Every finding on record at Brookside Multicare Nursing Center

Based on observations, record review, interviews during the Recertification Survey initiated on 11/19/2025 and completed on 11/25/2025, the facility did not ensure that it implemented a comprehensive person-centered care plan to meet each resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. This was identified for one (1) (Resident #67) of four (4) residents reviewed for Pressure Ulcers. Specifically, Resident #67 had physician's orders for bilateral elbow pads to be worn at all times and padded side rails while in bed. The resident was observed on multiple occasions wearing either one elbow pad or no elbow pads. Additionally, the side rail pads were on the floor while the resident was in bed on one occasion.The finding is: The facility policy titled Comprehensive Care Plans and Resident/Patient Meeting, Timing, and Revisions dated 02/15/2025 documented the facility develops and implements a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet the residents medical, nursing and mental and psychosocial needs that are identified in the assessment. The purpose of the assessment is to accurately communicate the resident's capability to perform daily life functions and to identify significant impairments in functional capacity and the plan suggested by the care plan team for improvement/maintenance for each of the resident's primary care issues. Resident #67 was admitted with diagnoses including Cerebral Palsy, Seizure Disorder, and Aphasia (a language disorder caused by damage to the brain that affects a person's ability to speak, write, read, and understand language). The Annual Minimum Data Set assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making. The resident was at risk for pressure ulcer development and currently had no pressure ulcers. A Comprehensive Care Plan titled Padded Side Rails effective 09/08/2025 was last updated on 11/21/2025. Interventions included the use of padded side rails for injury prevention during seizures due to decreased safety awareness; and to check padding regularly to ensure it is secure, intact, and free of damage. A care plan note dated 09/12/2025 documented a trial of least restrictive restraints was attempted and unsuccessful due to the resident's involuntary flailing of upper and lower extremities. A Comprehensive Care Plan titled At Risk for Pressure Ulcers effective 10/06/2018 and last updated 07/31/2025 documented the resident was at high risk for pressure ulcer development. Interventions included to provide diligent skin care. A Side Rail assessment dated [DATE] documented the side rails were applied to the resident's bed for safety due to convulsions. The assessment documented the resident could not enter or exit the bed independently. The side rails did not restrict the resident's movement and do not meet the definition of restraint. The physician's orders dated 11/10/2025 documented seizure precautions; bilateral elbow pads at all times when in bed and when in the chair for prophylactic (prevention) measures; and four one-half padded side rails while in bed secondary to unawareness of physical boundaries due to the diagnosis of Epilepsy. During an observation on 11/19/2025 at 12:25 PM, Resident #67 was lying in bed. The resident only had an elbow pad applied to their left arm. During an observation on 11/20/2025 at 10:25 AM, Resident #67 was in their room sitting in the Geri-chair with a lap tray. The resident was not wearing any elbow pads and the resident's elbows were resting on the lap tray. An elbow pad was observed on the bedside table. During an interview and observation on 11/20/2025 at 10:30AM, Certified Nursing Assistant #6 stated the resident does require elbow pads. Certified Nursing Assistant #6 was observed taking the elbow pad off the resident's bedside table and then placed it on the resident's left elbow. Certified Nursing Assistant #6 searched for another elbow pad in the closets and drawers in the room. Certified Nursing Assistant #6 found the elbow pad in a closet and placed the pad on the resident's right elbow. Certified Nursing Assistant #6 stated they forgot to place the elbow pads on the resident earlier this morning. During an interview and observation on 11/21/2025 at 08:20 AM, Resident #67 was lying in bed. The four half side rails were raised and the side rail pads were on the floor. Certified Nursing Assistant #6 and Certified Nursing Assistant #7 were present in the room. Certified Nursing Assistant #6 stated they (Certified Nursing Assistant #6 and Certified Nursing Assistant #7) had just entered the room to provide morning care to Resident #67, and the side rail pads were on the floor when they entered the room. Certified Nursing Assistant #7 confirmed the same. Certified Nursing Assistant #7 stated the resident used to have a bed with full side rails, but the new bed has four half rails and the side rail pads in the room were for full side rail pads. Certified Nursing Assistant #7 demonstrated that the full side rail pads did not fit properly on the half side rails and would not stay in place. Certified Nursing Assistant #7 stated the nurse knows about the side rail pads not fitting the new bed. Certified Nursing Assistant #6 confirmed the same. The Certified Nursing Assistants did not know when the resident was given a new bed. During an interview on 11/21/2025 at 08:25 AM, Registered Nurse #5 (Unit Manager) stated the elbow pads should be on the resident at all times and Certified Nursing Assistant #6 would have to be re-educated. Registered Nurse #5 stated they did not know that the side rail pads did not fit the half side rails. Registered Nurse #5 stated if they had known, they would have alerted the Rehabilitation Department to provide the appropriate side rail pads. Registered Nurse #5 stated the resident used to have full side rails about a year ago. Registered Nurse #5 stated the nursing staff attempted to use less restrictive side rails including two upper side rails, but they were not appropriate because the resident had involuntary movements and did not have bed boundary awareness. The resident was provided four half side rails as the least restrictive alternative to full side rails. Registered Nurse #5 stated it is possible that the side rail pads were for the full side rails. During an interview on 11/21/2025 at 09:30 AM, the Rehabilitation Department Director #1 stated the Rehabilitation Department does not provide side rail pads. Rehabilitation Department Director #1 stated nursing and housekeeping staff provide side rails pads for the residents. During an interview on 11/21/2025 at 09:37 AM, Housekeeping Director #1 stated they did not know the side rail pads did not fit the side rails on Resident #67's bed. Housekeeping Director #1 stated the nursing staff did not report the problem to the Housekeeping Department. Housekeeping Director #1 stated they do have half side rail pads in stock and they provide the side rail pads when requested by the nursing staff. During an interview on 11/21/2025 at 12:15 PM, the Director of Nursing Services stated the resident should wear the bilateral elbow pads at all times, as indicated on the physician's order. The Director of Nursing Services stated the side rail pads should be in place when the resident is in bed and the half side rail pads should have been provided when the resident's bed was changed. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 11/19/2025 and completed on 11/25/2025 the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was identified for two (2) (Resident #116 and Resident #140) of seven (7) residents reviewed for Dignity. Specifically, during a lunch meal observation on 11/20/2025, Certified Nursing Assistant #2 and Registered Nurse #2 were observed standing over the residents while they fed the residents the lunch meal.The finding is: The facility policy titled Assisting with Feeding dated 01/21/2025 documented residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Staff should not stand over residents while assisting them with meals. Resident #116 was admitted with diagnoses including Alzheimer's (brain disorder that causes memory loss), Depression and seizures (sudden burst of electrical activity in the brain that can cause changes in a person's behavior, movements, feelings, and consciousness). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 0, indicating the resident had severe cognitive impairment. The resident was dependent on staff members for eating and meal setup. The Comprehensive Care Plan for Nutritional status, initiated on 03/07/2023 and last revised on 10/25/2025, documented the resident was at risk for compromised nutritional status related to a mechanically altered diet and potential for dehydration. The Comprehensive Care Plan for Activities of Daily Living, initiated on 03/06/2023 and last revised on 05/13/2024, documented the resident should be provided extensive assistance with eating. Resident #140 was admitted with diagnoses including Dementia (loss of memory, language, problem-solving and other thinking abilities), Aphasia (difficulty speaking), and iron deficiency Anemia (not enough iron to make healthy red blood cells, which are needed to carry oxygen). