygen saturation, O2, refers to the level of oxygen carried by red blood cells) every shift were not carried through on readmission. The resident was found expired following the [MEDICAL CONDITION] and respiratory treatment without the physician ordered oxygen saturation monitoring performed. This was isolated and resulted in actual harm that is not immediate jeopardy. This was evidenced by: Policy & Procedure (P&P) entitled [MEDICAL CONDITION] (VPAP) Ventilatory Support and dated as created ,[DATE] documented the [MEDICAL CONDITION] Ventilatory Support system is a non-continuous ventilator and is intended to augment patient breathing. It must not be used as a life-support ventilator. Trained licensed professional staff can initiate [MEDICAL CONDITION] with a complete written physicians order. Indications included, patients with medically unacceptable hypoxemia despite administration of supplemental oxygen. Procedure included maintain settings as ordered, monitor for mask fit, ongoing assessment of effectiveness as reflected by skin color, monitor for skin irritation and breakdown, if problems arise that nursing is unable to remediate-nursing will contact respiratory care for further assistance, document all assessments, interventions, and findings. Job Title for Registered Nurse (RN) dated as revised [DATE] documented the RN main function, utilizes professional knowledge, judgment, and skills to assess, plan, implement, and evaluate nursing care to adult/geriatric residents. Listed under responsibility included, prepares, gives and evaluates the effectiveness of prescription and non-prescription drugs, administers oxygen and monitors its effectiveness, collects and analyzes resident data to ensure airway patency and adequate gas exchange, facilitates patency of air passage, collects and analyzes cardiovascular, respiratory and body temperature data to determine and prevent complications. Resident # 1: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident was transferred to the psychiatric hospital on [DATE] and was readmitted on [DATE]. She did have other previous admissions and discharges to the facility. She was alert and oriented with a BIMS score of 15 according to the Minimum Data Set ((MDS) dated [DATE]. Medication Administration Record (MAR, which provides authorized staff with a process for charting medication administration) dated [DATE] documented medications that included; [MEDICATION NAME] (used to prevent [MEDICATION NAME] in people with [MEDICAL CONDITION]) every four hours(q4h), [MEDICATION NAME] 0.5 milligram (mg)/2 milliliter (ml) via nebulizer (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) twice per day (BID), Daliresp (prevents worsening of [MEDICAL CONDITION]) 500 mcg at bedtime (HS), Performist (used to prevent [MEDICATION NAME]) 3 micrograms (mcg)/2 ml inhalation BID, and O2 Sats every shift. Physician orders [REDACTED]. Nursing progress note dated [DATE] at 2:17 pm documented resident left via ambulance on stretcher with continuous oxygen (O2) at 3 liters per minute. Is alert and oriented and agrees with transfer. Physician renewal orders dated [DATE] documented the order for O2 sats every shift. Discharge summary from the hospital psychiatry center dated [DATE] documented the patient was admitted on [DATE] and on [DATE] experienced severe respiratory decompensation. She was discharged to the hospital and admitted to the ICU (intensive care unit) where she was treated and transferred to the medical floor after 24 hours. She was readmitted to the psychiatry unit on [DATE]. Condition on discharge documented psychiatrically stable and improved. Physical condition is severe, chronic illness with both acute and chronic symptoms. Facility physician orders [REDACTED]. [MEDICATION NAME] 1 inhalation daily, [MEDICAL CONDITION] at setting ,[DATE] use prn, Daliresp 500 mcg at HS, Servant disc 1 inhalation BID, send to ED if O2 sat less than 70% for more than 60 minutes after placing on [MEDICAL CONDITION], O2 at 4 liters per minute via nc. There was no order for O2 sats to be completed every shift. Facility physician orders [REDACTED]. Facility physician orders [REDACTED].# 4 documented an order to discontinue the overnight oximetry reading due to the facilitys inability to perform a continuous reading. Progress note dated [DATE] at 4:15 pm and signed by RN # 4 documented, return fax from physician with new order to discontinue the overnight oximetry reading. There was no documentation that the 24 hour oximetry reading was never done and or there were no orders recieved to increase monitoring of the O2 sats. MAR dated [DATE] documented [MEDICATION NAME] bid and q4h as needed (prn), [MEDICATION NAME] 0.5mg/2 ml via nebulizer bid. [MEDICATION NAME] 1 inhalation daily, [MEDICAL CONDITION] at setting ,[DATE] use prn, Daliresp 500 mcg at HS, Servant disc 1 inhalation BID, send to ED if O2 sat less than 70% for more than 60 minutes after placing on [MEDICAL CONDITION], O2 at 4 liters per minute via nc. MAR dated [DATE] documented resident received additional [MEDICATION NAME] prn treatments from [DATE] thru [DATE] on the following: one additional treatments on 11 days, two additional treatments on 3 days, three additional treatments on two days. MAR dated [DATE] documented resident received [MEDICAL CONDITION] treatment on 13 occasions. Nurse note (NN)dated [DATE] at 10:27 am documented resident used [MEDICAL CONDITION] for O2 sat of 68% and later was 91%. NN dated [DATE] at 1:22 pm documented resident complained of (c/o) shortness of breath (sob) prn nebulizer treatment given with good effect. There was no O2 sat or other respiratory assessment documented. NN dated [DATE] at 1:35 am documented resident started with short bout of respiratory distress, placed [MEDICAL CONDITION] machine on. O2 sat increased to 94%. NN dated [DATE] as a late entry for [DATE] at ,[DATE] shift documented resident used [MEDICAL CONDITION] most of shift at her request. Attempted to remove several times but requested it put back on. O2 sats remained above 90%. NN dated [DATE] at 4:18 pm documented resident used [MEDICAL CONDITION] today times one. Lungs remain diminished. No O2 sat or other respiratory assessment was documented. NN dated [DATE] at 11:04 pm documented patient has been off and