Every finding on record at Andrus on Hudson

Based on observation, record review and interview conducted during the recertification survey from 6/25/25 to 7/2/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the annual water sampling report for the year 2025 was missing and not provided at time of survey. The findings are: The facility Legionella log revealed that the water sampling lab report for Legionella detection for the potable water system was last conducted 4/4/2024 and a current report was missing and not provided a time of survey. During an interview on 6/27/25 at approximately 12:30 PM, the Director of Facilities stated that the water sampling for Legionella had not been conducted since 4/4/2024. 10NYCRR 415.19

Based on observation, record review and interviews during the recertification survey conducted from 6/25/25 to 7/2/25, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services for 1 of 3 residents (Resident #163) reviewed for Activities of Daily Living. Specifically, Resident #163 required substantial/maximal assistance with showers/bathing and supervision with personal hygiene; they were observed during multiple observations with fingernails that were long and dirty. The findings include: The facility policy and procedure, Activities of Daily Living updated on 4/8/2022, documented a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #163 was admitted to the facility with diagnoses including schizophrenia, Bell's palsy, and muscle weakness. The Minimum Data Set (resident assessment tool) dated 3/21/25 documented the resident was cognitively intact and needed substantial/maximal assistance with showers/bathing and supervision with personal hygiene. The Comprehensive Care Plan, for Activities of Daily Living, last updated 10/18/23, documented the resident required substantial assistance from staff with showering/bathing self, and supervision assistance of one person with personal hygiene and oral care. During observations and interviews on 6/26/25 at 1:07 PM, on 6/26/25 at 1:54 PM, and on 7/2/25 at 10:03 AM, Resident #163 was in bed and their fingernails on both hands were long with dark brown matter underneath. The resident stated they would like their long and dirty fingernails to be clipped and cleaned, but they could not do it themself. The resident stated that the staff clipped their fingernails, but could not remember when it was last done. During an interview on 07/02/25 at 10:20 AM, Certified Nurse Aide #17 stated that every time they provided assistance with personal hygiene, they checked the resident's fingernails. The certified nurse aide stated they would clean and clip the resident's fingernails if they found them long and dirty. Certified Nurse Aide #17 stated that they provided assistance with personal hygiene for Resident #163 last week. Certified Nurse Aide #17 entered Resident #17's room to check Resident #163's fingernails. They stated that the resident's fingernails on both hands were long and dirty. Certified Nurse Aide #17 stated that they did not pay attention to Resident #17's fingernails last week. During an interview on 07/02/25 at 10:37 AM Licensed Practical Nurse #15 stated they were the regular day shift nurse on the unit, and they were familiar with Resident #163. They administered medications to the resident and monitored the resident during the day. Licensed Practical Nurse #15 stated certified nurse aides were responsible for residents' personal hygiene, which included grooming residents fingernails if they were long and dirty. They stated the nurses could also groom residents' fingernails. Licensed Practical Nurse #15 entered Resident #163 room, observed the resident's fingernails and stated that the resident's fingernails were long and dirty and needed to be cleaned and clipped. 10 NYCRR 415.12

Based on observation, record review and interviews during the recertification survey conducted from 6/25/25 to 7/2/25, the facility did not ensure that 1 of 4 residents (Resident #78) reviewed for Nutrition was monitored for nutritional status. Specifically, for Resident #78, a weight was struck out on 6/9/25, a re-weight which was requested on June 16, 2025, was not documented until June 20, 2025, the facility did not assure the resident was assessed and evaluated for poor oral intake in May and June 2025, and new interventions related to nutritional status were not implemented after weight loss was documented on June 20, 2025. The findings are: Resident #78 was admitted to the facility with diagnoses of non-Alzheimer's dementia, paraplegia, and depression. The Minimum Data Set (resident assessment tool) dated 5/30/25 documented the resident had moderately impaired cognition and required set-up assistance with eating. The facility policy and procedure, Weights updated on 5/1/2022, documented to keep an accurate record of each resident's baseline weight and weight fluctuations to monitor nutritional status and identify significant weight changes. Dietitian documents resident weights in residents' medical record. Dietitian completes a Nutritional Risk Assessment on admission, readmission, annual and significant change. Additional assessments are completed as indicated for significant changes in resident condition The Weight Record dated 5/8/25 documented the resident weighed 190 pounds. The Comprehensive Care Plan, The Resident Has a Potential Nutrition Problem, updated on 5/11/24, documented interventions including to encourage the resident's intake of both solids and liquids, monitor meal consumption records, report significant weight changes to the medical doctor and interdisciplinary team, monthly weight at same time of day and record. The May 2025 Documentation Survey Report (Certified Nurse Aide documentation) for Nutrition- Amount Eaten included documentation of meal intake of 0-25% on 21 of 31 days. The Weight Record dated 6/6/25 documented the resident weighed 183 pounds. The Weight Record dated 6/6/25 documented the weight was struck out on 6/9/25. The 6/16/25 Registered Dietitian email to Registered Nurse Unit Manager #9 documented to re-weigh the resident. The 6/20/25 Registered Nurse Unit Manager #9 email to the Registered Dietitian documented the resident's re-weight was 178 pounds. The Weight Record dated 6/23/25 documented Resident #78's re-weight was 178 pounds, which was a -6.32 % loss in 6 weeks. The June 2025 Documentation Survey Report (Certified Nurse Aide documentation) for Nutrition- Amount Eaten included documentation of meal intake of 0-25% on 23 of 30 days. During an observation and interview on 06/26/25 at 9:46 AM, Resident #78 stated that they missed breakfast. The resident stated they were sleeping, and nobody woke them up, and stated this happened quite often. No breakfast tray was observed in the resident's room. The resident's cheeks appeared sunken. During an observation and interview on 06/27/25 at 8:42 AM, Resident #78 was having breakfast in bed. The resident ate less than 25% of their breakfast. The resident stated that they did not like the food. The resident did not answer the question whether staff offered any alternate food for breakfast. During an observation on 06/27/25 at 12:58 PM, Resident #78 was in bed with their lunch meal on the over bed table, untouched. The resident stated they did not eat lunch because they did not like the food. Certified Nurse Aide #13 was observed entering the resident's room and asked the resident about their lunch. The resident stated that they did not eat lunch or breakfast, and stated they did not have an appetite. Certified Nurse Aide #13 offered the resident to bring an alternative food. The resident refused and asked Certified Nurse Aide #13 to cool down their orange juice. The Certified Nurse Aide picked up the tray and exited the room. Certified Nurse Aide #13 stated that they did not work often with the resident, but when they provided care for the resident last time, which was about one month ago, the resident had a good appetite. During a phone interview on 06/30/25 at 12:30 PM, Certified Nurse Aide #14 stated that they were familiar with Resident #78's care. Certified Nurse Aide #14 stated that Resident #78 did not like the facility meals and received food from their family member who visited the resident about four times a week. Certified Nurse Aide #14 stated that they encouraged the resident to eat and offered them alternatives. Certified Nurse Aide #14 stated that nurses asked them on the weekly bases, if the resident eats, but they did not ask about the amount of meal the resident ate. During an interview on 06/30/25 at 11:18 AM, Licensed Practical Nurse #15 stated they were the regular day shift nurse on the unit, and they were familiar with Resident #78. They administered medications to the resident and monitored the resident during the day. They stated the certified nurse aides documented the resident's meal intake and they did not check the certified nurse aide's documentation. They stated they asked the certified nurse aides how much the resident ate. They stated the certified nurse aides did not report any issues with poor meal intake. When asked how they monitor staff to ensure they are implementing care planned interventions, they stated they should follow the care plan, but stated they did not remember the interventions. They stated Resident #78's meal intake was good, and the resident had a good appetite. They stated that Resident #78 did not eat meals the facility offered on the days when family brought in food. They stated the resident's family usually came in once a week on Saturday mornings. They stated Resident #78 might have refused breakfast but ate other meals well. They stated they were not aware of any weight loss. They stated if the resident lost weight they would notify the dietitian and the unit manager. They stated they did not notify them because they were not aware of the resident's poor meal intake and weight loss. During an interview on 06/30/25 at 11:41 AM, the Registered Dietitian stated they enter resident's monthly weights. They stated they entered Resident #78's weights on 5/8/25 of 190 pounds and on 6/23/25 of 178 pounds. They stated they had not calculated Resident #78's weight difference, and they needed time to evaluate if significant weight loss had occurred. They stated the process of monitoring resident's weight included the nurses reporting weight loss, and notification to the Interdisciplinary Team about significant changes. They stated if they noticed weight loss, they would initiate the resident's assessment, check any clinical issues, discuss with resident, update the resident's preferences, talk to the family, and bring the situation to the Interdisciplinary Team. The Registered Nurse stated they do not calculate the amount of food the resident eats which was brought by family. They stated that the Nurse Practitioner had not been notified until today. During an interview on 06/30/25 at 03:59 PM, Certified Nurse Aide #16 stated they work the evening shift on the 3rd floor. They stated Resident #78 usually ate 25% of their dinner. They stated they should report to the nurse if a resident ate 50% or less of their meal, but stated they did not report Resident #78's 25% meal intake, because the nurses knew that the resident did not eat the facility's food, and that Resident #78's brother brought food almost every day. Certified Nurse Aide #16 stated they did not document the food intake brought from outside the facility. They stated they were not aware of Resident #78's weight loss. During an observation and interview on 07/1/25 at 4:22 PM, Registered Nurse Unit Manager # 9 stated they were not aware of the resident's weight loss or poor oral intake. In the presence of the surveyor, Resident #78 was re-weighed using the mechanical lift. The resident's weight was 178.5 pounds. During an interview on 07/02/25 at 11:21 AM, the Nurse Practitioner stated that they were not aware of Resident #78's weight loss. They stated that the weight loss from 190 pounds on 5/8/25 to 178 pounds on 6/23/25 and 178.5 on 7/1/25 was concerning. The Nurse Practitioner stated that no interventions had been put in place since they were not aware of the weight loss. They stated that they became aware of the weight loss on 6/30/25, and they ordered a 3-day calorie count, and lab tests and weekly weights. During a follow-up interview on 07/2/25 at 12:01 PM with the Registered Dietician, they stated that on 6/9/25 they struck out the 6/6/25 weight because it documented a weight loss of greater than 5 pounds since the last month's weight. They stated they did not email the nurse manager a request to re-weigh the resident until 6/16/25, and did not report the need for Resident #78's re-weight to the Director of Nursing. The Registered Dietician stated that re-weights should be completed within a few days. The Registered Dietician stated that after entering the re-weight on 6/23/25, they should have completed an assessment, should have implemented some new interventions such as offering a supplement and reviewing the resident's preferences. They should have followed up with staff to ask how often Resident #78's family visited, should have called Resident #78's family to ask if they noticed any shift in resident's oral intake of food brought from home, and should have reviewed Resident #78's oral intake. 10NYCRR 415.12(i)(1)

Based on interview and record review during the recertification survey from 06/25/25 through 07/02/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, five of five Certified Nurse Aides (#1, #2, #3, #4, #5) did not have a performance review documented at least once every 12 months. The findings include: Policy and Procedure Titled Certified Nurse Assistants Performance Reviews dated 7/2/2025 documented All Certified Nursing Assistants (CNAs) shall be formally evaluated for performance at least every 12 months. The Annual Performance Evaluation and Job Description should be reviewed and if necessary, updated, and used to evaluate an individual's work performance on the job to which he/she is assigned. The Performance Reviews documented Certified Nurse Aide # 1 with a hire date of 3/18/09 last had a performance review on 2/1/2024. Certified Nurse Aide # 2 with a hire date of 5/6/04 last had a performance review on 1/24/2024. Certified Nurse Aide # 3 with a hire date of 8/14/20 last had a performance review on 1/15/2024. Certified Nurse Aide # 4 with a hire date of 9/28/23 last had a performance review on 2/1/2024. Certified Nurse Aide # 5 with a hire date of 5/27/20 last had a performance review on 2/28/2024. During an interview on 7/1/2025 at 10:00 AM, the Human Resources Coordinator stated Certified Nurse Aide Performance Reviews were completed by department heads. They stated after the reviews were completed and presented to the employee, they should be returned to the human resource department for filing. They were unsure why the employee files did not have the current reviews. During an interview on 7/1/25 at 1:27 PM, the Director of Nursing stated performance reviews were completed by the unit manager. They stated they reviewed them, and then the managers reviewed them with the employee. They stated after review with the employee, the evaluations were to be sent to human resources for filing. 10NYCRR 415.26 (c) (2) (iii)