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 0, indicating the resident had severe cognitive impairment. The resident required maximal assistance with eating their meals. The Comprehensive Care Plan for Activities of Daily Living, initiated 11/09/2023 and last revised on 07/30/2024, documented the resident was dependent on staff members for feeding. During an observation of the Diamond Unit lunch meal service on 11/20/2025 at 12:21 PM, Registered Nurse #2 was feeding Resident #116 and Certified Nursing Assistant #2 was feeding Resident #140. Registered Nurse #2 and Certified Nursing Assistant #2 were both standing while feeding the residents. During an interview on 11/20/2025 at 01:51 PM, Certified Nursing Assistant #2 stated they usually sit down when feeding a resident. Certified Nursing Assistant #2 stated they were not sitting down because there were not enough chairs available. Certified Nursing Assistant #2 stated they should have been sitting when feeding a resident. During an interview on 11/20/2025 at 01:55 PM, Registered Nurse Unit Manager #3 stated that staff members should be seated next to the resident when assisting a resident with their meal. Registered Nurse Unit Manager #3 stated staff members are expected to sit and interact with the resident to maintain the resident's dignity and quality of life. During an interview on 11/25/2025 at 08:58 AM, the Director of Nursing Services stated that staff members are expected to sit next to and interact with the resident while assisting with a meal. The Director of Nursing Services stated the nursing staff members should have been at eye level with the residents while feeding and observing them for chewing. The Director of Nursing Services stated the staff members should never stand while feeding a resident. 10 NYCRR 415.5(a)

Based on observations, record review and interviews during the Recertification Survey initiated on 11/19/2025 and completed on 11/25/2025, the facility did not ensure that it provided a safe, clean, comfortable, and homelike environment. This was identified for one (1) (Broadway Unit) of seven (7) nursing units reviewed for Environment. Specifically, the ceiling in Resident #56's room had a hole that measured approximately one and half (1.5) feet by one and a half (1.5) feet. The hole had water stains along the edges and had draping plaster hanging on each side. Additionally, the wall above the window in Resident #56's room was poorly spackled and had water stains. The finding is: The facility policy titled Maintenance Requests Internal Work Orders, last revised on 01/2025, documented that anyone requesting a maintenance repair must fill out a maintenance request form. Maintenance mechanic/designee will collect all maintenance requests daily. Work orders will be prioritized and distributed to maintenance staff for completion. Time frames for work order completions will be based on the complexity of the work and the availability of materials. Completion dates will vary based on the scope of work. Resident #56 was admitted with diagnoses including Type 2 Diabetes, Acute Kidney Failure, and Bipolar Disorder (a mental health condition characterized by extreme mood swings). An Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #56 had intact cognition. During an observation on 11/19/2025 at 10:16 AM, Resident #56 was lying in their bed. The ceiling near the window of Resident #56's room had a one-and-a-half (1.5) feet by one-and-a-half (1.5) feet hole with draping plastic paper hanging on each side of the hole and the edging around the hole opening had water stains. The wall above the window in Resident #56's room was poorly spackled and had water stains. During an interview on 11/19/2025 at 10:25 AM, Resident #56 stated they told the nursing staff about the hole in the ceiling and could not remember when they reported the problem. Resident #56 stated the nursing staff were aware that the ceiling needed to be fixed. Resident #56 stated the ceiling leaks when it rains outside. Resident #56 stated their bed was not directly below the ceiling, but they were concerned about the leak. Resident #56 stated that Maintenance should have fixed the ceiling by now and they were frustrated with the condition of their room. During an observation on 11/20/2025 at 08:20 AM, Resident #56 was lying in their bed. The resident's room was in the same condition observed on 11/19/2025. A review of the maintenance request book revealed there were no requests made to repair the ceiling in Resident #56's room. During an interview on 11/20/2025 at 08:30 AM, Registered Nurse #1, the Unit Manager, stated that maintenance requests should be written in the maintenance request book. Registered Nurse #1 stated they knew that Resident #56's ceiling needed to be fixed and could not remember how long the hole has been in the ceiling. Registered Nurse #1 confirmed maintenance staff were notified about Resident #56's room condition but could not remember when. Registered Nurse #1 stated they did not know why the requested work order was not in the maintenance request book. During an interview on 11/20/2025 at 08:54 AM, the Director of Building Services stated they did not know that the ceiling in Resident #56's room needed to be fixed. The Director of Building Services stated they reviewed the maintenance request book and did not see any requests from the nursing staff to repair the ceiling in Resident #56's room. During an interview on 11/20/2025 at 09:19 AM, Maintenance staff member #1 stated they were assigned to Resident #56's room and did not know the ceiling in Resident #56's room needed to be fixed. Maintenance staff member #1 stated they did not remember if the nursing staff made a maintenance request for Resident #56's room. Maintenance staff member #1 stated they do environmental rounds everyday but did not notice the hole in the ceiling of Resident #56's room. During an interview on 11/20/2025 at 09:51 AM, Certified Nursing Assistant #1, who was regularly assigned to Resident #56, stated all the staff members were aware that Resident #56's room ceiling needed to be fixed. Certified Nursing Assistant #1 stated the condition of Resident #56's room had been reported numerous times, and they did not know why a work order was not in the maintenance request book. Certified Nursing Assistant #1 stated the resident's room was in disrepair for more than two weeks. During an interview on 11/21/2025 at 11:00 AM, the Administrator stated the unit nursing staff should have entered the request in the maintenance request book as soon as they observed the hole in Resident #56's room ceiling. The Administrator stated the maintenance staff should have fixed the ceiling in Resident #56's room. 10 NYCRR 415.5(h)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 6/17/2024 and completed on 6/26/2024, the facility did not ensure that all drugs were stored in accordance with professional standards. This was identified for three (Carnation, Broadway, and Azaelia) of seven units reviewed for the medication storage task. Specifically, 1) The Carnation unit medication storage Room was observed on 6/21/2024 with four bottles of Aspirin (blood thinner) 325 milligrams with an expiration date of 4/2024; 2) The Broadway Unit medication storage room was observed on 6/21/2024 with nine bottles of Aspirin 325 milligrams and three bottles of Vitamin B12 (a vitamin supplement) with an expiration date of 4/2024; and 3) The Azaelia Unit medication storage room was observed on 6/21/2024 with three bottles of Aspirin 325 milligrams with an expiration date of 4/2024. The findings are: The facility's Storage of Medicine policy last reviewed on 2/2024 documented the facility shall not use outdated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The nursing staff shall be responsible for maintaining medication storage. 1) During the medication storage task on 6/21/2024 at 6:11 AM, the Carnation Unit medication storage room was observed accompanied by Licensed Practical Nurse #4. There were four bottles of Aspirin 325 milligrams with an expiration date of 4/2024. Licensed Practical Nurse #4 was interviewed on 6/21/2024 at 6:11 AM and stated they were not sure who was responsible for removing the expired medications from the medication room. Licensed Practical Nurse #4 stated the expired Aspirin bottles should not remain on the unit. Unit Manager #10 was interviewed on 6/26/2024 at 11:20 AM and stated they checked the medication storage room every day and it was an oversight on their part that they did not identify the expired medications. 