on [MEDICAL CONDITION] all night. O2 would drop below 85% put [MEDICAL CONDITION] on O2 would go up. Finally able to keep O2 above 90%. NN dated [DATE] at 2:52 pm documented resident required [MEDICAL CONDITION] most of the shift. There was no O2 sat or other respiratory assessment documented. . NN dated [DATE] at 12:30 am documented [MEDICAL CONDITION] removed before dinner and O2 sat was 94%. Daily Communication Log dated [DATE] documented under Resident # 1's name on the 7:00 am to 3:00 pm shift, has been on [MEDICAL CONDITION] many times today, there were no O2 sats or other respiratory assessment documented. NN dated [DATE] at 2:29 pm documented resident requested prn nebulizer treatment. Nurse told resident it was too early for her nebulizer treatment as it is ordered every 4 hours. Resident offered [MEDICAL CONDITION] machine and resident said no. There was no O2 sat or other respiratory assessment documented. NN on [DATE] at 11:55 am documented resident removed [MEDICAL CONDITION] without requesting nursing to switch O2 back on to nc. There was no O2 sat or other repiratory assessment documented. NN on [DATE] at 3:04 pm documented resident wearing [MEDICAL CONDITION] and stated ease of respiration, O2 sat up to 94%. NN on [DATE] at 2:02 pm documented resident complained of shortness of breath this shift [MEDICATION NAME] given twice this shift with relief. [MEDICAL CONDITION] used this shift with good results. There was no O2 sat or other respiratory assessment documented. MAR dated [DATE] documented resident received [MEDICAL CONDITION] on [DATE] at 3:40 am. Documented resident received [MEDICATION NAME] treatment at 4:30 am. There was no documentation on the MAR or the NN in regards to O2 sat taken or other respiratory assessment completed. NN on [DATE] at 4:10 am documented resident requested [MEDICAL CONDITION] at 3:40 am with good results. There was no O2 sat or other respiratory assessment documented. Nurse note on [DATE] at 7:32 am documented the resident was found non-responsive at 4:50 am by RN and RN, Director of Nursing (DON). Resident was found to have absent heart sounds, no spontaneous respirations, no response to verbal or tactile stimuli, pupils were fixed and non-reactive to light. Resident's skin was pale. Assessment completed at 5:00 am, Physician notified. Daily Communication Log dated [DATE] documented under Resident # 1's name on the 11:00 pm to 7:00 am shift, [MEDICAL CONDITION] at 3:40 am. Resident pronounced dead at 5:07 am. Resident/Family Conference form dated [DATE] documented Resident's daughters (2) requested to meet with team about events on the night she passed away. DON who was there that night explained that was an ordinary night with Resident. At 3:00 pm (inaccurate time, incident occurred on the night shift) she asked for her [MEDICAL CONDITION] and then after asked for her breathing treatment. Discussed that she was encouraged to try to relax as her breathing was bad as normal especially when anxious. She gave the treatment said would be back later, when DON/staff revisited room they found resident dead. Daughter asked about why she wasn't brought to the emergency room for breathing, explained that her breathing was no different than any night and the resident was actually more calm than usual. During an interview on [DATE] at 10:45 am, the Medical Director stated that she wrote the resident ' s admission orders [REDACTED]. She would not have the discharge summary from the hospital to reference at this point, so she usually writes the resident's orders based on their medication administration record (MAR) from the hospital. She stated when the resident arrives to the facility with additional paperwork and the discharge summary, she relies on the nurses to check for any discrepancies with the orders and make her aware. She stated she would have expected to be notified that the resident's oxygen saturation could not be monitored for 24 hours when first admitted as she could have made a decision on what else to do. She further stated that she would expect the resident's oxygen saturation to be checked and an assessment to be completed before and after the resident received a breathing treatment or used her [MEDICAL CONDITION] machine. During an interview on [DATE] at 9:00 am the Registered Nurse Manager (RNM) stated she did not know what the physician was referring to in order to write the resident's admission orders [REDACTED]. She stated when a resident is admitted , their orders are reviewed and compared using the facility's medication reconciliation form. She stated in this case the medication reconciliation form was not completed as it should be and in hindsight the orders were not carried through appropriately. After the orders were obtained, the Licensed Practical Nurse (LPN) would write out the MAR and they would then be checked by the Registered Nurse (RN). At this point in the process however, the RN would not be comparing the orders using the medication reconciliation form, they would just be checking the transcription of the orders. She stated the physician would be faxed the resident's orders and transfer summary, and would reply with a fax back to the nurses. She was unable to provide any faxed communication with the physician regarding the resident's admission orders [REDACTED]. Specifically regarding the physician's orders [REDACTED]. She further stated that the resident's oxygen saturation should have been checked prior to applying and after removing the [MEDICAL CONDITION]. During an interview on [DATE] at 10:30 am, RN #1 stated she was working the night the resident passed. She stated that sometime after 2:00 am, the resident called for her and wanted her [MEDICAL CONDITION] on. She stated she put the resident's [MEDICAL CONDITION] on, but did not check her O2 sat. She stated she auscultated her lungs and the resident sounded wheezy. Later on, she was not sure what time, the resident yelled for her to take the [MEDICAL CONDITION] off. She stated she removed the [MEDICAL CONDITION] however did not check the resident's O2 sat. She stated she listened to the resident's lungs again, and they were clear. She stated she did not document either of these assessments. Some time after that, the resident called for her again and wanted