Every finding on record at Bronx Gardens Rehabilitation and Nursing Center

Based on observation, record review, and interviews conducted during an abbreviated survey (Incident # 2646947), the facility did not ensure residents received adequate assistance consistent with resident's needs to prevent accidents. This was evident in one (1) out three (3) residents (Resident #1) sampled. Specifically, on 10/18/2025 at 8:30 AM, Resident #1, who required two (2) person assistance for bed mobility, fell off the bed onto the floor while Certified Nursing Assistant #1 was turning the resident by themself. Resident #1 was assessed with cuts and bleeding to their chin and forehead. Resident #1 was transferred to the hospital on [DATE] and was diagnosed with laceration to the left side of the head, left subdural hematoma (a collection of blood between the brain and its outermost covering), adjacent parenchymal hemorrhage (bleeding that occurs within the brains functional tissue), and hematoma to the left upper anterior scalp (a collection of blood between the skull and scalp). This resulted in actual harm that is not Immediate Jeopardy. The findings include:The facility's policy and procedure titled Activity of Daily Living dated 02/08/2023, documented that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. The facility policy also documented that appropriate care, and services will be provided for residents who are unable to carry out activity of daily livings independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance. Resident #1 was admitted to the facility with diagnoses including Alzheimer's dementia, bipolar disorder, and diabetes mellitus.The Minimum Data Set (a resident assessment tool) dated 09/16/2025, documented Resident #1's cognition was severely impaired. Resident #1 was totally dependent on two (2) staff for bed-mobility (assistance of two [2] or more helpers is required for resident to complete activity.)The Resident Nursing Instructions/Kardex dated 04/15/2021 documented Resident #1 required one (1) person for bathing (bed-bath), two (2) persons physical assist for dressing, two (2) persons physical assist for personal hygiene, and two (2) persons physical assists for bed mobility.A Fall care plan dated 05/31/2025 documented fall prevention measures remained in place. The Fall care plan, last updated on 09/20/2025, documented interventions to continue safety measures and fall precaution. An Activity of Daily Living care plan dated 09/04/2025 documented interventions for two (2) persons assist for personal hygiene, dressing, and bed mobility. A nursing note, by Registered Nurse Supervisor #1 dated 10/18/2025, documented Resident #1 was observed in prone position at bedside nearby window. Resident was assessed with cut on forehead, chin, and left posterior side of the head. Resident was confused with no changes in range of motion. Nurse Practitioner notified and ordered Resident #1 to be transferred to the hospital. Nurse Practitioner was informed of the incident and ordered for resident to be transfer to the hospital for computer tomography scan and further evaluation.A Witnessed Fall Report (Accident/Incident) and Summary of Report dated 10/18/2025 at 8:30 AM documented Resident #1 was observed in a prone position next to their bed that was in the lowest position. Resident #1 was assessed with visible injuries on their forehead, chin, and on the left posterior side of their head. Resident #1 was provided first aid, next of kin and Nurse Practitioner notified with orders to send resident to the hospital for computer tomography scan (medical imaging test used to diagnose injuries) and for further evaluation. The facility investigated the fall and concluded that there is no evidence to support alleged abuse, neglect, exploitation or mistreatment may have occurred. According to the facility's investigation, Certified Nursing Assistant #1 failed to follow Resident #1's plan of care which indicates a need for one (1) staff assist for incontinent care and two-person (2) staff assist for bed mobility. Certified Nursing Assistant #1 performed bed mobility alone, failing to adhere to the established plan of care. A care plan for Activity of Daily Living dated 09/04/2025, last reviewed 10/29/2025, documented facility interventions include Personal Hygiene two (2)persons physical assist, Toilet Use one (1)person physical assist, bathing two (2)person physical assist, dressing two (2)person physical assist, bed mobility two (2)person physical assists.An Actual Fall care plan dated 10/18/2025, last updated on 10/24/2025, documented Resident #1 was transferred to the hospital and was admitted on [DATE] status post fall with active bleeding. A computed tomography scan was done and showed stable subdural hemorrhage. The resident was readmitted back to the facility on [DATE]. Resident #1 was moved closer to nurse station, maintained with low bed, and the staff were re-in-service for level of assistance during activity of daily living. The Resident Nursing Instructions/Kardex dated 10/21/2025 documented Resident #1 required two (2)person physical assist for bathing, dressing, personal hygiene, and bed mobility. They required one (1)person physical assist during toilet use. During a telephone interview on 10/30/2025 at 12:11 PM, Certified Nursing Assistant #1 stated they worked on the 12:00 AM to 8:00 AM shift on 10/18/2025. Certified Nursing Assistant #1 stated Resident #1 was on their assignment. Certified Nursing Assistant #1 stated that while they were providing incontinence care to Resident #1, they turned the resident away from them and the resident fell to the floor. As they realized Resident #1 was sliding down, they attempted to hold the resident but was unsuccessful. Certified Nursing Assistant #1 stated they were providing the care without assistance. Certified Nursing Assistant #1 stated Resident #1 was laying on their right-side when they slid off the bed. Certified Nursing Assistant #1 stated the bed height was over their waist level at the time Resident #1 fell to the floor. Certified Nursing Assistant #1 stated they immediately called for help while they stayed with Resident #1. During a telephone interview on 11/05/2025 at 12:39 PM, Certified Nursing Assistant #2, stated they worked on the 12:00 AM to 8:00 AM shift on 10/18/2025. Certified Nursing Assistant #2 stated there were two (2) Certified Nursing Assistants on the unit for the 12:00 AM to 8:00 AM shift on 10/18/2025. Certified Nursing Assistant #2 stated they were in the room across from Resident #1's room providing care to another resident. Certified Nursing Assistant #2 stated they heard Certified Nursing Assistant #1 calling another aide from the morning shift to get the nurse. Certified Nursing Assistant #2 stated they went into Resident #1's room and they observed Resident #1 on the floor bleeding from the head. Certified Nursing Assistant #2 stated Certified Nursing Assistant #1 did not ask them for assistance with Resident #1 prior to providing care. Certified Nursing Assistant #2 stated in the past; Certified Nursing Assistant #1 had asked them for assistance with Resident #1.During a telephone interview on 11/04/2025 at 12:54 PM, Certified Nursing Assistant #3 stated they worked on the 8:00 AM to 4:00 PM shift on 10/18/2025. Certified Nursing Assistant #3 stated they do not recall the time, as they were in the hallway passing the morning breakfast trays, they heard Certified Nursing Assistant #1 screaming for the nurse. Certified Nursing Assistant #3 stated they stopped giving the breakfast trays and they went to get Licensed Practical Nurse #1, who was in the medication room. Certified Nursing Assistant #3 stated Licensed Practical Nurse #1 came out and went to Resident #1's room. Certified Nursing Assistant #3 state they went back to continue passing their breakfast tray. During a telephone interview on 11/05/2025 at 12:00 PM, Licensed Practical Nurse #1 stated they worked on the 8:00 AM to 4:00 PM shift on 10/18/2025, and Resident #1 was on their assignment. Licensed Practical Nurse #1 stated on 10/18/2025, they did their rounds at around 8:00 AM. Resident #1 was asleep with the bed in low position. Licensed Practical Nurse #1 stated they saw Resident #1's roommate privacy curtain closed with Certified Nursing Assistant #1 providing care to Resident #1's roommate. Licensed Practical Nurse #1 then went to the medication room to prep their medication cart. Licensed Practical Nurse #1 stated they heard Certified Nursing Assistant #3 screaming their name. Licensed Practical Nurse #1 stated they came out, and Certified Nursing Assistant #3 told them that Certified Nursing Assistant #1 was calling for help and that Resident #1 was on the floor. Licensed Practical Nurse #1 stated it was approximately 8:30 AM, when they went into Resident #1's room and observed Resident #1 laying in prone position with a pool of blood around their head near the window side. Licensed Practical Nurse #1 stated they immediately called Registered Nurse Supervisor #1. Licensed Practical Nurse #1 stated Registered Nurse Supervisor #1 responded to Resident #1's room. Licensed Practical Nurse #1 stated Registered Nurse Supervisor #1 told them to call 911. During a telephone interview on 11/13/2025 at 4:40 PM, Licensed Practical Nurse #2 stated they worked on the 12:00 AM to 8:00 AM shift on 10/18/2025. Licensed Practical Nurse #2 stated they were the assigned nurse to Resident #1. Licensed Practical Nurse #2 stated at around 8:00 AM Certified Nursing Assistant #1 told them they will be staying to provide care to Resident #1 because they did not finish their care. Licensed Practical Nurse #2 stated their shift ends at 8:00 AM and they left the unit after talking to Certified Nursing Assistant #1. Licensed Practical Nurse #2 stated Resident #1 required one (1)person assist with incontinence care and two (2)person assist for bed mobility and transfer. Licensed Practical Nurse #2 stated they were not on the unit when Resident #1 fell. During a telephone interview on 11/05/2025 at 9:26 AM with Registered Nurse Supervisor #1, they stated they worked on-the 8:00 AM to 4:00 PM shift on 10/18/2025. Registered Nurse Supervisor #1 stated they were in the office doing their staffing around 8:30 AM. Registered Nurse Supervisor #1 stated they received a call from Licensed Practical Nurse #1 on the unit that Resident #1 fell. Registered Nurse Supervisor #1 stated they immediately responded to Resident #1's room with Registered Nurse #1 (Treatment Nurse). Registered Nurse Supervisor #1 stated they observed Resident #1 on the floor in a prone position at the bedside near the window with active bleeding from head. Registered Nurse Supervisor #1 stated they tapped Resident #1 asking if they were okay with no response. Registered Nurse Supervisor #1 stated Resident #1 was turned from prone position to supine, Resident #1 was awake with both eyes closed. Registered Nurse Supervisor #1 stated they told Licensed Practical Nurse #1 to call 911. Registered Nurse Supervisor #1 stated upon assessment of Resident #1, they noted blood coming from both nostrils, the forehead, and the chin. Registered Nurse Supervisor #1 stated Registered Nurse #1 (Treatment Nurse) provided first aid to Resident. Registered Nurse Supervisor #1 stated they notified Medical Doctor #1, and they ordered for Resident to be transferred to the hospital for computer tomography scan. During an interview on 10/30/2025 at 12:44 PM, the Director of Nursing stated they were informed about the alleged incident by Registered Nurse Supervisor #1 by telephone. The Director of Nursing stated they were informed that Resident #1 was on the floor with obvious injury to the head and bleeding. Director of Nursing stated Resident #1 was assessed by Registered Nurse Supervisor #1 and noted with active bleeding from the forehead, the chin and the left posterior of the head. The Director of Nursing stated 911 was called, the Medical Doctor was notified with the order to transfer Resident to the hospital for further evaluation. The Director of Nursing stated they obtained a telephone interview from Certified Nursing Assistant #1 who said that they were providing care to the Resident #1, and they turned Resident #1 to the right side-lying while they were placing the fitted sheet and the incontinent brief when Resident #1 fell off the bed in prone position. The Director of Nursing stated they asked Certified Nursing Assistant #1 why they provided care by themself, and Certified Nursing Assistant #1 did not say their reason. The Director of Nursing stated Certified Nursing Assistant #1 was in denial that Resident #1 requires two (2)person assist with bed mobility. Director of Nursing stated Resident #1 requires one (1) person assist for incontinence care but two (2)person assist for bed mobility. Director of Nursing stated their investigation concluded that there was no reasonable cause to believe abuse, neglect, exploitation or mistreatment may have occurred. The Director of Nursing stated Certified Nursing Assistant #1 failed to follow Resident #1's plan of care, which indicates a need for one (1) staff assist for incontinence care and two (2)person staff assist for bed mobility. Director of Nursing Assistant stated Certified Nursing Assistant #1 performed bed mobility alone, failing to adhere to the established plan of care. During a telephone interview with Medical Doctor #1 on 12/04/2025 at 4:00 PM, they stated that on 10/18/2025 (unsure of time), they were notified by Nurse Practitioner #1 that Resident #1 had a fall and had sustained a head trauma. Medical Doctor #1 stated that they ordered for Resident #1 to be transferred to the hospital for medical evaluation. Medical Doctor #1 stated the alleged incident happened on a weekend and that Nurse Practitioner #1 was on duty at the time. Medical Doctor #1 stated that the accident could have been prevented. During a follow up interview on 12/09/2025 at 1:20 PM, Medical Doctor #1 clarified that what they meant when they said the fall could have been prevented, they stated that they were speaking in general terms, how some falls can be prevented. However, since they were not working at the facility at the time of the incident, they couldn't speak specifically. Medical Doctor #1 further stated they were not at the facility to assess the resident, but in general when a resident has a fall, they would go and assess the resident. However, in this case they did not assess this resident and could not determine if the fall could have been prevented. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, review of the weekend staffing and the Payroll Based Journal Staffing Data Report showed low weekend staffing. The findings include but are not limited to: The Payroll Based Journal Staffing Data Report for the 2nd quarter of 2025 (01/01/2025 - 03/31/2025) documented that low weekend staffing was triggered. The facility's policy and procedure titled Nursing Staffing, last reviewed on 02/2025, stated that the Staffing Coordinator maintains the master staffing schedule. Anyone needing a change in the schedule must place the request in writing and date it, then present it to the Staffing Coordinator to review and approve or deny the request. In the event of an unexpected illness or event, the employee must notify the facility a minimum of at least 2 hours before the shift begins. The employee must speak to the Staffing Coordinator, shift supervisor, charge nurse or Director of Nursing. The Facility Wide Assessment which was last updated on 03/03/2025 stated that the facility has 7 units, with 199 bed capacity, and each unit has a capacity of 33-34 beds. The 4th floor is where ventilator dependent residents are assigned; the 3rd floor has specialty beds short-term rehab and the 6th and 7th floors are dementia/behavioral units. During the week of the Recertification Survey , the units were full with only 2-3 empty beds facility-wide. The current par levels for nursing staff as documented in the Facility Assessment were as follows: Day Shift (8:00 AM - 4:00 PM): 2nd Floor (bed capacity of 33) : 2 Licensed Nurses, 4 Certified Nursing Assistants 3rd Floor (bed capacity of 33): 1 Licensed Nurses, 3 Certified Nursing Assistants 4th Floor (bed capacity of 33): 2 Licensed Nurses, 4 Certified Nursing Assistants 5th Floor (bed capacity of 33): 2 Licensed Nurses, 4 Certified Nursing Assistants 6th Floor (bed capacity of 33): 1 Licensed Nurses, 3 Certified Nursing Assistants 7th Floor (bed capacity of 34): 1 Licensed Nurses, 3 Certified Nursing Assistants Evening Shift (4:00 PM - 12:00 AM): 2nd Floor: 2 Licensed Nurses, 4 Certified Nursing Assistants 3rd Floor: 1 Licensed Nurses, 3 Certified Nursing Assistants 4th Floor: 1 Licensed Nurses, 4 Certified Nursing Assistants 5th Floor: 2 Licensed Nurses, 3 Certified Nursing Assistants 6th Floor: 1 Licensed Nurses, 3 Certified Nursing Assistants 7th Floor: 1 Licensed Nurses, 3 Certified Nursing Assistants Night Shift (11:45 PM - 8:00 AM): 2nd Floor: 2 Licensed Nurses, 3 Certified Nursing Assistants 3rd Floor: 1 Licensed Nurses, 2 Certified Nursing Assistants 4th Floor: 3 Licensed Nurses, 4 Certified Nursing Assistants 5th Floor: 1 Licensed Nurses, 2 Certified Nursing Assistants 6th Floor: 1 Licensed Nurses, 2 Certified Nursing Assistants 7th Floor: 1 Licensed Nurses, 2 Certified Nursing Assistants Review of the actual weekend staffing schedule from 01/01/2025 through 03/31/2025 documented the following: 01/04/2025 (Saturday): Day Shift: Shortage of 1 Certified Nursing Assistant in 2nd Floor and 3rd Floor 01/05/2025 (Sunday): Day Shift: Shortage of 1 Certified Nursing Assistant in 2nd Floor Evening Shift: Shortage of 2 Certified Nursing Assistants in 2nd Floor, 1 Certified Nursing Assistant in 3rd Floor, 1 Certified Nursing Assistant in 4th Floor, 1 in 5th Floor Night Shift: Shortage of 1 Certified Nursing Assistant in 4th Floor 01/11/2025 (Saturday): Day Shift: Shortage of 1 Certified Nursing Assistant in 2nd Floor Night Shift: Shortage of 1 Certified Nursing Assistant in 2nd Floor and 4th Floor 01/12/2025 (Sunday): Day Shift: Shortage of 1 Certified Nursing Assistant in 2nd Floor and 3rd Floor 01/18/2025 (Saturday): Evening Shift: Shortage of 1 Certified Nursing Assistant in 4th Floor Night Shift: Shortage of 1 Certified Nursing Assistant in 4th Floor 01/19/2025 (Sunday): Day Shift: Shortage of 1 Certified Nursing Assistant in 2nd Floor, 3rd Floor, 4th Floor, and 7th Floor; 2 Certified Nursing Assistant in 5th Floor 02/08/2025 (Saturday): Day Shift: Shortage of 1 Certified Nursing Assistant in 2nd Floor, 3rd Floor, 5th Floor, and 7th Floor. 