Every finding on record at Bronx Park Rehabilitation & Nursing Center

Based on observation, record review, and interviews during the Abbreviated Survey (2624284), the facility failed to ensure that residents are free of significant medication error. This was evident for 1 (Resident #1) of 3 residents reviewed for medication administration. Specifically, Resident #1 was administered sixty (60) units of insulin when six (6) units was the physician ordered dose.The findings are:A Facility Reported Incident and Investigation dated 09/25/2025, documented that on 09/21/2025 at 7:14AM, Resident #1 was administered 60 units of insulin instead of 6 units of insulin. Licensed Practical Nurse #1 reported the medication error to Registered Nurse #1, the supervisor. Resident #1 was transferred to the hospital for observation.Resident #1was admitted to the facility with active diagnoses that included Non-Alzheimer's Dementia and Diabetes Mellitus with unspecified complications. The Minimum Data Set quarterly assessment dated [DATE], identified the resident's cognitive status as severely impaired. A Physician's Order dated 09/21/2025, documented Humulin Neutral Protamine [NAME] (NPH) Insulin subcutaneous suspension 100 Unit/Milliliter four (4) units to be administered subcutaneously every eight (8) hours.A Nursing Progress Note dated 09/21/2025, documented that during medication pass, Licensed Practical #1 realized that more insulin coverage was mistakenly administered to Resident #1. Blood glucose reading 189mg/dl.A Nursing Progress Note dated 09/21/2025, documented that Licensed Practical Nurse #1 reported to Registered Nurse #1, the nursing supervisor, that at approximately 7:14 AM a medication error had occurred. Resident #1 had a standing order for Humulin Neutral Protamine [NAME] (NPH) Insulin six (6) units to be administered every eight (8) hours. Licensed Practical Nurse #1 administered a higher dose of sixty (60) units of Humulin Neutral Protamine [NAME] (NPH) Insulin. Resident #1 was transferred to the hospital at 8:45 AM due to risk for hypoglycemia.A Glucose Monitoring Log dated 09/21/2025, documented Resident #1 had a blood glucose reading of 163mg/dl. Licensed practical Nurse #1 administered an insulin dose of sixty (60) units. Noted as a medication error. A Physician Progress Note dated 09/21/2025, documented Resident #1 was transferred to the hospital emergency room for observation after a Humulin Neutral Protamine [NAME] (NPH) Insulin medication error.A Transfer Form dated 09/21/2025, documented Resident #1 was transferred to the hospital for observation and increased risk of hypoglycemia. Resident #1 was accidently given high dose of insulin, sixty (60) units of Humulin Neutral Protamine [NAME] (NPH) Insulin.A Nursing Medication Incident and Accident Report dated 09/21/2025 7:14 AM, documented a physician's order for Humulin Neutral Protamine [NAME] (NPH) Insulin six (6) units to be administered to Resident #1, Licensed Practical Nurse #1 administered sixty (60) units of Humulin Neutral Protamine [NAME] (NPH) Insulin. Resident #1 was transferred to the hospital at 8:45 AM due to risk for hypoglycemia. Nurses were In-serviced on medication pass and insulin administration.On 10/29/2025 at 10:17 AM, Licensed Practical Nurse #1 was interviewed and stated that they were employed by the facility through a nursing agency. Licensed Practical Nurse #1 stated that on 09/21/2025 they checked the physician orders for Resident #1, and the resident was scheduled to receive six (6) units of insulin Humalog Humulin Neutral Protamine [NAME] (NPH). The resident did not have an insulin pen, so the insulin had to be drawn from a vial. They thought they drew up six (6) units of insulin but when they went to enter the six (6) unit dosage in the medication administration record (MAR), they realized that they had administered sixty (60) units of insulin to Resident #1. Licensed Practical Nurse #1 also stated that they informed the nursing supervisor of the medication error immediately. The Resident was assessed to be alert with vital signs stable and a blood glucose reading of 189 milligrams/deciliter (mg/dl) and was transported to the hospital for observation. On 10/28/2025 at 11:51 AM, an interview was performed with Registered Nurse #1, the nursing supervisor, who stated that they were working the night shift as the nursing supervisor on the 12am-8am on 09/21/2025 when Licensed Practical Nurse #1 called. Upon arrival on Unit Six (6), Licensed Practical Nurse #1 stated that they administered the wrong dose of insulin to Resident #1, Humulin Neutral Protamine [NAME] (NPH) Insulin sixty (60) units instead of six (6) units. Licensed Practical Nurse #1 then demonstrated that they had drawn up sixty (60) units from the insulin vial with a U one hundred (U100) syringe. Registered Nurse #1 also stated that they had not performed any previous medication observations with Licensed Practical Nurse #1. Registered Nurse #1 further stated that an assessment on the resident was performed. The Resident was alert with a blood glucose reading of 180 milligrams/deciliter (mg/dl). and no signs or symptoms of hypoglycemia. The Physician Assistant, the Director of Nursing and the Resident's family were called, and the Resident was admitted to the hospital for observation.On 10/28/2025 at 12:20PM, an Interview was performed with The Director of Nursing who stated that on Sunday 09/21/2025 at approximately 7:00 AM, Registered Nurse #1 called informing them that Licensed Practical Nurse #1 administered sixty (60) units of insulin instead of six (6) units. Registered Nurse #1 was then directed to call an ambulance for rapid transport, to call the family and the attending physician. The Director of Nursing also stated they called the facility administrator and the medical director who were all in agreement with sending the resident to the hospital. The Director of Nursing also stated they placed a telephone call to Licensed Practical Nurse #1 asking for an explanation, and they were unable to explain, only stating that they realized the medication error after they administered the insulin. Licensed Practical Nurse #1 was suspended and subsequently fired after the investigation.10 NYCRR 415.12