2) During the medication storage task on 6/21/2024 at 6:32 AM, the Broadway Unit medication storage room was observed accompanied by Licensed Practical Nurse #5. There were nine bottles of Aspirin 325 milligrams and three Vitamin B12 bottles with an expiration date of 4/2024. Licensed Practical Nurse #5 was interviewed on 6/21/2024 at 6:32 AM and stated they did not deal with expired medications because they work during the overnight shift. The day shift Unit Managers are responsible for checking the expiration dates for medications that are stored in the medication room. Unit Manager #11 was interviewed on 6/26/2024 at 11:23 AM and stated they checked for expired medications in the medication room every day. Unit Manager #11 stated they did not know how the expired Aspirin and Vitamin B12 bottles remained in the medication room because the Pharmacist also checks for expired medications every month. Unit Manager #11 stated the expired medications are expected to be removed from the medication room and placed in the Nursing Supervisor's office for proper disposal. 3) during the medication storage task on 6/21/2024 at 6:50 AM, Azaelia Unit medication storage room was observed accompanied by Licensed Practical Nurse #6. There were two bottles of Aspirin 325 milligrams with an expiration date of 4/2024. Licensed Practical Nurse #6 was interviewed on 6/21/2024 at 6:50 AM and stated they did not know there were expired Aspirin bottles in the medication storage room. Licensed Practical Nurse #6 stated all nurses are responsible for checking the expiration dates on all medications. Unit Manager #3 was interviewed on 6/26/2024 at 11:28 AM and stated they check for expired medications every day and did not know how the expired Aspirin bottles were left in the medication storage room. Unit Manager #3 stated they are expected to place the expired medications in the supervisor's office. Pharmacist #2 was interviewed on 6/26/2024 at 12:04 PM and stated they assist the facility in reviewing the medication storage areas monthly to ensure the expired medications are removed from the storage areas. Pharmacist #2 stated either the nurse or the Pharmacist is supposed to remove expired medications from the units. Pharmacist #2 stated they did not know why Carnation, Broadway, and Azaelia units still had expired medication bottles in the medication storage rooms. The Director of Nursing Services was interviewed on 6/26/2024 at 1:55 PM and stated the Pharmacist is expected to visit each unit every month to discard the expired medications. The Director of Nursing Services stated it was not acceptable to have expired medication in the medication storage areas. 10 NYCRR 415.18(e)(1-4)

Based on record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE] the facility did not ensure a person-centered comprehensive care plan was reviewed and revised to address each resident's needs. This was identified for one (Resident #73) of one resident reviewed for Advanced Directives. Specifically, Resident #73 had a Do Not Resuscitate (the resident does not want cardiopulmonary resuscitation (CPR) the person has no heartbeat and is not breathing) Advance Directive in place in [DATE], which was later rescinded in February 2022 by the resident's representative; however, the resident's comprehensive care plan was not revised to accurately reflect interventions for the resident's current Advance Directive, full code status (full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and is not breathing). The finding is: The facility's policy and procedure titled Comprehensive Care Plans (CCP) and Resident/Patient Meeting, effective [DATE], documented that the comprehensive care plans will be revised, or new care plans will be developed quarterly, annually, and as needed, within seven days of the Minimum Data Set Assessment completion. Resident # 73 had diagnoses including Diabetes Mellitus, Seizure Disorder, and Major Depressive Disorder. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status of 11 which indicated the resident had moderately impaired cognition. The Minimum Data Set documented the resident had behavioral symptoms of rejection of care for one to three days during the assessment period. A comprehensive care plan titled Advance Directive, effective [DATE] and last reviewed on [DATE] documented No Advance Directives in place; however, the interventions in the care plan included to ensure the resident's face sheet and armband reflect Do Not Resuscitate, obtain necessary physician orders to conform to residents wishes, and provide and review information regarding Advance Directives with resident/ family/designated representative. The Physician's orders as of [DATE] did not indicate that Resident #73 had Advance Directives in place. Social Worker #2 was interviewed on [DATE] at 4:02 PM and stated that the social workers are responsible for developing and updating the Advance Directives care plans. Social Worker #2 stated that Resident #73 did not have advance directors upon admission in 2015. In December of 2021, Advance Directives for Do Not Resuscitate and Do Not Intubate and comfort measures (no invasive life-sustaining procedures) were instituted. The resident's surrogate rescinded the comfort measures in February 2022 and requested the resident become a full code. Social Worker #2 stated that the interventions should have been changed in February 2022 to reflect the resident's full code status and they did not know why the interventions in the Advance Directives care plan were not corrected to remove the Do Not Resuscitate status. The Minimum Data Set Director was interviewed on [DATE] at 9:41 AM and stated that the comprehensive care plans should be updated along with the Minimum Data Set assessment schedule and as needed as changes occur. The Minimum Data Set Director further stated that the interdisciplinary team is responsible for ensuring the care plans are timely updated and accurate. The Minimum Data Set Director stated the Social Work department was primarily responsible for developing and updating the Advance Directives care plans. The Minimum Data Set Director stated that the interventions on Resident #73's Advance Directive care plans should have been revised to reflect that the resident was a full code. 10 NYCRR 415.11

Based on record review and staff interviews during the Recertification Survey initiated on 6/17/2024 and completed on 6/26/2024, the facility did not ensure that the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. This was identified for one (Resident #136) of five residents reviewed for Unnecessary Medications. Specifically, the Medication Regimen Review for Resident #136 dated 5/15/2024 documented a recommendation from the consultant Pharmacist to evaluate Rozerem (a sedative to treat sleeplessness) and to consider trial taper to as needed (PRN) for one week then discontinue, if appropriate. The Physician agreed with the recommendation; however, did not address the recommendation and did not document the plan in Resident #136's medical record. The finding is: The facility's policy and procedure titled Pharmacy Drug Regimen Reviews last revised on 7/25/2017 documented that the Consultant Pharmacist shall review the medical record of each resident and perform a Drug Regimen Review at least once each calendar month. The Attending Physician or licensed designee shall respond to the Drug Regimen Review within seven days of the receipt. The Physician must document on the Drug Regimen Review Sheet if in agreement or disagreement with the recommendation and provide a brief clinical rationale if no change is to be made. Resident #136 was admitted with diagnoses of Insomnia (difficulty falling and staying asleep), acute Respiratory Failure, and Diabetes. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The Quarterly Minimum Data Set (MDS) documented Resident # 136 received high-risk medications that included anti-anxiety and hypnotic (drug for sleep disorder) medications. The Insomnia Comprehensive Care Plan dated 2/4/2024 included interventions to administer medications as per the physician's order, monitor for adverse effects, and notify the Physician of any changes in the sleep pattern. A physician's order dated 4/8/2024 documented to administer Rozerem 8 milligrams one tablet by oral route once daily at bedtime for Insomnia. A Medication Regimen Review (MRR) dated 5/15/2024, completed by the consultant Pharmacist, documented Resident #136 was receiving Ramelteon (Rozerem) at bedtime for Insomnia. The consultant Pharmacist recommended that the Physician evaluate the current need and consider a trial to taper the medication to as needed (PRN) for one week, then discontinue, if appropriate. The report indicated that the Physician agreed with the consultant Pharmacist's recommendations; however, the Medication Regimen Review form was not signed or dated by the Physician. A Medical Progress Note from the Attending Physician dated 5/16/2024 at 1:28 PM documented that a review of medication management was performed. The note did not include a plan to address recommendations made by the consultant Pharmacist regarding Rozerem medication. Registered Nurse #4 was interviewed on 6/24/2024 at 10:30 AM and stated the Physician's note did not document or address recommendations made by the consultant Pharmacist regarding Resident #126's Rozerem medication use. Registered Nurse #4 stated the Physician saw Resident #136 on 5/16/2024 