02/09/2025 (Sunday): Day Shift: Shortage of 1 Certified Nursing Assistant in 2nd, 3rd, 5th, and 7th Floor Evening Shift: Shortage of 1 Certified Nursing Assistant in 3rd and 4th Floor 03/15/2025 (Saturday): Evening Shift: Shortage of 1 Certified Nursing Assistant in 3rd Floor 03/16/2025 (Sunday): Evening Shift: Shortage of 1 Certified Nursing Assistant ion 2nd, 3rd, 6th, and 7th Floor 03/23/2025 (Saturday): Day Shift: Shortage of 1 Certified Nursing Assistant in 2nd Floor, 3rd Floor, 4th Floor, and 7th Floor On 06/18/2025 at 11:22 AM, Resident #29 on the 3rd floor was interviewed and stated that it was common to have only two aides working on the unit during the day shift so that residents who wanted to get out of bed early had to wait for a long time. The resident stated, On the weekend, if you ring the call bell, you don't see or hear anybody, they are all too busy. On 06/20/2025 at 2:11 PM, Registered Nurse #5 was interviewed and stated that they work on the 7th floor on the day and evening shifts and frequently work with 2 aides, so that when one goes on a break, only one aide and the nurse are available to the residents. Registered Nurse #5 stated, How can I get the medication pass done when I have to have my eye constantly on the residents with behaviors and there is no one else to watch them? Who else will chase the residents trying to get into the exits? It is so stressful. On 06/23/2025 at 2:15 PM, the Staffing Coordinator was interviewed and stated that the facility has an 'all hands on deck' policy so that if any particular unit is working short, the assigned nurse and even the supervisor are expected to provide resident care. The Staffing Coordinator stated that when there is a staffing shortage, existing staff are asked to stay over, a call is placed to incoming staff to see if any can come in earlier, and a text message is sent out to all staff to notify every one of the opportunity to work. On 06/23/2025 at 4:20 PM, Certified Nursing Assistant #5 was interviewed and stated that they work on the ventilator unit on the evening shift and it's only God that helps us when we are short. Certified Nursing Assistant #5 stated that 4 aides are not enough for such a heavy care unit and that although the staff continues to try their best and they love what they do, it's not easy at all, you don't know the stress. On 06/23/2025 at 4:30 PM, Certified Nursing Assistant #6 was interviewed and stated that they work on the 3rd floor on the evening shift and today there are only 3 aides for 33 residents. Certified Nursing Assistant #6 stated, These residents are very demanding, and we are running from room to room. We try to take our breaks, but we have to put our residents first. On 06/24/2025 at 11:04 AM, the Director of Nursing was interviewed and stated that nursing staff in the facility is able to meet the needs of all the residents so there is no issue with staffing. On 06/24/2025 at 2:58 PM, the Administrator was interviewed and stated that the facility ensures that all the floors are covered and that in the event of last-minute callouts, the integrity of every unit is maintained. The Administrator stated that attrition is not a problem and that resumes are currently being received and could not explain why low weekend staffing had been flagged other than that the change from standard time to daylight savings time might have impacted staffing during the early spring. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Specifically, 1. The facility failed to ensure that a physician-ordered pulmonology consultation for 1 (Resident #41) of 3 residents was completed or appropriately followed up. 2. During wound care observation, Registered Nurse #4 did not apply the correct treatment ordered by the physician to treat Resident #116's arterial ulcers. Additionally, Resident #116 was not provided pressure relieving devices as ordered by the physician. This was evident for 1 (Resident #116) of 3 residents reviewed for pressure ulcer injury. The findings include: 1. The facility's policy titled Onsite/Offsite Consultant Services with a last reviewed date of 02/2025 stated Our facility may use as needed outside resources for consults to furnish specific services to residents and to the facility. Such personnel are employed on a consultant basis. The facility's policy titled Licensed Independent Practitioner Visits with a last reviewed date of 03/2025 documented that the intent of the policy is to have physician take an active role in supervising the care of the residents. The attending physician may refer or delegate to a specialist consistent to the qualification of that provider. The attending physician will write an order in the medical record and the order will be scheduled on the next scheduled visit day of the consultant or sooner if deemed necessary. Resident #41 was admitted with diagnoses that include Chronic Obstructive Pulmonary Disease, Anxiety Disorder, and Hypertension. The Quarterly Minimum Data Set, dated [DATE] documented Resident #41 had intact cognition and had shortness of breath when lying flat. The Comprehensive Care Plan for Respiratory Function and Oxygenation which was last revised on 03/20/2025 documented resident has anxiety, chronic obstructive pulmonary disease, asthma as evidenced by abnormal breath sounds, oxygen use/dependent, shortness of breath, anxious. The facility interventions included oxygen therapy, auscultate lung sounds, to administer medications, monitor respiratory status: oxygen saturation, lung sounds, cyanosis, use of accessory muscles, shortness of breath, oxygen therapy, and shortness of breath. The physician medication orders dated 06/05/2025 included montelukast 10 milligram tablet for Chronic Obstructive Pulmonary Disease; albuterol sulfate 2.5 milligram/3 milliliter (0.083 %) solution for nebulization for wheezing; budesonide-formoterol aerosol inhaler for Chronic Obstructive Pulmonary Disease; Ellipta 62.5 microgram/actuation powder for inhalation for Chronic Obstructive Pulmonary Disease. The Nursing Note dated 03/20/2025 documented staff responded to a call bell from Resident #41's bathroom at 2:05 AM and observed resident sitting on the toilet with shortness of breath and respiratory distress. The resident was unable to breath well and noted with changes in color complexion due to lack of oxygen. Oxygen was administered immediately. The nursing supervisor was called to the unit; vital signs were checked with oxygen saturation 100%. Nebulizer was administered and the respiratory therapist called to the unit. Covid test was done with negative result. Resident was stabilized and monitored throughout the tour. The Medical Note dated 03/25/2025 documented Resident #41 had history of chronic obstructive pulmonary disease, acute on chronic respiratory failure. The resident was seen and examined today to follow up on episode of shortness of breath and hypoxia over the weekend. The resident denied similar episode but reports worsening baseline breathing recently. The resident denied any cough or chest pain. Laboratory results, chest x-ray, and electrocardiogram results reviewed without significant changes. To start the resident on Albuterol nebulizer treatment and pulmonary consult. A physician's order for pulmonology consult was written on 03/25/2025 for worsening breathing. The Medical Note dated 04/01/2025 documented resident examined for reported shortness of breath this morning. Report feeling slightly tired and urinating slightly more frequent. Obtain tests, resident to continue oxygen via nasal cannula, with goal oxygen saturation >90%. The physician's order for continuous oxygen inhalation via nasal cannula at 3 liters per minute every shift was discontinued on 04/08/2025 and was changed to as needed. The Monthly Medical Note dated 04/17/2025 documented resident seen for monthly follow up on chronic medical conditions and review medications. Laboratory results, chest x-ray and electrocardiogram were done, and results reviewed without significant changes. Resident to start Albuterol nebulizer treatment and pulmonary consult. The Respiratory Therapy Note dated 05/22/2025 documented resident was seen for respiratory and orthopnea evaluation. Resident was experiencing shortness of breath, increased work of breathing and hypoxic when placed on supine position, indicating orthopnea present. Resident #41 was on oxygen via nasal cannula at 3 liters per minute for hypoxia, oxygen saturation was at 97%, and no respiratory distress noted, will continue monitoring the resident. The Monthly Medical Notes dated 05/28/2025 and 06/17/2025 documented resident with chronic obstructive pulmonary disease, stable and to continue inhalation, nebulization treatments and monitor for symptoms. The physician's order for pulmonology consultation, written on 03/25/2025 and was renewed on 06/05/2025, remained active in the medical record with no documented evidence of completion, cancellation, or reason for inaction. On 06/20/2025 at 12:40 PM, Resident #41 was observed lying in bed, receiving oxygen via nasal cannula connecting to wall oxygen regulator. The oxygen level setting was at 3 liters per minute. Resident #41 stated they are receiving medications and getting ongoing oxygen therapy for breathing problem. On 06/23/2025 at 01:22 PM, Medical Doctor #1 was interviewed and stated Resident #41 has chronic obstructive pulmonary disease and was seen in March 2025 when the nurse reported that resident was having respiratory distress. Medical Doctor #1 stated they evaluated the resident and ordered pulmonology consultation to evaluate resident's respiratory status. Medical Doctor #1 stated they do not recall reviewing the pulmonary consult report for Resident #41. Medical Doctor #1 stated they could not locate the report for the pulmonology consultation and that they did not see a message to review the evaluation in electronic medical record. On 06/24/2025 at 11:22 AM, the Medical Director was interviewed and stated the Medical Doctor is responsible for the residents overall plan of care and treatments. the medical doctor must monitor resident's condition regularly and adjust the course of treatment and interventions as appropriate. They stated the Medical Doctor may refer residents to a specialist and they must review the specialist recommendations. The Medical Director stated Resident #41 should have been evaluated by the pulmonologist in March when the consult has been ordered because the pulmonologist is in the facility once or twice a week. The Medical Director stated the Medical Doctor should follow up with the ordered consult and if it was not completed, it is their responsibility to address it and document the reason in the medical record. During an interview with the Director of Nursing on 06/24/2025 at 12:30 PM, they stated the facility has a staff coordinator who communicates with the medical specialists about residents needing consultation. They stated the coordinator has a list and documents their visit. The Director of Nursing stated the list of residents needing consultant services is reviewed monthly. They stated Resident #41 not being seen by the pulmonologist was an oversight. 2. The Facility Policy and Procedure titled Wound Care Treatment, reviewed 02/2025, documented that it is the policy of the facility to assess all residents and develop a plan of care that will prevent the development of wounds or provide for the healing of existing wounds. Resident wounds will have treatment performed as ordered by wound specialists. Resident #116 was admitted to the facility with diagnoses that included Cerebral Vascular Accident and Respiratory failure. The Minimum Data Set assessment dated [DATE] documented that Resident #116 required an Invasive Mechanical Ventilator. Resident had severely impaired cognition, totally dependent for all care needs and mobility, was at risk of developing pressure ulcers, and had current Moisture Associated Skin Damage that required applications of nonsurgical dressings, ointments/medications and pressure reducing devices for the bed and chair. A skin integrity care plan of the eschar covered arterial wound of the right Heel, effective 04/24/2025, documented that the wound developed in-house on 04/25/2025 with an Intervention to apply local treatments as ordered. A skin integrity care plan of the eschar covered arterial wound of the right, lateral Lower Leg, effective date 04/25/2025, documented that the wound developed in-house on 04/25/2025 with an Intervention to apply local treatments as ordered and to maintain turning and positioning schedule every 2 hours as recommended. A Physician's Order dated 04/25/2025 documented a treatment order to cleanse the right heel with normal saline, apply betadine ointment and cover with a dry protective dressing daily. A Physician's Order dated 05/16/2025 documented a treatment order to cleanse the right lateral lower leg with normal saline, apply Medi honey gel to the granulation, apply betadine to the eschar and cover with a dry protective dressing daily. A Physician's Order dated 06/08/2025, documented adaptive assistive devices: Bilateral heel floats to be worn at all times when in bed and to provide air mattress. During an observation with Registered Nurse #7 on 06/18/2025 at 9:50AM, Resident #116 was in bed without an air mattress. There was no heel floaters applied or any offloading of the feet. On 06/18/2025 at 10:00AM, a wound treatment observation for Resident #116 was conducted with Registered Nurse #4, who was the Wound Care Nurse. Registered Nurse #4 was observed to have applied Medi Honey gel to the entire right, lateral lower leg full thickness arterial Wound. Registered Nurse #4 was also observed to have applied a treatment of Medi Honey gel to the right heel eschar covered arterial wound. Registered Nurse #4 failed to administer the correct treatment as ordered by the physician. On 06/18/2025 at 10:28 AM, Registered Nurse #7, who was the unit manager, was interviewed and stated Resident #116 had no air mattress and no heel floaters. They stated they should have ordered the heel floaters and the air mattress when it was ordered by the physician. Registered Nurse #7 stated they should have reviewed the physician orders and performed rounds to ensure that the orders were implemented. On 06/18/2025 at 10:50 AM, Registered Nurse #4 was interviewed and stated they should have reviewed the physician orders before performing the wound treatment for Resident #116. They stated they applied Medi honey gel to the right lower leg and right heel eschar instead of applying betadine to the eschar. On 06/18/2025 at 11:17 AM, the Director of Nursing was interviewed and stated, the air mattress and heel floaters should have been provided to Resident #116. They stated this should have been carried out by the Wound Care Nurse or the nursing supervisor. They stated that the wound care nurse should have followed the correct treatment as ordered by the physician. 10 NYCRR 415.12