a breathing treatment. RN#1 got the Director of Nursing (DON) who was doing treatments that night who went to give the resident her breathing treatment. About half an hour after that she went down to check on the resident with the DON. At this time she found the resident not breathing, without a pulse, and was unable to get an oxygen saturation reading. She stated she interpreted the physician's orders [REDACTED]. She stated she would not check the resident's oxygen saturation prior to placing the resident on the [MEDICAL CONDITION] machine, but she would after one hour. She stated she would put the [MEDICAL CONDITION] right on and see how the resident felt, see what she looked like, and would look at her breathing. During an interview on [DATE] at 4:10 pm RN # 4 stated that if the resident complained of shortness of breath and requested her [MEDICAL CONDITION], she would expect the nurse to obtain an oxygen saturation reading prior to applying the [MEDICAL CONDITION] and after removing the [MEDICAL CONDITION]. She stated she would also expect the oxygen saturation to be checked prior to and after receiving a breathing treatment in order to check the effectiveness of the treatment. She stated when obtaining admission orders [REDACTED]. She stated the resident's medications would be reviewed and compared using the hospital records, MARs prior to transfer, and their medication reconciliation form, which in this case was not completed. The physician would be sent a fax noting any discrepancies and would decide what medications they wanted to continue and respond in a fax back to the nurses. She stated she could not locate any faxed communication with the physician regarding the resident's admission orders [REDACTED]. During an interview on [DATE] at 5:15 pm, LPN # 1 stated that she would check the resident's oxygen saturation before and after placing on her [MEDICAL CONDITION], however she did not always document it. She further stated she did not realize the resident's oxygen saturation was not being checked every shift as prior to discharge, however if she had, she would have corrected it. During an interview on [DATE] at 7:40 am, RN # 5 stated that he would check the resident's oxygen saturation before and after placing the resident on her [MEDICAL CONDITION] machine or when giving her a breathing treatment. He stated the order suggested that you would have to check the oxygen saturation before and after, otherwise how would you know if either treatment was effective or not. He stated within the last week he began to do medication audits in which he and the LPN double check the physician's orders [REDACTED]. During an interview on [DATE] at 8:25 am, RN # 6 stated that during the admission process the hospital MAR is compared to the medication reconciliation form, and then the medication reconciliation form is compared with the physician's orders [REDACTED]. She stated discrepancies should have been communicated with the physician and it seems "we fell through a crack here." She stated that she would expect an assessment of the resident, to include an oxygen saturation reading, before and after applying her [MEDICAL CONDITION] or giving her a breathing treatment. During an interview on [DATE] at 11:40 am, the DON stated that checking the resident's oxygen saturation every shift should have been included in her admission orders [REDACTED]. She stated she would expect the resident's oxygen saturation to be checked prior to applying the resident's [MEDICAL CONDITION] however the resident was end stage, impatient, and anxious and "had to call the shots." She stated her first interaction with the resident that night was after RN # 1 had put her [MEDICAL CONDITION] on. She stated the resident was anxious, the [MEDICAL CONDITION] wasn't working and she wanted a breathing treatment. She stated she sat with the resident, tried to calm her, sat her up in bed. The resident calmed down, and stated "I really don't feel good." She stated she did not assess the resident or obtain an oxygen saturation although the machine was in the room. She stated the resident was too anxious, too upset, she wanted the breathing treatment. About ,[DATE] minutes later, she and RN #1 went to check on the resident. Upon assessment they found that the resident had passed. She stated in hindsight, as with any situation, many things could have been done differently. She stated the only person to check the physician orders [REDACTED]. They are just starting to have a nurse on each shift check the orders. They also started having the ,[DATE] shift do medication audits. She further stated that in this case, the medication reconciliation form was not completed which was a problem. It is time consuming, but it needs to be done. During an interview on [DATE] at 9:35 am, RN #2 stated that she would check the resident's O2 sats after having her [MEDICAL CONDITION] on for an hour. Sometimes I would check it before, sometimes I wouldn't. When her oxygen saturation was low she had very clear physical symptoms. When she was just anxious, she didn't have those symptoms, her color would be good. My concern would be if she didn't get better with the [MEDICAL CONDITION]. She stated she would basically go on symptoms, if her O2 sat was below 90% she would start to see symptoms. She stated she wasn't aware if other nurses were aware of these symptoms, but that is what she went on. She stated they never carried through with the order for 24 hour oximetry readings as the facility did not have the equipment for that. She stated it would have been "prudent practice" to obtain an order to monitor the resident's oxygen saturation every shift upon admission, as she had in place prior to discharge, however you do not need a physician's orders [REDACTED]. She stated on admission the resident's old medications, or the medications they were receiving prior to discharge, were compared to the medications the resident was receiving in the hospital. This was done using the facility's medication reconciliation form, which in this case was not completed. Only one nurse would check the orders. When medications were received from the pharmacy, two nurses would be comparing the medications with the order, however at this point they would not be comparing the medications to other documents. During an interview on [DATE] at 2:30 pm, the attending physician stated that the Medical Director wrote the resident's admission orders [REDACTED]. She would also expect the resident's O2 sats to be checked prior to applying and after removing the resident's [MEDICAL CONDITION] machine. She stated she was notified after the fact that the resident's regular insulin was not ordered. She was not aware that the [MEDICATION NAME] and Magnesium had been increased to BID and not carried through on the orders. She stated if there were any issues with the orders the nurses would call her, however this is the first time she heard there were issues. 10NYCRR 415.12(k)(6)