and documented that a review of the medication management was performed; however, the Physician did not make changes to the Rozerem medication use as recommended by the Pharmacist. A physician's order dated 6/24/2024 documented to administer Rozerem 8 milligrams one tablet by oral route once daily for seven days at bedtime as needed. The Attending Physician #1 was interviewed on 6/25/2024 at 8:10 AM and stated they reviewed and agreed with the recommendation made by the consultant Pharmacist on the Medication Record Review (MRR) on 5/16/2024 and did not document the plan to taper the Rozerem from 8 milligrams per day to as needed. The Director of Nursing Services was interviewed on 6/25/2024 at 9:17 AM and stated Attending Physician #1 should have documented their plan for Rozerem dose reduction in the progress notes. The Consultant Pharmacist was interviewed on 6/25/2024 at 1:54 PM and stated that medications for Insomnia are reviewed periodically. The Consultant Pharmacist stated long-term use of Rozerem causes drowsiness which is why they recommended tapering of the medication use. 10 NYCRR 415.18(c)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 6/17/2024 and completed on 6/26/2024, the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Resident #301) of two residents reviewed for Accident Hazards. Specifically, Resident # 301 had a physician's order for Premarin (a cream containing a mixture of estrogen hormones to treat menopause symptoms) vaginal cream to be applied to the vaginal area by the facility staff. During an observation on 6/17/2024, a tube of conjugated (joined together) Premarin vaginal cream was observed on the resident's overbed table. The resident was using the Premarin vaginal cream daily and was applying the cream to their abdominal folds and groin areas themselves. The resident did not have a physician's order to self-administer their medications. The finding is: The facility Medication Administration and Documentation-General policy and procedure, last revised on 6/7/2024, documented that only Physicians or Licensed Nurses may administer medications unless the resident is permitted to administer their medications on the order of the Physician. The Licensed Nurse is responsible for ensuring that medications are not left unattended and are kept secured in a locked area or visible control at all times. Resident # 301 was admitted with diagnoses of Postmenopausal Atrophic Vaginitis, Diabetes, and Asthma. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated Resident #301 had intact cognition. Resident # 301 was receiving antibiotics, diuretics (a medication used to reduce fluid buildup), and hypoglycemic (lowers blood sugar) medications. A physician's order dated 4/23/2024 documented to apply conjugated (joined together) Premarin (estrogen) 0.625 milligrams per gram vaginal cream; Insert one applicator (2 grams) by vaginal route once daily. The Comprehensive Care Plan for Vaginitis dated 4/23/2024 documented interventions including administering medications as per physician's orders and monitoring the resident for any adverse reactions. A review of the Electronic Medication Administration Record (EMAR) revealed conjugated Premarin vaginal cream was administered to Resident #301 daily by the nurses, as evidenced by nurses' signatures. During an observation on 6/17/2024 at 10:30 AM, Resident # 301 was sitting in a wheelchair in their room, next to the overbed table. A tube of half-used conjugated Premarin vaginal cream was observed on the overbed table. The conjugated Premarin vaginal cream tube did not have a label with the resident's name or administration directions. There was no staff member present in Resident # 301's room at the time of the observation. Resident # 301 was interviewed on 6/17/2024 at 10:45 AM and stated they have been applying the Premarin vaginal cream daily to their abdominal fold and groin area. Resident #301 did not recall how they got the conjugated Premarin vaginal cream. A review of the physician's orders from 4/23/2024 to 6/17/2024 revealed that Resident # 301 did not have an order to self-administer any of their medications. A review of the electronic medical record from 4/23/2024 to 6/17/2024 revealed that Resident #301 was not assessed to self-administer their medications. Registered Nurse #2 was interviewed on 6/17/2024 at 10:50 AM and stated Resident #301 was not supposed to have any medications in their room. The conjugated Premarin vaginal cream should have been stored and locked in the treatment cart. Registered Nurse #2 stated that Resident #301 did not have any order to self-administer any medications. Licensed Practical Nurse #2 was interviewed on 6/18/2024 at 11:28 AM and stated they administered the conjugated Premarin vaginal cream to Resident #301 when they worked as a medication nurse on the resident's unit. Licensed Practical Nurse #2 stated they did not observe the conjugated Premarin vaginal cream on Resident #301's overbed table during their shift. Licensed Practical Nurse #2 stated that Resident #301 should not have any medications in their room. The Pharmacist was interviewed on 6/21/2024 at 8:55 AM and stated conjugated Premarin vaginal cream is considered a hazardous drug because the medication contains estrogen and when applied topically, the medication can cause darkening of the skin, redness, irritation, burning, and itching. The Pharmacist stated Premarin vaginal cream can also cause mood changes, fatigue, insomnia (problems falling and staying asleep), irritability, and hair loss therefore, the medication should be administered as per the Physician's Order. The Director of Nursing Services was interviewed on 6/25/2024 at 9:31 AM and stated that all medications should be stored in the medication or the treatment carts. The medications should not be left in the resident's room without proper supervision. The Director of Nursing Services stated the unit staff should notify the unit nurse when they observe unattended medications in the resident rooms. 10 NYCRR 415.12(h)(1)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that the resident environment remains as free of accident hazards as possible. This was identified for 2 (Resident #307 and Resident #159) of 7 residents reviewed for accidents and in the Carnation/Broadway unit dining room. Specifically, 1) A bottle of Pharma [NAME] [MEDICATION(S)] (CBD) Oil, a bottle D-Mannose capsules (Supplement for urinary tract), a bottle of Acidophilus 100 million organism tablets, and a bottle of Cranberry 4200 milligram (mg) with vitamin C soft gels, were observed unattended on Resident #307 bedside table, 2) Two Acetaminophen tablets were observed in a souffle cup on Resident #159's bedside table, 3) On 10/25/2022 during an initial tour in the shared Carnation and Broadway unit dining room, the ice machine was observed to be leaking with a tray under the ice machine that contained water. Two wet blankets and a wet towel were observed on the floor near the ice machine. The ice machine cord was unplugged and hanging over a garbage pail which was positioned under the ice machine table. The findings are: 1) The Facility Protocol for prohibited substances and unprescribed medications dated June 2018 documented that all unprescribed medications found in the resident's room will be removed pending physician evaluation. Resident # 307 has diagnoses of [CONDITION(S)] and Femur Fracture. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition. On 10/25/2022 at 1:23 PM, Resident #307 was observed in their bed. The bedside table had a bottle of Pharma [NAME] CBD oil, a bottle of D-Mannose capsules, a bottle of Acidophilus 100 million organism tablets, Cranberry 4200 mg, and vitamin C soft gels. A review of the current Physician's orders dated 9/25/2022 did not include any of the supplements observed on the bedside table by the surveyor on 10/25/22. The Certified Nursing Assistant (CNA) #10 was interviewed on 11/01/2022 at 3:26 PM. CNA #10 stated they (CNA #10) never observed the resident's supplements on the Resident's bedside table. The Licensed Practical Nurse (LPN) # 7 was interviewed on 11/02/2022 at 11:11 AM and stated that they (LPN #7) never observed the supplements or oil stored on the resident's bedside table. They (LPN #7) further stated that the resident is not allowed to have any supplements on their bedside table without a Physician's order. On 11/1/2022 at 12:07 PM Resident #307 was observed in their bed. The bedside table had a bottle of Pharma [NAME] CBD oil, a bottle of D-Mannose capsules, a bottle of Acidophilus 100 million organism tablets, Cranberry 4200 mg, and vitamin C soft gels. The Unit Registered Nurse (RN) Manager #7 was interviewed on 11/1/2022 at 12:07 PM and stated they did not know that Resident #307 had supplements in their possession. RN #7 stated that Resident #307 was not allowed to have any supplements in their possessions without a Physician's order since the Resident had a history of pocketing medications. RN #7 stated that they (RN #7) did not know if any of these supplements would interfere with the medications