Based on observation, record review, and interview the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 1 (2nd floor) of 2 units. Specifically, residents' rooms in 2nd floor had mismatched paints and the dirty linen room had chipped paint. The findings include: The facility's undated policy titled Environmental Services documented it is the policy of the facility to provide homelike environment for all residents. On 06/16/2025 to 06/23/2025 between 10:00 AM and 2:00 PM, the following observations were made on the 2nd Floor: a.) Rooms 201, 202 and 203 had mismatched paint on the walls. b.) The paints were chipped on the clean and dirty linen room doors. The Maintenance and Housekeeping logs showed no evidence of repair requested for the above concerns. On 06/24/2025 at 11:23 AM, the Director of Maintenance was interviewed stated they are busy on the other units and have not been able to address the mismatched and chipped paint on the 2nd Floor. On 06/24/2025 at 12:20 PM, the Administrator was interviewed stated they were notified today of the residents' rooms with mismatched chipped paints, and it will be taken care of immediately. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews, the facility failed to provide appropriate respiratory equipment at the resident's bedside for immediate access , such as for unplanned extubation. This was evident for 1 (Resident # 89) out of 3 residents reviewed for Respiratory Care out of 38 sampled residents. Specifically, Resident #89, who had a tracheostomy, was observed without an ambu bag immediately available at bedside. The findings include: The undated facility's policy titled Tracheostomy Tube Change Procedure stated that ambu bag shall be readily available for emergency use for residents who has tracheostomy. Resident #89 had diagnoses that included Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia and Chronic Lung Disease. The annual Minimum Data Set assessment dated [DATE] documented that Resident #89 had severed impaired cognition and received tracheostomy care and suctioning while residing in the facility. The interdisciplinary Care Plan on respiratory / tracheostomy was initiated on 08/13/2024 and was last reviewed on 06/02/2025. The care plan documented that Resident #89 had a potential for respiratory distress related to signs of respiratory infections. It documented that Resident # 89 is provided with suctioning and related tracheostomy care. On 06/16/20 25 at 11:02 AM, Resident #89 was observed in bed. Resident had tracheostomy and was receiving 40% oxygen via tracheostomy collar. There was no ambu bag observed at bedside. On 06/17/25 11:20 AM Respiratory Therapist #1 was interviewed stated that ambu bag must be readily available at bedside for residents with tracheostomy. They stated they did not realize that Resident #89 had no ambu bag available at bedside. On 06/18/2025 at 9:16 AM, Registered Nurse #9 was interviewed stated Respiratory Therapists are responsible in ensuring all emergency equipment is at bedside including ambu bag. They stated they did not notice there was no ambu bag at Resident #89's bedside. On 06/24/2025 at 11:26 AM, the Director of Respiratory Department was interviewed stated an ambu bag must be readily available at bedside for residents with tracheostomy in case of emergency. 10 NYCRR 415.12(k)(5)(4)

Based on observation, record review, and interviews, the facility failed to ensure food was stored in accordance with professional standards for food service safety. This was evident for 1 of 3 kitchen refrigerators that were observed during the initial kitchen tour. Specifically, the kitchen snack/nourishment refrigerator was observed to contain staff food. The findings include: The facility's policy and procedure titled Food Storage reviewed on 02/2025 documented that it is the policy of the facility that food brought into the facility ensures proper storage and infection control practices. Staff food is not to be stored in patient food refrigerators. On 06/16/2025 at 9:34 AM, an initial kitchen observation was conducted with the Food Service Director. The Snack/ Nourishment Refrigerator was observed with a plastic bag that contained an unlabeled and undated quart sized bowl of spaghetti and meatballs. On 06/16/2025 at 9:39 AM, the Food Service Director was interviewed and stated that the undated, unlabeled quart sized bowl of spaghetti and meatballs that was observed in the snack/nourishment refrigerator was determined to be one of the dietary staff's food brought in from the outside that should not have been stored in the resident food refrigerator. The Food Service Director also stated that all refrigerators are inspected daily for prepared food items that are to be discarded within 72 hours. The Food Service Director further stated that the dietary staff was recently reeducated on proper food storage practices that includes the restriction of storing personal food items in resident refrigerators. 10 NYCRR 415.14(h)

Based on record review and interviews conducted during an Abbreviated Survey (NY00368174), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result in serious bodily injury, to the administrator of the facility of the facility and to other officials (including to the State Agency and adult protective services where state law provides for judications in long term care facilities). This was evident for one (1) out of four (4) (Resident #2) residents sampled. Specifically, on 01/03/2025 at around 10:00 AM Resident #2 reported to the Physician Assistant that Resident #3 grabbed their hands then held them by the throat on the morning of 01/02/2025 while they were in their room. The facility investigated the alleged allegation of abuse, but did not report it to New York State Department of Health. The findings are: The facility policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property was reviewed on 01/2025. The policy states that the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation do not involve abuse or result in serious bodily injury, to administrator of the facility and to other officials (including to State Survey Agency and adult protective services where state law provides for judication in long-term care facility) in accordance with State Law through established procedures, local enforcement will be notified of any reasonable suspicious of a crime against a resident in the facility. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Resident #2 was admitted to the facility on with diagnoses including Intellectual Disability, Seizure Disorder, and Depression. The Minimum Data Set, an assessment tool, dated 10/26/2024 documented Resident #2 had severe cognitive impairment. Resident #3 was admitted to the facility with diagnoses including Alzheimer's Disease and Parkinson's Disease. The Minimum Data Set, dated [DATE] documented Resident #3 had severe cognitive impairment. The facility's Investigation Report Summary dated 01/03/2025 documented Resident #2 verbalized to the Physician Assistant that another resident grabbed them by the hand and then held their throat. The facility suspected the alleged perpetrator was Resident #3 who was the only resident that wandered on the unit's hallway. Staff interviews revealed that Resident #3 wanders in the hallway and likes to touch staff and other residents by holding their hand with no harm. An investigation was immediately initiated by interviewing staff members who worked on the morning shift and other residents on the unit. Resident #2's roommate, who was alert and oriented times four reported that no one entered their room, and they did not hear anything going on in the room. Camera review showed Resident #3 ambulating in the hallway. Resident #2 and Resident #3 never made any physical contact and Resident #3 never entered Resident #2's room. They determined within two hours that abuse did not occur. The investigation also concluded that the alleged incident did not happen. During an interview with the Physician Assistant on 01/11/2024 at 11:00 AM, they stated Resident #2 reported to them on 01/03/2025 at 10:00 AM that Resident #3 grabbed their hands and held them by their throat on the morning of 01/02/2025 (not time identified). Resident #2 was unable to identify the alleged resident. The Physician Assistant stated they immediately performed a full body assessment and Resident #2 did not have any redness or bruising at their throat or on their body. The Physician Assistant stated Resident #2 reported that they did not report the incident to anyone, but they are now reporting it to them. The Physician Assistant stated they immediately reported the allegation to the unit Registered Nurse Manager #2 on 01/03/24 at 10:30 AM. During an interview with the Director of Nursing on 03/14/2025 at 11:58 PM, they stated they immediately (does not recall time) informed the Administrator of the alleged incident. The Director of Nursing stated they reviewed the investigation with the Administrator and the Medical Director, and they all decided not to report the alleged incident to New York State Department of Health because the incident did not occur. The Director of Nursing stated they were able to rule out abuse based on camera review, physical assessment of Resident #2, staff members interviews, and other residents including Resident #2's roommate. The Director of Nursing stated they were able to determine within two hours that the alleged incident did not happen. The Director of Nursing stated the nurse managers, and the supervisors are mandated to report allegations of abuse to the New York State Department of Health. During an interview with the Administrator on 03/12/2025 at 11:58 AM, they stated they immediately reviewed the camera for the alleged incident of 01/03/2025 (do not recall the time). The Administrator stated Resident #3 was observed wandering in the hallway and Resident #2 was sitting in their wheelchair. There was no direct physical contact between both residents and Resident #3 never entered Resident #2's room. The Administrator stated that they investigated the allegation quickly and was able to conclude that the alleged incident was unsubstantiated. The Administrator stated they did not report to the New York State Department of Heath as per their facility's policy, because the alleged incident did not happen and there was nothing to report. The Administrator stated the allegation of Resident-to-Resident altercation or physical abuse are reportable to law enforcement based the regulation. The Administrator stated they did not save a copy of the camera recording. 10 NYCRR 415.4 (b)