Based on medical record review and staff interview, the facility failed to ensure that necessary care and services were provided to maintain 11 (#s 8, 24, 26, 33, 35, 49, 55, 67, 71, 74 and 75) of 16 residents reviewed during the extended recertification survey at their highest practicable physical, mental and psychosocial well-being, in accordance with their comprehensive assessment and plan of care. Specifically, the facility failed to: ensure an adequate diabetic management program was developed and implemented; ensure physician(MD) orders were complete and transcribed accurately (#s 33 and 35); ensure daily Insulin was administered as ordered by the physician (#s 24, 26, 33, 35, 49, 55, 71, 74, and 75); ensure accurate sliding scale coverage Insulin was administered as ordered by the physician (#s 8, 33, 67, 71, and 75) ; ensure nurses acted within their scope of practice by notifying the physician and obtaining orders from the physician when Insulin was not administered (#s 8, 24, 26, 33, 35, 49, 55, 74, and 75); ensure a safe protocol was in place to identify and treat episodes of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] (#s 8 and 75); ensure Insulin medication errors were identified and a medication error report was initiated when incorrect doses of Insulin were administered (#s 8, 24, 26, 33, 35, 49, 55, 67, 71, 74, and 75); ensure blood glucose levels were checked as ordered by the physician (#s 8, 33, 35, 55) and failed to ensure the physician was notified in a timely manner of critical lab value results (#75). This had the potential to affect all residents with diabetes mellitus in the facility. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. This was evidenced by: Finding #1 The facility failed to ensure an adequate diabetic management program was developed and implemented. During an interview on 10/16/12 at approximately 4:30pm the Registered Nurse Clinical Manager (RNCM) stated the facility had no policy or procedure which addressed [DIAGNOSES REDACTED] (low blood sugar-BS) or [MEDICAL CONDITION] (high BS), or a policy which addressed when to hold Insulin (parameters). During an interview on 10/16/12 at 4:15pm and on 10/17/12 at approximately 8:40am the licensed practical nurse (LPN #1) administering medications for the unit, stated if a resident's BS is low (below 70 or critical low) and the resident was able to take food or drink by mouth (po), the resident should be given something to eat. If the resident was not alert or unable to take po, the resident should be administered Insta Glucose Gel as it absorbs into the side of the resident's mouth. The LPN stated she knows this procedure, because it is in the facility's policy. LPN #1 stated she was unsure where this policy was kept. During an interview on 10/17/12 at approximately 3:30pm LPN #2 stated if a resident's BS is at a critical value (<60 or >450), she would do the following: for a high BS, she would follow the resident's sliding scale, if there was one, and notify the RN so the MD could be notified. LPN #2 stated she does not document when the RN is notified. LPN#2 stated if the resident's BS was low (<60) and the resident was alert, she would administer juice and carbohydrates. If the resident was not responsive, LPN #2 stated she would administer Insta Glucose Gel and notify the RN to obtain an order for [REDACTED]. During an interview on 10/18/12 at approximately 9:30am the RN in charge of the unit (RNCN) stated if a resident's BS was less than 40 or low, and the resident was alert, she would administer a low carbohydrate snack to the resident. The RNCN stated the facility keeps a list of appropriate snacks in the kitchen. If the resident's BS was low and the resident was unresponsive, the RNCN stated she would administer glucose gel under the resident's tongue, and call the MD for an order for [REDACTED]. On 10/16/12 at approximately 2:45pm, a request was made for the facility's Diabetic Management Policy. The Director of Nursing (DON) produced a copy of the "Alice Hyde Medical Center Critical Values" policy. Listed under the area of POLICY: "Competent, qualified Registered Nurses will ensure that critical values are relayed to the Physician or licensed staff associated with the Physician's office. Documentation of the call including time, date, and who received the critical values must be in the patient's medical record. During an interview on 10/17/12 at 6:00 pm, the DON stated the facility did have a guide for treatment of [REDACTED]. She stated this guide instructed staff what to do for resident's with blood glucose levels between 50-69 mg/dl. The DON stated she did not know the nursing staff on the units were unaware of this protocol and she was surprised at this. The DON then provided the surveyor with a copy of the treatment guide that was last revised on 7/17/09. The guide documented if a resident's BS was between 50 - 69 mg/dl, to give [MEDICAL TREATMENT] residents the amount listed for apple juice, cranberry juice and soda and to give non-[MEDICAL TREATMENT] residents the amount listed for apple juice, cranberry or prune juice, fat free milk, and regular soda. The DON also stated the facility had not done quality assurance in the area of Diabetic Management because they had not been aware of issues like this. The DON agreed at the time of this interview that, based on surveyor findings, there was the potential for something terrible to happen to residents. During an interview on 10/17/12 at approximately 12:40pm the Medical Director stated she was unaware of any policies or protocols in place