Based on record review and interview conducted during the Recertification survey from 09/16/2024-09/23/2024, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of skilled services. Specifically, the facility did not provide the Notice of Medicare Non-Coverage for Medicare Part A at least two calendar days before Medicare covered services ended as required, did not ensure that notices were mailed on the same day telephone notification was made, and did not provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form for residents who were remaining in the facility after discharge from skilled services. This was evident for 2 (Resident #89 and Resident #14) of 3 residents reviewed for Beneficiary Notification out of 38 sampled residents. The findings are: The facility policy titled Medicare Beneficiary Notice for Non-Coverage of Service dated 2/18/23 states that the purpose is to have a notification process that complies with the Medicare regulations and the notification used was the Notice of Medicare Non-Coverage (NOMNC) CMS-10123. The policy also stated that residents/representatives are notified in writing when a decision of Medicare non-coverage is made a minimum of two days' notice before the last covered Medicare day. The policy did not include any reference to the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 states that the form must be delivered at least two calendar days before Medicare covered services end and included the requirement that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. The instructions also stated that if the provider is personally unable to deliver a Notice of Medicare Non-Coverage to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise them when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. The instructions also state that when direct phone contact cannot be made, the notice should be sent to the representative by certified mail, return receipt requested. The Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024) states that Medicare requires Skilled Nursing Facilities to provide the notice to original Medicare patients prior to providing care that Medicare usually covers but may not pay for because the care is not medically reasonable and necessary; or considered custodial. 1. Resident# 89 was discharged from skilled services on 04/26/2024 with 66 days remaining and remained in the facility. The Notice of Medicare Non-Coverage form documented that the last day for Medicare Part A service was 04/26/2024. The Notice of Medicare Non-Coverage form also documented that Resident #89 was notified and their guardian received telephone notification of termination of coverage from the Social Services director on 4/25/24 which was one day before covered services were to end. There was no documented evidence that the notice was mailed on the same day that telephone notification was made. In addition, there was no documented evidence that the facility provided Resident #89 and/or their guardian with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage notice at the termination of skilled services. 2. Resident #14 was discharged from skilled services on 8/15/24 with 44 days remaining and remained in the facility. The Notice of Medicare Non-Coverage form documented the last day for Medicare Part A service was 8/15/24. The Notice of Medicare Non-Coverage form also documented that Resident #14 was made aware, however was unable to sign. A telephone call was made to Resident #14's representative and a message was left on voicemail on 8/12/24. There was no documented evidence that the Notice of Medicare Non-Coverage form was sent by certified mail when direct telephone contact was not made. In addition, there was no documented evidence that the facility provided Resident #14 with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form at the termination of Medicare coverage. On 09/17/2024 at 3:23 PM, the Director of Social Services was interviewed and stated they work with the Rehabilitation Director to give the Notice of Medicare Non-Coverage notices to residents, families, or legal guardians. The Director of Social Services also stated that if the resident is confused, they will document it on the form and then inform the resident's family or legal guardian. The Director of Social Services further stated that they usually provide the letter two days before Medicare services are terminated and is not sure why one of the notices was given only one day before. The Director of Social Services Social Services Director stated they were not aware of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage notice and provides the notices that are given to them by the Director of Rehabilitation. On 09/17/2024 at 3:35 PM, the Director of Rehabilitation was interviewed and stated they prepare the Notice of Medicare Non-Coverage notices with the date included and then gives the letters to the Director of Social Services who then gives the notification to the resident, family member, or legal guardian. The Director of Rehabilitation also stated that the Notice of Medicare Non-Coverage notice must go out at least two to three days before Medicare services are terminated in order to allow the resident time to appeal the decision. The Director of Rehabilitation further stated that they were unaware that if a voicemail had been left for a family member that a copy of the notice should be sent by certified mail. In addition, the Director of Rehabilitation stated that they had no knowledge of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form. On 09/17/2024 at 3:59 PM, the Administrator was interviewed and stated that they are not involved in the beneficiary notification process as this is handled by the Director of Rehabilitation and the Director of Social Services. 10 NYCRR 415.3(g)(2)(i)

Based on record review and staff interviews conducted during the Recertification Survey from 09/16/2024 to 09/23/2024, the facility did not ensure that residents' and their representatives were provided with a summary of the baseline care plan. This was evident in 1 (Resident #76) of 3 reviewed for Urinary Catheter, 1 (Resident #92) of 1 resident reviewed for Pain, and 1 (Resident #220) of 2 residents reviewed for Behavioral/Emotional out of 38 total sampled residents. Specifically, residents or their representatives did not receive a copy of their baseline care plan. The findings include but are not limited to: The facility's policy and procedure titled Baseline Care Plan, last revised on 04/10/2024, documented that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. The resident and representative are verbally informed of their baseline care plan and provided with a written statement. 1. Resident #76 was admitted to the facility with diagnoses that included Urinary Tract Infection and Acute Kidney Failure. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #76 had moderately impaired cognition. Section Q of the assessment documented that Resident #76 and family participated in the assessment and goal setting. On 09/18/2024 at 10:14 AM, Resident #76 was interviewed and stated that they did not remember if they received a copy of the baseline care plan. A Baseline Care Plan form dated 07/30/2024 and 07/31/2024 was completed for Resident #76 with signatures of interdisciplinary staff. There was no documented evidence that Resident #76 or a family representative was provided with a written copy of the baseline care plan. 2. Resident #92 was admitted to the facility with diagnoses that included Malignant Neoplasm of the Tongue and Hypertension. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #92 had intact cognition. Section Q documented that Resident #92 participated in the assessment and goal setting. On 09/20/2024, at 11:47 AM, Resident #92 was interviewed and stated they had not received a copy of their baseline care plan. A Baseline Care Plan form dated 07/03/2024, 07/04/2024 and 07/07/2024 was completed for Resident #92 with signatures of interdisciplinary staff. There was no documented evidence that Resident #76 received a written copy of the baseline care plan. 3. Resident #220 was admitted to the facility with the diagnosis that include Anxiety Disorder and Diabetes Mellitus. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #220 has severely impaired cognition and never/rarely made decisions. Section Q documented that Resident #220 family participated in the assessment and goal setting. A Baseline Care Plan form dated 05/28/2024 and 05/29/2024 was completed for Resident #220 with signatures of interdisciplinary staff. There was no documented evidence that Resident #220's family representative was provided with a written copy of the baseline care plan. On 09/23/2024 at 11:04 AM, Unit Manager #1 was interviewed and stated that the baseline care plan is initiated on admission. Unit Manager #1 also stated that the former Assistant Director of Nursing was responsible for informing the family about the baseline care plan. Unit Manager #1 further stated that they did not know if a copy was provided to the residents and the family representatives. On 09/23/2024 at 8:51 AM, the Director of Social Service was interviewed and stated the baseline care plan is completed within 48 hours of admission. The Social Service staff reviews the baseline care plan and explains the care and goals to the family. The Director of Social Service also stated that nursing is responsible for providing a copy of the baseline care plan to the residents and family representatives. The Director of Social Service further noted that the previous Assistant Director of Nursing informed the family of the baseline care plan, and the facility had no evidence that a copy had been provided to residents or their representatives. On 09/20/2024 at 12:39 PM, the Director of Nursing was interviewed and stated that a baseline care plan is initiated for all new admissions. All departments are required to complete the baseline care plan in 48 hours. The Director of Nursing also stated that they discuss the baseline care plan with cognitively intact residents and family representatives but do not provide them with a copy. The Director of Nursing further stated that the facility policy states they must explain the baseline care plan to the resident and family and give them a copy. The Director of Nursing did not explain why this was not being done. 10 NYCRR 415.11 (c)