Based on observation and interview conducted during the recertification and abbreviated (NY00378520) surveys from 6/25/25 to 7/2/25, the facility did not ensure residents were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, when a test tray was sampled the tuna salad was not cold to taste, and yogurt was held at 58 degrees Fahrenheit in the kitchen during an observation of the lunch meal service. Findings include: The facility policy, Food Preparation, approved 3/14/05 documented prepared cold foods held on ice or in refrigerators will be kept cold (40 degrees Fahrenheit or below), temperatures will be recorded. During an observation on 6/30/25 at 11:27 AM of the lunch meal service, yogurts, sodas, and desserts were observed on resident's meal trays on racks near the hot steam table in the kitchen. Hot food had not yet been placed on the resident trays at that time. A temperature taken of yogurt by the Food Service Director documented it was at 58 degrees Fahrenheit. At that time, the Food Service Director was interviewed and stated the procedure was to pre-assemble the racks of meal trays with cold food items prior to the start of tray line, and stated they store the meal racks in the walk-in refrigerator until 11:15 AM. Then they are pulled from refrigeration and left in the kitchen until tray line begins. They stated this was done to facilitate timely meal delivery to the units. They stated they followed the procedure today. On 6/30/25 at 12:09 PM lunch meal trays were delivered to Unit 2. The lunch meal for Resident #62 was intercepted prior to delivery to the room at 12:27 PM and was used as a test tray for palatability and temperature. When tasted, the tuna salad was not cold to taste. At 12:32 PM, the tuna salad had a temperature of 57 degrees Fahrenheit; the temperature was taken by the Dietary Operation Manager. During an interview on 6/30/25 at 3:08 PM, Dietary Aide #11 reported cold food items like salads, yogurt, and milk were routinely pulled from refrigeration at 11:00 AM for lunch meal service and they stated the tray line started at 11:30 AM. They expressed concern because cold foods were not kept on ice when they were pulled from refrigeration, and stated they were concerned that cold foods should not be kept out of refrigeration for that length of time. During a follow up visit to the kitchen on 7/2/25 at 3:56 PM to review the documented temperatures of cold food items at lunch, no record of cold food temperatures in the log were documented for any meal. During an interview at that time, Dietary Supervisor #10 stated they did not take temperatures of cold foods or document the temperatures. They stated only the hot food temperatures were obtained before lunch service at 11:30 AM. 10 NYCRR 415.14 (d)(1)(2)

Based on record review and interviews conducted during an abbreviated survey (NY00332256), the facility did not ensure residents right to be free from abuse for 1 of 3 sampled residents (Resident #1). Specifically, on 1/14/2024 a Certified Nursing Assistant (Staff #1) was observed on the facility Closed-Circuit Television footage, roughly and inappropriately handing Resident #1 by pulling them from behind, lifting them off their feet from behind, carrying them a few steps, and swinging them into their room. The findings are: The Facility Policy titled 'Abuse, Neglect, Mistreatment and Exploitation' last revised on 2/10/2020 documented that the facility makes efforts to ensure all residents are protected from physical and psychosocial harm, and reports all alleged violations. Resident #1 had diagnoses including but not limited to dementia, anxiety, and depression. The Minimum Data Set (MDS-a resident assessment tool) annual assessment dated [DATE] documented the Resident had severely impaired cognition, physical and verbal behavioral symptoms, rejection of care, and wandering behaviors which put resident at risk. The MDS assessment documented the resident required supervision/touching assistance with transfers and ambulation 150 feet. The facility Accident & Incident (A&I) report / investigation dated 1/25/2024 documented that abuse on an undisclosed date and time and place was reported by a staff witness, and Closed-Circuit Television footage was reviewed by the facility Administrator, Assistant Administrator, and Director of Nursing Services. In the 5-day report submitted to the NYS DOH, the facility documented that the resident did not manifest any sign of injury based on assessments, other staff were interviewed and did not corroborate the reporter's allegation, the reporter's failure to recall the date and time of the incident made it impossible to substantiate the claim of abuse, however during a review of Closed-Circuit Television footage, it was observed that the accused Certified Nursing Assistant #1 rough handled Resident #1 inappropriately which resulted in immediate termination. During an interview conducted on 2/6/2024 at 11:25 AM, the Administrator stated they reviewed the Closed-Circuit Television footage 2 weeks prior to the reported allegation, as they were not given a specific date or time of occurrence. The Administrator stated that what they observed on the Closed-Circuit Television footage dated 1/14/2024 at 1:05 AM was not the specific abuse that was reported to them, but it was very inappropriate. The Administrator stated that there is never any reason to handle a resident the way that Resident#1 was handled by Certified Nurse Aide (CNA)#1. The Administrator stated that Certified Nursing Assistant #1 was not on the schedule for 1/25/2024, they were suspended on 1/26/2024, then terminated on 1/30/24 based on the video footage. Resident #1's family was notified. The Administrator stated that Certified Nursing Assistant #2(the reporter) asked to remain anonymous. The Administrator stated the following staff reviewed the Closed-Circuit Television footage: the Administrator reviewed on 1/27/2024, Assistant Administrator reviewed on 1/26/2024, Director of Nursing reviewed on 1/26/2024, the Medical Director reviewed on 1/30/2024, the Chief Officer reviewed on 1/29/2024, Chief Medical Officer reviewed on 1/29/2024. During a review of the Closed-Circuit Television footage on 2/6/2024 at 11:25 AM, 2 surveyors observed that on 1/14/2024 at 1:05 am, Resident #1 was ambulating down the corridor and Certified Nursing Assistant #1 was observed monitoring Resident #1. Resident #1 then approached another Resident's doorway and Certified Nursing Assistant #1 was then observed grabbing Resident #1 from behind and forcefully removing Resident #1 from the doorway. Resident #1 then grabbed the handrail. Certified Nursing Assistant #1 was then observed forcefully swinging Resident #1 away from the handrail by lifting Resident #1 off their feet from behind, carrying Resident #1 a few steps, and then swinging Resident #1 to their room doorway. The facility cameras only captured the corridor. During an interview on 2/6/2024 at 12:00 PM the Director of Nursing Services stated that they assessed all the 5th floor residents for any signs of abuse on 1/25/2024 and had no findings of concern. During an interview on 2/6/2024 at 2:48 PM the Director of Nursing Services and Assistant Administrator stated that Aide #2 declined to be interviewed by the New York State Department of Health surveyors and wanted to remain anonymous. During an interview on 2/8/2024 at 11:15 AM, the Medical Director stated they viewed the Closed-Circuit Television footage from 1/14/2024 at 1:05 am and felt that Certified Nurse Assistant #1 inappropriately handled Resident#1 roughly. The Medical Director stated that based on body/skin assessment and psychosocial assessment, Resident#1 did not suffer any bodily or psychosocial harm from the incident. On 2/8/2024 at 11:30 AM, surveyor reached out and attempted to conduct a telephone interview with the accused Certified Nurse Assistant #1. The telephone number was disconnected. During an interview on 2/8/2024 at 12:43 PM with the Assistant Administrator, they stated that when they viewed the Closed-Circuit Television footage from 1/14/2024 at 1:05 AM, they were a little bit alarmed by Certified Nurse Assistant #1 rough handling of Resident #1 and felt Certified Nurse Assistant #1 actions were unnecessary. During a follow-up interview on 2/8/2024 at 12:45 PM with the Director of Nursing Services, they stated that when they viewed the Closed-Circuit Television footage from 1/14/2024 at 1:05 AM, they observed Certified Nurse Assistant #1 alarmingly inappropriate and unnecessarily rough in handling Resident #1. The Director of Nursing Services stated that Certified Nurse Assistant #1 should have gotten assistance from another staff if they were unable to redirect Resident #1. The Director of Nursing Services stated that Certified Nurse Assistant #1 should not have approached Resident #1 from behind. 10 NYRCC 415.4(b)(I)(i)

Based on observation, interviews and record reviews conducted during an Abbreviated Survey (NY00326823), the facility did not ensure that a resident's care plan was revised with specific interventions/instructions needed to provide effective and person-centered care for 1 of 4 residents (Resident #3) reviewed. Specifically, Resident #3 fell out of the Hoyer lift on 10/22/2023 during a two person assist transfer, allegedly due to a sudden jerking movement. Resident #3 sustained right forehead superficial laceration, upper arm abrasion and a right wrist skin tear and transferred to the hospital. Resident #3's care plan was not updated with interventions to monitor for sudden movements during transfers or to anticipate unsafe movements. The findings are: Review of the facility Policy and procedure titled, Care Plan Review and Revisions dated 04/14/2023 documented the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Resident #3 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Major Depressive Disorder and Chronic Pain. The Minimum Data Set (MDS, an assessment tool) dated 09/08/2023, documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 12/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The facility Accident/Incident Occurrence Report dated 10/22/2023 documented Resident #3 fell out of the mechanical lift during a transfer with two persons assist. Report documented Resident #3 was being transferred from their bed to their wheelchair when Resident #3 made a sudden jerking movement and fell . Resident #3 sustained laceration to right forehead, upper arm abrasion and right wrist skin tear.Residenr #3 was able to move upper extremities,and had no changes in mental status. Report documented Resident #3 denied knowing what occurred and Resident #3's physician and family member were notified. Resident #3 Fall care plan revision dated 10/22/2023 documented interventions applied included immediate local treatment to affected area, head to toe assessment, pain management, physician and family notification, sideline equipment for inspection, change Hoyer lift pad to smaller size and re in- service staff on the use of mechanical device and been vigilant during procedure. There were no documentation of specific interventions addressing/ monitoring for unsafe movements during transfer. During an interview with Staff #4(Registered Nurse) on 12/20/2023 at 12:38 PM, they stated that on 10/22/2023 Staff #3(Certified Nursing Aide) asked to assist with transferring Resident #3 from bed to wheelchair. Staff #4 stated when they were transferring Resident #3 into the chair Resident #3 leaned forward and fell out of the mechanical lift. Staff #4 stated they were so shocked and unsure of how Resident #3 fell . Staff #4 stated they immediately completed an assessment of Resident #3 and notified the physician and family. Staff #4 stated Resident #3 was ordered and transferred to the hospital for evaluation due to a skin tear on the head. During an interview with Staff #3(Certified Nurse Aide) on 01/02/2024 at 5:35 PM, they stated on 10/22/2023 after caring for Resident #3 they asked Staff #4 for assistance with mechanical lift transfer. Staff #3 stated they had Resident #3 in the mechanical lift and were guiding them into the wheelchair. Resident #3 made a sudden jerking movement and fell out of the mechanical lift on the floor. Staff #3 stated Staff #4 immediately attended to Resident #3 while they went to get additional assistance. Staff #3 stated Resident #3 was sent out the hospital for evaluation. Staff #3 stated they could not explain how Resident #3 jerked out of the mechanical lift. After the incident they were re in serviced on the safety/use of mechanical lifts. During a telephone interview on 01/02/24 at 2:02pm with Staff #5(the Assistant Director of Nursing, they stated that the care plan for Resident #3 should have been updated with interventions addressing monitoring for jerking and sudden unsafe movements during transfer. Staff #5 stated they in serviced all staff to be more vigilant of the sudden movements but forgot to update the care plan. 10 NYCRR 415.11 (c)(2)