the resident was taking. The resident's Primary Care Physician was not available for an interview. The covering Physician (MD#1) was interviewed on 11/02/2022 at 12:15 PM and stated that they (MD #1) were the covering doctor for Resident #307's Primary Care Physician. MD #1 stated they (MD #1) did not know the resident's medical history, but it was not safe for any resident to have these supplements in their possession as consumption of the supplements may interfere with the prescribed medications. MD #1 stated they (MD#1) will have a team meeting including the resident to see if it was safe for the resident to keep these supplements in their possession. The Director of Nursing Services (DNS) was interviewed on 11/02/2022 at 2:00 PM and stated that since the covering doctor did not think to give Resident #307 permission for self-medication administration, we took the supplements away from the resident. The DNS stated they (DNS) did not know Resident #307 had the supplements in their possession and it is not okay because of potential interaction with the prescribed medications. The DNS stated the resident has a history of using supplements inappropriately, but they did not know all the details. The DNS further stated they (DNS) will have a care plan meeting with the interdisciplinary team, and they will include Resident #307 in the meeting to discuss the resident having the supplements in their possession and self-administration of the supplements. 2) The facility Administration of Medication Policy and Procedure updated 4/20/2019 documented that medications are administered in accordance with Prescriber orders, including any required time frame. The policy did not address medication being left at the bedside without a Physician's order for self-administration. Resident #159 was admitted with diagnoses that included [CONDITION(S)], [CONDITION(S)], and Hypertension. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition. The resident required assistance for all activities of daily living. A Physician's order dated 10/9/2022 documented Acetaminophen 500 milligram (mg) 2 tablets by oral route every 12 hours for right shoulder pain. During an observation on 11/2/2022 at 10:55 AM a souffle cup containing two white round tablets was observed on Resident #159's bedside table. Resident #159 was interviewed on 11/2/2022 at 10:55 AM, immediately after the observation was made. Resident #159 stated that they had two Tylenol tablets in a souffle cup that were given to them (Resident #159) during the medication administration pass. Resident #159 stated that they usually take the Tylenol with apple sauce and would take them soon. Licensed Practical Nurse (LPN) #6 was interviewed on 11/2/2022 at 11:01 AM and stated they (LPN #6) had administered Tylenol to Resident #159 and that they (LPN #6) thought the resident had taken the medication. LPN #6 and the state surveyor entered Resident #159's room and LPN #6 confirmed there were two Tylenol tablets in the souffle cup. Resident #159 then took the Tylenol tablets. LPN #6 stated that medications should not be left at the resident's bedside, and they (LPN #6) should have ensured that the resident had taken all their medications prior to leaving the resident's room. Registered Nurse (RN) #4 was interviewed on 11/2/2022 at 11:09 AM and stated at no time should medications be left at the resident's bedside. RN #4 stated that the medication nurse must ensure that all medications are taken by the resident before leaving the resident's room. RN #4 further stated that LPN #6 should not have left the Tylenol tablets at the resident's bedside. The Director of Nursing Services (DNS) was interviewed on 11/2/2022 at 2:27 PM and stated that LPN #6 should have waited until Resident #159 took all their medications before leaving the resident's room. The DNS stated medications are left at the resident's bedside for residents who had a Physician's order for self-administration of medication. A review of the resident's Physician orders was conducted by the DNS. The DNS stated that Resident #159 did not have an order for self-administration of Tylenol, therefore, LPN #6 should not have left the Tylenol at the resident's bedside. The DNS stated that leaving the Tylenol at the bedside put the resident at risk of pocketing the Tylenol and potentially taking more than the ordered dose of Tylenol at a later time. 3) On 10/25/22 at 11:21 AM during an initial tour in the shared Carnation and Broadway unit dining room an ice machine was observed to be leaking. There were two wet blankets and a wet towel observed on the floor, a tray with water was observed on a rack under the ice machine table, the ice machine was unplugged, and the cord was hanging over a garbage pail that was also under the table. Several residents were sitting in wheelchairs in the dining room and residents were ambulating in the hallway outside the dining room. There was no signage observed that indicated the presence of a wet floor. The Maintenance Director was interviewed on 11/2/2022 at 3:09 PM and stated they (Maintenance Director) were not aware that the ice machine was leaking until it was brought to their attention by the Surveyor. The Maintenance Director stated the staff that identified that the ice machine was leaking should have placed a wet sign in the area to alert others of the wet floor and to prevent accidents. The Maintenance Director stated that the housekeepers always have a wet sign on their cart in case of an emergency and that any staff could have placed the wet sign in the dining room. The Maintenance Director stated a wet sign should have been placed immediately in the dining room by the ice machine to prevent accidents. 415.12 (h)(1)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that residents are adequately equipped to call for staff assistance through a communication system directly to a staff member or centralized staff work area from each resident's bedside. This was identified for 3 (Resident #137 #240 and #252) of 11 residents in the initial pool reviewed for Environmental Task. Specifically, 1) Resident #137 was observed in bed on 10/25/2022 and the call bell was observed on the floor out of the resident's reach; 2) Resident #240 was observed in bed on 10/25/2022 and 10/26/2022 with the call device out of the resident's reach; 3) Resident #252 was observed in their room on 10/25/2022 with the call device out of the resident's reach. The findings are: The facility Accident Prevention Policy dated 2/26/2018 documented, in the safety measures section, call bells and personal items should be within the resident's reach. 1) Resident #137 was admitted with diagnoses that included [CONDITION(S)], Chronic Obstructive Pulmonary Disease, and [CONDITION(S)]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 13 which indicated intact cognition. The resident had no behavioral symptoms and required assistance of staff for all activities of daily living. During an observation on the Broadway Nursing Unit on 10/25/2022 at 2:00 PM, Resident #137 was observed in bed with the head of the bed elevated. The resident was awake and responded appropriately to greetings. The resident's call bell was not visible at the resident's bedside. Certified Nursing Assistant (CNA #7) was notified of the observation. Upon entering the resident's room CNA #7 was unable to find the call bell next to the resident. CNA #7 observed the call bell on the floor behind the head of the resident's bed. The call bell was observed without a clip to attach the cord to the resident's sheet. CNA #7 was interviewed on 10/25/2022 at 2:09 PM and stated that they (CNA #7) were the assigned CNA for Resident #137 on 10/25/2022 from 12 PM through 10 PM. CNA #7 stated they (CNA #7) could not recall when they last saw Resident #137. CNA #7 stated that the resident's call bell should have been next to the resident and within the resident's reach. CNA #7 stated the call bell must have fallen. CNA #7 stated that the CNAs were responsible for ensuring the resident's call bell is always within reach. The Registered Nurse (RN) #4, who was the RN Manager, was interviewed on 10/26/2022 at 10:45 AM. RN #4 stated that all staff were responsible for ensuring that the residents' call bells are within reach at all times. RN #4 stated that there should have been a clip attached to the call bell cord to secure the call bell next to the resident. 