Based on observation, record review, and interviews conducted during the Recertification Survey from 09/16/2024 to 09/23/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 2 (Resident #112 and Resident #181) of 3 residents reviewed for Skin Conditions (non-pressure) out of 38 sampled residents. Specifically, the Physician Assistant and Registered Nurse #5 failed to comply with infection control protocols during wound care. The findings are: The facility policy titled Wound Care, revised 01/31/2024, documented that the treatment in the facility of various types of wounds, is performed to ensure optimal healing and prevention of complications. The policy also documented that one key responsibility is to ensure compliance with infection control protocols and safety standards in wound care practices. The facility policy titled General Infection, revised 02/15/2024, documented that it is the policy of the facility to comply with the Center for Disease Control and other government agencies infection disease related recommendations as appropriate. 1. Resident #112 was admitted to the facility with diagnoses that include Peripheral Vascular Disease and Diabetes Mellitus. The Minimum Data Set assessment dated [DATE], documented that Resident #112 had moderately impaired cognitive skills for daily decision making and one venous or arterial ulcer present. The Physician Treatment Order dated 09/13/2024, documented twice a day wound care as: Cleanse left foot and right leg abrasions with normal saline solution. Apply 1% Silvadene Cream topically to the left foot and right leg abrasions. Cover with bordered gauze dressing. During a wound treatment observation on 09/19/2024 at 11:03 AM, the Physician Assistant was observed performing wound care for Resident #112. The Physician Assistant used one cotton swab to apply 1% Silvadene cream to three separate wounds (left foot abrasion, and two right leg abrasions). After the Physician Assistant applied the cream, Registered Nurse #5, who was assisting the Physician Assistant, opened packages of gauze and placed the packages on the sheet of Resident #112's bed without first setting up a clean field. The gauze pads and bordered gauze dressings were then applied to Resident #112's left foot and right leg open wounds by the Physician Assistant. 2. Resident #181 was admitted to the facility with diagnoses that include a Non-Pressure Chronic Ulcer of the Left Lower Leg and Non-Alzheimer's Dementia. The Minimum Data Set assessment dated [DATE], documented that Resident #181 had moderately impaired cognitive skills for daily decision making and one venous or arterial ulcer present. The Physician Treatment Order dated 09/19/2024 documented twice a day wound care as: Cleanse left lower extremity with normal saline solution. Apply 1% Silvadene Cream topically to the left lower extremity and cover with Kerlix wrap. During a wound treatment observation on 09/19/2024 at 11:19 AM, Registered Nurse #5 was observed assisting the Physician Assistant. Registered Nurse #5 opened packages of gauze with kerlix rolls and placed the packages on the sheet of Resident #181's bed sheet without first setting up a clean field. The gauze and Kerlix dressings were then applied to Resident #181's left lower extremity wound by the Physician Assistant. On 09/19/2024 at 11:10 AM, the Physician Assistant was interviewed and stated that they had not done dressing changes for a while as they are usually assisted by a wound nurse who is no longer employed by the facility. The Physician Assistant also stated that they should have used a separate swab for each wound. The Physician Assistant further stated that Registered Nurse #5 did not set up a barrier before placing the gauze pads and bordered gauze on Resident #112's and Resident #181's bed sheet. On 09/19/24 at 3:33 PM, the Infection Control Nurse was interviewed and state that Registered Nurse #5 was recently hired and was not yet in-serviced on wound care. The Infection Control Nurse also stated that in-services had been rescheduled as the facility was being surveyed this week. On 09/19/2024 at 4:09PM, Registered Nurse #5 was interviewed and stated that they felt rushed while assisting the Physician Assistant and therefore they made many errors during the wound treatments for Resident #112 and Resident #181. Registered Nurse #5 also stated that they placed dressings on Resident #112's and Resident #181's bed and should have set up a clean field for dressings on the bedside table. On 09/19/24 at 04:33 PM, the Director of Nursing was interviewed and stated that the Physician Assistant cross contaminated the wound by not using a separate swab for each wound. The Director of Nursing also stated that the previous Assistant Director of Nursing would complete the wound care with the Physician Assistant, but they are no longer employed at the facility. The Director of Nursing further stated that Registered Nurse #5 will be the new wound care nurse, but they had not been oriented to that role yet and the Physician Assistant had been instructed not to have Registered Nurse #5 assist them with wound treatments until they were trained. 10 NYCRR 415.19 (a)(1-3)

Based on observation, interview, and record review conducted during the Recertification Survey from 09/16/2024 to 09/23/2024, the facility did not ensure that food was served at an appetizing temperature during meal service. This was evident for 1 (Resident #203) of 3 residents reviewed for Food out of 38 total sampled residents. Specifically, food served during lunch meal service was not maintained at palatable and appetizing temperatures. The findings are: The facility's policy and procedure titled Hot Food Holding Policy dated October 2022, documented hot foods should be 135 degrees Fahrenheit or above at the time food is served to the residents. Resident #203 had diagnoses which included Diabetes Mellitus, Hypertension, and Heart Failure. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #203 had intact cognition. On 09/16/2024 at 10:56 AM, Resident #203 stated meals are delivered to their room and the food is routinely served cold. On 09/23/2024 at 12:42 PM, the food delivery truck arrived on Unit 6. Staff distributed trays to residents located in the dining room and then distributed meal trays to residents located in their rooms. On 09/23/2024 at 12:59 PM, a test tray was conducted and revealed the following temperatures: soup 125.2 degrees Fahrenheit, jerk chicken 124.3 degrees Fahrenheit, rice 106 degrees Fahrenheit, and zucchini and squash 110.8 degrees Fahrenheit. On 09/18/24 at 10:37 AM, Certified Nursing Assistant #3 was interviewed and stated sometimes Resident #203 reports their grilled cheese sandwich is not warm enough and requests that staff heat it up. Certified Nursing Assistant #3 also stated that no other residents on the unit have complained of cold food. On 09/23/2024 at 1:09 PM, the Director of Dining Services was interviewed and stated the food temperatures should be above 135 degrees Fahrenheit. The Director of Dining Services also stated that test tray temperatures are monitored once per week, and they have found no issues. The Director of Dining further stated the food truck, and the insulated plate covers are supposed to keep the food temperatures above 135 degrees Fahrenheit. 10 NYCRR 415.14(d)(1)(2)