Based on observation, record review and interviews, conducted during the Recertification survey from 4/17/23 - 4/24/23, the facility did not ensure that garbage was properly disposed. Specifically, the garbage receptacle was not covered while garbage was being transported to the dumpster area. This was evident during the Kitchen facility task. The findings are: The Nutrition Service policy titled Waste Disposal effective date 1/2019, review date 2/2023, states to handle dispose waste efficiently, safely and in a sanitary manner, containers must be non-porous, durable, rust free, and chip free with a cover. The procedure states that all garbage containers must be covered with a tight-fitting lid or cover. Trash bags are sealed and transported to the garbage dumpster. On 4/21/23 at 11:08 AM, Dietary Aide (DA) #1 was observed doing trash disposal. DA #1 took the lid off of the large garbage receptacle housed just outside of the kitchen. DA #1 then transported the uncovered garbage receptacle through a long tunnel that leads into the adjacent hospital where the dumpster area was located. The tunnel exited to a floor in the hospital where there were offices and people walking in the hallway. An interview was immediately conducted with DA #1 at the dumpster area who stated that they removed the garbage receptacle lid because they did not want to deal with the lid by the dumpster. The Food Service Director was present throughout the tour. On 4/21/23 at 2:38 PM during an interview the Food Service Director (FSD) stated that the policy is that garbage should be covered, and that DA #1 was nervous during the observation. The FSD also stated that DA #1 had received in-service on 2/14/23 on garbage disposal. 415.14 (h)

Based on observation, interviews and record review conducted during the Recertification and Abbreviated survey (NY00305634) from 4/17/23 through 4/24/23, the facility did not ensure that person-centered care plans (CCP) with measurable goals, time frames and interventions were developed to address a resident's concerns. This was evident for 1 (Resident #88) of 5 residents reviewed for accidents out of a sample of 38 residents. Specifically, a CCP was not developed to address Resident #88's left tibia fracture. The findings are: A facility policy titled Resident Assessment with effective date 8/21/2019, last reviewed 8/10/22 documented a comprehensive assessment includes development of the comprehensive care plan. Resident #88 has a diagnosis of respiratory failure/ventilator dependence and quadriplegia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #88 was severely cognitively impaired, and the resident had no fractures. The facility Incident Investigation initiated 11/1/22 and completed on 11/4/22 documented Resident #88 was found lying on the right side of their bed and was transferred to the hospital for further evaluation. The Hospital Discharge Summary dated 11/15/22 documented Resident #88 was diagnosed with a left tibia fracture. Nursing Note dated 11/15/22 documented Resident #88 was readmitted to the facility with a left leg splint with non-removable bandage/ace wrap. An Occupational Therapy Note dated 11/17/22 documented Resident #88 was non-weightbearing on the left lower extremity due to a tibia/fibula fracture. A Physical Therapy Note dated 11/19/22 documented a left lower leg splint as a precaution for Resident #88. An X-ray Report dated 12/6/22 documented Resident #88 had left leg pain and an x-ray of the left tibia and fibula showed evidence of impacted angulated fractures involving the medial lateral malleoli. There was no documented evidence a CCP related to a new diagnosis of left tibia fracture upon readmission from the hospital on 11/15/22. An interview was conducted on 04/24/23 at 10:52 AM with Registered Nurse Manager (RNM) #1, who stated CCPs are initiated by the RNM or Nurse Supervisor. The RN assessing the resident for readmission is responsible for ensuring the CCPs are reactivated and new CCPs added. Resident #88 did not have a CCP related to their left tibia fracture because it was an oversight. On 4/24/23 at 11:48 am, an interview was conducted with the Director of Nursing Services (DNS) who stated if a resident has a new fracture with splint in place upon readmission from the hospital, they should have a CCP initiated related to the fracture. 415.11 (c)(1)

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% or greater. Specifically, the Registered Nurse did not administer Vitamin B12 as ordered, and the resident's first name on the medication labels for two medications administered was incorrect (Resident #490). This resulted in a total medication error rate of 11.54 %. This was observed during the Medication Administration task. The findings are: The facility Policy and Procedure titled Medication/Treatment Administration last revised on 2/10/23 documented residents shall receive all medications as ordered by the physician. Nurses will safely administer medications with knowledge of the therapeutic effects, contraindications, side effects and drug interactions that may occur. The nurse will review the Medication Administration Record and pour all medications for the individual resident observing the five rights of medication administration that included the right dose, and record administration after the resident has taken the medication or treatment. On 04/20/23 at 11:13 AM, during the Medication Administration observation task, Registered Nurse (RN) #5 administered the following medications to Resident #490: Acetaminophen 325mg 2 tablets by mouth, Buspirone 300mg 1 tablet by mouth, [NAME] 150mg 1 tablet by mouth, Aripiprazole 2mg 1.5 tablets by mouth and Vitamin D5 1000 Units 1 tablet by mouth. During review of Resident #490's physician orders, it was noted that Vitamin B-12 1 tablet by mouth was scheduled to be given at 10:00 AM, and was not observed being administered to the resident during the medication administration observation. In addition, it was observed that the name printed on the medication label for [NAME] and Aripiprazole listed Resident's 490 first name incorrectly. The RN #5 was immediately interviewed about the issue and stated that they will stop passing medications and review the information. On 04/20/23 at 02:11 PM, an interview was conducted with RN #5 who stated that they had received proper training on the five rights of medication administration, and have been giving medications to this residents for a while. RN #5 also stated that they were aware of the resident's correct first name, and the two medication labels had a different first name. RN #5 further stated they could not explain how the discrepancy with the label, but that the order was correct. In reference to the Vitamin B 12, RN #5 stated the medication was ordered last night but had not been delivered. On 04/20/23 at 02:30 PM, an interview was conducted with RN #6 who stated that Administration was in contact with the pharmacy to address the discrepancy regarding Resident #490's name. RN #6 stated that the resident's date of birth is correct, and that there was no resident currently in the facility carrying the incorrect name placed on Resident #490's medication. RN #6 further stated that it was discovered that Resident #490's name was printed incorrectly upon admission and had been corrected by pharmacy, but the medication with the incorrect name had not been removed from the cart. RN #6 stated that Vitamin B 12 is a stock medication and they did not know why the nurses did not request it. RN #6 then stated that Vitamin B 12 is provided by a medical supply company and currently the facility did not have it in stock. On 04/24/23 at 03:20PM, an interview was conducted with the Director of Nursing (DON) who stated that the issue with Resident #490 had been identified on admission, corrected within five days, and those medications should have been removed. The DON also stated that competencies and inservice are done for medication administration. 415.12(m)(1)

Based on observations and interviews conducted during the Recertification survey from 4/17/23 to 4/24/23, the facility did not ensure the safe and secure storage of medications in accordance with currently accepted professional standards. Specifically, Lumigan 0.01 % eye drops and Brimonidine 0.2 %-Timolol 0.5 % eye drops were kept in the resident's bedside table. This was observed during the Medication Administration Task. (Resident #490) The findings are: The facility policy titled Medication Storage dated 2/10/23 documented the facility will store medications in a manner that maintains the integrity of the product, ensure the safety of the residents. The policy also documented that the medications are to be stored and locked in medication rooms, providing security standards. Resident #490 was admitted to the facility with diagnoses which included Bipolar disorder and Vitamin B12 deficiency anemia. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #490 had a moderately impaired cognition and required limited assistance when performing personal hygiene. On 04/20/23 at 11:13 AM, during Medication Administration observation for Resident #490, Lumigan 0.01 % eye drops and Brimonidine 0.2 %-Timolol 0.5 % eye drops were observed in the resident's bedside table. Resident #490 was immediately interviewed and stated they were given the medications by a nurse, and they administer these two medications themselves. Resident #490 also stated that no one gave them instructions on how to use the medications and they had been using them before coming to the nursing home. The Physician orders dated 04/05/2023 documented Lumigan 0.01 % eye drops give 1 drop by ophthalmic route once daily in the evening. Please allow 5 minutes before administering other medication. Brimonidine 0.2 %-Timolol 0.5 % eye drops instill 1 drop by ophthalmic route every 12 hours one drop in each eye. The Medication Administration Record dated April 2023 contained documentation that the medication had been administered by the nurses. On 04/20/23 at 02:11 PM, an interview was conducted with Registered Nurse (RN) #5 who stated that they were not aware that Resident #490 had eye drops stored in their bedside table. RN #5 also stated that the resident does not receive eye drops on their shift as it is given at 7 AM. RN #5 further stated that they did not know if Resident #490 was able to self-administer medication. On 04/20/23 at 02:30 PM, an interview was conducted with RN #6 (Manager) who stated that no resident on the unit had been cleared to self-administer medication. RN #6 also stated that the medications are not supposed to be kept in the room unless the resident has a care plan for self-administration of medication. RN #6 further stated that review of the medical record contained no evidence that resident had been evaluated for self-administration of any medication. On 04/20/23 at 03:30 PM, an interview was conducted with the Director of Nursing who stated that Resident #490 had not been assessed for medication self-administration, and therefore the resident should not be storing medications in their bedside table drawer. The DON also stated that all medications should be stored in the medication room and medication carts. 415.18(e)(1-4)

Based on observations, record reviews and interviews, conducted during the recertification and abbreviated survey (# NY00303337, NY00305634) from 4/13/23 to 4/24/23, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation result in serious bodily injury. This was evident for 2 (Residents #145 and #88) of 5 residents reviewed for Accidents of 38 total sampled residents. Specifically, 1.) the facility did not report Resident #145's left hip fracture from an unwitnessed fall to the NYSDOH within 2 hours of occurrence, and 2) the facility did not report Resident #88's unwitnessed fall resulting in hospitalization and left tibia fracture to the NYSDOH within 2 hours of occurrence. The findings are: The facility policy titled Reporting Requirements to Local State & Federal Authority last revised 10/2022, documented incidents resulting in serious bodily injury must be reported within two hours after forming the suspicion. All other incidents must be reported within 24 hours. 1) Resident #145 had diagnoses of cerebrovascular accident (CVA) and chronic obstructive pulmonary disease. A Nursing Note dated 9/19/22 documented Resident #145 was found on the floor of their room in a seated position and was unable to provide an account of what occurred. An x-ray was ordered and completed 9/19/22 and found Resident #145 had a right femoral neck hip fracture with resultant angular deformity. Resident #145 was transferred and admitted to the hospital. The facility Incident Investigation dated 9/19/22 documented Resident #145 had an unwitnessed fall and suspected right femur neck fracture that was reported to the state agency as required by regulation. The X-ray Report dated 09/19/22 documented Resident #145 had an acute fracture of the right femoral neck with resulting angular deformity. The hospital Patient Review Instrument (PRI) dated 9/27/22 documented Resident #145 had a new diagnosis of right femoral neck fracture due to a fall. A Nursing Note dated 9/28/22 documented Resident #145 was readmitted from the hospital, and it was determined that infection was present in the right hip joint. Resident #145 did not sustain a right femoral neck fracture as reported on 9/19/22. There was no documented evidence the facility reported Resident #145's unwitnessed fall and suspicion of right femoral neck fracture to the NYSDOH within 2 hours of occurrence. On 04/24/23 at 02:17 PM, an interview conducted with the Director of Nursing (DON) who stated the original suspicion that Resident #145 sustained an acute femoral neck fracture was incorrect. The hospital records did not confirm that Resident #145's fracture occurred, and this is the reason the DON did not consider Resident #145's injury reportable to the NYSDOH. On 04/24/23 at 02:40 PM, the Medical Doctor was interviewed and stated the hospital suspected there was suspected osteomyelitis around Resident #145's joint there was no clear finding re: the presence of a femoral neck fracture. 45349 2) Resident #88 has a diagnosis of respiratory failure/ventilator dependence and quadriplegia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #88 was severely cognitively impaired, and the resident had no fractures. The facility Incident Investigation initiated 11/1/22 and completed on 11/4/22 documented Resident #88 was found lying on the floor on the right side of their bed, sustained a bump to the head, and was transferred to the hospital for further evaluation. The conclusion documented Resident #145 could have fallen off the bed causing the bump on their head. The Hospital Discharge Summary dated 11/15/22 documented Resident #88 had a trauma workup and was positive for left distal tibia and fibula fracture of indeterminate age. A Nursing Note dated 11/15/22 documented Resident #88 was readmitted to the facility with a left leg splint with non-removable bandage/ace wrap. An Occupational Therapy Note dated 11/17/22 documented Resident #88 was non-weightbearing on the left lower extremity due to a tibia/fibula fracture. An X-ray Report dated 12/6/22 documented Resident #88 had left leg pain and an x-ray of the left tibia and fibula showed evidence of impacted angulated fractures involving the medial lateral malleoli. There was no documented evidence the facility reported Resident #88's unwitnessed fall and left tibia fracture to the NYSDOH within 2 hours of occurrence. On 4/21/23 at 1:51 PM and 4/24/23 at 10:39 AM, an interview was conducted with the Director of Nursing (DON) who stated if a fall is unwitnessed and there is an injury, the facility investigates first. If there is suspicion of abuse or if there is a major injury, the facility reports the incident to the NYSDOH within 2 hours. Resident #88 was transferred to the hospital with a hematoma. The DON was unable to attribute Resident #88's fracture to their unwitnessed fall and the incident did not need to be reported to the NYSDOH. 415.4(b)(2)