2) Resident #240 was admitted with diagnoses that include Mild Cognitive Disorder, Convulsion, and Mood Disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderately impaired cognition. The resident had no mood or behavioral symptoms and required assistance for all Activities of Daily Living. During an initial tour of the Broadway Nursing Unit on 10/25/22 at 11:29 AM Resident #240 was observed in bed asleep. The resident's call bell was observed draped over the night table and was resting on the floor under a chair on the left side of the resident's bed. A second observation was conducted on 10/26/2022 at 10:30 AM. The resident was awake in bed and was observed wearing a left-hand roll. The call bell cord was observed lodged between the mattress and the left side rail and was out of the resident's reach. Licensed Practical Nurse (LPN) #6 was interviewed on 10/26/2022 at 10:40 AM. Upon entering the resident's room LPN #6 acknowledged the call bell tucked between the resident's mattress and the left side rail. The resident was unable to reach the call bell and was wearing a left-hand roll. LPN #6 stated that it was the responsibility of all the staff to ensure that the resident's call bell is within reach at all times. LPN #6 stated that the call bell should have been at the resident's bedside on the unaffected side in the resident's reach. LPN #6 placed the call bell on the right side of the bed next to the resident and the resident demonstrated ability in using the call bell CNA #6, who cared for Resident #240 on 10/26/2022, was interviewed on 11/2/2022 at 10:22 AM. CNA #6 stated the resident uses a left-hand roll and is able to use the call bell with their right hand. CNA #6 stated that they were responsible for ensuring that the resident's call bell was within reach at all times. CNA #6 stated that they (CNA #6) usually place the resident's call bell within reach and did not know how the call bell got between the mattress and the side rail. CNA #6 stated that at no time should the resident be without their call bell. The Director of Nursing Services (DNS) was interviewed on 11/2/2022 at 2:35 PM and stated that it was the responsibility of all staff to ensure that the resident's call bell is within reach. The DNS stated that the resident moves around in the bed and probably dislodged the call bell; however, staff should make frequent rounds to ensure the resident's call bell was at their bedside within reach. The DNS further stated that there should be a clip on the call bell cord to keep the resident's call bell in place. 3) Resident #252 has diagnoses of Sleep Apnea, Social Pragmatic Communication Disorder, and Leigh's Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated that the resident was cognitively intact. The MDS documented the resident required extensive assistance of one person for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS documented the resident utilized a wheelchair for mobilization, had no limitation in range of motion, and was frequently incontinent of bladder and occasionally incontinent of bowel. The Comprehensive Care Plan (CCP) for vision dated 9/7/2022 documented adequate vision. The intervention including to keep objects in the visual field. The CCP for communication dated 9/21/2022 documented interventions including to keep the call bell within reach. During an observation on 10/25/2022 at 2 PM, Resident #252 was observed sitting in a wheelchair in their room by the room entrance door. Resident #252 asked for assistance to retrieve their call bell. Resident #252's bed was observed against the wall and the call bell was not visible. The Assistant Director of Nursing (ADNS) was asked to locate Resident #252's call bell. The ADNS found Resident #252's call bell underneath the upper corner of the resident's mattress and was out of the resident's reach. The ADNS was interviewed on 10/25/2022 at 2 PM immediately after the observation and stated that the call bell was out of Resident #252's reach. The ADNS further stated the call bell should always be available and within the resident's reach. Resident #252 was interviewed on 10/25/2022 at 2:01 PM and stated that the call bell was wrapped on the side rail overnight but during the day shift the staff did not place the call bell on their bed where Resident #252 could reach the call bell when needed. Resident #252 further stated they want to be able to utilize the call bell during the day. The 6 AM-2 PM shift Certified Nursing Assistant (CNA) #12 was interviewed 11/01/2022 at 12:18 PM and stated that they (CNA #12) remembered they placed the call bell within Resient#252 reach when they got the resident out of the bed in the morning. CNA #12 stated they (CNA #12) do not know how the call bell ended up under the mattress. CNA #12 further stated that Resident #252 utilizes the call bell to call for assistance. The ADNS was interviewed on 11/01/2022 at 11:31 AM and stated that Resident #252 preferred their (Resident#252) call bell attached to the left side of the bed on the side rail at night, and preferred the call bell placed on the bed during the day time. The ADNS stated maybe the day shift CNA forgot to place the call bell on the bed in the morning. The ADNS stated that it was not possible for the resident to have placed the call bell under the mattress as observed on 10/25/2022. The ADNS further stated that it was not acceptable that Resident #252's call bell was not within their reach. The RN Unit Manager #7 was interviewed on 11/01/2022 at 1:36 PM and stated that Resident #252's call bell should have been within reach, and it should be clipped on the bed. The Unit Manager further stated that they will educate the CNAs to make sure they are placing the call bells on the bed during the day. The Director of Nursing Services (DNS) was interviewed on 11/2/2022 at 2 PM and stated that Resident #252's call bell should always be within the resident's reach. 415.29

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022 the facility did not ensure that housekeeping and maintenance services were provided to maintain a sanitary, orderly, comfortable, and homelike environment on 4 of 7 residential units and the main kitchen area. Specifically, 1) On the [NAME] unit, in room number 16, there were water stains on the ceiling, patched areas of wall that were not painted, floor molding missing from the sink area, a hole in the wall behind the room entrance door, and broken wood covering radiator pipes; 2) On the Broadway unit, in room 22 a dry dirt-like substance was observed on the floor and in the grout at the resident's bedside, in the corners of the room, and in front of the sink area; 3) On the Petal unit, in room 12, the floor was observed with yellow, brown, and black spots in the center of the room and blackened accumulated debris under and around residents' beds; 4) The walls and ceilings in the corridors of the Diamond, [NAME], and Broadway nursing units were noted with unpainted spackling throughout; 5) The [NAME] unit dayroom walls and ceiling were noted with unpainted spackling; 6) The Broadway nursing unit was noted with peeling paint; and 7) The ceiling in the main kitchen in the basement was noted with unpainted spackling by the dishwasher room and by the food preparation area. The findings include but are not limited to: The facility's policy titled Internal Work Orders (Maintenance Requests), dated 12/2021, documented maintenance mechanic/designee will collect all maintenance requests daily. Work orders will be prioritized and distributed to maintenance staff daily in order to ensure a proper mechanism for residents, staff, and family members to report maintenance issues that require repair. The facility's undated policy titled Room Readiness and Unit Cleanliness for Housekeeping Staff documented any maintenance-related concerns should be placed in the maintenance book that is located at every unit nursing station. 1) On 10/25/2022 at 11:36 AM an observation of [NAME] unit room 16 was made. The resident who resided in the room complained about environmental conditions in the room. There were rusty, brown water damage areas on the ceiling, multiple wall areas that were patched but not painted, missing floor molding by the sink, a hole in the wall behind the room entrance door (this was not a spot where the door handle makes contact), and broken wood that was covering the radiator pipes. The Maintenance Director and Maintenance Engineer were interviewed concurrently on 10/27/2022 at 8:38 AM and the conditions in room 16 were observed, which had not been repaired yet. They (Maintenance Director and Maintenance Engineer) stated they were not aware of the hole behind the door. The resident who resided in the room was also present in the room. The resident stated that the hole in the wall was not new and had been there since the resident was admitted . Regarding the missing molding by the sink and the multiple patched areas in the wall by the sink, the Maintenance Director stated the old-style sink with the platform was replaced with a new sink and that is why the molding is missing and the walls are patched up. The Maintenance Director could not identify when the sink replacement took place. Regarding the rusty, brown water-damaged areas on the ceiling, the Maintenance Engineer stated the damage was from a water leak that occurred a few weeks ago and was fixed, and the room is slated to be repainted. Regarding the broken wood covering the radiator pipes, the Maintenance Director stated the facility has the material to replace the broken wood and it would be done today. Housekeeper #2 was interviewed on 10/27/2022 at 9:36 AM and stated they (Housekeeper #2) clean room 16 daily. Housekeeper #2 stated the wall was broken by a past resident who is no longer in the facility. Housekeeper #2 stated they (Housekeeper #2) had documented the broken wall concern in the maintenance logbook. Housekeeper #2 reviewed the maintenance book and could not identify where or when they (Housekeeper #2) had logged the concern of the hole in the wall in room 16. The Maintenance Director was re-interviewed on 11/1/2022 at 8:30 AM. The Maintenance Director stated all staff can enter maintenance issues in the maintenance logbook. The Maintenance Director stated painting should be done within a few days after walls are patched or water damage has occurred, and the leak is fixed. The Maintenance Director stated the painting had not been done yet because the staff were busy patching other areas in the facility. 