Based on record review and interviews conducted during an abbreviated survey (NY 00299268), the facility failed to ensure that an alleged violation involving abuse was reported to the New York State Department of Health (NYSDOH), immediately but not later than 2 hours after the allegation was made. Specifically, on 7/15/2022, the Director of Nursing (DON) received a call from the hospital Social Worker #1 (SW #1), who stated that Resident #1 reported that they were abused on the 6th floor and does not want to return to that floor. The facility did not report the incident to NYSDOH. The findings are: The facility's Policy and Procedure entitled Abuse, Neglect, and Mistreatment last revision dated 12/19/2011, documented: report of all alleged violations and all substantiated incidents to the State Agency and to all other agencies as required and take all necessary corrective actions depending on the result of the investigation. The Facility's Grievance Report dated 7/15/2022, documented that Resident #1 was currently hospitalized after calling emergency services number (911) and the police for complaints of chest pain. The Director of Nursing (DON) received a call from the hospital SW #1, who stated that Resident #1 reported being abused on the 6th floor and does not want to return to that floor. Resident #1 had a history of calling the police, fabricating stories of abuse, and changing units in the past. As per hospital SW #1, Resident #1 want to return to the facility on another unit. During an interview done by the facility SW # 2 with Resident #1, regarding the complaint of abuse that was made to the hospital SW #1. Resident #1 stated that they never said that they were abused, they don't want to go back to the 6th floor unit but requested to place on another floor. Resident #1 with diagnoses including Psychosis, Manic Depression, and Diabetes Mellitus. The Minimum Data Set (MDS, a resident assessment tool) dated 06/01/22, documented that Resident #1 has a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 12 of 15. Resident #1's cognition was moderatly impaired. The Comprehensive Care Plan (CCP) on Abuse Prevention dated 3/4/2022, with a target date of 6/6/2022, documented the following interventions: Separate the victim, monitor for mood and behavior, Psychiatric consultation, send Resident #1 to the emergency room , if the behavior is unmanageable and dangerous, relocate Resident #1, and change the bedroom. The After Visit Summary dated 7/14/2022, documented the reason for the visit: Chest Pain. Recommended cardiology follow-up. Resident #1 requested to be transferred to a different floor at the facility. During an interview on 7/20/22 at 12:57 PM, the Director of Social Service (DSS), stated that they were informed by DON that on 7/15/2022, a telephone call was received from the hospital SW #1 who stated that Resident #1 said that he/she were abused on 6th floor and wanted to be moved to a different floor. No names of abusers were revealed. During an interview on 7/20/2022 at 1:20 PM, DON stated that on 7/14/2022, Resident #1 called 911 complaining of chest pain and was transferred to the hospital. DON stated that the hospital SW #1 called the facility on 7/15/2022 and told them that Resident #1 is returning to the facility but requesting to be transferred to another unit because someone was abusing Resident #1 on the 6th unit. DON stated that SW #1 did not reveal who was abusing Resident #1. DON stated that no names were revealed. DON stated that nobody reported to them that Resident #1 was sexually abused. DON stated when Resident #1 returned to the facility, Resident #1 was transferred to another unit and did not file a grievance report. DON stated that during interview, Resident #1 denied that someone abused him/her. There was no evidence of abuse, and the allegation was not reported to NYSDOH because Resident #1 has a history of accusatory behavior and calling 911. DON stated that any alleged abuse, neglect, or mistreatment should be reported within 2 hours to NYSDOH. During an additional telephone interview on 7/22/2022 at 3:20 PM, the DON stated that he/she was the acting Administrator due to the Administrator being on vacation. DON stated that when they received a call from hospital SW #1 that Resident #1 said that they were abused while in the facility on the 6th floor, he/she informed the Administrator but does not recall what time. DON stated that he/she does not recall what time he/she received a call from the hospital SW #1. During a telephone interview on 8/8/2022 at 12:24 PM, the Administrator stated that the DON is responsible for investigating incidents and Adminisrator is responcible for reporting to NYSDOH. The Administrator stated that he/she was on vacation between 7/8/2022-7/21/2022 and was notified of the allegation of abuse. The Administrator does not recall the exact day. The Administrator stated that alleged abuse should be reported to the Administrator within 24 hours. If the abuse occurred, the Administrator should be notified immediately. The Administrator stated that the incident was not reported to NYSDOH because it was immediately ruled out that abuse did not occur. The Administrator also stated that DON has the authority to report incidents to NYSDOH, but the Administrator still reports even if he/she is on vacation. 10 NYCRR: 415.4(b)(1)(i)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure a resident received necessary care and services to prevent pressure ulcers. This was evident for 1 (Resident #52) of 2 residents reviewed for Position, Mobility/Limited Range of Motion, out of a total sample of 39 residents. Specifically, Resident #52 was ordered to wear a Multipodus boot (MB) on the left foot and was observed on several occasions without the MB in place. The findings are: The facility policy titled Special Devices last revised 01/2022 documented devices are to be used as ordered by physician. On 06/13/22 at 12:36 PM, 06/14/22 at 12:16 PM, 06/16/22, between 09:40 AM and 1:30 PM, and 06/17/22 between 9:30 AM and 12:02 PM, Resident #52 was observed sitting in a reclining wheelchair in the day room. A MB was not observed on Resident #52's left foot. Resident #52 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #52 was moderately cognitively impaired, was totally dependent upon staff to perform activities of daily living (ADL), was at high risk for developing pressure ulcers, and had skin and ulcer treatments including a pressure reducing device for chair and bed. The Comprehensive Care Plan (CCP) related to devices dated 3/16/2022 documented Resident #52 was at high risk for developing a pressure ulcer and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MB was ordered removed during hygiene, ADL care, and to check Resident #52's skin. On 06/17/22 at 10:47 AM, Certified Nursing Assistant (CNA) #1 was interviewed and stated the evening shift applies the MB to Resident #52's foot when Resident #52 is transferred to bed at night. CNA #1 has been assigned to Resident #52 for 6 months and was unaware the MB was ordered to be applied from 9AM to 9PM. On 06/17/22 at 11:58 AM, Unit Manager/Registered Nurse (RN) #1 was interviewed and stated Resident #52 has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNA is responsible for placing the MB on the resident's foot and RN #1 did not notice Resident #52 has not been wearing the MB as ordered. On 06/17/22 at 02:46 PM, the Rehabilitation Director (RD) was interviewed and stated Resident #52 was ordered the MB to improve foot mobility and pressure relief. Once there is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RD stated they were not aware Resident #52 was observed without the MB in place according to Physician order. On 06/22/22 at 09:15 AM, RN #2 was interviewed and stated they supervisor Resident #52's unit on the evening shift and did not know whether the MB was being applied to Resident #52's left foot as ordered by the Physician. On 06/22/22 at 09:43 AM, the Assistant Director of Nursing (ADNS) was interviewed and stated the RN Supervisors are responsible for making rounds to ensure devices are applied appropriately and according to Physician order. The ADNS was unable to explain the reason Resident #52 was observed without their MB on their left foot. 415.12(c)1

Based on observation and interview the facility did not ensure that infection control practices were maintained. Specifically, a nurse did not wash her hands in between feeding a resident, pouring supplements for other residents, and assisting another resident with their meal. This was evident for 1 of 6 resident floors (4th floor) observed during Dining Observation. The finding is: The facility policy and procedure for Handwashing Technique dated 9/2014 documented: To prevent cross-infection, hand washing must be done before and after rendering care to each resident. On 9/21/17 from 12:28 PM to 12:55 PM the following was observed during lunch in the 4th floor dining room: The Licensed Practical Nurse (LPN #1) saw a resident holding his spoon but not feeding himself. The LPN asked the resident if he needed help and took the spoon from him and began assisting with feeding. The LPN was standing over the resident while feeding him. While the resident was still eating, the LPN put down the spoon and went to the medication room and took a large bottle of Ensure Plus and styrofoam cups from the top of the medication cart. She did not wash her hand before doing so. The LPN then re-entered the dining room. She was holding the stack of cups with a finger inside the top cup to keep it stabilized. The LPN then poured Ensure for a few residents. She then placed the Ensure bottle and cups on top of the food truck. She then returned to the resident she was feeding and opened the thickened water for him. She then exited the dining room again to obtain a plastic spoon for another staff member. She then returned to the resident's side and monitored him. The resident was holding the spoon but not eating. The LPN then took the spoon from the resident and began feeding him again. Another staff member arrived with a sandwich for another resident. The LPN took the sandwich and went to another resident and assisted them with opening the sandwich and putting it in their hand. She then returned to the resident she was feeding and sat beside him to complete the meal. The LPN did not wash her hands between feeding the resident and assisting other residents with supplements and food. On 9/27/17 at 11:36 AM, the LPN was interviewed and stated that she usually uses hand sanitizer before feeding residents and in between residents. She further stated she must have forgotten to use it. On 9/28/17 at 10:17 AM, the LPN Charge Nurse was interviewed and stated staff should sit while feeding residents so that they can see the resident better. She also stated that sitting makes the experience easier for the resident. The LPN Stated staff should also wash their hands before and after feeding the residents. They should not go from resident to resident without washing their hands. On 9/28/17 at 11:03 AM, the Director of Nursing was interviewed and stated that staff should wash their hands before and after feeding residents. 415.19(a)(1-3)

Based on observation and interview, the facility did not ensure that residents were fed in a manner that enhanced or maintained their dignity. Specifically, a staff member was observed feeding a resident while standing over them and doing other tasks. This was evident for 1 of 6 resident floors observed during the Dining Observation (4th floor). The finding is: The facility policy and procedure for Nutrition dated 10/10 documented: The CNA (Certified Nursing Assistant) must assume a position that is comfortable for the mechanics of feeding. CNA must sit next to resident. On 9/21/17 from 12:28 PM to 12:55 PM the following was observed during lunch in the 4th floor dining room: The Licensed Practical Nurse (LPN) saw a resident holding his spoon but not feeding himself. The LPN asked the resident if he needed help and took the spoon from him and began assisting with feeding. The LPN was standing over the resident while feeding him. While the resident was still eating, the LPN put down the spoon and went to the medication room and took a large bottle of Ensure Plus and styrofoam cups from the top of the medication cart. She did not wash her hand before doing so. The LPN then re-entered the dining room. She was holding the stack of cups with a finger inside the top cup to keep it stabilized. The LPN then poured Ensure for a few residents. She then placed the Ensure bottle and cups on top of the food truck. She then returned to the resident she was feeding and opened the thickened water for him. She then exited the dining room again to obtain a plastic spoon for another staff member. She then returned to the resident's side and monitored him. The resident was holding the spoon but not eating. The LPN then took the spoon from the resident and began feeding him again. Another staff member arrived with a sandwich for another resident. The LPN took the sandwich and went to another resident and assisted them with opening the sandwich and putting it in their hand. She then returned to the resident she was feeding and sat beside him to complete the meal. On 9/27/17 at 11:36 AM, the LPN was interviewed and stated she as standing because the resident is at risk for choking and she needs to stand so she can watch him. She stated that she is ready to do any maneuvers if needed, and the suction machine cart is ready for use. On 9/28/17 at 10:17 AM, the LPN Charge Nurse was interviewed and stated staff should sit while feeding residents so that they can see the resident better. She also stated that sitting makes the experience easier for the resident. On 9/28/17 at 11:03 AM, the Director of Nursing was interviewed and stated that staff should sit while feeding residents to see if they are swallowing, pocketing, or spitting out food. She stated the resident should be fed until the meal is completed. Staff are not doing other things while feeding the resident. 415.5(a)