Based on observations, interviews and record review conducted during an abbreviated survey (NY00328308, NY00317607) the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 4 residents (Resident #1 and Resident #2) reviewed. Specifically, Staff #1(Certified Nursing Aide) was scheduled for monitoring/supervision of residents in the rotunda. Staff #1 left her post without informing the nurse. Resident #1 fell forward out of their wheelchair while sitting in the rotunda with no supervision. Resident #1 sustained a hematoma with lacerations to the forehead and a cut to the bridge of the nose. Resident #1 was transferred to the hospital for further medical evaluation. Resident #2 who was under the supervision of Staff #2(Certified Nurse Aide) fell out of their wheelchair when the wheelchair rolled backwards while outside getting some fresh air. Facility video footage reviewed by the administrator showed Staff #2 on their cell phone with their back towards the resident unsupervised. Resident #2 sustained a hematoma to the left frontal occipital region of the forehead. In addition, Staff #2 picked Resident #2 up and placed them back in the wheelchair before calling for assistance. Findings include: Resident #1 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Hyperlipidemia and Congestive Heart Failure the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented no Brief Interview for Mental Status (BIMS) score as the resident had severe cognitive impairment. The resident required dependent and substantial/maximal assist for Activities of Daily Living (ADLs). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severe cognitive impairment. The resident required dependent and substantial/maximal assist for Activities of Daily Living (ADLs). The comprehensive care plan (CCP) initiated 10/25/2023 documented that Resident #1 was high risk for falls related to dementia, muscle weakness, unsteady gait, impaired safety awareness and incontinent of bowel and bladder. Interventions included to anticipate and meet resident's needs, follow fall protocol, and ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The facility security camera footage was reviewed on 12/12/2023 and Resident #1 is seen siting in their wheelchair in the rotunda with a bed side table in front of them. There were approximately 14 other residents seen on video in the rotunda with the Staff #6(Recreation Therapist) engaged in a BINGO activity. Resident #1 moved their leg and leaned over the bed side table sliding out of the wheelchair and onto the floor. Facility Accident/Incident Occurrence Report dated 11/16/2023 documented Resident #1 had a fall in rotunda at 2:02 PM and sustained superficial laceration to forehead and nasal bridge, hematoma to forehead, bruising and bleeding to nose. Ice was applied to forehead and nasal bridge, wounds cleaned. Wounds cleaned with normal saline bacitracin applied and covered with dry pressure dressing. Neuro checks initiated immediately until Emergency Medical Service arrived. Physician and Resident #'s1 family notified. An interview was conducted with Staff #1(Certified Nursing Aide) on 12/12/2023 at 12:04 PM and they stated they were assigned rotunda duty on 11/16/2023 from 1:30 PM to 2:00 PM. Rotunda duty is to monitor and supervise the resdients in the rotunda. Staff #1 stated when they started their rotunda duty, the residents were having a BINGO activity and one of the activity staff was in the rotunda calling out the BINGO numbers. Staff #1 stated they were prepping for a colonoscopy the next day and needed to go to the restroom. Staff #1 stated they did not inform anyone they were leaving their post to the restroom. As they were exiting the restroom, they heard someone scream and when they got to the rotunda, Resident #1 was on the floor. Staff #1 stated they had a meeting with the floor nurse and Staff #4(Assistant Director of Nursing) after the incident and was suspended for 2 days. Staff #1 stated they were in serviced on the importance of rotunda duty and communicating when they need to leave their post as well as ensuring they are alert and aware of residents where abouts while on duty. An interview was conducted on 12/12/2023 at 1:15 PM with Staff #6 (Recreation Therapist and they stated they were in the rotunda conducting a BINGO game with the residents when Resident #1 fell . Staff #6 stated they were calling out the numbers and all of a sudden they looked up and Resident #1 was on the floor. Staff #6 stated they went over and grabbed the wheelchair because the chair was on top of the resident. Staff #6 stated the nurse came to assist. They then realized there was no aide in the rotunda. The routine is that there is an aide assigned to the rotunda to monitor/supervise the residents but there was no aide at the time of the incident. An interview was conducted with Staff #4(Assistant Director of Nursing) on 12/12/2023 at 1:37 PM and they stated they were notified of Resident #1's fall in the rotunda by Staff #3 (Registered Nurse). Staff #4 stated during their investigation, Staff # 1 stated they left their post at the rotunda without making other staff members aware. Staff #4 stated the rotunda duty was put in place as a precaution to prevent resident falls. Staff #1 was suspended during the the investigation and retrained on rotunda duty and its significance. Resident #2 was admitted on [DATE] with diagnoses including Chronic Kidney Disease, Essential Hypertension and Heart Failure. The Minimum Data Set (MDS, an assessment tool) dated 10/06/2023, documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 08/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Review of Resident #2 Incident/Accident Report dated 05/31/2023 documented, at approximately 2 PM a nurse was called to assist with Resident #2 as the resident had a fall while outside in front of the building. Hematoma observed to left side of forehead. Ice pack applied with first aid rendered. No major injuries noted. Residdent was assessed by physician. Neuro checks ordered and x-rays to head and bilateral hips ordered. Staff #2 assigned to monitor resident reported Resident #2 fell while they were outside in front of the building. Resident #2 stated staff accidently wheeled them onto a rough surface that caused wheelchair to turn and fall. Facility Investigation concluded: based on review of facility camera system (CCTV), staff interview and Resident #2's account of the incident, the fall could have been avoided. Review of Employee Disciplinary Notice dated 05/31/2023 given to Staff #2 stated on 05/31/2023 at approximately 1:50 PM a rapid response was called. Upon responding, Staff #2 was observed with Resident #1 in wheelchair and hematoma noted to left frontal occipital region. Staff #2 was asked what happened in which they stated that the sun blinded them while they were pushing Resident #2 outside and Resident #2 fell . During an interview with Resident #2 they stated they should know there was a curb there and I fell . Upon reviewing the facility camera system (CCTV), it was observed that Staff #2 was on their phone with their back turned to Resident #2. Resident #2 was unsupervised when the wheelchair wheeled backwards, and Resident #2 fell and sustained injury-hematoma. Staff #2 also picked Resident #2 up and placed them back in the wheelchair before calling for assistance. There was a violation of providing safe care and usage of cellular device while providing care. This action indicated gross misconduct and negligence with impaired judgment that has the propensity to harm other residents. Staff #2 was terminated and last day of employment with the facility was 05/31/2023. During an interview on 12/20/2023 at 11:31 AM with Staff #2 they stated they took Resident #2 outside on 05/31/2023 to get some fresh air. Staff #2 stated the lock on Resident #2's wheelchair was broken and Resident #2's chair went off the sidewalk and Resident #2 fell . Staff #2 stated they were assisted by a painter that was working outside the building to pick up the resident and put them back into their wheelchair. Resident #2 had a bruise on the side of their head but kept stating that they were okay. Staff #2 stated they reported the fall to the nurse and the resident was assessed. Staff #2 stated they were called down to department head' office and the facility camera footage was reviewed with them. Staff #2 stated they wrote a statement on what happened and were fired for using their phone. Staff #2 stated they understood why they were fired. Prior to the incident, they were trained on what to do when a reisdent falls but they panic during the incident and moved the resident before they were assessed by a nurse. During an interview on 12/20/2023 at 11:41 AM with Staff #4, they stated the previous Director of Nursing conducted the investigation for Resident #2's fall on 05/31/2023. Staff #4 stated Staff #2 was terminated after the investigation was concluded. Staff are trained on fall prevention and staff must notify a nurse immediately after a fall and not touch/move the resident. During an interview on 12/20/2023 at 12:26 PM with Resident #2, Resident #2 had in both hearing aids but would not respond to surveyor. Resident #2 continued to asked surveyor who they were multiple times but was not responsive to questioning. During an interview on 12/20/2023 at 1:13 PM with Staff #10(Administrator), they stated they were notified by Staff #7(previous director of nursing) of the investigation regarding Resident #2's fall. Staff #10 stated they usually do not fire staff before the conclusion of an investigation but in this case all the department heads came together and reviewed the investigation and agreed to terminate Staff #2. Staff #10 stated the facility videos were not been saved at the time of the incident so they did not have the footage available at the time of the onsite investigation for the surveyor to review. Presently all facility video footages are been stored on a flash drive for review when needed. 10NYRCC 415.12(h)(2)

Based on observations, record reviews and interviews conducted during an abbreviated survey (NY00317051) the facility failed to ensure that the medical care of 1 of 5 residents (Resident #1) reviewed for Physician services was appropriately supervised by a physician. Specifically, Resident #1 was identified as needing a change in the way medications were being administered and the corresponding Physician order to formally effect the change was not issued. Findings include: Facility Medication Administration Policy and Procedure Dated 11/15/2022 was reviewed and documented Medications are administered as ordered by the Physician. It indicated Crush medications as ordered, do not crush medications with do not crush order. Resident is [AGE] years old admitted to the facility on [DATE] with diagnoses that include but not limited to Stroke, Seizure Disorder, Dysphagia and Quadriplegia. The Quarterly MDS (MDS, an assessment tool) dated 3/11/2023 documented Resident #1 had severely impaired cognition and had total dependence of one staff for eating, dressing, personal hygiene, and required extensive assist of two staff for transfers and toileting. A Review of Resident #1 Nursing care plan for nutritional problems dated 3/10/23 documented staff to monitor/document/report as needed any signs of dysphagia: pocketing, choking, coughing. The resident has nutrition problem r/t mental and medical status Care Plan dated 3/10/23. Diet not listed on the care plan. A Review of Resident # 1 Nursing care plan for oral/dental problems dated 7/6/2022 documented staff to administer medications as ordered, diet as ordered, consult with dietician, and change if chewing/swallowing problems are noted. Review of the Physicians order dated 2/21/2023 documented the resident's diet order as soft bite size texture, regular thin liquids. ST Progress Note dated 3/8/23 documents patient seen for final ST and discharge. At this time, it appears patient has reached maximum potential, continue diet recommended on 02/21/2023 from bedside swallow evaluation; soft and bite sized textures, thin liquids, aspiration precautions, and one to one feeding. Nursing Progress Note dated 3/12/23 documented s/p IV fluids for poor intake, consumed about 75% of meals, Resident was given PO medications in food and consumed 100% of medications. Physician Comprehensive Progress Note dated 3/16/23 documented Dysphagia, currently on soft pureed diet, tolerating well, continue aspiration precautions. ST evaluation as needed with the goal that the resident will be able to swallow safely by 12/31/23. Review of Physician orders dated 6/28/2019 to 5/13/2023 revealed no order for Resident # 1's medication to be crushed. Review of Nursing Progress Notes dated 3/1/2023 through 5/23/2023 revealed Resident # 's medications were administered crushed or in food. Review of Medication Administration Record (MAR) from 3/1/2023 to 5/23/2023 was completed. There was no physician order for Resident #1's medications to be crushed. During an interview with Registered Nurse unit manager (RNUM # 1) on 5/24/2023 at 10:34 AM, the RNUM stated any resident who required crushed meds should have an order to crush meds. If the nurses notice that residents have difficulty swallowing meds they should report it, get an order to crush the meds, and request for the resident to have a speech therapy evaluation. During an interview with Licensed Practical Nurse (LPN# 2) conducted on 5/24/2023 at 10:42 AM, LPN #2 stated, I gave Resident #1 their medication this morning crushed. LPN # 2 stated they know to crush the medications based on their evaluation of the resident, and they were also told by other nurses on the unit. If I float to another floor, I find the directions on the face sheet, in the medication administration record (MAR), or the care plan. LPN #2 stated that a doctor's order is needed to crush medication. During an interview with LPN #3 on 5/24/23 at 10:55 AM, LPN # 3 stated they worked in the facility for 6 years and if a resident received medications whole that caused choking, they would report the incident and any changes in the resident's condition, and obtain a new order for medication administration to maintain safety. During an interview with Speech Therapist (ST) on 5/24/23 at 01:38, ST stated that after they conduct a swallow evaluation, the Physiatrist signs the recommendations, and orders the diet. ST only makes recommendations based on their evaluations. During an interview with Pharmacy Consultant (PC) on 5/24/23 at 01:50 PM, the PC stated in order to have medications crushed for residents on a modified diet a doctor's note is required. The order is entered in the electronic medical record (EMR), and nurses administer the medications as ordered. The PC stated anyone on a puree diet would have their medications crushed. The PC stated they are required to review residents' medication regimen during the monthly medication regimen review (MRR), and identify residents on a puree diet, notify the physician, and obtain an order to crush their medications. PC sated they will be conducting an in-service on crushing medications because they feel the staff need clarification. During an interview with on the Registered Dietician (RD) on 5/25/23 at 10:55 AM, the RD stated special diet orders for altered texture is guided by the Speech Therapist's (ST) recommendation. RD Stated the ST enters their recommendations for the residents' diet in the EMR, all disciplines are made aware of the diet changes and updates to the care plan. During an interview with LPN #1 (the accused staff) on 5/25/23 at 03:50 PM, LPN # 1 stated they worked with Resident #1 on the day of the incident (3/17/2023) and administered their medications as it was ordered by the MD. LPN # 1 stated they check the medication orders before giving medications and administer them in the form ordered. LPN #1 stated if the resident needs a crush order, they notify the MD. LPN #1 stated they have never witnessed Resident #1 choking on their medication, and Resident # 1 had no episode of choking or other unusual event on their shift on 3/17/23. During an interview with LPN #4 on 5/26/23 at 9:49 AM, LPN # 4 the LPN who worked with Resident #1 on the morning shift following the alleged incident) stated they worked the day shift on the date of the alleged incident, and they did not see any red marks or bruising on the resident's neck. They also did not notice any changes in the resident's psychosocial behavior. I administered medications to Resident # 1 on 3/18/23, they had no difficulty swallowing their crushed medications in applesauce and tolerated their meals that day. During an interview with Resident #1's primary care physician (PCP) on 5/26/23 at 11:45 AM, the PCP stated they were the PCP for Resident #1 for two years. PCP stated Resident #1 takes their medications by mouth and needs to take them crushed. Resident #1 had their diet changed in February to soft and bite size texture with thin liquids. The PCP stated they never evaluated how Resident #1 took their medications. The PCP stated that they rely on the Pharmacist Consultant's oversight of the medications identified to be administer crushed, to ensure that nurses do not crush medications that should not be crushed. The PCP stated Resident #1 had an order to crush their medications. However, the PCP could not show the surveyor in the EMR from February 2023 to 5/24/2023 (the start of the survey) any physician order to crush Resident #1's medications. During an interview with the Director of Nursing (DON) on 5/26/23 at 1:56 PM, the DON stated nurses follow the facility standard for crushing medications, the staff are trained in the International Dysphagia Diet Standardization Initiative (IDDSI, a globally developed intake texture guideline). The DON stated when they identify a resident on a modified diet, such as puree or thickened liquid, the staff know that the resident's medications cannot be administered whole. The DON stated the nurse would reach out to the Physician for a crush med order and notify the nurse manager. The DON stated residents who have difficulty swallowing have a Speech Therapy (ST) consult and are seen by the Dietitian. The DON stated the residents' care plans are updated according to the recommendations from the ST and the Dietician. The DON stated if medications are crushed without an order, the nurse must have identified the need, but did not follow through to get the order. The DON stated that the Physician or the Nurse Practitioner reviews the residents' medication profile every month. 415.15(b)(i)(ii)