2) During an initial tour conducted on 10/25/2022 at 11:38 AM on the Broadway nursing unit, a resident who resided in Room 22 complained that the floor in their room was not mopped frequently. On observation, a dry dirt-like substance was observed on the floor and in the grout at the resident's bedside, in the corners of the room, and in front of the sink area. Housekeeper #3 was interviewed on 11/2/2022 at 11:13 AM. Housekeeper #3 stated the rooms are swept daily and mopped every other day. Housekeeper #3 stated they were not aware of the condition of the floor in room 22. The Housekeeping Director was interviewed on 11/2/2022 at 3:16 PM. The Housekeeping Director stated that the rooms are mopped every other day and upon request. The Housekeeping Director stated that they were never informed that room 22 was not being mopped every other day. The Housekeeping Director stated that the floor in the resident's room should never be in such condition. The Housekeeping Director stated that they do make rounds; however, they did not go into room 22. 3) Room 12 of the Petal Unit was observed on 10/25/2022 at 11:33 AM. The floor was observed with yellow, brown, and black spots in the center of the room and blackened accumulated debris under and around residents' beds. The RN Unit Manager #10 was interviewed on 10/25/2022 at 11:33 AM and stated that they reported the dirty floor concerns to the housekeeping department a month ago. The RN Unit Manager #10 stated the room 12 floor needs to be cleaned and waxed. Housekeeper #4 was interviewed on 10/25/2022 at 12:35 PM and stated that even though the room has been cleaned every day, the floor still feels sticky. Housekeeper #4 further stated the stains on the floor were not coming off with daily mopping. The Housekeeping Director was interviewed on 10/25/2022 at 12:39 PM and stated that they (Housekeeping Director) were aware of the room's stained floor condition and that the stains were because of dirt buildup. 415.5(h)(2)

Based on observation, interviews, and record review during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified on one of seven nursing units during the medication storage task. Specifically, on the [NAME] unit, Resident #302's [MEDICATION(S)] pen was erroneously stored in a plastic bag that was labeled for Resident #60's [MEDICATION(S)] pen. The finding is: The facility's policy titled Storage of Medications, dated 8/2021, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding areas to prevent the possibility of mixing medications of several residents. Resident #302 has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #60 has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A medication storage observation was conducted on the [NAME] unit with Licensed Practical Nurse (LPN) #1 (medication nurse) on 11/1/2022 at 10:54 AM. A review of insulin pens in LPN #1's medication cart revealed that a [MEDICATION(S)] pen with Resident #302's name and medical label was in a plastic bag that had Resident #60's name and medical label. There were no other insulin pens in the bag. LPN #1 stated it was a mistake that Resident #302's insulin pen was in Resident #60's plastic bag. LPN #1 stated they (LPN #1) had administered Resident #60's 9 AM dose of [MEDICATION(S)] this morning and then threw out the insulin pen and storage bag that had Resident #60's name on it. LPN #1 did not know how Resident #302's [MEDICATION(S)] pen was placed in a bag with Resident #60's name and medical label. The Director of Nursing Services (DNS) was interviewed on 11/2/2022 at 8:53 AM. The DNS stated it was an error to have one resident's insulin pen or medications in another resident's medication storage bag. The DNS stated the facility staff is trained to check the medication labels before administering a medication, especially injectable medications, to prevent medication errors. The DNS further stated they (DNS) will again provide in-service education to staff to ensure that the residents' medications are stored appropriately. LPN #2 (In-service coordinator) was interviewed on 11/2/2022 at 9:27 AM and stated that the initial training for nurses upon hire includes education on appropriately storing the medications. LPN #2 stated it sounds like Resident #302's insulin pen was put in the wrong storage bag. LPN #2 stated all medications should be stored appropriately to prevent medication errors. 415.18(e)(1-4)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022 the facility did not ensure an infection prevention and control program was established to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified on one of seven nursing units. Specifically, 1) a training toilet room currently used by residents on the Carnation unit did not have a means for residents to sanitize their hands before leaving the room; and 2) on the Carnation unit two Certified Nursing Assistants (CNA)s were not wearing appropriate Personal Protective Equipment (PPE) while providing care to Resident #47, who was placed on contact and droplet precautions as per their physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings are: The facility's undated policy titled Room Readiness and Unit Cleanliness for Housekeeping Staff, documented to check that all dispensers are properly filled, and the bathroom must be disinfected from top to bottom. The facility's policy titled Infection Control Surveillance, dated 9/14/2020, documented effective measures are in place to prevent, identify, and control acquired infection or infection brought into the facility from the community. The responsibility of the Infection Control Preventionist is to detect and record all nosocomial infections and to institute proper, effective control measures. 1) On 10/26/2022 at 11:48 AM an observation of the training toilet room on the Carnation unit was made. The room has an entrance door from the hallway with only a toilet in it. There was no sink or alcohol-based hand sanitizer in the training toilet room. On 10/27/2022 at 8:25 AM Registered Nurse (RN) #2-unit supervisor was interviewed. RN #2 stated the training toilet is currently used by unit residents. RN #2 observed the training toilet room and that there was no means to sanitize hands prior to leaving the room. RN #2 stated the toilet is used by people who are ambulatory on the unit and also by residents who need assistance. RN #2 stated residents can sanitize their hands either at the hallway alcohol-based sanitizer, at their room sink, or in the shower room next door. On 10/27/2022 at 9:31 AM CNAs #3 and #4 were interviewed concurrently. CNA #3 and #4 stated the training toilet is used by alert ambulatory residents. When asked where residents sanitize their hands after using the training toilet, both CNAs chuckled and then stated at the hallway alcohol-based sanitizer or at the residents' room sink. RN #1, who was the Infection Preventionist and the Assistant Director of Nursing Services, was interviewed on 11/1/2022 at 12:20 PM. RN #1 stated there should be a hand sanitizer in the training toilet room, and that as soon as they (RN #1) heard that there was no hand sanitizer in the training toilet room, they (RN #1) got in touch with the maintenance department to have one installed. RN #1 stated the housekeeping and maintenance departments do their rounds and should have noticed that there was no hand sanitizer in the training toilet room. The Housekeeping Director was interviewed on 11/1/2022 at 1:14 PM and stated that the unit housekeeper is supposed make sure the hand sanitizer containers are full. The unit housekeeper is also responsible to do a quick visual check of the training toilet room to make sure nothing is out of order or missing, and, if so, log it in the maintenance logbook. Housekeeper #1 was interviewed on 11/1/2022 at 1:22 PM and stated they (Housekeeper #1) are the housekeeper for the unit. Housekeeper #1 stated if the hand sanitizer was not in the training toilet room, they (Housekeeper #1) would log it in the maintenance logbook. An observation of the maintenance logbook was made with Housekeeper #1 and there were no entries for a missing hand sanitizer. 