Based on record review and staff interview conducted during Abbreviated Survey (NY 315), the facility did not ensure that the policies and procedures to investigate and report allegations of abuse in accordance with federal and state regulations. Specifically, 1) Facility staff failed to report an allegation of Abuse and to the facility Administrator or designee and New York State Department of Health (NYSDOH) within 2hrs of being notified of the allegations. 2) The facility did not initiate an investigation until 6 days after and did not take actions to prevent further potential abuse while the investigation was in progress. This was evident for 1 of 3 residents investigated for allegations of Abuse (Resident #1). The findings are: CFR §483.12(c)(1) instructs: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, 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 or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility's Policy and Procedure titled Resident Abuse Neglect and Mistreatment, Resident Exploitation Identification and Prevention Program dated 1/2021 documented that any alleged violation involving neglect, abuse, mistreatment, or exploitation including injuries of an unknown source must be reported to the Abuse, Neglect, and Mistreatment committee within 24 hours of their occurrence. An immediate investigation must be made, and findings reported to the Administrator within 24 hours of the occurrence of such incident and to the New York Department of Health (NYSDOH) Hotline. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 10/06/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 10/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). A review of the Complaint/Recommendation Form dated 11/30/2021 revealed that on 11/24/2021 the Recreation Director reported that Resident #1 stated that (name redacted) Registered Nurse (RN) #1 was rough while the nurse was changing his/her diaper. The employee that was identified was interviewed and denied providing care to Resident #1. Staff on the unit was interviewed and denied rough handling. The facility concluded that abuse did not occur. Review of the nurses' progress notes dated from 11/24/2021 to 11/30/2021, revealed there was no documented evidence that Resident #1 was assessed for injury after an allegation of rough handling. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was ordered nine days after the allegation was reported on 11/24/2021. A Medical Doctor (MD) Note dated 12/02/2021 at 2:32 PM revealed that the MD evaluated Resident #1 due to alleged rough handling by staff. Unremarkable Physical Exam. No bruises or swelling were noted. Resident #1 was referred to Psych for counseling. This MD's progress note was written nine days (11/24/2021) after the incident was reported and while surveyor was onsite investigating the allegation on 12/02/2021. During an interview on 12/01/2021 at 4:00 PM, the Complainant stated that during an onsite visit on 11/24/2021 Resident #1 was crying hysterically stating that the nurse was rough during care. The Complainant stated that Resident #1 told him/her (complainant) that the nurse worked every Monday. The complainant stated that he/she called a recreation person via phone to come to Resident #1's room and he/she told the recreation person that a nurse was rough with the resident. The complainant stated that the recreation person said that he/she would follow up with the allegation. During an interview on 12/02/2021 at 10:30 AM, Resident #1 stated that RN #1 was rude and rough during the care. Resident #1 stated that RN #1 was angry and wanted to do everything fast and that Resident #1 told RN #1 that he/she did not like that. Resident #1 stated that RN #1 was good for a week and two days ago RN #1 was rough again. Resident #1 also stated that RN #1 removed his/her gown roughly. Resident #1 stated that he/she complained to the chief nurse and to the Social Worker two days ago (11/30/2021) and that RN #1 has not returned to the room. During an interview on 12/02/2021 at 12:40 PM, the RN Unit Manager stated that all abuse concerns should be reported immediately, and the Medical Doctor notified. The RN Unit Manger also stated that the RN should have assessed the resident and document in the resident's medical record. During an interview on 12/02/2021 at 4:00 PM, the Director of Nursing Service (DNS) stated that he/she does not recall the Director of Recreation (DR) notifying him/her of the abuse on 11/24/2021. The DNS stated that he/she recalled the DR mentioning the incident on 11/30/2021 after the morning report. The DNS also stated that Resident #1 was not assessed after the allegation was made and that the assessed would be done today 12/02/2021. The DNS stated that the incident was not reported to NYSDOH and that the allegation would be reported to NYSDOH today 12/02/2021. During an interview on 12/03/2021 at 3:35 PM, the RD stated that on 11/24/2021, the complainant asked if RN #1 was working (name redacted) on the unit because Resident #1 stated that the nurse was rough during care. The DR stated that he/she was not familiar with the name of the nurse and stated that he/she went downstairs and reported the allegation of rough handling to the DNS (on 11/24/2021). 415.4(b)

Based on interviews and records review conducted during an Abbreviated Survey (NY 315), the facility did not ensure that an alleged violation involving Abuse was reported to the New York State Department of Health (NYSDOH) within two hours after the allegation was made. Specifically, the facility failed to report allegations of Abuse to the facility Administrator or designee and NYSDOH within 2hrs after being notified of the allegations. This was evident for 1 of 3 residents (Resident #1). The findings are: The facility's Policy and Procedure titled Resident Abuse Neglect and Mistreatment, Resident Exploitation Identification and Prevention Program dated 1/2021 documented that any alleged violation involving neglect, abuse, mistreatment, or exploitation including injuries of an unknown source must be reported to the Abuse, Neglect, and Mistreatment committee within 24 hours of their occurrence. An immediate investigation must be made, and findings reported to the Administrator within 24 hours of the occurrence of such incident and to the New York Department of Health (NYSDOH) Hotline. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 10/06/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 10/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). The Complaint/Recommendation Form dated 11/30/2021 revealed that on 11/24/2021 the Recreation Director stated that Resident #1 reported that (name redacted) Registered Nurse (RN) #1 was rough while he/she was changing the resident diaper. The nurse was identified and denied providing care to Resident #1. Staff members on the unit were interviewed and denied rough handling of Resident #1. The facility concluded that abuse did not occur. There was no documented evidence that the incident was reported to NYDOH or to the Administrator or designee timely. There was no documented evidence that the MD was notified timely. The incident was reported to NYSDOH while surveyor was onsite 12/02/2021. A Medical Doctor (MD) Note dated 12/02/2021 at 2:32 PM revealed that the MD evaluated Resident #1 due to an alleged rough handling by staff. Unremarkable Physical Exam. No bruises or swelling noted. The resident was referred to Psych for counseling. The assessment and progress note were done while surveyor was onsite conducting the investigation. During an interview on 12/01/2021 at 4:00 PM, the complainant stated that during an onsite visit on 11/24/2021, Resident #1 was crying hysterically stating that a nurse was rough with him/her during care. The complainant stated that Resident #1 said that the nurse worked every Monday. The complainant reported that he/she called a recreation person via phone to come to the resident's room and that he/she reported to the recreation person that a nurse was rough with Resident #1. The recreation person said that he/she would follow up. During an interview on 12/02/2021 at 10:30 AM, Resident #1 stated one nurse, RN #1 was rude and rough during the care. Resident #1 stated RN #1 was angry and wanted to do everything fast and that he/she told RN #1 that he/she did not like it. Resident #1 stated that RN #1 was good for a week and two days ago (11/30/2021) RN #1 was rough again. Resident #1 stated that RN #1 removed his/her gown roughly. Resident #1 stated that he/she complained to the chief nurse and to the Social Worker two days ago and that RN #1 has not been back to the room. During an interview on 12/02/2021 at 4:00 PM, the Director of Nursing Service (DNS) stated that he/she does not recall the Director of Recreation (DR) notifying him/her of the abuse on 11/24/2021. The DNS stated that he/she recalled the DR mentioning the incident on 11/30/2021 after the morning report. The DNS stated that the incident was not reported to NYSDOH and that the allegation would be reported to NYSDOH today 12/02/2021. During an interview on 12/03/2021 at 3:35 PM, the RD stated that on 11/24/2021, the complainant asked if RN #1 was working (name redacted) on the unit because Resident #1 stated that the nurse was rough during care. The DR stated that he/she was not familiar with the name of the nurse and stated that he/she went downstairs and reported the allegation of rough handling to the DNS. 415.4(b)(1)(i)

Based on observation, interviews and record review conducted during an Abbreviated Survey (NY 315), the facility did not ensure that an allegation involving abuse was thoroughly investigated. This was evident for 1 of 3 residents sampled (Resident #1). Specifically, on 11/24/2021, Resident #1 family member reported that Resident #1 complained that a nurse handled him/her roughly during care. 1) The facility did not initiate an investigation until six days after and did not take immediate actions to protect Resident #1. 2) Resident #1 was not assessed by the Registered Nurse (RN) or the Medical Doctor (MD). 3) There was no documentation in Resident #1's medical record. The findings are: The facility's Policy and Procedure titled Resident Abuse Neglect and Mistreatment, Resident Exploitation Identification and Prevention Program dated 1/2021 documented that any alleged violation involving neglect, abuse, mistreatment, or exploitation including injuries of an unknown source must be reported to the Abuse, Neglect, and Mistreatment committee within 24 hours of their occurrence. An immediate investigation must be made, and findings reported to the Administrator within 24 hours of the occurrence of such incident and to the New York Department of Health (NYSDOH) Hotline. This document also revealed that upon receiving reports of physical or sexual abuse, the charge nurse shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 10/06/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 10/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Record review of the progress notes revealed there was no documented evidence that Resident #1 was assessed by a nurse or physician. The Complaint/Recommendation Form dated 11/30/2021 revealed that on 11/24/2021 the Recreation Director reported that Resident #1 said that (name redacted) Registered Nurse (RN) #1 was rough while, the nurse was changing him/her diaper. The nurse was identified and denied providing care to Resident #1. Staff members on the unit were interviewed and denied rough handling of Resident #1. The facility concluded that abuse did not occur. Record review revealed that the Physician ordered Psychology and Psychiatry Consults on 12/02/2021, nine days after the complainant reported the allegation of rough handing. A Medical Doctor Note dated 12/02/2021 at 2:32 PM revealed that the MD evaluated Resident #1 due to alleged rough handling by staff. Unremarkable Physical Exam. No bruises or swelling were noted. This note was written during the surveyor's onsite investigation on 12/02/2021. During an interview on 12/01/2021 at 4:00 PM, the complainant stated that during an onsite visit on 11/24/2021, Resident #1 was crying hysterically stating that a nurse was rough with him/her during care. The complainant stated that Resident #1 said that the nurse worked every Monday. The complainant reported that he/she called a recreation person via phone to come to the resident's room and that he/she reported to the recreation person that a nurse was rough with Resident #1. The recreation person said that he/she would follow up. During an interview on 12/02/2021 at 10:30 AM, Resident #1 stated one nurse, RN #1 was rude and rough during the care. Resident #1 stated RN #1 was angry and wanted to do everything fast and that he/she told RN #1 that he/she did not like it. Resident #1 stated that RN #1 was good for a week and two days ago (11/30/2021) RN #1 was rough again. Resident #1 also stated that RN #1 removed his/her gown roughly. Resident #1 stated that he/she complained to the chief nurse and to the Social Worker two days ago and that RN #1 has not been back to the room. During an interview on 12/02/2021 at 4:00 PM, the DNS stated that the investigation was completed when and that abuse did not occur. The DNS stated that the Director of Recreation (DR) said that he/she told him/her (DNS) about the allegation on 11/24/2021. The DNS stated that he/she does not recall the DR informing him/her (DNS) of the allegation. The DNS stated that he/she remembered that the DR mentioned after the morning report on 11/30/2021, that Resident #1's family member told him/her (DR) that Resident #1 was complaining about a person (named redacted). The DNS stated that they needed to identify the staff because the RNs don't usually provide care to residents. The DNS stated that Resident #1 was not assessed after the complaint of rough handling was made. During an interview on 12/03/2021 at 3:35 PM, the RD stated that on 11/24/2021, the complainant asked if RN #1 was working (name redacted) on the unit because Resident #1 stated that the nurse was rough during care. The DR stated that he/she was not familiar with the name of the nurse and stated that he/she went downstairs and reported the allegation of rough handling to the DNS. During the follow-up interview on 12/31/2021 at 11:00 AM, the DNS stated that when an allegation of abuse is made, staff should identify the alleged perpetrator and remove the person from the schedule pending investigation outcome. The DNS stated that an investigation should have been conducted immediately and statements collected from staff. The DNS also stated, staff should have been re-in-serviced on abuse. 415.4(b)(ii)