Based on observation, record review and staff interview the facility did not ensure that a resident received the necessary care to maintain the highest psycho-social well being. Specifically, during multiple resident observations the resident was noted to be in pain, when asked the resident verbalized pain and the family reported that the resident experienced pain. There was no documented evidence that the resident was routinely assessed for and/ or treated for [REDACTED]. This was evident for one resident reviewed for pain during Stage 2 of the survey. The finding is: Resident #213 is a [AGE] year old female admitted to the facility 12/8/2014. Medical [DIAGNOSES REDACTED]. A significant change minimum Data Set (MDS) completed 6/8/2016 documented that the resident was cognitively impaired, but usually understands and usually understood. Requires extensive assistance for bed mobility, dressing and personal hygiene and extensive assistance with transfer and toilet use. Pain assessment interview was conducted and document no pain present. Comprehensive care plan dated 6/8/2016 for pain documents pain/alteration in comfort as evidenced by history of right femur fracture, [MEDICAL CONDITION] (OA), Arthritis right knee, use of Tylenol and [MEDICATION NAME]. The goal is optimal level of comfort and absence of signs and symptoms of pain x90 days. Interventions include take medications as ordered, monitor VS (vital signs), encourage resident to verbalize need for pain medication and monitor for constipation. Resident was interviewed 7/5/16 at approximately 10:00 AM with a Spanish facility staff translator and verbalized that she has pain to right knee, she proceeded showed the knee which was noted to be swollen. An interview was conducted with the resident's family on 7/6/16 at approximately 11:30AM who reports that she constantly complains of pain to the right knee. The daughter states that she notified facility staff multiple times. She further stated her mother tells her she does not sleep because of the pain. An interview was conducted with the Certified Nursing Assistant (CNA) #1 who regularly cares for the resident on 7/7/2016 at 12:52 PM who stated that the resident is total care and requires assistance with Activities of Daily Living (ADL), she is aware of the [MEDICAL CONDITION] as part of her medical diagnoses. CNA #1 states that the resident reports pain to the right knee usually 3/5 days that she works with her and she notifies the nurse of the pain. She does not document the pain as it is reported verbally. An interview was conducted with the CNA #2 who regularly cares for resident on 7/7/2016 at 4:15 PM who stated that resident can verbalize pain when asked. She states that the resident makes facial grimace and she has verbalized dolor pointing to her right knee and or hip almost daily during care. CNA #2 states that she reports the pain to the nurse but she does not document the pain. An interview was conducted with the medication Licensed Practical Nurse(LPN) #1 on 7/7/2016 at 1PM who stated that every time she gives medication she assesses the resident on a scale of 1-10 and for facial grimace or body language. She also asks for the location of pain. As needed (PRN) pain medication is when they complain of pain or noted with facial grimace or physical signs of pain. She further stated when resident has multiple orders for PRN, she administers narcotic for a pain scale of 6-10 and Tylenol is administered if the pain is 5 or less. She goes back to the resident after 30 min or an hour to reassess the pain scale or monitor for facial grimace if medication is not effective she will provide ice packs or alternative measure. During the shift she assesses the resident during morning medications with lunch and prior to end of shift. These assessments are not documented. The CNA reports to her when resident has pain and she is medicated. She states that the resident is assessed for pain each shift. However, it is only documented on the MAR if medication was given. An interview was conducted with the LPN #2 who regularly works 4-12 PM on 7/7/16 at approximately 4:07 PM. She states that she asks residents if they are in pain and observe for facial grimace. She states that the resident is able to verbalize pains and other times she moans & groans. She further stated that the resident has not asked for pain medication during her shift. She further states that if the resident reports pain to the CNA, they notify her and she will assess and medicate as indicated. An interview was conducted with the Registered Dietician on 11/8/16 at approximately 12 PM who stated, that resident's intake is poor. The resident tolerates breakfast, but eats little at other meals. She further states that the resident takes meals with family in small amounts and is given ensure plus three times a day. She further stated, When she first started not eating she verbalized pain and it was reported to the nurse. An interview was conducted with the Director of Nursing 7/8/2016 at approximately 10:15AM who states that nurses are expected to assess residents for pain every time they give medication. She further stated residents who are confused should be assessed based on facial grimace or body language. The assessments are not documented. An interview was conducted with the Medical Doctor on 7/8/2016 at approximately 11:15AM who stated that his expectation is that patients request pain medication or express the need for pain medications. For residents that are cognitively impaired the patients can usually express that they are in pain. He further stated that this resident has [MEDICAL CONDITION] and previous hip surgery. The hip is not aligned so pain is anticipated. However, resident is able to verbalize pain. Staff can see that she's in pain. He expects that resident will express to staff when she needs pain medication. When asked about the residents diminished cognitive status and decreased ability to notify staff of pain he stated that the facility should anticipate her pain. Resident was seen and examined at bedside per MD note dated 6/15/16 for right hip and right knee pain follow up, Ortho consult done. Impression documents poor oral intake likely secondary to dementia [MEDICAL CONDITION]- nonunion please clarify recommendations ANA RF negative Rheumatology consultation supportive care. Review of the Medication Administration Record (MAR) dated 5/30/2016--6/30/2016 documents that resident received [MEDICATION NAME] oral tablet 325mg; 2 tablets by mouth every 4 hours as needed. Nurses signature indicating receipt daily 5/31/2016- thru 6/9/2016. There is no documented evidence that the resident had an ongoing pain assessment. The facility policy on pain recognition documents Because pain can significantly affect a persons well-being, it is important that the facility recognize and address pain promptly. 415.12

Based on interview and record review the facility did not ensure that an individual's financial record and quarterly statements were provided to their legal representative as requested. The finding is: Resident #213 is a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A significant change minimum Data Set (MDS) completed 6/8/2016 documented a resident as having impaired cognition but, usually understands and is usually understood. Requires extensive assistance for bed mobility, dressing and personal hygiene and extensive assistance with transfer and toilet use. Pain assessment interview was conducted and document no pain present. On 7/7/16 at 12:30PM an interview was conducted with the daughter of the resident, who is also the resident's legal representative. She stated, I manage my mother's personal finances. My mother has a personal funds account held by the facility, but I do not know the balance in the account. I do not receive any statements from the facility. Because of my mother's cognitive impairment I manage all her financial and medical decisions. On 7/7/16 at 12:30PM the Assistant to Finance/ Admissions was interviewed and stated, The facility does not have any documentation for personal funds account statements mailed out to families, resident representatives and guardians. The process is that I have two piles, one that I give the personal statements to the resident and one that I mail out. The facility does not have any documentation that they mail out these personal funds account statements. For this resident, the daughter is the representative payee. There is no documented evidence that the daughter was sent out or given the quarterly statement. 415.26(h)(5)(ii)(a-c)