which addressed diabetic management, [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. The Medical Director also stated if a resident's BS was low, and the resident was not symptomatic, the staff should administer orange juice or sugar. If the resident was symptomatic, the staff should transfer the resident to the emergency room . The Medical Director also stated if the resident was unresponsive, or unable to take po, an intravenous line should be started. The Medical Director stated an unresponsive resident should never be given Insta Glucose Gel. Resident #33 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident's cognitive skills for daily decision making were intact. The Comprehensive Care Plan (CCP)dated 9/18/12,entitled Diabetes related to [DIAGNOSES REDACTED]. Approaches included, diet compliance, blood glucose Point of Care Testing ( POCT) and medications according to the MD orders. Monitor for [DIAGNOSES REDACTED] and [MEDICAL CONDITION], and notify MD of changes in the residents condition. The physician's orders [REDACTED]. [MEDICATION NAME] Insulin 18units (u) subcutaneous (sc) with meals [MEDICATION NAME] Insulin 50u sc everyday at bedtime(hs) Point of Care Glucose (BS level) three times a day (TID) with [MEDICATION NAME] Insulin sliding scale coverage as follows: 301-350 give 8u sc 351-400 give 10u sc 401-450 give 12u sc 451-500 give 14u sc greater than or equal to 501 give 16u and do a chem 6 (a blood test) The Medication Administration Record (MAR) dated September 2012 documented the resident's [MEDICATION NAME] was held on 9/7/12, and the [MEDICATION NAME] with meals was held at 5pm on the following dates: 9/1/12, 9/2/12, 9/3/12, 9/4/12, 9/15/12 and 9/17/12. This same MAR also documented on 9/8/12 at 11:45am, the resident's BS was 344. The nurse signed that the 18u of [MEDICATION NAME] was administered at 11:00am, and also documented "18u" under the coverage scale. The resident was ordered to receive a 18u and 8u coverage for a BS 344. The Progress Note Report (NN) contained no documented evidence that the MD was notified of the above doses of Insulin being held, that an order was received from the MD to hold the Insulin or that the MD was notified the resident received the incorrect dosage of Insulin on 9/8/12. The Risk Management Reports documented no evidence the above medication errors were identified by the facility or that medication error forms were completed. The physician's orders [REDACTED]. [MEDICATION NAME] Insulin 50u sc everyday at hs [MEDICATION NAME] Insulin 18u sc with meals Point of Care Glucose (blood sugar-BS level) three times a day (TID) with 301-350 give 8u sc 351-400 give 10u sc 401-450 give 12u sc 451-500 give 14u sc greater than or equal to 501 give 16u and do a chem 6 The physician's orders [REDACTED]. The MAR dated October 2012 documented: [MEDICATION NAME] Sliding Scale 301-350 give 8u sc 351-400 give 10u sc 401-450 give 12u sc 451-500 give 14u sc greater than or equal to 501 give 16u and do a chem 6 This same MAR documented the [MEDICATION NAME] 18u with meals was held at 7:00am on the following days: 10/3/12, 10/4/12, 10/5/12, 10/6/12, 10/7/12 and at 5:00pm on 10/11/12. There was also no documented evidence the [MEDICATION NAME] was administered as ordered on [DATE] at hour of sleep. The NN, dated 10/3/12 through 10/12/12, contained no documented evidence that the MD was notified of the above doses of Insulin being held or not administered. During an interview on 10/18/12 at approximately 9:30am the Registered Nurse in charge of the unit (RNCN) stated nurses will sometimes hold resident's Insulin based on either the amount of food a resident consumes, or based on the BS results. The RNCN stated different nurses have different opinions. When shown the errors and the blanks on the above MARs, the RNCN stated the blanks should have been reported to the RN and the RN should have called the nurse involved to clarify if the Insulin was administered. The RNCN stated if the Insulin was not administered as ordered, a medication error form should have been completed and the MD should have been notified. During interview on 10/16/12 at approximately 4:30pm the Registered Nurse Clinical Manager (RNCM) stated if the medication nurse has concerns about a resident's BS or their meal consumption, and feel the Insulin should be held, the medication nurse should ask the RN for guidance. If the RN determines the Insulin should be held, it is based on the history with the resident and nursing judgment. The RNCM stated sometimes the RN will decide to hold the resident's Insulin based on the meal consumption. If a resident eats at least 50-75% of the meal, the Insulin should be given, if not, the Insulin should be held. The RN should then send a fax to the MD and document in the NN that the Insulin was held. The RNCM stated [MEDICATION NAME] is a long [MEDICATION NAME] Insulin and should never be held unless the resident's BS is "bottoming out" (very low). When shown the above MARs, the RNCM stated she was unable to determine why the Insulin was held on multiple days. The RNCM stated the MD should have been notified the Insulin was held and the nurse should have documented all of this in the NN. When shown the dose that was administered on 9/8/12 at approximately 11:00am, the RNCM stated the resident should have received 26u total (18u standing dose and 8u coverage). The RNCM stated there was no medication error form completed for this error. The RNCM also stated the facility had no policy or procedure which addresses [DIAGNOSES REDACTED] (low BS) or [MEDICAL CONDITION] (high BS), or a policy which addresses when to hold Insulin (parameters). During interview on 10/17/12 at approximately 12:40pm the Medical Director stated she was unaware of any policies or protocols in place which addressed diabetic management, [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. The Medical Director stated she would expect to be notified anytime Insulin was held by the nurse. The Medical Director also stated she would expect both the standing Insulin and the sliding scale Insulin to be administered as ordered by the physician. During interview on 10/17/12 at 6:00 pm, the DON stated they previously educated staff and completed quality assurance audits for specific