Based on interviews and records review conducted during an Abbreviated Survey (NY 315), the facility did not ensure that a resident's medical record contain the resident's assessment. This was evident for 1 of 3 residents sampled (Resident #1). Specifically, on 11/24/2021, Resident #1's family member reported that a staff member rough handled Resident #1 during care. Resident #1 was not immediately assessed and there was no documentation in Resident #1's medical record. The Medical Doctor assessed and wrote a note in Resident #1's medical record on 12/02/2021 while New York State Department of Health surveyor was onsite conducting the investigation. The findings are: The facility's Policy and Procedure titled Resident Abuse Neglect and Mistreatment, Resident Exploitation Identification and Prevention Program dated 1/2021 documented that upon receiving reports of physical or sexual abuse, the charge nurse shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 10/06/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 10/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). A review of the Complaint/Recommendation Form dated 11/30/2021 revealed that on 11/24/2021 the Recreation Director reported that Resident #1 stated that (name redacted) Registered Nurse (RN) #1 was rough while the nurse was changing his/her diaper. The employee that was identified was interviewed and denied providing care to Resident #1. Staff on the unit was interviewed and denied rough handling. The facility concluded that abuse did not occur. Review of the nurses' progress notes dated from 11/24/2021 to 11/30/2021, revealed there was no documented evidence that Resident #1 was assessed for injury after an allegation of rough handling. A Medical Doctor Note dated 12/02/2021 at 2:32 PM revealed that the MD evaluated Resident #1 and documented in Resident #1's medical record nine days after the allegation of rough handling by staff and while surveyor was onsite conducting the investigation. During an interview on 12/01/2021 at 4:00 PM, the complainant stated that during an onsite visit on 11/24/2021, Resident #1 was crying hysterically stating that a nurse was rough with him/her during care. The complainant stated that Resident #1 said that the nurse worked every Monday. The complainant reported that he/she called a recreation person via phone to come to the resident's room and that he/she reported to the recreation person that a nurse was rough with Resident #1. The recreation person said that he/she would follow up. During an interview on 12/02/2021 at 10:30 AM, Resident #1 stated that one nurse, RN #1, was rude and rough during the care. Resident #1 stated that RN #1 was angry and wanted to do everything fast and that he/she told RN #1 that he/she did not like it. Resident #1 stated that RN #1 was good for a week and two days ago (11/30/2021) RN #1 was rough again. Resident #1 stated that RN #1 also removed his/her gown roughly. Resident #1 stated that he/she complained to the chief nurse and to the Social Worker two days ago and that RN #1 has not been back to the room. During an interview on 12/02/2021 at 4:00 PM, the DNS stated that the Director of Recreation (DR) said that he/she told him/her (DNS) about the allegation on 11/24/2021. The DNS stated that he/she does not recall the DR informing him/her (DNS) of the allegation. The DNS stated that he/she remembered that the DR mentioned after the morning report on 11/30/2021, that Resident #1's family member told him/her (DR) that Resident #1 was complaining about a person (named redacted). The DNS stated that they needed to identify the staff because the RNs don't usually provide care to residents. The DNS stated that Resident #1 was not assessed after the complaint of rough handling was made. During an interview on 12/03/2021 at 3:35 PM, the RD stated that on 11/24/2021, the complainant asked if RN #1 was working (name redacted) on the unit because Resident #1 stated that the nurse was rough during care. The DR stated that he/she was not familiar with the name of the nurse and stated that he/she went downstairs and reported the allegation of rough handling to the DNS. 415.22(a) (1-4)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, the resident's dental status reflected on the Minimum Data Set (MDS) did not include broken and carious teeth. This was evident of 1 out of 1 resident reviewed for Dental Care out of a sample of 38 residents (Resident #435). The finding is: The facility policy titled Processing of Consultation policy dated 8/22/10 and last reviewed dated 9/18/20 documented under the section titled policy All residents will receive consultant services per written request of attending Physician. These services are provided in the Nursing Home except in circumstances where needed equipment to render service is not available in the Nursing Home. The facility policy titled MDS 3.0 dated 12/94 and last reviewed 3/2020 documented under the section titled Purpose: the facility shall conduct initial and periodical assessments that are accurate, standardized and reproducible for all its residents. The policy further states The Resident assessment Instrument (RAI) is the catalyst to the accurate assessment of each nursing home resident. Resident #435 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Set Data ((MDS) dated [DATE] documented the resident was cognitively intact. The MDS further documented the resident had no dental concerns in the section for Oral/Dental Status (Section L). The Comprehensive Care Plan titled Dental Care: Actual Impairment dated 7/30/2020 documented the resident had some teeth. On 09/28/20 at 10:54 AM, the resident was observed sitting in wheelchair in their room. Some of the resident's teeth were protruding from the mouth, and they had brown and dark areas. The resident denied any pain. On 09/29/20 at 08:54 AM, the resident was interviewed and denied any issues with eating regular food or mouth pain. The Speech Therapy Progress note dated 7/31/2020 documented a speech and swallow assessment was completed. The note documented the resident lacked dentition but was able to masticate regular foods without difficulty. A Dietary progress note dated 7/31/2020 documented the resident was seen for an initial assessment. The dietician documented the resident had poor dentition but denied chewing and swallowing issues. The Nursing Admission/Re-assessment dated [DATE] documented under the section titled Review of systems with subgroup heading General oral screening' documented Dentitions (has some /all teeth). A Medical progress note dated 8/3/2020 documented the resident had periodontal disease and a Dental consult was ordered. The Dental consult dated 8/4/2020 documented no dentures or removable bridge, some/all-natural teeth lost. Does not have or did not use dentures or partial plate. Broken loose or carious teeth. Oral hygiene fair. No mouth odor. Patient functional with present oral condition, soft tissue within normal limits. New admission soft tissue within normal limits, mostly edentulous with remaining teeth in poor condition. On 09/29/20 at 11:36 AM an interview was conducted with Staff # 1, Clinical Reimbursement Manager (CRM). The CRM stated she is an MDS Assessor and completes MDS assessments for the facility. CRM stated before she completes the MDS, she sees the resident and reviews the chart, which includes reading all the progress notes and consults. The dental consult was not in the resident's chart at the time of review. It had not been uploaded by the Medical Clerk yet. Even though the consult was completed 8/4/2020, it was not uploaded until 8/13/2020. The CRM stated she assumed the dental consult would be completed within the first 30 days of admission, and she did not think that the consult would be completed within the first eight days. The CRM stated she did not ask any staff if the consult was completed, and she based her completion of the MDS on the Nursing Admission Assessment. She saw the resident before completing the MDS and was aware the resident had crooked teeth, but she did not ask the resident to open their mouth, therefore she was unable to see if the resident had cavities inside the mouth. The CRM added the MDS will be modified to include the resident has broken or carious teeth. On 09/29/20 at 11:54 AM, an interview was conducted with Staff #2, Director of Clinical Reimbursement (DCR). The DCR stated she is responsible for monitoring the MDS Assessors and ensuring the assessments are completely accurately and on time. The DCR stated all the assessors sign-off on the completed books to confirm that they are accurate. The DCR stated she monitors the Assessors for completion and accuracy by reviewing the assessment and sign-off once the MDS book is completed. The DCR stated the MDS Assessor reported the dental consult was uploaded late in the system on 8/13/20 after the resident's ARD, so the consult was not available for review. The DCR added the MDS will be modified to reflect the resident status. On 09/30/20 at 11:12 AM, an interview was conducted with the Director of Nursing (DON). DON stated MDS assessment accuracy has not been identified as an issue previously. When completing the dental section, MDS assessors look for dental consults. Consultants have a list of residents to see, and when they complete the assessment it is handed off to the clerk in the nursing office within a day or two for filing and upload. 415.11(b)

Based on observation, interview and record review, during a COVID-19 Focused Infection Control Survey and Complaint Investigation Survey (#NY 611) conducted on 7/17/20, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not follow the cohorting requirements documented in the Dear Administrator Letter (DAL) dated April 29, 2020, for 3 (#s 2, 6 and 7) of 6 units reviewed. The findings are. The Executive Order 202.11 dated March 27,2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The New York State Department of Health DAL dated April 29, 2020 documents the following: As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful separate outpatients in individual facilities. The facility policy and procedure titled, COVID-19 (Health Screening, Surveillance, Restrictions on Visitation, PPE's, Hand Hygiene, Resident Discharge/Admissions, Education, Administrative and Engineering Controls) last revised 05/11/2020 documented the facility has identified three categories for the delivery of care amidst the COVID-19 pandemic. They are confirmed COVID-19 positive as evident by testing, presumed COVID-19 positive as evident by COVID-19 related symptoms and asymptomatic/non-COVID-19. As such, no COVID-19 positive residents will be cohorted with presumed COVID-19 positive or asymptomatic/non-COVID-19 and/or vice versa . On 07/17/2020 the Director of Nursing (DON) reported a census of 178 residents, a bed capacity of 199 beds and there were no residents identified as either COVID-19 positive or presumed positive. The DON also reported residents #1, #2, #3, #4, and #5 had never been tested for COVID-19. During an observation on 7/17/20 from 04:00 PM to 04:08 PM, the following was revealed: 1) Resident #1 and #6 resided in a 2 bed room on unit #2. As per the DON's statement, Resident #1 was not tested for COVID-19 and status was unknown. Resident #6 tested negative for COVID-19 on 06/02/2020. 2) Resident #3 and #8 resided in a 2 bed room on unit #6. As per the DON's statement Resident #3 was not tested for COVID-19 and status was unknown. Resident #8 tested negative for COVID-19 on 06/01/2020. 3) Resident #4 and #9 resided in a 2 bed room on unit #7. A progress note dated 06/10/2020 documented Resident #4 refused to be tested for COVID-19 and COVID-19 status was unknown. Resident #9 tested negative for COVID-19 on 06/24/2020. During interview on 07/17/2020 at 1:35 PM, the DON stated the Department of Health completed COVID-19 testing for the facility on 05/22/2020. At that time all residents were tested except for 5 residents who refused to be tested (Resident #1, #2, #3, #4, #5). The DON also stated she was aware of guidelines sent by the Department of Health (DOH) regarding cohorting. The DON stated the 5 untested residents have been asymptomatic and are monitored every shift by checking their vitals including temperature, blood pressure, and oxygen saturation as are all other residents. The DON stated the 5 untested residents and the 5 roommates were not offered room changes. On 07/17/2020 at 03:45 PM and at 04:10 PM, an interview was conducted with the Administrator. The Administrator stated he was aware of DOH guidelines regarding cohorting however, the facility did not have the capacity to move those 5 residents to another room due to census and room availability. 415.19(b)(1)