Based on observation, record review and interview the facility did not ensure the required nurse staffing and resident census was posted for 2 out of the 4 survey days . This was evident for the entire facility. The finding is: During the initial tour and random observations conducted throughout the survey from 7/5/16 to 7/6/16 of the facility, the required Nurse staffing and resident census information was not posted for the residents and visitors. On 7/7/16 at approximately 10:00AM the Nurse Staff Posting was present on the cork board on the wall outside of the Nursing Office. It did not document the total number of hours of the Registered Nurses (RNs) and the Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNA's) on duty. Immediately following this observation, this surveyor interviewed the Director of Nursing Services who stated that the night supervisor is responsible to complete the form and post it on the cork board. On 7/8/16 at approximately 6:45AM the night Registered Nurse(RN) Supervisor was interviewed over the phone. She stated that she is the one who is responsible to post the nurse staffing and resident census information. She stated that she worked on 7/5 and 7/6/16 but is not sure what had happened that the required information was not posted on the bulletin board outside of the Nursing office. She further stated that she did not know that the hours worked by the Nursing staff needed to be included but will include them going forward. On 7/8/16 at approximately 11:35 AM the Director of Nursing was interviewed and stated that the form will reflect the total amount of hours worked by the Nurses and the CNA's. She stated that she checks to see that the Nurse Staffing is posted daily and saw it posted next to the Nursing schedule on 7/5 and 7/6/16. 415.13(a)(l)(i-iii)

Based on record review and staff interviews, the facility did not ensure that the Physician reviewed the resident's total plan of care. Specifically, the Physician did not follow up to ensure that the ordered diagnostic test and recommended consult was done. This was evident for 1 of 10 residents reviewed for Unnecessary Medications Use. (Resident # 174). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy The finding is: 1) Resident # 174 is a [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] documented moderately impaired cognition and a Brief Interview for Mental Status (BIMS) score of 12. The Comprehensive Care Plan for Alteration in [MEDICAL CONDITION] Status dated 6/7/12 includes interventions for medical follow up as needed, monitor and report any blood in urine, [MEDICAL CONDITION], pain, report any abnormalities to the MD (Medical Doctor). The care plan further documente that the resident was seen by the urologist. The Genito-Urinary Consult dated 12/5/13 documents CT (Computerized Tomography) abd (abdomen)/pelvis ...F/U (follow up) 3 weeks & (with) CT films and report. The interim Physician order [REDACTED].(abdomen)/pelvis without contrast, urine cytology " The order documents " scheduled Jan. 3, 2013 " The transportation company arrangement sheet dated 1/3/13 documents that the ambulette was scheduled to transport the resident to CT Scan study and it was marked " refused. " Review of the Physician interim notes and Monthly Assessments for the period 12/12/12- 2/7/13 revealed no reference to the CT Scan of the abdomen and pelvis, the residents refusal of the test, or the recommendation for the Urology follow-up. The Physician was interviewed by phone on 3/18/13 at 9:30 AM and stated that she routinely follows up on all of her orders and reviews the results. The Physician further stated if she does not see the results, she inquires with the nurses and documents that the results are pending or resident refused in her monthly notes. The Physician further stated that the resident was transferred to a new unit and that she was providing urgent care and not providing complete medical management from 1/15/13. The Medical Director was interviewed by phone on 3/18/13 at 1:40 PM and stated it is the MDs (Medical Doctors) responsibility to follow up with all of his/her orders. The MD should address and document the resident's refusal of a procedure, if the MD determines the procedure is no longer necessary along with a rationale for that decision. The Director further stated that the previous attending MD should communicate with a new MD either in person or via a summary of all medical concerns and pending issues and added that since the new MD was absent, the previous MD was responsible for overseeing the residents complete medical plan of care. 415.15(b)(2)(iii)

Based on record review and staff interviews, the facility did not ensure that care and services provided were in accordance with professional standards of quality. Specifically, the nursing staff did not notify the Physician about the limited results of an ultrasound test in a timely manner. This was evident for 1 of 10 residents reviewed for Unnecessary medications. (Resident # 174). This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident # 174 is a [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] documented moderately impaired cognition and a Brief Interview for Mental Status (BIMS) score of 12. The Physician's progress note dated 2/13/13 documents " patient said he had blood in urine ...now clear urine .... " The interim physician's orders [REDACTED]. " The Abdominal and Pelvic Sonogram results dated 2/14/13 documented the study was technically limited since the patient was unable to cooperate with the technician. Review of the medical record revealed no documented evidence that the nurses had informed the unit Physician about the limited results of the abdominal sonogram. The Facsimile tracking report from the diagnostic services provider dated 3/18/13 documents the Abdominal and Pelvic Sonogram results were originally forwarded by facsimile to the facility on 2/15/13. On 3/15/13, the Registered Nurse Manager (RNM) contacted the diagnostic service provider and obtained the results of sonogram. The current Medical Doctor (MD) was interviewed by phone on 3/15/13 at 2:15 PM. The Doctor stated that usually the ultrasound results would be obtained per his order,and he would review the findings. The MD further stated if the nurses had notified him about the limited results of the sonogram, he would have ordered the test to be repeated, but he was not aware of this issue until today. The Registered Nurse Manager (RNM) was interviewed on 3/18/13 at 9:50 AM. The RNM stated that the ultrasound results are sent in by facsimile to the nursing office on the following day, they are reviewed by nursing and placed in the MD folder. The RNM further stated that if the results are limited, the nurses would notify the MD and usually another attempt would be made to obtain the test. The RNM further stated he was not sure if there was currently a tracking system in place for the radiology requisitions and results, but the order for the abdominal and pelvic sonogram dated 2/13/13 had " slipped through " since the follow up was not done until today and added "It was an oversight. " The Director of Nursing (DON) was interviewed on 3/18/13 at 1 PM and stated that the facility did not maintain a log of the test requisitions and results for tracking purposes. The DON further stated that she just instituted a new log system for radiology services and in-serviced her staff. 415.11 c (3) (i)