medication errors brought to their attention, but did not audit MARs for diabetic management because they did not know there were any medication errors in this area or problems in this area. She stated that they had not done quality assurance in this area because they had not been aware of issues like this. She agreed at the time of this interview that based on the survey findings, there was the potential for something terrible to happen to residents. The DON also stated she could see how the facility needed to streamline and make resident diabetic management easier to follow for documentation with the licensed staff. Resident # 75: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was alert to self only, with mild long and short term memory problems. The Comprehensive Care Plan (CCP)dated 8/17/12, entitled Diabetes related to [DIAGNOSES REDACTED]. Approaches included, diet compliance, blood glucose Point of Care Testing and medications according to the MD orders. Monitor for [DIAGNOSES REDACTED] and [MEDICAL CONDITION], and notify MD of changes in the residents condition. Monitor and notify MD of laboratory results. The physician's orders [REDACTED]. Point of care testing before meals (AC) three times a day (TID) and at bedtime (HS) with [MEDICATION NAME] Insulin sliding scale (SS) coverage as follows: 150-200 give 1u sc 201-250 give 2u sc 251-300 give 3u sc 301-350 give 5u sc 351-400 give 7u sc [MEDICATION NAME] Insulin 10u sq everyday at bedtime (HS) A physician's telephone order signed and dated 8/18/12 at 5:00pm documented to add to current [MEDICATION NAME] SS order 401-450 give 10u subq. Over 450 call MD. An additional telephone order was received 8/20/12 at 11:50am to add to SS [MEDICATION NAME] order 451-500 give 12 u sub q. Over 500 call MD. The NN on 8/29/12 at 2:27pm documented that the resident's 11:00am blood sugar was 209. Insulin was held per order of the RN because the resident was not eating. There was no evidence that the physician was notified the Insulin was held and there was no order to hold the Insulin. The NN on 8/29/12 at 10:01pm documented the resident's blood sugar was 204 at 4:00pm was due for sliding scale (SS) [MEDICATION NAME]2 units sub-q. SS Insulin was held related to low blood sugar today, blood sugar of 312 at 8:00 pm was due for 5 units SS [MEDICATION NAME] and 5units of [MEDICATION NAME]. Resident did not eat supper, only drank 120cc tomato juice for supper. [MEDICATION NAME] and [MEDICATION NAME] Insulins were held. There was no evidence that the physician was notified the Insulin was held and there was no order to hold the Insulin. During an interview on 10/17/12 the RN #1 who wrote the note of 8/29/12 at 2:27pm was asked if she felt the BS of 209 on 8/29/12 was too high or too low and for what reason did she tell the LPN to hold the insulin. The RN stated that she felt that the insulin should be held at 11:00 based on the resident's presentation. When asked if the resident showed signs of [DIAGNOSES REDACTED], she stated no, but she knew her residents and used her nursing judgment. This RN stated that an order should have been given by the MD to hold the insulin and that she acted out of her scope of practice. During an interview on 10/17/12 at 3:45pm the RN#2 who was on duty on 8/29/12 who wrote the 10:01 pm note, stated she did not call the MD. She stated that she knew her residents, and used her nursing judgment to hold the Insulin. This RN stated that an order should have been given by the MD to hold the insulin and that she acted out of her scope of practice. During an interview with the DON and Clinical Nurse Educator on 10/18/12, at approximately 10:20am, they stated that the actions of the RNs were wrong and that knowing the residents does not excuse the need for a medical order to be received before treatment is given or held. There were no medication errors made out for the errors noted. POCT on 8/30/12 readings at 4:33pm and 6:16pm documented the BS level was critically high over 500. There was no documentation in the NN to indicate the physician was notified, or any action was taken. POCT on 9/1/12 at 5:38 am documented a BS of over 500 critical level. NN documented that the RN attempted to notify the physician at 5:55am, and again at 6:00am. A page was placed at 6:00am with no response. TheNursing Manager was called with no response. The physician was paged again at 6:20am and again no response. At 6:45am they called the physician's cell phone with no response. At 6:45 the medical director was called and orders were received to do a Chem-6 now and give 16u of [MEDICATION NAME] Insulin and repeat POCT in 2 hours. The repeat POCT taken at 8:44am was documented at critical level over 500. There was no documentation in the NN to indicate that any physician was notified at that time. During an interview with the DON and Clinical Nurse Manager on 10/18/12 at approximately 2:30pm, they were asked what procedure should have been followed for a resident who has critical high readings and the nurse is not able to reach the attending physician. They stated that the staff has been instructed to call the Emergency Department (ED )and report a critically high level in a patient for evaluation immediately. They stated that knowing the resident does not take the place of good nursing judgment and the ED should have been notified within 15 minutes. Medication error reports were reviewed and were requested from the DON for the above diabetic administration errors none were found. Resident #8 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated 9/19/12 assessed the resident understood and was able to understand with moderately impaired cognition. The MD orders dated 6/30/12 documented orders for Accuchecks ( A blood sugar monitoring test) three times a day, [MEDICATION NAME] 40 units subcutaneously every morning, and [MEDICATION NAME] 55 units subcutaneously at bedtime daily. These monthly physician orders [REDACTED]. The sliding scale on this date was documented as follows: Accucheck Insulin Dose 250-300 4 units 301-350 6 units 351-400 8 units 401-450 10 units greater than 451 call the physician An interim physician's orders [REDACTED]. The MD orders dated 7/23/12 documented orders for Accuchecks three times a day, [MEDICATION NAME] 40 units