Based on observation and staff interviews during the recertification survey, the facility did not ensure that internal temperatures of hot and cold foods were maintained at an acceptable range. Specifically, Observations of tray line service were conducted. The temperatures of yogurts and sandwiches were measured above the acceptable temperature range. Also, after the retherm (reheating) process which is conducted at the docking station the hot and cold foods were not maintained at acceptable temperature ranges. This deficient practice had the potential to affect the whole facility. The findings are: The Hospital's policy and procedure titled HACCP (Hazards Critical Control Points) Plan with a revision date of 12/10/2014 documented: Time control sensitive (TCS) foods held cold for service must be at 40 degrees F or below. Monitoring: Temperatures of food held cold for service will be randomly checked every 2 hours with a calibrated Thermometer. 1) An observation was done on 8/15/18 at 2:30 PM with the patient service manager at the tray line service during the kitchen observation. The kitchen is located in the Hospital building. The following was observed: Yogurt was 48 degrees F, Chicken salad sandwich was 42 degrees F,Turkey and cheese sandwich was 44 degrees F, Ham and cheese sandwich was 49 degrees F. The state agency surveyor (SA) and patient service manager checked the temperatures of the sandwiches in the refrigerator. The temperature of the refrigerator was 36 degrees F. The sandwich in the refrigerator was 44 degrees F. The Patient Service Manager was interviewed on 8/15/18 at approximately 3:00 PM. She stated that they just finished prepping the sandwiches at 2:00 PM and then they put them in the refrigerator and sent them over to the nursing home where they serve it and/or put it in the refrigerator in the pantry. The SA interviewed the Interim General Manager on 8/15/18 at 3:45 PM. The SA asked how do they ensure that the cold food temperatures are maintained at appropriate temperatures. The General Manager (GM) stated that it is not their practice to check the temperature of the sandwiches. In regards to the yogurt temperatures, the GM stated that the yogurts should have been taken directly from the refrigerator and placed on the tray line. The SA stated that the observation was that the food service worker took the yogurts out of the milk crates, which were not in the refrigerator and then placed them on the tray line. The GM responded that the yogurts are supposed to be kept in the three compartment refrigerator and taken from there to be placed on the tray line. Another interview was conducted with the the GM on 8/16/18 at 10:50 AM. The SA asked what TCS stands for? The GM stated TCS is cold food with mayonnaise and meats. 2) Another observation was done in the kitchen on 8/16/18 at 11:55 AM. This observation was made at the docking station where the trucks where the hot foods are heated and cold foods are cooled. These trucks are then sent to the Nursing Home for food service distribution. The following food trays were measured: On Nursing Home Unit 5: Puree Rice was 117 degrees F.<BR/(NAME)chicken was 118 degrees F Carrots were 149.5 F On Nursing Home Unit 3: Meat loaf was 93.2 degrees F Beans was 140 degrees F Rice was 149.7 degrees F Yogurt was 42 degrees F Juice was 45 degrees F Milk was 51.7 degrees F The Interim General Manager (GM) was interviewed right after the observation and stated the hot foods should be above 140 degrees F. The GM explained the facility's and hospital's procedure for when the hot food does not reach temperature. He stated that they reheat hot food items in a microwave located on the resident unit and the patient service manager would recheck the temperatures on the floor. The GM stated that for cold foods we ideally want the temperature between 40 to 45 degrees F or below. They would bring the cold food items on the unit and would either put it in the pantry refrigerator or serve it because it would not be out more than a half an hour to point of service. 415.14

Based on observation, record reviews, and interviews, during the recertification survey the facility did not ensure that the resident (res) received adequate supervision to prevent accidents. Specifically, Resident #107 was assessed as a high risk for falls. A CCP (Comprehensive Care Plan) was developed with interventions that included thirty minute monitoring of resident to prevent falls. Despite the CCP plan for frequent monitoring of the resident. The resident's medical record documented a pattern of 6 recorded incidents of unwitnessed falls by the resident. The facility did not provide evidence of adequate monitoring or supervision to prevent resident's 6 recorded incidents of unwitnessed falls. This was evident for 1 out of 5 residents reviewed for accidents within a total sample of 39. The number of unwitnessed falls indicates a pattern of the facility failing to monitor this resident to prevent accidents. The findings is: Resident # 107 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/15/18 at 10:16 AM the res was observed lying in low bed with constant motion of her right leg. She was again seen at 03:47 PM in bed fully dressed with the Registered Nurse (RN) and the Certified Nursing Assistant (CNA) at her bedside encouraging her to rise for floor ambulation. She refused by standing for a few seconds and pulling away, letting go of the rollator and placing herself back in bed in a lying position. The Minimum Data Set (MDS) assessment dated [DATE] documented that the res is non-verbal and is severely impaired in cognition and daily decision making. The MDS further documented that the resident exhibits mood of restlessness that occurs 7 to 11 days. She requires total assist of two people for bed mobility, transfer, toilet use and bathing, and has no limitations in upper and lower extremities. The assessment identified that the res had 1 fall with no injury and received Physical Therapy (PT) 5 days per week that started on 5/24/18. The Comprehensive Care Plan (CCP) with revision dates of 6/18, 6/19, 6/23, 6/27, 7/4, and 7/13/18 documented a problem of actual falls with interventions of every 30 minute visual monitoring for safety, low bed, floor mats, anticipate toileting Q2 - 4 hours, anticipate resident's needs and meet them in a timely manner, maintain in a highly visible area when out of bed on her geri chair, engage in therapeutic recreation activities during all programing hours for diversion and mental stimulation, provided Pommel chair cushion, and PT restorative program for strengthening and training. The Accident/Incident (A/I) reports documented the following: 1) On 6/18/18 at 2:15 PM observed sitting on side of bed on floor mat, very confused, non amb (ambulatory), no injuries, with corrective action of psychiatry re-evaluation, and bed on its lowest level. 2) On 6/19/18 at 4:55 PM at side of bed observed sitting on the floor, unwitnessed, slightly confused, non amb, no injuries, with corrective action of q 30 minutes monitoring. 3) On 6/23/18 at 2:35 AM in the res room fall, very confused, non amb, identified as high risk, no injuries, with corrective actions of anticipate needs & assist in timely manner. 4) On 6/28/18 at 11:30 AM in front of nsg station, unwitnessed, fall, very confused, non verbal, non ambulatory, identified as high risk, no injuries, with corrective action of placed on [MEDICATION NAME] 50mg daily at bedtime for 3 days, on q30 min monitoring, and placed in highly visible area. 5) On 7/4/18 at 1:45 AM in the res room, observed sitting on the floor mat next to bed, unwitnessed, very confused, non ambulatory, no injuries, with corrective action of continue safety measures in careplan, continue to monitor closely. 6) On 7/12/18 at 2:20 PM the res was observed on the floor in the hallway, fall unwitnessed, slightly confused, non ambulatory (non amb), identified as high risk for for A/I, no injuries with preventive action taken of every (q) 30 min monitoring, floor mat, placed in highly visible area, bed in lowest position. The 24 hour report dated 8/16/18 12:40 AM documented that the res was observed with 3 episodes of restlessness. The half hourly visual check form dated 6/19/18 thru 8/16/18 documented that the res predominantly remains in bed more times than being out of bed. The Fall risk evaluations dated 6/18/18, 6/19/18, 6/23/18, 6/26/18, and 7/4/18, documented that the res is assessed as being disoriented at all times, and high risk with total score from range of 14 to 18. The activity assessment dated [DATE] documented that the res is a passive participant with no behaviors, and prefers attending small group and 1:1, and very important to her to listen to music, fresh air, and attend religious activities, On 08/15/18 at 04:13 PM CNA #1 who performs rehab was interviewed. CNA #1 stated that he comes to ambulate res daily and sometimes she does not want to get oob (out of bed) & has to be encouraged a lot before cooperating sometimes. She stands and takes a few steps, however will sit in w/c at times and will try to get up on her own. On 08/16/18 at 10:33 AM the CNA who has been providing daily care to the resident since (MONTH) 1, (YEAR) (CNA#2) was interviewed. CNA#2 stated the res is on 30 minutes monitoring which is documented in the 30 min 24 hour monitoring book. The res has behavior of resisting to get out of bed, so they don't force her to come out of room. They try to get her out of the room and if she comes out staff keeps her at the nursing station or in recreation. CNA #2 state that the res has had no falls in August. She said she was told she had falls before. CNA# further stated that the res continues to do a lot of movement on her own in bed. On 08/16/18 at 12:43 PM the recreation director was interviewed and stated that the regularly assigned staff for the unit went on trip today. The SA asked the question of res involvement in terms of recreation attendance for monitoring as specified in the CCP and she responded and stated Initially res was more agitated & now more calmer as per daughter she was very active in church, family, everything she did was involving church. we did everything for her regarding church activities such as reading bible to res & prayers. She does not attend the off unit activities due to asleep in morning when checked & no attempts made to awaken her. She is usually in her room or in the dining area. She had several falls in the beginning & interventions were to keep her in close proximity during recreation & all the activities she attended is documented in the recreation binder kept in the office. The director proceeded to get the binder and returned stating binder unable to be located at this time. On 08/16/18 at 01:12 PM the RN #1 was interviewed and stated that whenever there is a fall the CCP is updated by the supervisor on duty at the time of the fall. The CCP should be revised by all disciplines . I was the manager on duty on 6/26/18 when res fell . I assessed res MD informed & res sustained no injury . I updated CCP to reflect the fall & intervention of GNP notified and [MEDICATION NAME] ordered. On 08/16/18 at 01:31 PM the RN #2 was interviewed and stated that she is familiar with res who had multiple falls. when have fall process is to initiate investigation, inform fame/doctor, interview staff & I completed the 6/18/18 incident in which she was re-evaluated by psych & low bed was initiated. sup on duty who initiated the A/I report revises the CCP. the res was assessed as high risk from admission & needs were anticipated with call bell within reach to make needs known, although res not able to use due to cog impairment. The res was seen by psych initially on 6/1/18. On 6/18/18 res fell and fell again on 6/19/18. At this time new interventions of 30 min monitoring were implemented. On 6/23/18 the res fell . New interventions were put into place to anticipate needs & provide timely care & on 6/26/18 the resident was given a pommel cushion. However, no assessment was done as to the frequent episodes of being found on the floor. She stated that monitoring was being done, but 5 minutes later would be found on floor. There is no documented evidence that after multiple unobserved falls more frequent monitoring was used as an intervention to prevent falls. The res continued to be found on the floor. The res was placed at the nursing station as a monitoring intervention to ensure visibility, but on 6/28/18 the res was found on floor in front of station with no witness to the fall. The facility did not ensure that a res who who was assessed as a high risk for falls was appropriately supervised to prevent falls. The resident had six unobserved falls in a thirty day period. The falls occurred in a time frame of 1 to 7 days between incidents. The CCP was not reviewed to determine the causative factors that led to the falls. The CCP did not indicate that a review of the monitoring tool was conducted. There was no documented evidence in either the A&I or CCP that nursing staff was monitoring resident while she was at nursing station on 6/28/18. In addition there was no evidence that the Interdisciplinary team discussed the possibility of of more frequent visual checks. The 30 min monitoring tools shows staff sporadically signing off on monitoring. As such there is no documented evidence to reflect that visual monitoring checks were being done consistently. 415.12(h)(1)