Based on record review and staff interviews, the facility did not ensure that services provided were in accordance with the written plan of care. Specifically, 1) physician's orders [REDACTED].# 174) and 2) Medication was not administered as ordered. (Resident # 29). This was evident for 2 of 10 residents reviewed for Unnecessary Medications Use. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy The finding is: 1) Resident # 174 is a [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] documented moderately impaired cognition and a Brief Interview for Mental Status (BIMS) score of 12. The Comprehensive Care Plan for Alteration in [MEDICAL CONDITION] Status dated 6/7/12 includes interventions for medical follow up as needed, monitor and report any blood in urine, [MEDICAL CONDITION], pain, report any abnormalities to MD (Medical Doctor). The care plan further documents that the resident was seen by the urologist. The [MEDICAL CONDITION] Consult dated 12/5/13 documents CT (Computerized Tomography) abd (abdomen)/pelvis ...F/U (follow up) 3 weeks & (with) CT films and report. The interim Physician order [REDACTED].(abdomen)/pelvis without contrast, urine cytology " The order documents " scheduled Jan. 3, 2013 " The transportation arrangement sheet dated 1/3/13 documents that the ambulette was scheduled to transport the resident to CT scan study and it was marked " refused. " Review of the nursing notes for period 11/30/12 - 2/8/2013 revealed no documented evidence of the resident's refusal of the CT scan or notification to the physician regarding the refusal. There is no documented evidence that the CT scan of abdomen and pelvis was done. The Registered Nurse Manager (RNM ) was interviewed on 3/18/13 at 10:40 AM and stated that routinely, if the resident refuses a procedure, as a CT scan, the nurse would notify the MD and document the resident's refusal and Physician notification in the progress notes. The RNM stated that he was on the unit when the resident refused, but he could not recall the reason for the refusal, how it was addressed by staff, or if the MD was notified. The Licensed Practical Nurse (LPN) was interviewed on 3/18/13 at 11:30 AM and stated that if the resident refuses a procedure, the RNM and MD are notified by the nurse and this is all documented in progress notes. The LPN further stated that the MD usually repeats the request and if the resident refuses again despite the staff encouragement, the Social Worker is notified to explore the reasons for the refusal as well as to encourage family support. The Director of Nursing (DON) was interviewed on 3/18/13 at 1PM and stated if the resident is refusing any procedure, this should be appropriately documented in the medical record, MD should be notified and the care plan updated. 2) Resident # 29 is [AGE] years old with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident BIMS (Brief Interview of Mental Status) score was 3 which indicates severe cognitive impairment. The Physician order [REDACTED]. Give one tablet by mouth at Bedtime for Gastritis. The Medication Administration Record (MAR) dated 3/12/13 to 4/11/13 was reviewed and documented transcription of the order for [MEDICATION NAME] Tab 300 mg- Give one Tablet By Mouth At Bedtime for Gastritis. The MAR further documents the medication administration time is 10 PM. There were no nurses initials on the MAR on 3/12, 3/13 and 3/14/13, to indicate that the medication was administered per the physician's orders [REDACTED]. An attempt was made to conduct a medication reconcilliation by reviewing the blister pack for the [MEDICATION NAME]. The RNS (Registered Nurse Supervisor) was unable to locate the blister pack for the medication. On 3/18/13 at approximately 12:03 PM the Licensed Practical Nurse #1 was interviewed. The LPN stated that she administered the [MEDICATION NAME] 300 mg. to the resident and signed the blister pack, but did not sign the MAR for this medication on 3/13 and 3/14/13 and she will be more careful in the future. On 3/18/13 at approximately 12:10 PM, the Registered Nursing Supervisor (RNS) was interviewed and stated that the Supervisors are responsible to reviewing the MAR's at the end of the month for omissions and accuracy of the documentation. The facility's Medication Administration and Documentation policy was reviewed and documented the responsibilities of the Licensed Nurse as follows: Documents administration of medication on the medication administration record immediately following administration. 415..11(c)(3)(ii)

Based on record review and interview during an abbreviated survey, the facility did not provide services that meet the professional standards of quality. This was evident in 1 of 4 sampled residents (Residents #1). Specifically, the facility did not ensure that an order for [REDACTED]. This resulted in no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Complaint #: NY 305 The findings include: Resident #1 was admitted to the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) Assessment 3.0 dated 1/27/11 identified that the resident is independent in cognitive skills for daily decision making. He required limited assist with eating, bed mobility and ambulation. The resident required extensive assist with all other Activities of Daily Living (ADL ' s). The Monthly physician's order [REDACTED]. The Medical Doctor (MD) indicated this order cancellation with a line through the medication name. The MD hand-wrote in a new order for [MEDICATION NAME] 1000mg twice daily. A nurse ' s note dated 4/14/11 4:00PM written by the Licensed Practical Nurse (LPN) stated that the MD evaluated the resident and changed the resident ' s [MEDICATION NAME] order from 850mg to 1000mg. The nurse ' s note stated that the MD orders were implemented. The March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" daily " at 7:00AM. This copy of the MAR indicated [REDACTED]. A second version of this same MAR provided by the facility, dated 4/14/11 documented [MEDICATION NAME] 1000mg daily at 7:00AM. However, the word " daily " was crossed out from the order and " BID " was written. Additionally, this second version of the MAR indicated [REDACTED]. This second version includes initials for administration of [MEDICATION NAME] at 5:00PM, which were not on the first version of the MAR. The 5:00 PM administration entries reflected administration on 4/14/11 and 4/17/11-4/20/11. There are no entries for 4/15/11 and 4/16/11 at 5:00PM. A Blister Pack for [MEDICATION NAME] 1000mg was observed and has " one tablet orally twice daily " written on it. An MD Progress Note dated 4/22/11 documented in reference to the medication error that the resident took [MEDICATION NAME] 1000mg once a day instead of BID and no ill effects noted. On 1/31/12 at 2:15PM an interview was conducted via phone with one of the LPNs that were responsible for reconciling the monthly order sheet to ensure that the medications were transcribed as ordered with the MAR for Resident #1. While she recalled the incident and signing the order for the change in [MEDICATION NAME] dosage, she did not remember why she did not reconcile this with the Medication Administration Record. On 9/13/11 at 10:00AM the Director of Nursing Services (DNS) was interviewed. She stated that during the monthly review, the MD just put a slash mark through the [MEDICATION NAME] 850mg on the physician's order [REDACTED]. The DNS said that the MD should have written " discontinue " next to the 850mg. The LPN transcribed the new order onto the MAR indicated [REDACTED]. He then went back and added in 5:00PM and signed that he had given it at that time. This error was noticed by the night Registered Nurse Supervisor (RNS) at 8:00AM on 4/20/11, who noted that the order was for twice daily and was only being given in the morning. On 9/23/11 at 10:15AM the DNS was interviewed again. She stated that two other LPNs had signed the Monthly Orders Sheet without reconciling it with the MAR. The Facility Policy and Procedures for ordering and obtaining medications documents that new handwritten orders are signed by the Physician. The Charge Nurse on duty at the time the order is received enters and notes the order on the Physician order [REDACTED]. The Facility Policy and Procedure for Administering Medications documents that the Nurse must check to ensure the resident receives the correct medications, dosage and at the time scheduled. The Medication Record Sheet should be checked against the blister pack label just prior to removing the medication. The blister pack is to be initialed and dated for each dose removed. The LPN/RN is responsible for checking the blister pack with the order prior to administration of the medication. 415.11 (c)(3)(i)

Based on interviews and documentation review during an abbreviated survey, the facility did not provide routine drugs in a timely manner. This was evident in 1 out of 4 sampled residents (Resident #2). Specifically, an MD order for Lacrilube (eye ointment) was not supplied to the facility by the vendor pharmacy. Complaint #: NY 049 The findings include: Resident #2 was admitted to the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. The MDS 3.0 dated 8/14/11 identified the resident is severely cognitively impaired. Upon re-examination the resident was documented as moderately impaired. The Monthly Assessment and Physical dated 9/1/11documented that the resident complained of a sticky eyelid in the morning. The physician's order [REDACTED]. A review of the Nursing Incident Reports, dated 9/29/11 identified that on 9/28/11 the Registered Nursing Supervisor (RNS) noted that the Lacrilube was not available for administration and when she inquired was not available on the unit. The nursing incident report stated that the Pharmacy had received the order for Lacrilube on 9/1/11, but never sent the ointment. A Pharmacy Error Reporting Form, dated 9/27/11 revealed that the order for the Lacrilube was received on 9/1/11 and processed on 9/2/11. The report stated that due to an error, the order was marked as not needed/already filled and was not sent to the nursing home. At 2:00PM on 1/31/12 a Pharmacist from the vendor pharmacy was interviewed by phone. She stated that the pharmacy does not provide stock items to nursing homes and Lacrilube is a stock item at some, but not at others. The technician that processed the order for Resident #1 documented the order as "stock" and did not send it to the nursing home. She did not check the list to see if it was a stock item at Bronx Park Rehab and did not consult computer records. Stonebridge Pharmacy now does a quality assurance check on all orders for all residents sooner than they had done before. The facility policy titled " Dispensing Medication, " dated 10/10 stated that the pharmacy dispenses all medication. The nurse on duty, who receives the delivery from the pharmacy, is required to check all medications and report any discrepancies to the nursing supervisor. 415.18(a)