Based on observation, record review, and interview conducted during the recertification survey from 03/09/2023 to 03/17/2023, the facility failed to revise a comprehensive care plan for 1 of 4 residents (Resident #52) reviewed for position/mobility. Specifically, Resident #52's care plan failed to address the use of wheelchair elevating leg rests and calf and/or foot board as ordered. The findings are: Resident #52 was admitted to the facility with diagnoses including but not limited to Alzheimer's Disease, Non-Alzheimer's Dementia, and Unspecified Osteoarthritis. A review of the 12/15/2022 Quarterly MDS (Minimum Data Set, a resident assessment tool) documented the resident had severe cognitive impairment; required extensive assist by 2+ staff members for bed mobility and transfers, extensive assist of 1 staff for wheelchair locomotion, and had functional limitation of both upper and lower extremities. A review of Resident #52's Occupational Therapy (OT) Evaluation performed 04/14/2021 to 04/27/2021, documented the referral was made for occupational therapy after nursing observed the resident sliding out from their wheelchair. The OT evaluation concluded recommendations for Resident #52 included a standard wheelchair and elevating leg rests. A review of Resident #52's EMR (Electronic Medical Record) revealed a provider order dated 04/21/2021 for a standard wheelchair, elevating leg rests, calf/foot board, and a wedge cushion. A review of Resident #52's comprehensive care plan dated 12/22/2022 revealed no documentation for the use of elevating leg rests or calf/foot boards on Resident #52's wheelchair. Multiple observations were conducted during the following dates and times: -On 3/8/2023 at 12:32PM, Resident #52 was in the wheelchair, with both feet dangling and intermittently dragging when being pushed from the dining room to the activity room, making no attempt to self-propel. The elevating leg rests or calf/foot board were not on the wheelchair. -On 3/9/2023 at 08:48AM, Resident #52 was in a slouched position, in the wheelchair and noted to be sliding forward and down, holding their abdomen, with both feet extended and dangling above the floor, and not making any attempt to self-propel or reposition. No elevating leg rests or calf/foot board were observed on the wheelchair. - On 3/13/2023 at 10:20AM, Resident #52 was in the activity room, not fully upright in the wheelchair, both feet were dangling and not touching the floor, and no attempt was made to self-propel. No elevating leg rests, or calf/foot board were observed on the wheelchair. During an interview on 03/13/2023 at 10:25AM, Certified Nursing Assistant (CNA # 3) stated they took Resident #52 out of bed and into their wheelchair earlier that morning. CNA #3 stated Resident #52 was supposed to have leg rests and a calf board on their wheelchair and did not report to the nurse that Resident #52's wheelchair was missing leg rests. CNA #3 stated that often times when residents' wheelchairs are sent for cleaning, the wheelchairs come back without leg rests. During an interview on 03/13/2023 at 3:28PM, Registered Nurse Unit Manager (RNUM #1) stated there was no part of Resident #52's care plan that included the use of prescribed elevating leg rests or calf/foot board, and stated nursing is responsible for Resident #52's care plan. RNUM #1 stated the rehab department developed the parts of Resident #52's care plan for mobility and positioning devices and the use of elevated leg rests/calf board should have been included in the care plan. During an interview on 03/13/2023 at 03:46PM, Physical Therapist (PT #1) stated rehab is responsible for developing and maintaining the resident care plans for residents requiring the use of wheelchairs and adaptive equipment. PT#1 stated there was no portion of Resident #52's care plan that included the use of elevating leg rests and calf/foot board and stated resident care plans should include the use of mobility equipment. 483.21 (f)(iii)

Based observation, record review, and interview conducted during the recertification survey from 03/08/2023 to 03/17/2023, the facility failed to ensure that residents received care and treatment in accordance with professional standards for one of four residents (Resident #52) reviewed for positioning and mobility. Specifically, Resident #52 was not provided positioning devices for their wheelchair as ordered. The findings include: Resident #52 was admitted to the facility with diagnoses including but not limited to Alzheimer's Disease, Non-Alzheimer's Dementia, and Unspecified Osteoarthritis. A review of the 12/15/2022 Quarterly MDS (Minimum Data Set, a resident assessment tool) documented the resident had severe cognitive impairment; required extensive assist by 2+ staff members for bed mobility and transfers, extensive assist of 1 staff for wheelchair locomotion, and had functional limitation of both upper and lower extremities. A review of Resident #52's Occupational Therapy (OT) Evaluation performed 04/14/2021 to 04/27/2021, documented the referral was made for occupational therapy after nursing observed the resident sliding out from their wheelchair. The OT evaluation concluded recommendations for Resident #52 included a standard wheelchair and elevating leg rests. A review of Resident #52's EMR (Electronic Medical Record) revealed a provider order dated 04/21/2021 for a standard wheelchair, elevating leg rests, calf/foot board, and a wedge cushion. A review of Resident #52's comprehensive care plan dated 12/22/2022 revealed no documentation for the use of elevating leg rests or calf/foot boards on Resident #52's wheelchair. Multiple observations were conducted during the following dates and times: -On 3/8/2023 at 12:32PM, Resident #52 was in the wheelchair, with both feet dangling and intermittently dragging when being pushed from the dining room to the activity room, making no attempt to self-propel. The elevating leg rests or calf/foot board were not on the wheelchair. -On 3/9/2023 at 08:48AM, Resident #52 was in a slouched position, in the wheelchair and noted to be sliding forward and down, holding abdomen, with both feet extended and dangling, and not making any attempt to self-propel or reposition. No elevating leg rests or calf/foot board were observed on the wheelchair. -On 3/13/2023 at 10:20AM, Resident #52 was in the activity room, not fully upright in the wheelchair, both feet were dangling and both toes were not touching the floor, and no attempt was made to self-propel. No elevating leg rests, or calf/foot board were observed on the wheelchair. During an interview on 03/13/2023 at 10:38AM, Licensed Practical Nurse (LPN #4) stated Resident #52 was supposed to have elevating leg rests on their wheelchair and if a component to the wheelchair was missing, staff were to notify the nurse manager or the rehab department. During an interview on 03/13/2023 at 12:06PM, Registered Nurse Unit Manager (RNUM #1) stated that Resident #52 was supposed to have elevating leg rests on their wheelchair and was not made aware by staff of Resident #52's leg rests missing. RNUM #1 stated that if a component of a wheelchair was missing, staff were to escalate the issue to the nurse or the nurse manager, who was supposed to notify the rehab department. During an interview on 03/13/2023 at 03:46PM, Physical Therapy (PT #1) stated sometimes when wheelchairs were washed, the leg rests were lost. PT #1 stated the rehab department was not aware resident #52's wheelchair was missing elevated leg rests and calf board. S 483.25

Based on observation, interview and record review conducted during the recertification and abbreviated surveys (NY00286859,NY00293521), the facility did not ensure that residents were adequately supervised and the environment remained free from accident hazards for 2 of 3 residents (Resident #63 and #58) reviewed for accidents. Specifically, observation revealed that a closet door in room [ROOM NUMBER]A which had previously fallen on Resident #63 was broken and not on the track. Resident #58 was identified at risk for elopement and exited the building undetected. The findings are: The policy and procedure titled Accident and Incident Report dated 9/19/22, documented it was the policy of the facility to ensure that the resident environment remained as free from accidents/incidents as possible through adequate supervision and individualized interventions for prevention. The purpose was to effectively investigate potential and actual injuries to residents and minimize adverse resident outcomes. Resident #63 was admitted to facility on 1/26/16 with diagnosis of Unspecified Dementia with other Behavioral Disturbance, History of Falling, and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set (MDS) documented Resident #63 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated severely impaired cognition and the resident required extensive assistance of one person for bed mobility, transfers, eating and toileting. The 11/20/21 nursing note documented that Licensed Practical Nurse (LPN #2) reported a broken closet door accidentally fell on to Resident #63 causing a left eyebrow abrasion with a small amount of bleeding. The broken closet door was removed by maintenance and the family was informed. Observation on 3/13/23 at 9:27 AM and 3/15/23 at 11:07 AM revealed Resident #63's closet door was broken and off the track. During an interview on 3/15/23 at 1:09PM Certified Nurse Assistant (CNA #1) stated they saw the closet door broken today (3/15/23) around 10:00 AM. CNA #1 stated that the closet door was tilted off the track and they forgot to report it to the nurse. During an interview on 3/25/23 at 1:12PM, Registered Nurse Unit Manager (RNUM#1) stated CNA #1 just informed them the closet door was broken in room [ROOM NUMBER] and that they would call maintenance to come and fix the door. During an interview on 3/15/23 at 1:30 PM the Director of Maintenance stated they had not been made aware the closet door was broken in room [ROOM NUMBER]. 2. The 9/18/2017 facility policy and procedure titled Elopement Prevention; Missing Resident, Dr Search documented it was the policy of this facility that residents would be maintained in a safe secure manner and protected from actual harm while encouraging resident rights. Resident #58 was admitted to facility with diagnoses including Dementia, Depression, and Hypertension. The 3/23/2022 Significant Change Minimum Data Set Significant (MDS, an assessment tool) documented Resident #58 had a Brief Interview for Mental Status (BIMS) of 2 which indicated severe cognitive impairment. The 10/28/2020 Elopement Care Plan with revision dates of 9/14/2022, 3/10/2022 documented the resident was an elopement risk related to a history of attempts to leave the facility unattended. Interventions included a wander guard (electronic monitoring device) on the left ankle to be checked every shift, redirect the resident from the elevators and exit doors, engage the resident in purposeful activities, provide structured activities and schedule time for walks. Review of the March 4, 2022, Elopement Assessment documented the resident was at risk for elopement. The 3/30/2022 Accident/Incident Occurrence Report documented at around 9:50 AM the concierge alerted the Director of Nursing (DON) about a person whom they saw sitting outside the building. The DON and Assistant Director of Nursing (ADON) responded to find the resident sitting outside of the front lobby. The March 2022 Physician Orders documented an order for an elopement/wander guard to be placed on the resident and checked every shift for placement and functionality. The March 2022 Treatment Administration Record (TAR) documented the wander guard was checked every shift for placement and that it was in working order. The record documented the wander guard was last checked on the 3/29/2022 night shift. Review of the 3/30/2022 Nursing Progress Note documented the resident was alert, responsive and ambulatory. The resident was found outside the front lobby and was brought back by the staff. The Wander guard was checked and noted to be functioning well and a new wander guard was applied to the left ankle. During an interview on 3/7/2023 at 11:26 AM, Certified Nursing Assistant (CNA #6) stated they worked on the unit that day and the resident was more agitated than normal, CNA #6 stated the resident had a wander guard and did make several attempts to get on the elevator but was redirected when the alarms sounded. CNA #6 stated they told other staff the resident was a little more agitated and to keep an eye on the resident. CNA #6 stated that as they were picking up the breakfast trays they noticed the resident was not in the room, so they started looking for the resident and alerted the rest of the staff and supervisor that the resident was missing. CNA #6 stated a few minutes later they were notified the resident had been found. During an interview on 3/1/2023 at 3:30 PM Licensed Practical Nurse (LPN #2) stated it was around breakfast time and the resident was attempting to get on the elevator but was redirected by LPN # 2 and by CNA #6. LPN # 2 stated the breakfast trays came up, so the staff were able to redirect the resident to sit and eat breakfast. LPN # 2 stated they did notice that the resident got up again and the resident was redirected to their room. LPN # 2 stated since it was breakfast time the staff was busy with serving trays and feeding residents and LPN #2 began passing medications. LPN # 2 stated when the nurse manager asked if the resident had been seen the staff immediately began to search for the resident and were informed within 5 minutes the resident had been found. During an interview on 3/7/2023 at 23PM the front desk concierge stated they were working the front desk during the morning on 3/30/2022. The concierge stated multiple people were entering and leaving the facility at the same time and they did not notice the resident in the group of people exiting the facility, but the alarm did sound. The concierge stated looking back now they did not remember if the code was entered to silence the alarm. The concierge stated they went outside and found the resident sitting on the ground to the left of the main door. The concierge stated they notified the staff. The concierge stated they had been trained on Elopement and was aware of the elopement list with pictures that was kept behind the front desk. During an interview with the DON on 3/7/2023 at 9:45 AM, the DON stated the wander guard system at the front door required the front desk staff to enter a code if the wander guard alarm was activated. The DON stated If the front desk staff heard the alarm, they should go to the door and check that no residents have exited the building prior to entering the code. The DON stated the concierge did state at the time that the resident may have exited the building when he unlocked the door for a group of people who were entering and exiting the building. The DON stated at the time of the event they reviewed the camera and did see the resident leave the floor via the staff elevator and exit the front door of the building. 415.12(h)(2) 47626