Based on interviews and record review conducted during an abbreviated survey, the facility did not ensure that residents were free from significant medication errors. This was evident in 1 of 3 residents sampled for medication errors (Resident #1). Specifically, Licensed Practical Nurse #1 (LPN #1) administered [MEDICATION NAME] 180mg by mouth to Resident #1 on 10/23/2015. This medication was intended for Resident #1's roommate. Resident #1 became unresponsive after lunch and 911 called. The Medical Emergency Team treated Resident #1 in the facility with [MEDICATION NAME]. She was also transferred to the Hospital where she received two additional dosages of [MEDICATION NAME]. The facility physician's orders [REDACTED].#1 did not have an order for [REDACTED].>Complaint # NY 905 The findings include: Resident #1 is an [AGE] year old female initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified the resident with intact cognition. Review of the facility's Resident/Visitor Accident/Incident Report dated 10/23/2015 revealed that LPN #1 administered the wrong medication, [MEDICATION NAME] 180mg, to Resident #1. (The medication was intended for Resident #1's roommate who has an order for [REDACTED].#1 stated that she asked the Rehab Transporter to identify the resident (the same resident, she administered the [MEDICATION NAME] 3 tablets 60mg each tablet - totaling 180mg). The facility's investigation further revealed that after lunch, LPN #1 went to Resident #1's room (501) and observed her unresponsive to all stimuli. The Registered Nurse #1 (RN #1) responded to the room and assessed Resident #1 with pin-hole size pupil. 911 was called and upon their arrival, they assessed Resident #1 with pin-hole size pupil. The Emergency Medical Team suspected opioid toxicity and administered [MEDICATION NAME]. Resident #1 was transported to the hospital where she was admitted for management of unknown substance toxicity. Review of the nurse's progress note dated 10/23/2015 revealed that RN #1 was called to Resident #1's room, because staff was unable to get Resident #1 to respond. The RN assessed Resident #1 with respiration 24 and oxygen saturation 65% on room air. Oxygen implemented and 911 called. Resident #1 left the unit via ambulance to the ER. Review of the physician's orders [REDACTED].#1 to the emergency room (ER). Review of the physician's orders [REDACTED].#1 did not have an order for [REDACTED].>The facility's Nursing Transfer Summary form dated 10/23/2015 documented that Resident #1 was observed in bed unresponsive. Review of a hospital document titled, Documents Review Report dated 10/23/2015, revealed that Resident #1 was observed with an 18 gauge needle to her left arm. The needle was placed by the EMS who also documented that the resident was found unresponsive with pinpoint pupils. [MEDICATION NAME] 0.5mg was administered via IV route and the resident was placed on a cardiac monitor. The hospital document further revealed that Resident #1 urine toxicology tested positive for opiates. Documents from the hospital, further revealed that Resident #1 received [MEDICATION NAME] 0.4mg via IV route with minimal response and second dose of [MEDICATION NAME] 1.6mg was administered. A telephone interview was conducted on 5/24/2016 at 12:42PM with LPN #1 who administered the wrong medication to Resident #1. She stated that the Rehab Transporter identified the resident that was with him as Resident #1's roommate; she administered the medications to that resident. When the LPN was asked if she administered [MEDICATION NAME] to the resident that the transporter identified as Resident #1's roommate, she stated yes. The LPN was asked if she had checked the resident ID band prior to administering the medication and she stated no. She relied on the Rehab Transporter's identification of the resident. LPN #1 further stated, after lunch, she went to Resident #1's room and she was unable to wake her. She called for LPN #2 and 911 was called. A telephone interview was conducted with the Rehab Transporter on 6/8/2016 at 10:07AM. He stated that when he went to the unit to escort Resident #1 to therapy, he observed her sitting at the medication cart. The transporter further stated, LPN #1 did not ask him to identify any resident. A telephone interview was conducted with LPN #2 on 5/24/16 at 11:25AM. She stated upon her arrival to Resident #1's room, the resident was unresponsive and she called RN #1. In a subsequent interview with LPN #2 on 6/14/2016 at 9:35AM, she stated between 12:30PM and 1:00PM, she fed Resident #1 lunch and after lunch the resident had vomitus of undigested food. She further stated, Resident #1 stated that she was okay and that she just wanted to lie down. In addition, she stated that everyday we put her back to bed, it's normal. She also stated that LPN #1 called her to Resident #1's room and she observed Resident #1 in bed unresponsive approximately 1:30PM. When LPN #2 was asked if she had informed the supervisor or the doctor that Resident #1 vomited prior to being found unresponsive, she stated no. A telephone interview was conducted with RN #1 on 5/24/16 at 3:15PM. She stated that Resident #1 was observed unresponsive with constricted pupils and snoring sounds. She also stated, 911 was called and when they arrived, they asked her if Resident #1 was on narcotics. They also informed her that they gave Resident #1 [MEDICATION NAME]. When RN #1 was asked if Resident #1 was on any narcotics, she stated she reviewed Resident #1's chart and she was not on narcotics, but Resident #1's roommate was on narcotics. A subsequent telephone interview was conducted with the Director of Nursing (DON) on 6/3/2016. He stated that he interviewed LPN #1 and she initially denied administering the wrong medication to Resident #1. However, when he interviewed her the second time, she began crying and verbalized that she administered the [MEDICATION NAME] to the wrong resident. He further stated, LPN #1 informed him that she did not check Resident #1's ID band prior to administering the medications to the resident. The facility Policy & Procedure Manual titled Administration of Medication. Under Procedures the policy documented that the nurse should check the Medication Administration Record [REDACTED]. 483.25 (m)(2)

Based on interviews and record review during an abbreviated survey, the facility did not ensure that a resident received the necessary care and services to maintain the highest practicable well-being. This was evident for 1 of 3 sampled residents (Resident #1). Specifically, a resident with a [MEDICAL CONDITION] decannulated (removal of [MEDICAL CONDITION]) herself. The physician ordered to conduct an Arterial Blood Gas (ABG) analysis (to measure acidity and levels of oxygen and carbon [MEDICATION NAME] in the blood from an artery). The facility did not carry out the physician's order [REDACTED]. Subsequently, the resident went into respiratory distress and expired in the facility. Complaint # NY 6315 The findings include: Resident #1 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION] on admission. A Minimum Data Set (MDS) 3.0 with an assessment date of [DATE] identified that the resident was cognitively intact. The Interdisciplinary Care Plan initiated [DATE] documented that the resident had ineffective airway clearance related to [MEDICATION NAME] secretions or obstruction. The resident was discontinued from the ventilator. The interventions included assessing the resident ' s lung function, assessing the breathing pattern, and providing respiratory care. The Physician order [REDACTED]. A Respiratory Therapist (RT)'s Progress Note dated [DATE] at 6:00 PM documented that the resident decannulated herself. The note documented Stoma stable and closed. No respiratory distress noted. Lungs clear, respiration rate 14 per minute and oxygen saturation 100%. Resident left stable on nasal cannula 2 liters per minute and oxygen saturation at 100%. A Registered Nurse Supervisor (RNS)'s Progress Note dated [DATE] at 7:00 PM documented that he was informed that the resident pulled out her [MEDICAL CONDITION]. He observed the resident to be restless and fixated to go to the hospital. The note documented that the RT was not able to reinsert the [MEDICAL CONDITION] as the stoma was closed. The resident was placed on oxygen at 2 liters per minute via nasal cannula and the stoma was covered with a gauze. The note documented that the resident was monitored and saturating well at 100% with no respiratory distress. The MD (Medical Doctor) was notified. The review of the medical record revealed no documents of the resident ' s condition or MD orders from 7:00PM on [DATE] to 12:00AM on [DATE]. An RN ' s Progress Note dated [DATE] at 12:35 AM documented that the resident remained on oxygen throughout the shift. The note documented that the resident was in stable condition until 12:05 AM when she was not able to breathe. The resident had no heart rate. The staff started CPR (Cardio [MEDICAL CONDITION] Resuscitation) and called 911. The resident was pronounced at 12:28AM. An RT ' s Progress Note dated [DATE] at 12:40 AM documented that at 12:05AM the resident had no pulse and CPR was started. The note documented that chest compressions were done until EMS (Emergency Medical Services) arrived. The facility ' s Policy and Procedure titled Respiratory Therapy Services dated ,[DATE] documented that all requests for respiratory therapy will be written on a Respiratory Care Prescription Form specifically for the Rehab and Continuing Care Center. The prescription form must be dated, timed, and labeled. The policy also documented that all services will be provided only upon receipt of a completed request, signed by the physician or physician assistant. On [DATE] at 4:00 PM an interview was conducted with the Charge RN on the unit during the 4:00 PM - 12:00 AM shift on [DATE]. The RN stated that at about 6:05 PM on [DATE], a nurse informed her that the resident had decannulated herself. The RN stated that an RT told her that he was not able to reinsert the [MEDICAL CONDITION] to the resident. The RN stated that she notified the RNS, who contacted the MD on call. The RN stated that the RNS told her that the MD ordered to do an ABG test, so she referred the RNS to the RT. The RN stated that she saw the resident after 10:00PM, and the resident ' s pulse oximeter was at 100%. She stated that she did not receive any unusual report about the resident during the evening until at midnight when the night shift nurse made the rounds. The night shift nurse stated that the resident was gasping. The RN stated that she grabbed the AED (Automated External Defibrillator) and began ambu-bagging the resident until the RT responded. On [DATE] at 10:30 AM an interview was conducted with the RNS. The RNS stated that the Charge RN called him around 6:00 PM on [DATE] to report that the resident decannulated herself. The RNS stated that the RT told him that he could not reinsert the [MEDICAL CONDITION]. The RNS stated that the nursing and respiratory staff told him that the resident had removed the inner cannula earlier in the day. The RNS stated that the resident ' s pulse rate was in the 60 ' s (normal rate: ,[DATE] beats per minute) and oxygen saturation was at 100%. He stated that the stoma was covered with a gauze and the resident was calmly sitting up in bed. The RNS stated that he informed the MD and the MD ordered to check the ABG. The RNS stated that he found out that the RT is responsible for drawing blood for the ABG. He stated that usually when the MD gives telephone order for blood work, he draws the blood himself. The RNS stated that he told the RT that the MD ordered to check the ABG. The RNS stated that the RT stated that there was no clinical indication for checking the ABG because the resident was stable, then the RT walked away. The RNS stated that he did not write the telephone order in the medical record. He stated that his intention was to inform the RT of the MD ' s order first to get the process going before writing the request slip for the ABG and documenting in the medical record. The RNS was not sure of the time, but he stated that he went back to check on the resident. He stated that the resident waved her hand to him as if to say she was okay. He stated that he did not ask any more about the ABG. He stated that he documented in the progress note that the resident was fixated to go to the hospital because the resident completely decannulated herself. He stated that the resident did not verbalize or make any gesture that would suggest she wanted to go to the hospital. On [DATE] at 12:25 PM an interview was conducted with RT #1. RT #1 stated that at approximately 4:00PM on [DATE], he was asked to see the resident. He stated that the resident ' s [MEDICAL CONDITION] inner tube was coming out, so he pushed it back in. He stated that he did not document this incident in the medical record because he was busy. RT #1 stated that at approximately 6:00PM on [DATE] the nursing staff reported that the resident decannulated herself. RT #1 stated that the resident was not in distress. RT #1 stated that he was not able to reinsert the tube because the stoma was closed. He stated that he placed the resident on oxygen via nasal cannula and continued to monitor the resident. He stated that he also called his RT Supervisor at the hospital (connected to the nursing facility) to notify her that he needed a cannula for CO2 (Carbon [MEDICATION NAME]) end tidal (level of CO2 released at the end of an exhaled breath) to monitor the resident. RT #1 stated that this monitoring device was not available at the nursing home side, so the supervisor told him that the relief RT would bring the device over at the change of shift at 7:30PM. When asked about the ABG test as mentioned by the RNS, RT #1 stated that he did not have any discussion with the RNS about the ABG test. He stated that in order to do an ABG test, the MD would order it and a request slip would be given to the RT. When asked if he told the RNS that ABG was not needed because the resident was stable, he stated no. He stated that he would have done it with a proper request. He stated that the resident was stable for the rest of his shift. On [DATE] at 1:25 PM an interview was conducted with RT #2. RT #2 stated that on [DATE], he worked from 7:00AM to 7:30PM at the hospital side, but his supervisor instructed him to go to the nursing home to work from 7:30PM to 11:00PM. He received the report that the resident had decannulated herself and needed to be placed on the CO2 end tidal. RT #2 stated that he brought the CO2 end tidal device and began the monitoring process. He stated that he made his rounds between 7:45PM and 10:45PM. RT #2 was not sure of the time, but he stated that he checked on the resident that evening. He stated that the CO2 reading fluctuated between ,[DATE] mmHg (millimeters of mercury) (normal rate: ,[DATE] mmHg) and the respiratory rate was ,[DATE] breaths per minute (normal rate: ,[DATE] breaths per minute). He stated that he would have been concerned with the CO2 rate if the respiratory rate was in the 30's. He stated that with the respiratory rate of ,[DATE], they would not need to complete an ABG test. RT #2 stated that he was not aware that the MD had ordered to check the ABG. RT #2 stated that he left the unit at 11:00PM and instructed the charge nurse to call the RT on duty at the hospital if needed. RT #2 stated that he did not document anything about the resident in the medical record that evening. On [DATE] at 12:40 PM an interview was conducted with the On Call MD, the Chief [MEDICAL CONDITION]/Critical Care MD of the hospital. The MD stated that he covers in the nursing home twice a week. The MD stated that the RNS notified him at approximately 6:15PM to 6:30PM on [DATE] that the resident had decannulated herself and that the tube could not be inserted again. The MD stated that he was also told that the resident had decannulated herself 2 hours prior to the incident and that the tube was reinserted at that time. The MD stated that the RNS told him that the resident had [MEDICAL CONDITION] and had not been on a ventilator for several months. The MD stated that based on the information he received from the RNS about the resident's condition, the resident was stable and did not need to be transferred to the hospital. The MD stated that he was not sure if the CO2 end tidal could be measured in the nursing home since the resident was not on the ventilator and he did not know if the device was available. He stated that he ordered an ABG test to be done within an hour as a precaution. He stated that he instructed the RNS to call him with any abnormal findings. He stated that the next call he received was after the resident had expired. 415.12