Based on observation and resident and staff interviews, the facility did not ensure that housekeeping and maintenance services were provided to maintain a sanitary and comfortable environment as evidenced by: residents' equipment and supplies were soiled, torn and broken. This was noted for 3 of 30 sampled Residents (Residents #16, #17, and #19) and 1 of 6 resident units (3rd floor). This resulted in no actual harm with the potential for more than minimal harm. The findings are: 1) During the initial tour of the facility on 01/25/12 at 9:30 AM, the 3rd floor clean utility room was observed with nine (9) bath towels tied together. The towels were dingy in appearance, rough in texture and torn. The Director of Housekeeping Services was interviewed on 01/25/12 at 11:00 AM and stated that he has a outside contractor that washes and deliver the towels. He stated that housekeeping staff should have informed him of the condition of the towels. 2) Resident # 16 is a male admitted on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented that the resident is cognitively intact. The Resident was and interviewed in his room on 01/26/12 at 9:45 AM and it was observed that the resident's television was covered with dust. Additionally, the resident's oxygen concentrator, oxygen tubing and nasal cannula were covered with dust. During the resident's interview, the resident stated that the facility could do a better job with cleaning and dusting. The housekeeping staff member responsible for cleaning the resident's unit was interviewed on 1/26/12 at 9:50 AM and stated that the resident is always in bed and the resident's floor is cleaned every day when the resident is awake. The housekeeping staff member stated that he did not clean the television or the oxygen concentrator. 3) Resident # 17 is a female and admitted on [DATE] with [DIAGNOSES REDACTED]. On 01/26/12 at 10:15 AM an observation of the Resident's room found a vinyl chair with an 8" vertical tear on the seat cushion, exposing the inner cotton-like fibers. The Certified Nursing Assistant assigned to the resident was interviewed on 1/26/12 at 10:15 AM and stated that she did see the tear on the seat cushion and did not report this to the nurse. 4) Resident # 19 is a male admitted on [DATE] with [DIAGNOSES REDACTED]. On 01/30/12 at 9:13 AM, it was observed that the front drawer to the resident closet was broken. The Certified Nursing Assistant assigned to the resident was interviewed on 1/30/12 at 9:10 AM and stated that she had seen the resident's broken closet door and did not report this to the nurse. 415.5(h)(2)

Based on record review and interview, the facility did not ensure that residents or their designated representatives were provide the opportunity to formulate advanced directives on a yearly basis. This was evident for 4 of 30 sampled residents (Residents #20, #23, #25 and #26). This resulted in no actual harm with the potential for more than minimum harm that is not immediate jeopardy. The findings include but are not limited to: 1) Resident #23 is a [AGE] year old female with [DIAGNOSES REDACTED]. The MDS 3.0 dated 11/28/10 documents that she has long and short term memory problems and moderately impaired decision making. Record review reveals an Advanced Directives form dated 4/7/00 which documents "Resident is unable to understand DNR order and has no Designated Representative. Therefore. there is NO DNR order signed...Resident is unable to understand Health Care Proxy." The "Social Service-Assessment" dated 10/2710 documents that the resident has no Advanced Directives. The Social Worker was interviewed on 12/13/10 at approximately 11:30 AM and stated there have been no updates because the resident does not have capacity and there is no family or guardian involved. She continued that the facility has been working on putting changes in place to address residents' without family or guardian. 2) Resident #25 is a [AGE] year-old male admitted [DATE] with [DIAGNOSES REDACTED]. The resident has no family. The Minimum Data Set 2.0 assessment ((MDS) dated [DATE] documented that the resident has moderately impaired decision-making skills and cognition. On 12/13/10 at 11:28pm, the resident was interviewed to see if he discussed advance directives with his social worker. The resident knew who the social worker was when given her name. He stated that he talked to her about wanting to go home. The resident was not familiar with the term advance directives. The surveyor tried to give examples and explanations of advance directives, and the resident did not seem able to understand the concepts. The resident said that he did not think that his social worker talked to him about these things. The "Advance Directives" sheet dated 9/27/00, in the front of the resident's chart, documented that the resident had not opted to sign a Do Not Resuscitate order or a Health Care Proxy form. The annual "Social Service Assessment" dated 9/15/10 documented that the resident had no advance directives. There was no documented evidence in the medical record that the Advance Directives were reviewed with the resident since 9/27/00. The Social Worker assigned to the resident was interviewed on 12/13/10 at 11:25am and 11:46am and stated that she is supposed to review advance directives at the time of her annual assessment and document it in the annual note. She further stated that she reviewed advance directives with this resident in simple terms annually, and he appeared to understand. The Director of Social Work was interviewed on 12/13/10 at 11:50am and stated that the resident may not be able to understand advance directives due to his cognitive deficits. She further stated that they will get a psychiatrist to evaluate the resident for capacity to make decisions about advance directives. She also stated that advance directives are reviewed annually and documented in the chart. The Administrator was interviewed on 12/13/10 at 3:30 PM and stated that Advanced Directives needs to be addressed on a yearly basis and documented in the resident's charts. 415.3(e)(1)(ii)

Based on observation and staff interviews, the facility did not ensure that residents receive services in the facility with reasonable accommodations of individual needs by not providing a functioning shower on the fourth floor. This was evident for 1 of 30 sampled residents (resident #20) and 8 of 9 out-of-sampled residents. (Residents # 32, #33, #34, #35, #36, #37, #38 and #39) This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings include but are not limited to: During an initial tour of the facility's 4th floor on 12/7/10 at 10:30 AM, the residents common shower/tub room was observed to be locked. The RN (registered nurse) who accompanied the surveyor on the tour was immediately interviewed and stated that the key was in the possession of the medication nurse. The LPN (licensed practical nurse) was interviewed at 10:35 AM and stated that the room was not available for use due to construction. 1. a)An interview was conducted with a CNA (certified nursing assistant ) on 12/7/10 at 10:50 AM . The CNA stated that the shower room was out of use for the past 2-3 months. He also stated that residents who needed a shower were cared for in resident #20's bathroom, room [ROOM NUMBER], as there was a private shower located there. He further stated that the resident residing in room [ROOM NUMBER] was removed from the room and brought to the day room each time the shower was "borrowed". Resident #20 is a [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. The MDS 2.0 (minimum data set) assessment dated [DATE] identified the resident as moderately impaired with decision making. Resident #20 resides in room [ROOM NUMBER] which contains a private shower/bathroom. 2. a)Resident #32 a [AGE] years old male admitted to the facility with [DIAGNOSES REDACTED]. The CNA (Certified Nurse Assistant) Accountability Record (CNAAR) dated 12/10/10 documented that the resident is to bath twice a week on Tuesday and Saturday on the 3-11 shift. The CNAAR documented that the resident was last given a shower on 12/10/2010. b)Resident #35 is a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. The CNAAR dated 12/10 documented that the resident showers twice a week on Tuesdays and Fridays during the 3-11 shift and the last shower was on 12/10/2010. c)Resident #38 is a [AGE] year old female admitted to the facility with [DIAGNOSES REDACTED]. The CNAAR dated 12/10/10 documented that the resident baths twice a week on Tuesday and Thursday. This record last documented that the resident received a shower on 12/09/2010. A CNA was interviewed on 12/07/10 at 3:30 PM and stated that the residents were being showered on the 5th floor or in room [ROOM NUMBER]. On 12/09/2010 at 5:00PM, the 3-11 shift CNA was interviewed and stated that when resident #20 is in the dining room, they take the residents schedule for a shower to resident #20's bathroom. They stated that they asked permission from the resident. If the resident is in her room, they take the residents to the 5th floor shower room . On further interview with the maintenance supervisor on 12/09/2010 at 5:10 PM, he stated " the shower was under repair and took this length of time because of issues with the contractor and the plumbing. He further stated "it was opened this morning, however this was not communicated to the unit manager . 415.5 (e)(1)