Based on observations interviews and record review during a recertification survey (3/8/23-3/17/23), the facility did not ensure that professional standards for food safety and prevention of food borne illness were followed. Specifically, wait staff #1 did not perform hand hygiene between serving residents while passing out food during a lunch meal to prevent cross contamination and infection. The finding are : The facility policy on Hand Hygiene dated 6/9/20 and 8/16/21 states all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The attached table documents hand hygiene to be performed between resident contacts. Observations were made on 3/8/23 in the first-floor dining room beginning at 12:10pm. Wait staff #1 was observed pushing a serving cart of lunch plates with bare hands over to a dining table of 3 residents. Wait staff #1 stopped pushing the cart, touched the resident menu with their hands, touched the meal plate and put their finger in the hole of the lid to remove the lid and place the plate in front of the resident, returned to the cart, got another plate, removed the lid, placed it on the table, pushed the cart around the table touching the handle, adjusted their face mask, touched the resident shoulder, and returned to remove plates from the cart, removing lids and placing them on the table. At 12:24pm an observation was made of wait staff #1 who passed out plates of cake to residents at the tables, scratched their arm, walked to the refrigerator, touched the door handle, took out a soda, brought the soda to the resident table and put the soda on the table then walked to get coffee from the pot, returned to the resident table and for each coffee refill, lifted the resident cup by its handle, refilled the coffee and placed the cup back on the table and proceeded to the next resident. There was no hand sanitizer on the cart or on the walls. A small bottle of hand sanitizer was on each table but never used by wait staff #1. There was no hand hygiene performed by the wait staff #1. During an interview on 3/8/23 at 12:34pm Wait staff #1 stated they did not know they needed to perform hand hygiene and had not had Infection Control training by the facility. During an interview on 3/8/23 at 12:30pm Dietary Supervisor #1 stated hand sanitizer is in the kitchen and on tables and stated staff should be using sanitizer before each pass of clean lunch plates to the resident. They stated staff take a 3-day class before serving residents then competencies are done by a supervisor. The Dietary Supervisor #1 was unable to provide evidence of training records for wait staff #1. S483.60(i)(2)

44673 Based on observations, interviews and record review during a recertification survey from 3/8/23 to 3/18/2023 the facility did not ensure that Infection Control practices and procedures were maintained. Specifically, 1) Housekeeping staff #1 did not properly distribute clean laundry to residents in a manner that would prevent the spread of infection, 2) Certified Nursing Assistant (CNA) #4 handled linen on a clean linen cart while wearing dirty gloves and 3) the front desk concierge did not handle COVID19 test specimens and maintain the COVID19 testing area in a clean and sanitary manner to prevent the development and transmission of communicable disease and illness. The findings are: 1. On 3/15/2023 at 1:35PM Housekeeper #1 was observed distributing clean laundry from a linen cart in hallway C of the third floor. Housekeeper #1 collected uncovered clean laundry on hangers for Residents #134 #129, #167 and #63 and proceeded to hallway B then entered the room of Resident #129, placed resident #129's clothing articles in their closet and collected dirty hangers from the closet while failing to separate dirty hangers from the clean clothing of other resident's in-hand. Housekeeper #1 then proceeded to the room of Resident #134, #167 and #63 in the same manner delivering clean clothes and collecting dirty hangers. During an interview on 03/15/2023 at 01:48 PM Housekeeper #1 stated that linen is covered for infection control, and that clean linen is supposed to be distributed to one resident at a time, distributing clothing articles directly from the covered clean linen cart to the resident's room but stated they did not perform the proper procedure because they had just a few articles of clothing for the hallway C. Housekeeper #1 stated they distributed the linen's uncovered because the clean linen cart is very large and it is hard to see over the cart, and they did not want to accidentally run-into or injure a resident in the process of linen distribution. During an interview on 03/17/2023 at 09:33 AM the facility's Director of Capital Projects, stated the distribution of clean laundry is done by housekeeping and the covered clean laundry cart should be brought outside of each resident room, and housekeeping should individually distribute clean laundry directly from the covered laundry cart and into the resident's room, one resident at a time. During an interview on 03/17/2023 at 11:55 AM the facility's administrator stated they could not provide a policy for proper linen distribution. 2. On 3/9/23 at 9:25 AM CNA#4 was observed on the fourth floor pushing a Hoyer lift while wearing gloves on both hands. CNA #4 stopped in front of a covered clean linen cart in the hallway and grabbed briefs and sheets with the gloved hands then returned to push the Hoyer lift down the hall and into Resident room [ROOM NUMBER]. During an interview on 3/13/23 at 11:39 AM CNA#4 stated they were not thinking at the time and knows that staff should not be wearing gloves outside a resident room and should not have touched clean linens with gloved hands. During an interview on 3/08/2023 at 10:00AM Registered Nurse Unit Manager #2 stated CNA's should not be touching clean linen carts while wearing gloves. 3. On 3/15/23 10:45AM, an observation was made in the front lobby of Concierge #1 during visitor testing. Concierge #1 was observed assisting two visitors for COVID19 testing in the testing area. The visitors swabbed their own noses but when they could not place the swab in the test cartridge properly, Concierge #1 offered and took the swabs from the visitors with their bare hands and put the swab in the correct position on the test cartridge and placed both tests aside to develop. There was no hand hygiene performed by the Concierge or gloves donned for the procedure. A second observation was made 3/15/23 at 10:54 AM of Concierge #1 assisting another visitor, opened a swab handed swab to visitor who in turn swabbed their nose, then took the swab from the visitor and placed it on the test cartridge . The test cartridge was placed on a lobby end table without a barrier to develop. The Concierge returned to the front desk to log in visitors, touched pens and tabletop surfaces without performing hand hygiene or wiping down test tables and end table after each use. The Concierge did not wear gloves when handling test specimens. During an interview on 3/15/23 at 12:00PM Concierge #1 stated that they were not aware they needed to wear gloves during testing and does clean the testing area tables twice an hour and feels that was good enough. During an interview on 3/17/23 at 8:45 AM the Director of Nursing (DON) stated training, and ongoing updates of Infection Control has been relayed to the Concierge. The DON stated the correct procedure is to have visitors do their own testing and if they need help the concierge should wear gloves and assist visitors. The DON stated test kits should stay on the testing table. They should not be moved to end tables. Tables and test areas needs to be wiped down after each test not twice an hour. 483.80 48045

F609 Based on record reviews and interviews conducted during an abbreviated survey (NY 509), the facility failed to report all alleged violations involving neglect, abuse, including injuries of unknown source within prescribed timeframes to the New York State Department of Health (NYSDOH). Specifically, Resident #1 was noted with swollen left knee on 3/23/2022. Diagnostic imaging of left knee indicated acute nondisplaced oblique fracture of the left femur. The incident was not reported to NYSDOH until 3/30/2022. The findings are: The facility policy titled Resident Abuse, Neglect, Mistreatment, and Exploitation, with approval date 7/01/2022 documented that all alleged violations involving abuse, neglect, exploitation or punishment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse/neglect or result in serious bodily injury. Resident #1 was admitted to the facility 4/19/2016 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment tool) dated 4/2/2022 identified the Resident with a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident was moderately cognitively impaired and required extensive assist of two staff for transfers. Review of the Facility Occurrence Report dated 3/30/2022 documented that resident # 1 complained of pain to the left knee on 3/23/2022. Xray results documented acute nondisplaced oblique fracture of distal diaphysis of the left femur, moderate osteopenia, and severe arthritis. The incident was not reported to NYSDOH until 3/30/2022 more than 24hrs after the incident. The Facility documentation that an investigation was completed to rule out abuse, neglect or mistreatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Statements from staff indicated staff did not follow resident care plan to transfer with 2 person assist. Physician ordered X-rays stat and pain medication was administered. The statements supported that care was not provided with 2 staff assist as indicated on care plan. The assigned CNA documented on 3/23/22 s/he completed a transfer with 1 person assist. During an interview with Licensed Practical Nurse (LPN#1) on 8/29/22 at 3:13 PM, LPN#1 stated CNA1 reported that resident had left knee pain on the morning of 3/23/22. LPN#1 stated they reported incident to Nursing Supervisor/Registered Nurse (RN), and they went to assess the resident. LPN stated they informed Assistant Director of Nursing (ADON), and Physician (MD). MD ordered x ray. Interview with Director of Nursing (DON) on 8/29/22 at 3:45 PM, DON stated the procedure after an incident, the procedure was that the CNA reported to LPN of left knee pain, LPN then reported to the nurse manager and then nurse manager reported it to the Assistant Director of Nursing (ADON). At the time of the incident the ADON was the only one at facility. DON and Administrator were both out of facility on time off. ADON initiated and completed the investigation. DON stated they reported the incident to NYS Department of Health (NYSDOH) upon their return to facility. DON stated that usually a report of unknown origin should be reported to NYSDOH within the 5-7 days. DON stated if Administrator and DON were present, they would have reported it within 48 hours. Assistant Director of Nursing was unavailable to be called for interview due to their scheduled time off out of the country. 415.4(b)(1)(i)