subcutaneously every morning, and [MEDICATION NAME] 55 units subcutaneously at bedtime daily. These monthly physician orders [REDACTED]. The sliding scale on this date was documented as follows: Accucheck Insulin Dose 250-300 4 units 301-350 6 units 351-400 8 units 401-450 10 units greater than 451 give 15 units and call the physician These orders dated 7/23/12 continued as written with no change for the monthly physician orders [REDACTED]. The MARs for 7/2012 and 8/2012 contained blanks for fingerstick Accuchecks and sliding scale insulin administration for the dates of 7/9/12 at 12:00 pm, 7/17/12 at 12:00 pm, 7/28/12 at 12:00 pm, and 8/13/12 at 12:00 pm. The MAR dated for 7/2012 on 7/13/12 at 12:00 pm documented an Accucheck fingerstick of 488. On this date and at this time, the nurse documented that she administered 10 units of insulin to the resident. There was no documented evidence of the physician having been notified of this fingerstick Accucheck that was greater than 451 or of the medication administration nurse having received physician advisement on the amount of insulin to administer to the resident. On 7/26/12 at 4:00 pm, the resident's fingerstick Accucheck was documented to be 456 on the MAR and it was noted that 15 units of [MEDICATION NAME]was administered to the resident. On 7/28/12 at 4:00 pm, the resident's fingerstick Accucheck was documented to be 467 and that 15 units of Insulin had been administered to the resident. There was no documented evidence that the physician was notified of these fingerstick Accuchecks per the resident's sliding scale insulin orders. On 8/10/12 at 12:00 pm, the resident's fingerstick Accucheck was documented to be 251. The resident should have received 4 units of [MEDICATION NAME]administered per the [MEDICATION NAME]sliding scale coverage ordered by the physician. There was no documentation that the insulin was administered as ordered. On 9/5/12 at 4:00 pm, the resident's fingerstick Accucheck was documented to be 337. It was documented that the resident received 8 units of [MEDICATION NAME] insulin. The sliding scale [MEDICATION NAME] Insulin coverage administered should have been 6 units of [MEDICATION NAME] insulin. On 10/17/12 at 6:00 am, the resident's fingerstick Accucheck was documented to be 60. A progress note documented by the Registered Nurse Unit Manager (RNUM) dated 10/17/12 at 2:39 pm documented that the resident's blood sugar was 60 that morning and noted that the resident ate breakfast and a repeat blood sugar was done with sliding scale coverage administered. There was no documented evidence of a hypoglycemic protocol having been followed or of physician notification. During an interview on 10/17/12 at 3:15 pm, the Registered Nurse Manager stated that the Accucheck machine for checking resident fingerstick blood sugars was linked to their facility computer system. For the date of 7/9/12 at 12:00pm, she stated there was no fingerstick blood sugar recorded in the Meditech computer system for this date and time so it must not have been done as ordered. For the date of 7/17/12 at 12:00 pm, the resident's fingerstick blood sugar was recorded in the Meditech computer system as 270 and she stated that the resident then should have received 4 units of insulin coverage, but then stated that she could not tell if anything was administered to the resident as ordered because there was no documented evidence of such on the MAR. She stated that for the date of 7/28/12 at 12:00 pm, the resident's fingerstick blood sugar was recorded in the Meditech computer as 319 and the resident should have then received 6 units of [MEDICATION NAME]coverage per the ordered sliding scale, but stated she could not tell if it had been administered because it was blank. She stated again that for the date of 8/13/12 at 12:00 pm, the resident's fingerstick blood sugar was recorded in the Meditech computer system as 319 and the resident should have then received 6 units of [MEDICATION NAME]coverage per the ordered sliding scale, but stated she could not tell if it had been administered because it was blank. She stated that on the date of 7/13/12 at 12:00 pm when the resident's fingerstick Accucheck was 488, the nurse should not have administered 10 units of insulin to the resident and should have immediately notified the physician for advisement on what to do at that time. She stated this was very concerning to her that the nurse administered insulin to the resident when the order at that time clearly wrote to call the physician for fingerstick blood sugars greater than 451. She stated that the LPN administering medications on this date of 7/13/12 should have also notified the Registered Nurse Supervisor about this fingerstick blood sugar that exceeded the physician ordered sliding scale parameters. She stated that good nursing practice would be for the physician to be notified for resident blood sugars over 450 with a recheck of the blood sugar in a couple hours after physician advisement. She stated that the resident should have received 4 units of [MEDICATION NAME]on 8/10/12, but per the MAR had not received any insulin. She stated that on 9/5/12, the resident's fingerstick was 337 and the resident received 8 units of insulin, but should have received the ordered 6 units. She stated that the whole diabetic management system at the facility was very confusing because there were so many places to write things down. She stated that on this date of 10/17/12, the resident's fingerstick was 60 at 6:00 am. She stated the 7:00 am to 3:00 pm LPN informed her that the resident's fingerstick had been 60 earlier in the morning and that she then told the LPN to hold the sliding scale insulin until she could get a hold of the physician. She stated she then called the physician at 7:30 am for advisement on what to do and in the meantime, the resident ate her breakfast. She stated the resident received her routine daily dose of [MEDICATION NAME]and the physician then returned a call to the nurse at 10:30 am. She stated that they had not rechecked the resident's blood sugar until just before lunch at which time the resident's blood sugar was 224 and the resident then got her sliding scale [MEDICATION NAME]coverage. She stated that the staff really needed to be given