F656- Based on observation, record review and interviews conducted during an Abbreviated Survey (NY 509), the facility did not ensure that the comprehensive person-centered care plan (CCP) was implemented to meet the resident's goal for safety for 1 of 3 residents reviewed for Activities of Daily Living (ADL). Specifically, Resident #1 was care planned as needing extensive physical assist of 2 for transfer. Resident #1 was injured while being transferred from wheelchair to bed with a physical assistance of 1 and sustained an acute nondisplaced oblique fracture of distal diaphysis of femur. The finding are: Resident #1 was admitted to the facility 4/19/2016 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS, an assessment tool) dated 1/31/2020 documented Resident #1 had moderate impairment in cognition with a Brief Interview for Mental Status (BIMS) score of 8. Resident was totally dependent of two staff for transfers. The Resident ADL-Self Care Performance Deficit Care Plan initiated 6/5/20 documented the resident required extensive assist of 2 for bed mobility, transfers, and toileting. Review of the Facility Occurrence Report dated 3/30/2022 documented that Resident # 1 complained of pain to the left knee on 3/23/2022. Nurse Practitioner was informed, and they ordered X-ray STAT to left knee for pain and swelling. Xray results documented acute nondisplaced oblique fracture of distal diaphysis of the left femur, moderate osteopenia, and severe arthritis. Statements from staff indicated staff did not follow resident care plan to transfer with 2 people assist. Certified Nursing Assistant (CNA#2) statement dated 3/28/2022 documented they are responsible for getting the resident dressed and transferred to wheelchair. CNA#2 stated that in the afternoon around 2-3 PM, they needed to put resident back to bed from wheelchair to change resident's diaper. Resident stated she was not feeling well and requested CNA#2 to put him/her back to bed with 1 person assist. CNA#2 documented that they transferred resident with assist of 1 and nothing eventful happened. The statements supported that care was not provided with 2 staff assist as indicated on care plan. The assigned CNA documented on 3/23/2022 s/he completed the transfer with 1 person assist. A review of Resident #1's ADL Self-Care Performance Deficit Care Plan initiated 6/5/20 revealed resident needed extensive assist of 2 staff for transfers. During a review of CNA Instructions dated 3/01/2022 documented resident required extensive assist of 2 staff for transfers. Review of a facility undated statement on 8/30/ revealed Licensed Practical Nurse (LPN#1) documented they were informed by Certified Nurse Assistant/ CNA#1 who was assigned to Resident #1 that the resident had swelling of the left leg. LPN#1 examined resident and observed resident with left leg swelling. Statement documented LPN #1 was informed by CNA#2 that resident was transferred with assist of 1 person. LPN stated they reported incident to Nursing Supervisor/Registered Nurse (RN), and the Resident was assessed. LPN stated they informed Assistant Director of Nursing (ADON), Nurse Practitioner (NP) and Medical Doctor (MD). NP ordered x ray. During an interview with Certified Nurse Assistant/CNA#2 on 8/29/2022 at 2:54 PM, CNA#2 stated resident #1 wanted to go back to bed after lunch because the resident's behind/buttock was very uncomfortable from sitting in the wheelchair. CNA#2 stated the resident begged him/her even though s/he already told the resident s/he was not supposed to transfer without assistance of a second person. CNA#2 stated that s/he proceeded to do the transfer by holding onto resident's waist and lifted the resident up from wheelchair. CNA#2 stated the bed was not too high, so s/he was able to lower the resident to the bed easily and the resident did not weigh a lot (68 pounds) and s/he was able to lift the resident by himself/herself. CNA#2 stated that the resident did not make any complaints of pain during and after the transfer. CNA#2 stated that they received abuse and neglect training more than once a year. CNA#2 stated after incident they were in serviced on following care plan and specifically transferring a resident with assist of 1 when the resident was supposed to be transferred with assist of 2. During an interview with Certified Nurse Assistant/CNA #1 on 8/29/2022 at 3:05 PM, CNA #1 stated during morning care on 3/23/2022 the resident reported pain in left knee. CNA #1 stated they then reported this to the nurse. The Nurse went to assess the Resident. CNA #1 stated that they received abuse and neglect training more than annually. CNA #1 stated that following the incident they received in services on following the care plan and specifically following care plan about transferring resident. During an interview with Licensed Practical Nurse/ LPN#1 on 8/29/2022 at 3:13 PM, LPN stated CNA #1 reported that resident complained of left knee pain on the morning of 3/23/2022. LPN#1 stated they reported incident to Nursing Supervisor/Registered Nurse (RN), and they went to assess the resident. LPN stated they informed Assistant Director of Nursing (ADON), and MD. MD ordered x ray. During an interview with Medical Doctor/MD 8/29/2022 at 3:17 PM, the MD stated the resident complained of left knee pain. At that time MD stated there was no evidence of trauma, no discoloration or bruising. MD stated the left knee had mild swelling. MD stated they ordered an x-ray and resulted in a fracture of left knee but did not feel it was related to trauma. 415.11(c)(1)

Based on record review and interview conducted during an abbreviated survey (Complaint # NY 592), the facility did not ensure that the resident's legal representative upon written request, was provided with a copy of Resident's health care records within 2 working days advanced notice to the facility. Specifically, on 08/13/2020 an Authorization for Release of Health Information was received by the Medical Records Coordinator requesting Resident #1's medical records. The medical records requested were not received by the legal representative of the resident until 01/27/2021. The facility's policy and procedure titled Medical Record, Release Information dated 5/5/2020 directed staff that after a written request, they have up to 10 business days to furnish residents with a copy of their records. This policy is not in alignment with federal or state regulations which provides the residents the right to receive a copy of their medical record within 2 working days of advance notice to the facility. This deficient practice has the potential to affect all residents and or their representatives within the facility. The finding is: Resident # 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Policy entitled Medical Record, Release Information dated 05/05/2020 documented that copies of medical record will be made available within 10 business days upon written request or completion of Authorization for Release of Information. An Authorization for Release of Health Information from the resident/ resident representative dated 08/13/2020 was reviewed. Review of an email from the Medical Records Coordinator dated 09/16/2021 documented that the residents full certified chart was sent to resident representative on 01/27/2021. An interview was conducted with the Medical Records Coordinator on 09/16/2021 at 11:30 AM who stated that he/she received the request for medical records on 08/13/2020 and that according to their policy, he/she had 10 business days to send the documents. A telephone interview was conducted with the Administrator on 09/30/2021 at 11:45 PM who stated that he/she is aware that their facility policy is to release copies of medical records within 10 business days. The Administrator also stated that he was aware that the Medical Records Coordinator was preparing the medical records after receiving the request on 08/13/2020 but on 08/24/2020 (8th business day) they received a summon from the court and they had to hold the release of the records. 415.3(c)(1)(iv)

Based on interview and record review conducted during an abbreviated survey (NY 696), it could not be ensured for 1 (Resident #1) of 3 residents reviewed for medications that 1. the facility provided the necessary care and treatment to prevent complications associated with [CONDITION(S)]. Specifically, a medication (blood thinner) was omitted during the submission of the physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was subsequently discharged to the hospital on 2/16/2021 per Resident and family request. The Admission Minimum Set (MDS: an assessment tool) dated 2/11/2021 revealed: admission from acute hospital, resident cognition was intact for decision making, Health conditions included shortness of breath or trouble breathing, and Medications received included injection 1/7 days, antibiotic 5/7 days, diuretic 7/7 days, and opioid 2/7 days. Special Treatments in the last 14 days included Oxygen therapy and IV medications. Hospital record for admission of 2/5/21 noted previous medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] .Fib (on [MEDICATION(S)]), prior DVT (with IVC filter), recent [MEDICATION(S)] abscess drainage, PAF ([CONDITION(S)]): continue [MEDICATION(S)], DVT/PE with history of filter: continue [MEDICATION(S)], PAD (peripheral artery disease): chronic LE (lower extremity) PAD with no current evidence of limb ischemia, continue AC (anticoagulant) and clinical follow up LE PAD. Discharge Summary dated 2/4/21 included a Comprehensive Discharge Medication list which documented [MEDICATION(S)] 20 mg daily #30 tablet 11/27/20. Pertinent Admission Physicians orders included but were not limited to: 2/5/21 Abuterol Sulfate Nebulizer Solution 2.5 mg /0.5 ml 0.5 ml inhaler orally 4x/day for SOB 2/5/21 [MEDICATION(S)] Suspension Reconstituted 250 mg/5ml, give 5ml by mouth 2x/day for [CONDITION(S)] for 14 days 2/5/21 [MEDICATION(S)] Capsule 100 mg give 3 capsules by mouth at bedtime for constipation 2/5/21 [MEDICATION(S)] capsule 0.4 mg give 1 capsule 1x/day for [CONDITION(S)] 2/5/21 [MEDICATION(S)] Tablet 100 mg by mouth 1x/day for fungal 2/6/21 [MEDICATION(S)] 2.5 mg 1 tablet by mouth one time a day for [CONDITION(S)] 2/6/21 [MEDICATION(S)] 25 mg 1 tablet by mouth 2x/day for [CONDITION(S)] 2/6/21 [MEDICATION(S)] 20 mg tablet, 1 tablet 2x/day for CHF No admission order for [MEDICATION(S)] (anticoagulant) were noted. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Sulfate Nebulization solution 2/5/21 - 3 of 4 doses omitted, 2/6/21 - 4 of 4 doses omitted, 2/7/21 - 3 of 4 doses omitted. [MEDICATION(S)] Suspension 6 AM/6PM doses omitted 2/6/21. [MEDICATION(S)] 9 pm dose omitted 2/5/21 and 2/6/21 [MEDICATION(S)] 8:30 AM dose omitted 2/6/21 [MEDICATION(S)] 9:00 am dose omitted 2/6/21 [MEDICATION(S)] 1:30 PM dose omitted 2/6/21 [MEDICATION(S)] 9AM and 5 pm omitted 2/6/21, 5 PM dose omitted 2/7/21 [MEDICATION(S)] 9AM and 5 pm doses omitted 2/6/21, 5 PM dose omitted 2/7/21 The resident's plans of care included: Resident has altered cardiovascular status related to arrythmia, CHF, [CONDITION(S)], [CONDITION(S)]. Goal: free from cardiac complications. Interventions: Administer cardiac medication as per MD order. Monitor/document/report prn and changes in lung sounds on auscultation (i.e. crackles), [CONDITION(S)], changes in weight. Monitor/document/report prn any s/sx of CAD (coronary artery disease) i.e. shortness of breath, dependent [CONDITION(S)] .color/warmth of extremities. Resident has [CONDITION(S)], H/O pulmonary emboli: Will be free of s/sx of respiratory infections through date. Interventions: Administer oxygen per MD order, 2L/min via nasal cannula. Give aerosol and bronchodilators as ordered. Monitor /document any side effects/effectiveness. Monitor for difficulty breathing (Dyspnea) on exertion. Monitor for s/sx of acute respiratory insufficiency. Monitor/document/report any s/sx of respiratory infection. Monitor/document for anxiety, offer support, give prn medication for anxiety as ordered. A Physicians note dated 2/8/21 documented A/P: Heart failure. We will continue diuretics as ordered. [CONDITION(S)]: We will continue with oxygen and nebulizer treatments. AFib: We will continue with the anticoagulation as ordered. Continue with current medications. Nurses notes revealed: 2/7/21 LPN (T.M.) Medication not delivered and not available in-house stock. Supervisor was notified and spoke with pharmacy representor. 2/8/21 LPN (D.H.) Some of the Resident's medication were delivered around 1-3AM today 2/8, oncoming shift made aware some medications available, will f/u with pharmacy regarding missing medication. 2/16/21 12:30 PM RN (M.M.) resident complaint of difficulty breathing. Crackles scattered t/o. Insp. Wheeze noted. Desatted 82% when PT tried to get out of her bed. Resident is on Oxygen 2 IN.C. 2/16/21 12:36 PM RN (M.M.) Oxygen increased to 4 In.c and sat is presently 96%. Dr. F. notified and ordered Solumedrol 125mg stat. Given LUA. Dr. F saw resident via tele. [MEDICATION(S)] 40 mg IM ordered and given stat RUA. Both resident and daughter insisting resident be sent to SJRH. Dr. F made aware and K. DON. Dr. F requested daughters phone number and daughter notified MD will be calling. Resident states she does not feel any better. Continues to c/p of difficulty breathing. Wheezing has subsided. RLE 2 plus pedal [CONDITION(S)] noted. Foot is warm to touch. Pulse is positive. Abdomen is softly distended and bowel sounds are hypoactive LLQ. All other quadrants WNL. Resident has poor appetite but is very thirsty. Awaiting to hear back from Dr. F. Sat is presently 96% on 4 LNC. Dr. F. is aware of all of the above. 2/16/21 13:27 PM RN (M.M.) Family called ambulance and ambulance arrived at 1:25 PM and resident left. Daughter and ambulance driver and took mother to SJRH. Face sheet requested and given. Resident #1 was subsequently readmitted to the facility on [DATE]. The Hospital Discharge Summary dated 2/25/21 documented: 2/16/21: U/S (Ultrasound) venous doppler: Right leg DVT is seen . 2/16/21: U/S arterial doppler: predominantly decreased monophasic flow is seen within the right posterior tibial artery. 2/16/21: CTA chest: .several acute-appearing right lower lung field segmental pulmonary emboli are noted as is better visualized on CT [MEDICATION(S)] performed the same date. A telephone interview of the Registered Nurse Manager (RNM #1) conducted on 2/25/2021 at 11:32 AM revealed: RNM#1 was the person responsible for reconciling the Resident's medications with MD from the hospital discharge summary. When asked, RNM #1 reported she did not know why the anticoagulant was missed. Telephone interviews of the Medical Director conducted on 3/2/2021 at 12:36 and 12:56 PM revealed: Resident was hospitalized related to a low flow state which caused discoloration of the lower extremity, was evaluated by vascular and was readmitted to the facility. In response to Surveyors further inquiries, MD reviewed the resident's discharge form hospitalization of 2/16-2/25/2021 and reported the Resident had testing in hospital as follow: Ultrasound of right lower extremity with finding of [CONDITION(S)] (DVT), and CTA (Computed tomography [MEDICATION(S)], a technique used to visualize arterial and venous vessels throughout the body) with finding of right lower lung field segmental pulmonary embolism (PE). MD revealed he was made aware (date not recalled) that the resident had not received the anticoagulant during her admission prior to hospitalization and reported that factors of the low flow state and not receiving the anticoagulant contributed to the DVT and PE. Telephone interviews conducted on 3/2/2021 at 12:49 PM and 1:52 PM with the Director of Nursing Operations (DO) revealed: On 2/8/21 she reviewed the resident's medication orders and noted blanks on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to an IT glitch the orders did not hit the pharmacy system until 2/7/21, and so did not populate the MAR. The shift report documented that the pharmacy was called. Correspondence was sent to the pharmacy and response from pharmacy was received. A telephone call was placed to the facility's Pharmacy Representee (PR) on 3/5/21 at 11:40 AM. The PR revealed the following: Nursing types orders into the PCC (Point Click Care) software system and the residents admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/5/21 the pharmacy received Resident #1's the other resident specific formation but did not receive medication or treatment orders until 2/7/21. PR further revealed that she spoke with facility DO, DO inquired about the orders, and asked that PR to check with pharmacy IT, PR did so, and no issues were identified. The PR then discussed with DO that there was no issue on the Pharmacy's' end and Pharmacy recommended that facility put in a ticket with the PCC software system to look into the issue, and PR has not heard back from the facility. PR revealed that the Resident's medications were first delivered to facility on 2/7/21. A follow up interview of the DO on 3/5/21 at 12:43 PM revealed that PCC has not responded to the facility's inquiry. DO further revealed that when medications are not received the MD or Physician should be called to obtain further direction and the MD was not informed of medications not received for Resident #1 until the facility identified this on 2/8/21. DO further reported that she spoke with the MD about the Resident's medications not being received but could not recall the date of the conversation. In a follow up interview conducted on 3/5/21 at 1:47 PM the MD reported: The DO had called him at some point (could not recall date) and told him there was a pharmacy issue that was straightened out. MD reported he then reviewed the policy and procedure with DO and emphasized that for any order delays, concerns, or orders not followed through he should be contacted right away. MD further reported that he did not recall being notified that the Resident had not received medications as ordered. 415.12