parameters of when to hold insulin and when it was appropriate to give the physician a return call with a recheck of the resident's blood sugar after abnormal fingersticks occurred. She stated this resident was very hard to regulate because she had a known pattern of going high then going low. Medication error reports were reviewed and were requested from the DON for the above diabetic administration errors and none were found. During an interview on 10/17/12 at 6:00 pm, the DON stated that the facility did have a guide for treatment of [REDACTED]. She stated that this guide instructed staff with what to do for resident's with blood glucose levels between 50-69 mg/dl. She stated she did not know that the nursing staff on the units were unaware of this protocol based on none of the staff mentioning this on interview. She stated she was surprised at this. She then provided the surveyor with a copy of this treatment guide that was last revised on 7/17/09. It documented that if a resident's blood glucose was between 50 - 69 mg/dl, to give [MEDICAL TREATMENT] residents the amount listed for apple juice, cranberry juice and soda and to give non-[MEDICAL TREATMENT] residents the amount listed for apple juice, cranberry or prune juice, fat free milk, and regular soda. She stated that they had not done quality assurance in this area because they had not been aware of issues like this. She agreed at the time of this interview that based on surveyor findings, there was the potential for something terrible to happen to the residents. She stated that they previously educated staff and completed quality assurance audits for specific medication errors brought to their attention, but did not audit MARs for diabetic management because they had not known there were any medication errors in this area or of any problems in this area. She stated she could see how they needed to streamline and make resident diabetic management easier to follow for documentation with the licensed staff. 10 NYCRR 415.12

Based on record review and staff interview the facility was not administrated in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident during the extended recertification survey. Specifically, the Administration failed to ensure an adequate diabetic management program was developed and implemented. A failure to develop and maintain an adequate diabetic management protocol and the failure to ensure that nurses practiced within their scope of practice, has resulted in the potential for serious harm and Immediate Jeopardy for the health and safety of all residents within the facility with a [DIAGNOSES REDACTED]. Refer to Quality of Care, F-309- scope and severity - K Refer to Quality Assurance, F- 520- scope and severity-K The facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care by failing to have an adequate diabetic management program. During an interview on 10/17/12 at 6:00 pm, the DON stated the facility did have a guide for treatment of [REDACTED]. She stated this guide instructed staff what to do for resident's with blood glucose levels between 50-69 mg/dl. The DON stated she did not know the nursing staff on the units were unaware of this protocol and she was surprised at this. The DON then provided the surveyor with a copy of the treatment guide that was last revised on 7/17/09. The guide documented if a resident's BS was between 50 - 69 mg/dl, to give [MEDICAL TREATMENT] residents the amount listed for apple juice, cranberry juice and soda and to give non-[MEDICAL TREATMENT] residents the amount listed for apple juice, cranberry or prune juice, fat free milk, and regular soda. The DON also stated the facility had not done quality assurance in this area of Diabetic Management because they had not been aware of issues like this. The DON agreed at the time of this interview that, based on the survey findings, there was the potential for something terrible to happen to the residents. During interview on 10/17/12 at approximately 12:40pm the Medical Director stated she was unaware of any policies or protocols in place which addressed diabetic management, [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. The Medical Director also stated if a resident's BS was low, and the resident was not symptomatic, the staff should administer orange juice or sugar. If the resident was symptomatic, the staff should transfer the resident to the emergency room . Finally, the Medical Director also stated if the resident was unresponsive, or unable to take po, an intravenous line should be started. The Medical Director stated an unresponsive resident should never be given Insta Glucose Gel. During an interview 10/18/12 at 2:00pm the Administrator and the Director of Nursing stated they did not identify the diabetic management program as a potential source of harm to the residents. 10NYCRR 415.27(a-c)

Based on record review and staff interviews the Quality Assurance (QA) program failed to have a program that readily identified issues that had the potential to cause serious harm to residents during the extended recertification survey. Specifically, QA failed to identify the facility lacked an adequate diabetic management program that ensured written policies and procedures were available that ensured physician orders [REDACTED]. Additionally, QA did not identify a safe protocol was in place to identify and treat episodes of [DIAGNOSES REDACTED] or [MEDICAL CONDITION]; ensure Insulin medication errors were identified and a medication error report was initiated when incorrect doses of Insulin were administered. This had the potential to affect all residents with diabetes mellitus in the facility. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety. During an interview on 10/17/12 at 6:00pm the Director of Nurses (DON) stated the facility had not done quality assurance in the area of Diabetic Management because they had not been aware of issues like this. The DON agreed at the time of this interview that, based on the survey findings, there was the potential for something terrible to happen to residents. During an interview on 10/18/12 at 2:00pm the Administrator and the DON stated the QA program did not identify the diabetic management program as a potential source of harm to the residents. 10NYCRR 415.27(a-c)