Based on interview and record review conducted during an Abbreviated Survey (NY 696), the facility did not ensure that residents are free of significant medication errors. Specifically, for 1 of 3 (Resident #1) residents reviewed for medications, an anticoagulant medication was not ordered by the facility physician upon admission as per hospital discharge instructions which resulted in the resident not receiving the anticoagulant from 2/5/2021 through 2/16/2021. The findings are: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was discharged to the hospital on 2/16/2021 per Resident and family request. The Admission Minimum Set (MDS; a resident assessment tool) dated 2/11/2021 revealed that Resident #1's cognition was intact for decision making with a Brief Interview for Mental Status (BIMS) score of 15/15. Resident #1's health conditions included shortness of breath (SOB) or trouble breathing. Resident #1 received medications including injection 1/7 days, antibiotic 5/7 days, diuretic 7/7 days, and opioid 2/7 days. Special Treatments in the last 14 days included Oxygen therapy and intravenous (IV) medications. Review of a 2/3/21 Hospital Progress Note revealed the Resident was a 74year old. with previous medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] .DVT/PE with history of filter: continue [MEDICATION(S)]. PAD (peripheral artery disease): chronic LE PAD with no current evidence of limb ischemia. Appreciate vascular consult and, continue Anticoagulant and clinical follow up Left Extremity LE PAD. The Hospital Discharge Summary dated 2/4/2021 included a Comprehensive Discharge Medication list which included [MEDICATION(S)] 20 mg daily #30 tablet 11/27/20. The 2/5/2021 Admission Physician's Orders did not include [MEDICATION(S)] ([MEDICATION(S)]-anticoagulant) as per the 2/4/21 hospital discharge summary. Review of the 2/1/2021-2/28/2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician's Note dated 2/8/2021 documented that for Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continue with current medications. Review of a 2/16/2021 at 12:30PM Nurse's Note written by RN #1 showed that Resident #1 complained of difficulty breathing. Upon auscultation, scattered crackles and wheezing noted. Oxygen Saturation was measured to be at 82% when the Physical Therapist (PT #1) attempted to get Resident #1 out of bed. A follow up Nurse's Note dated 2/16/2021 at 12:36PM written by RN #1 was reviewed which showed that Resident #1's Oxygen had been increased to 4L/min with a positive effect, saturation rose to 96%. The Physician was notified, ordered Solumedrol 125mg stat and conducted a telehealth visit. [MEDICATION(S)] 40 mg was also ordered and given stat. Resident #1 stated that he/she does not feel any better and continued to complain of difficulty breathing. Wheezing has subsided. Right Lower Extremity (RLE) pedal [CONDITION(S)] noted and Resident #1's foot was warm to the touch. Pulse is positive. Abdomen is softly distended and bowel sounds are hypoactive at the Lower Left Quadrant (LLQ). All other quadrants Within Normal Limits (WNL). Resident has poor appetite but is very thirsty. Awaiting return call from MD. A Nurses' Note dated 2/16/2021 at 1:27PM written by RN #1 showed that Resident #1's family called an ambulance which arrived at 1:25PM. The ambulance transported Resident #1 and his/her daughter to the emergency room (ER) where he/she was admitted . Review of the Hospital Discharge Summary dated 2/25/21 documented that on 2/16/2021, an Ultrasound (U/S) Venous Doppler identified that a Right leg DVT is seen . The 2/16/2021 U/S Arterial Doppler showed that predominantly decreased monophasic flow is seen within the right posterior tibial artery. Furthermore, a 2/16/2021 Computed Tomography [MEDICATION(S)] (CTA; a technique used to visualize arterial and venous vessels throughout the body) showed, .several acute-appearing right lower lung field segmental pulmonary emboli are noted as is better visualized on CT [MEDICATION(S)] performed the same date. An interview conducted on 2/22/2021 at 2:13 PM with the Director of Nursing Operations (DO) revealed: Last night she was completing record reviews of admission and identified that the resident ' s hospital discharge summary dated 2/4/2021 documented [MEDICATION(S)] 20 mg p.o. daily, and when compared to admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DO reported usual procedure is to reconcile medications within 48 hours, however she was on vacation and when she returned on 2/8/2021, was in process of catching up and so found the error last night. DO further reported that if she is not in facility Nursing does a 3-person check of the admission medications, a disciplinary process will be taken for the Nurse responsible for the error, and staff will be educated. : A telephone interview of the Registered Nurse Manager (RNM #1) conducted on 2/25/2021 at 11:32AM revealed RNM#1 was the person responsible for reconciling the Resident ' s medications with MD from the discharge summary. When asked, RNM #1 reported she did not know why the anticoagulant was missed, and further reported that the next two Nurse ' s shifts should have also reconciled the medications A telephone interviews of the Medical Director conducted on 3/2/2021 at 12:36 and 12:56 PM revealed: The Resident was hospitalized related to a low flow state which caused discoloration of the lower extremity, was evaluated by vascular and was readmitted to the facility. In response to Surveyors further inquiries, The MD reviewed the resident ' s discharge form for the hospitalization of 2/16-2/25/2021 and reported the Resident had testing in hospital as follows: Ultrasound of right lower extremity with finding of [CONDITION(S)] (DVT), and CTA (Computed tomography [MEDICATION(S)], a technique used to visualize arterial and venous vessels throughout the body) with finding of right lower lung field segmental pulmonary embolism (PE). The MD revealed he was made aware (date not recalled) that the resident had not received the anticoagulant during her admission prior to hospitalization and reported that factors of the low flow state and not receiving the anticoagulant contributed to the DVT and PE. Interviews were conducted with the facility Pharmacist on 6/28/2021 at 11:10AM and 11:54AM. The Pharmacist explained that at the time of Resident #1's initial admission (2/5-2/16/21), the facility's process on a resident's admission was that the Nurse and Prescriber/Physician would conduct the medication reconciliation. The Pharmacist reported that he/she became aware that Resident #1's anticoagulant was left off of the initial orders. The Pharmacist reported that he/she reviewed Resident #1's record and identified that for the 11 days between admission (2/5/2021) and discharge to the hospital (2/16/2021), Resident #1's anticoagulant had been omitted and not administered. The Pharmacist further explained that the omission of the anticoagulant for 11 days may possibly have caused Resident #1's DVT and PE. An interview was conducted on 6/28/2021 at 11:39AM with the Nursing Supervisor (NS #1) who explained that he/she was responsible to cover the entire facility. NS #1 stated that it was the responsibility of the admitting Nurse is to reconcile admission medication orders with the MD. It was the NS' responsibility to ensure that the medications are in the facility but not for checking the admitting medication against the hospital discharge medications. 483.45(f)(2)

Based on interview and record review during an Abbreviated Survey (#NY 660), the facility did not ensure the resident representative/emergency contact for 1 of 3 residents (Resident #1) reviewed for notification, was notified of a change in the resident's physical status and the associated treatments that were ordered. Findings include: Resident #1 was a [AGE] year-old admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS; a resident assessment tool) dated 10/20/2020 documents intact cognition indicated by a Brief Interview for Mental Status (BIMS) score of 15. The MDS documents that Resident #1 required extensive assistance for bed mobility, transfers, dressing, toilet use, hygiene, and bathing. Resident #1 also required setup and supervision during mealtime. Resident #1's representative was listed as Emergency Contact #1, Next of Kin and Friend in the profile section of the medical record. Review of the facility policy on Criteria for Notification of Change in Condition - updated 3/1/2020, states that it is necessary to inform a resident's representative when there is a significant change in the resident's physical status. It stated that the Licensed Practical Nurse (LPN) will notify the resident's representative of all changes in a resident's condition and/or clinical interventions including but not limited to infections, within a reasonable timeframe. Review of a Nurse's Note dated 12/18/2020 revealed that at 10:30AM, Resident #1 was noted with [CONDITION(S)], Oxygen Saturation (O2 Sat) of 69% in room air and that the Physician was made aware. Oxygen (O2) via nasal cannula at 2 liters per minute (Lpm) was applied. Resident #1 was noted with lethargy and jerky movements and sluggish to verbal as well as tactile stimuli. The physician ordered a Complete Blood Count (CBC), a Basic Metabolic Panel (BMP), a Brain Natriuretic Peptide (BNP), a Chest X-Ray (CXR), a Urinalysis (UA) and a Urine Culture and Sensitivity (UC&S) which were picked up at 12:00 PM. The resident was more alert and responsive. The Physician also ordered for Resident #1 to use a Bilevel Positive Airway Pressure ([CONDITION(S)]) with settings of 8/4 (Inspiratory Positive Airway Pressure / Expiratory Positive Airway Pressure) and increase to 10/5 after 2 hours. At 3:00PM, Resident #1 was noted to be alert, oriented and responsive with an O2 Sat of 96% on Oxygen at 2 Lpm. A Nurse's note dated 12/18/2020 documented an order to monitor Resident #1's O2 Sat every 4 hours for 24 hours secondary to [CONDITION(S)]. The note also documented the [CONDITION(S)] delivery and that the supervisor was aware. Physician's orders dated 12/18/2020 documented that Resident #1 is to have labs completed (CBC, BMP, BNP, urinalysis, urine culture and sensitivity), Stat Chest X-Ray, Oxygen saturation every shift, Oxygen saturation every 4 hours for 24 hours. The order further states that Resident #1 is to utilize the [CONDITION(S)] 8/4 then increase to 10/5 at bedtime for a minimum of 6 hours per night for 5 days, Oxygen at 2Lpm via nasal cannula as needed for shortness of breath/[CONDITION(S)], [MEDICATION(S)]-[MEDICATION(S)] Solution 3ml every 3 hours for Pneumonia, [MEDICATION(S)] 500 mg by mouth once on 12/19/2020 for Pneumonia, [MEDICATION(S)] 250 mg by mouth for 4 days start 12/20/2020 for Pneumonia. A Nurse's note dated 12/19/2020 documented Resident #1 with no distress noted, O2 Sat at 95% on O2 via nasal cannula at 2Lpm. The Physician ordered Intravenous (IV) [MEDICATION(S)] 100 mg every 12 hours for 5 days for Pneumonia. Physician's orders dated 12/20/2020 document [MEDICATION(S)] 100 mg via IV every 12 hours for 5 days for Pneumonia. A Nurse's note dated 12/20/2020 documented that Resident #1 is alert and oriented while able to make needs known. IV [MEDICATION(S)] was noted to be in progress for Pneumonia. [MEDICATION(S)] 250 mg once a day for 5 days was also documented to be in progress for Pneumonia with no adverse reactions noted. IV site to left forearm with no infiltration also noted. O2 Sat was at 98% on O2 via nasal cannula at 2 Lpm. A Physician's note dated 12/21/2020 documented that Resident #1 was seen for follow-up to an acute respiratory failure/[CONDITION(S)] episode on Friday (12/18/2020) with O2 desaturation. A Chest X-Ray conducted on 12/18/2020 found Resident #1 to have had left lower lobe Pneumonia. Resident #1 was markedly improved upon examination. Resident #1 was alert, however, remained confused; stating she has just come from the store, which is not at baseline for Resident #1. The Physician ordered for Resident #1 to continue nebulizer treatments every 3 hours and the [CONDITION(S)] was to be utilized at night. The Physician's note also detailed that the lab results were: urine negative for nitrites, CXR positive for acute Pneumonia, elevated White Blood Count (WBC) with left shift indicating acute infection, BNP markedly elevated, antibiotics initiated and continue to monitor closely. An interview was conducted on 2/22/2021 at 9:30AM with the Registered Nurse Unit Manager (RNUM). The RNUM stated she did not call the resident's representative when the resident experienced a change in condition on 12/18/2021 and the Physician placed new orders. An interview was conducted with the Director of Social Work (DSW) on 2/22/2021 at 11:22 AM. The DSW stated that the complainant is the Emergency Contact as listed in the resident's profile. The DSW stated that Resident #1 was alert, verbally responsive and stated that she wanted the complainant to be the primary contact. The DSW stated that Resident #1 completed her own Medical Orders for Life-Sustaining Treatment (MOLST) form with the DSW which specified Do Not Resuscitate (DNR), Do Not Intubate (DNI), no feeding tube and it was signed by the physician. On 2/22/2021 a telephone interview was conducted at 1:30PM with Registered Nurse (RN #1). RN #1 stated that she did not call Resident #1's representative when the resident started an antibiotic on 12/19/2020. She stated that the nurse who puts the order in usually calls the resident's representative. On 2/22/2021 at 1:46 PM an interview was conducted with the Registered Nurse Supervisor (RNS) who placed the [MEDICATION(S)] order into the Electronic Medical Record (EMR) on 12/19/2020. She stated that she does not remember if she called Resident #1's representative. She further stated that she usually does call families and resident representatives when there is a new order or a change in condition. On 4/21/2021 at 2:56PM, a follow up telephone interview was conducted with the RNS who placed the [MEDICATION(S)] order on 12/19/2020. The RNS stated that the procedure to notify resident representatives is to call them if the resident experiences any change in condition. The communication is to be documented on a Next of Kin template in the resident's Electronic Medical Record (EMR). The RNS stated she does not remember if she notified the resident's representative but if she had, she would have written a note in the resident's EMR. She stated that the nurse taking care of the resident is to call the resident's representative, not her. On 4/26/2021 at 12:41PM, a follow up telephone interview was conducted with Resident #1's representative. The representative stated that her expectations were that she would be notified of important happenings regarding Resident #1. She further stated that when Resident #1 was sick around 12/18/2020, she was not notified. The representative stated that the Social Worker and the Financial Coordinator were the only facility staff she spoke with during Resident #1's stay at the facility. The representative explained that there was one call from a nurse on the day that Resident #1 was transferred to the hospital. The resident's representative stated she received no other calls from a nurse, nurse practitioner, or physician regarding any changes in Resident #1's condition. 483.10(g)(14)(i)-(iv)

Based on record reviews and staff interviews conducted during an abbreviated and partial extended survey, the facility failed to ensure that staff were sufficiently trained to accurately identify residents' wishes regarding Cardio-Pulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) orders. Specifically, in January, 2011 the facility changed its policies and procedures regarding the CPR/DNR status of residents. Prior to January, 2011 a green face sheet in a resident's medical record indicated the resident elected to have CPR performed and a white face sheet indicated DNR (Do Not Resuscitate) status. After January, 2011, a white face sheet was used in all medical records regardless of CPR/DNR status. Facility staff were to rely, instead, on other indicators of CPR/DNR status, such as the presence or absence of green wrist bands and green dots on the medical chart. The failure to fully educate staff on these changes in policies and procedures resulted in confusion when staff were confronted with a resident (Resident #1) who was in [MEDICAL CONDITION] and had a white face sheet in her chart. The facility staff incorrectly determined the resident was a DNR, did not attempt to resuscitate her and she subsequently expired as a result of cardiopulmonary arrest. This resulted in actual harm to Resident #1 that is Immediate Jeopardy and Substandard Quality of Care, and the potential for serious harm to the health and safety of 53 residents who have CPR orders. Complaint ID Number: NY 320 The findings are: Resident #1 was an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the psychosocial assessment dated [DATE] documents the resident was oriented to person, place and time. A review of the Advanced Directive Information form dated [DATE] and signed by the Social Worker (SW) documents the resident elected to have CPR performed. A green band was applied to her wrist on that date to indicate her CPR status. A review of the social service progress notes dated [DATE] reveals that a green band was applied to the resident's wrist to indicate her CPR status and a second green band was taped to the inside of the medicine cabinet in the resident's bathroom. A review of the Policy and Procedure entitled "Emergency Procedure for Cardiopulmonary Resuscitation" dated [DATE] reveals all residents electing CPR will have a green face sheet in their medical record. A review of the Policy and Procedure entitled "Advanced Directives" dated [DATE] indicates that if a resident elects CPR status, two green wrist bands will be issued to the resident: one to be applied to the resident's wrist and the other to be taped inside the medicine cabinet of the resident's bathroom. In addition, a green dot will be placed on the spine of the resident's medical record to further indicate CPR status. The green face sheet formerly used to identify residents with CPR status, was eliminated and all face sheets were now white, regardless of the CPR/DNR status of the resident. The SW will be responsible for maintaining and updating a list, on green paper, of those residents with CPR status. This list will be distributed to all nursing units. If a resident refuses to wear the green wrist band, an asterisk will be placed by his/her name on the green CPR list and the green band will be taped to the inside of the medicine cabinet in the resident's bathroom. A review of a facility investigation report revealed that on [DATE], at approximately 6:45 AM, Resident #1 was observed by a Certified Nursing Assistant (CNA) having difficulty breathing. The CNA informed the ,[DATE] Registered Nurse (RN) of this change in the resident's status. The RN assessed the resident and found her oxygen saturation level to be 84% (low). The RN notified the RN Supervisor, who also assessed the resident. This second assessment revealed that the resident's oxygen level decreased to 76%. The RN Supervisor determined that [DATE] should be called. The RN Supervisor went to the nurses' station and informed the staff RN she was sending the resident out to the hospital. She asked the staff RN if the resident was a DNR. The Supervisor stated the staff RN informed her Resident #1 was a DNR. [DATE] was called at 7:10 AM. According to the facilty's investigation report, the RN Supervisor stated that when she checked the resident's chart she only looked at the face sheet, which was white, and concluded the resident was a DNR. The RN Supervisor returned to the resident's room and noted the resident had ceased breathing. CPR was not initiated because the RN Supervisor believed the resident was a DNR, based on the color of the face sheet in her medical chart. Emergency Medical Service and local police arrived and requested the DNR form. The RN Supervisor reviewed the chart and determined there was no DNR order in place. The on-call Physician was notified and pronounced the resident at 7:31 AM. During an interview with the Administrator and Acting Director of Nursing (DON) on [DATE] at 10:00 AM, they stated the policy for CPR/DNR was revised in September, 2010. The new policy called for the inclusion of a green face sheet in a resident's medical chart to indicate the resident elected CPR. At a later date, it was determined that the use of the green face sheet was confusing to staff when the resident's CPR/DNR status changes. In January, 2011 the facility reverted to its original practice of using only white face sheets in medical charts for all residents regardless of their CPR/DNR status. During an interview with the ,[DATE] RN Supervisor on [DATE] at 12:15 PM, she stated that when she assessed Resident #1, she found her short of breath with very poor skin color. She asked the staff RN if the resident was a DNR and was told "yes." The RN Supervisor further stated that she called [DATE] and then looked in the resident's medical chart, noting that the face sheet was white. She said it was her understanding that a white face sheet meant the resident was a DNR and a green sheet meant the resident was a CPR. She later realized there was no DNR order in place when she examined the resident's medical chart. The RN Supervisor stated she did not check to see if the resident was wearing a green wrist band or if there was a physician's orders [REDACTED]. The RN Supervisor further stated she was not aware that the facility had conducted inservice training in January, 2011 when the policies and procedures were changed and the green face sheet was no longer used to identify CPR status. Review of the inservice attendance sheets for Identification of Resident DNR/CPR Status dated [DATE], [DATE] and [DATE] revealed the RN Supervisor did not attend this inservice. During an interview with the DON and the Administrator on [DATE] at 10:00AM they stated they were unaware that all staff were not inserviced on the change in policy. The ,[DATE] Licensed Practical Nurse (LPN) #1 was interviewed on [DATE] at 2:30 PM. She stated she saw the green dot on the spine of Resident #1's medical chart, which she knew meant "go do CPR." LPN #1 stated she told this to the RN Supervisor, but the RN Supervisor told LPN #1 that this was incorrect because the resident had a white face sheet in her chart. The LPN stated she thought there may have been a change in the physician's orders [REDACTED]. The ,[DATE] LPN #2 was interviewed on [DATE] at 2:40 PM. She stated she went into the resident's room and noted the resident's oxygen and nebulizer were being utilized and the resident looked "ashen." She asked the staff RN if the resident was a DNR but the RN did not answer. The LPN #2 said she then went to the nurses' station to check the resident's chart. The RN Supervisor and LPN #1 were present. LPN #2 asked the RN Supervisor if the resident was a DNR and the RN Supervisor answered in the affirmative. LPN #1 said "no, she has a green dot that means to go do CPR." LPN #2 stated that, at that point, the RN Supervisor agreed that "green means to go and do CPR," but the resident had a white face sheet in her chart. LPN #2 stated they should have called a code. (a procedure to alert staff of an emergency situation). Staff interviews conducted on [DATE] and [DATE] revealed that staff were confused as to how to accurately determine a resident's CPR/DNR status and showed a lack of understanding of the current policies and procedures in place to identify a resident's advanced directive status. ? Two out of seven RNs incorrectly identified the face sheet as one of the primary means to determine a resident's advanced directive status. During an interview with the RN Supervisor on [DATE] at 12:15 PM she stated she saw the white face sheet on the resident's chart, which she believed indicated the resident was a DNR. During an interview with a ,[DATE] RN on [DATE] at 4:20 PM she stated a green face sheet in the resident's medical record means CPR. ? Three of out seven LPNs incorrectly identified the face sheet as one of the primary means to determine a resident's advanced directive status. During an interview on [DATE] at 3:45 PM, LPN #3 stated that a green wrist band on the resident indicates the resident is a DNR and a green face sheet in the chart also indicates the resident is a DNR; During an interview on [DATE] at 3:55 PM, LPN #4 stated that an asterisk on the green CPR sheet means "no CPR" and a green face sheet means CPR. During an interview on [DATE] at 4:05 PM, LPN #5 stated that a green face sheet in the medical chart means DNR. Review of the Certificate of Death dated [DATE] documents that Resident #1 expired at 7:31 AM of cardiopulmonary arrest. 415.12

Based on record review and interviews conducted during an abbreviated and partial extended survey, the Administrator failed to ensure that the facility was administered in a manner that enables resources to be used effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the facility Administrator failed to ensure that all nursing staff had been effectively and thoroughly educated on how to identify the advance directive status of residents after the facility changed its policies and procedures in January, 2011. The failure to adequately educate the nursing staff resulted in confusion when staff were confronted with a resident (Resident #1) who was in [MEDICAL CONDITION] and had a white face sheet in her chart. The facility staff incorrectly determined the resident was a DNR, did not attempt to resuscitate her and she subsequently expired as a result of cardiopulmonary arrest. . This resulted in actual harm to Resident #1 that is Immediate Jeopardy and the potential for serious harm to the health and safety of 53 residents who have CPR orders. See F-309 Complaint ID Number: NY 320 The findings are: A review of the facility ' s policy and procedure for CPR dated [DATE] documented that a green face sheet identified a resident as a CPR. On [DATE] the policy was changed and the green face sheet was eliminated. A green dot was placed on the spine of the resident's chart to indicate CPR. All green face sheets were to be removed from the charts and replaced with white face sheets for all residents regardless of CPR/DNR status. Green wrist bands are worn by all residents with CPR status and a list of CPR residents is maintained at each nursing station. An asterisk next to the name indicates the resident refuses to wear the wrist band and a second wrist band is taped in the medicine cabinet of the resident's bathroom. A review of the in-service sign in sheets revealed that not all staff were in-serviced regarding the change in policy and the elimination of the green face sheets to indicate CPR status. During staff interviews, 5 of 14 Licensed Nurses, including an RN Supervisor, were unable to demonstrate an accurate understanding of the facility's current policies and procedures related to identifying a resident's advanced directive status. Interviews revealed that nursing staff were confused as to the meaning of various indicators of a resident's status, including the color of the face sheet in the chart, the green resident wrist bands and the meaning of an asterisk next to a resident's name on the CPR/DNR sheet maintained at all nursing stations. The Administrator was interviewed on [DATE] at 10:30 AM. She stated that she became aware of the problem regarding staff confusion over identification of CPR status after Resident #1 expired on [DATE]. She stated she believed that all of the staff was in-serviced regarding the change in CPR policy in [DATE]. 415.26