2) The facility's policy titled Transmission Based Precautions, dated 10/17/2022, documented for droplet precautions when providing care personal protective equipment (PPE) should include mask, gloves, gown, and eye protection. For contact precautions wear a gown when entering the room if you anticipate substantial contact with the resident, environmental surfaces, or items in the patient's room. Resident #47 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/1/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. The MDS documented that the resident required total assistance of two staff members for transfers. Review of nursing progress notes revealed that on 10/28/2022 at 12:11 PM RN #2 documented that Resident #47's roommate (Resident #72) had presented with a sore throat, and a rapid COVID-19 test was administered with a positive result. Resident #72 was moved to the Emerald unit for isolation. Observation on 11/1/2022 at 08:30 AM revealed Resident #47's room had a yellow contact/droplet sign at the doorway. The sign documented that everyone must clean hands when entering the room, wear a face mask, wear eye protection, and a gown and gloves at the door. There was no PPE supply outside the room. CNA #1 and CNA #2 were observed in the room with a Hoyer lift preparing to transfer Resident #47, who was in their bed and was visible from the hallway. The CNAs had gloves and surgical masks on, but no eye protection or gowns and had come in contact with the resident's bed in positioning the Hoyer lift. Both CNAs approached the doorway and were asked by the surveyor about the sign at the doorway indicating contact/droplet precautions. Both CNAs stated they did not know that Resident #47 was on contact/droplet precautions. RN #1, who was the Infection Preventionist and the Assistant Director of Nursing, was interviewed on 11/1/2022 at 12:25 PM and stated Resident #47's room is on contact and droplet precautions for 10 days from 10/28/2022 because Resident #72 tested positive for COVID-19 and was a close contact of Resident #47, who currently resides in the room. RN #1 stated both CNAs should have been wearing gowns and eye protection as the sign indicated and there should have been a PPE cart outside the room. RN #1 stated staff have previously been in-serviced about PPE usage and precaution signs. RN #1 stated they (RN #1) explained to the CNAs, whenever you see a sign, if you are not sure, just ask. RN #1 stated there should also be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed Practical Nurse (LPN) #2, who was the in-service coordinator, was interviewed on 11/1/2022 at 12:33 PM. LPN #2 first stated the yellow contact/droplet sign means the residents in the room are COVID-19 negative, but under watch to see if any symptoms develop. LPN #2 stated technically the CNAs did not have to wear gowns because Resident #47 is COVID-19 negative. LPN #2 was asked by the surveyor to clarify why the contact/droplet sign is at the doorway. LPN #2 stated a sign is necessary if the resident is COVID-19 positive. LPN #2 stated a sign should not be there if the COVID-19 positive resident is not in the room. The Director of Nursing Services (DNS) was interviewed on 11/1/2022 at 2:02 PM and stated that the CNAs were probably not aware that they should have been wearing the appropriate PPE. The DNS stated if the resident was exposed to a positive COVID-19 roommate, the resident is placed on contact and droplet precautions for 10 days. The CNAs caring for Resident #47 should have been wearing gowns and eye protection. LPN #3, the unit medication nurse, was interviewed on 11/2/2022 at 8:44 AM and stated there was confusion yesterday (11/1/2022) because the unit supervisor was not in and we were not sure if Resident #47's was on contact and droplet precautions because we have been doing serial COVID testing and Resident #47 was negative. LPN #3 stated the infection Preventionist clarified with us that Resident #47's room is on contact/droplet precautions for 10 days until 11/7/2022. 415.19(a)(1-3)

Based on record review and interviews during the Recertification Survey and Abbreviated survey (NY 536) initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs and residents who use [CONDITION(S)] drugs receive behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This was identified for one (Resident #712) of six residents reviewed for unnecessary medications. Specifically, Resident #712 was prescribed [MEDICATION(S)] (antianxiety medication) 0.5 milligrams (mg) and [MEDICATION(S)] (hypnotic medication) 10 mg as needed (PRN). There was no documented evidence that the facility staff provided non- pharmacological interventions to the resident prior to administering [MEDICATION(S)] 0.5 mg or [MEDICATION(S)] 10 mg. The finding is: The Antipsychotic Medication policy dated 4/2019 documented prior to the use of a PRN (as needed basis) Anti-Psychotic medication administration non-pharmacological interventions should be implemented. Antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non- pharmacological interventions. Resident #712 was admitted with diagnoses including [CONDITION(S)], [CONDITION(S)], and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #712 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognitive function was intact. The MDS documented the resident received antianxiety and hypnotic medications during the 7 of 7 days during the assessment look back period. The [CONDITION(S)] Drug Use Comprehensive Care Plan (CCP) dated 8/04/2022 documented Resident #712 was on [CONDITION(S)] medications secondary to Depression and Anxiety. There were no documented interventions for this CCP. The [CONDITION(S)] CCP dated 8/03/2022 documented interventions including to administer medications as per the Physician's (MD) order, monitor for adverse effects, monitor for desired effect, monitor the resident's sleep pattern, and notify the MD of changes in the resident's sleep pattern. The physician orders dated 8/2/2022 documented to administer [MEDICATION(S)] 0.5 milligrams (mg) tablet, give 1 tablet (0.5 mg) by oral route every 8 hours and [MEDICATION(S)] 10 mg tablet by oral route once daily at bedtime for 7 days as needed (PRN). The Medication Administration Record dated 8/2/2022 through 8/9/2022 documented Resident #712 was administered the [CONDITION(S)] medications daily. The readmission physician orders dated 8/16/2022 documented to administer [MEDICATION(S)] 0.5 milligrams (mg) tablet, give 1 tablet (0.5 mg) by oral route every 8 hours and [MEDICATION(S)] 10 mg tablet by oral route once daily at bedtime for 7 days as needed (PRN). The physician orders dated 8/25/2022 documented to administer [MEDICATION(S)] 10 mg tablet by oral route once daily at bedtime for 7 days as needed for sleep. The physician orders dated 9/4/2022 and 9/13/22 documented to administer [MEDICATION(S)] 10 mg tablet by oral route once daily at bedtime for 14 days as needed for sleep. The physician orders dated 9/14/2022 documented to administer [MEDICATION(S)] 0.5 mg tablet, give 1 tablet (0.5 mg) by oral route every 8 hours for 14 days as needed. The Medication Administration Record dated 8/16/2022 through 9/27/2022 documented Resident #712 was administered the [CONDITION(S)] medications daily. A review of the medical record from 8/2/2022 to 9/27/2022 revealed that the facility did not ensure that non- pharmacological interventions were implemented prior to administration of the [CONDITION(S)] medications. Pharmacy review dated 9/14/2022 documented- receiving [MEDICATION(S)] ([MEDICATION(S)]) 10 mg at bedtime PRN for [CONDITION(S)]. Please note that the maximum recommended dose in geriatrics is 5 mg at bedtime. Please evaluate, consider trial taper to 5 mg at bedtime PRN, if appropriate. The Physician documented they disagreed- the resident had [CONDITION(S)] and will re-evaluate in 2 to 4 weeks. The Assistant Director of Nursing Services (ADNS) #1 was interviewed on 10/28/2022 at 10:58 AM and stated the [CONDITION(S)] CCP should have included interventions to direct nurses to use non-pharmacological interventions, obtain Psychiatry consult, monitor the resident, and watch for signs and symptoms of drowsiness/lethargy. The ADNS could not explain why the interventions were not developed. The Registered Nurse (RN) Manager # 4 was interviewed on 10/31/2022 at 10:52 AM and stated the [CONDITION(S)] medication CCP should have listed interventions to address the resident's use of [CONDITION(S)] medications. RN Manager #4 further stated Resident #712 was on these medications prior to admission and non-pharmacological interventions were not implemented. The RN # 5 was interviewed on 10/31/22 at 3:52 PM and stated the resident was very alert and instructed nursing to come in at certain times to administer [MEDICATION(S)] and other times to administer [MEDICATION(S)]. The resident should have had a CCP developed to include interventions to address the use of [MEDICATION(S)]. The resident was on these medications prior to admission and non- pharmacological interventions were not considered. 415.12(l)(2)(ii)

Based on record review and staff interviews during the Recertification Survey and Abbreviated survey (NY 536) initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure that Comprehensive Care Plans (CCP) were reviewed and revised by the interdisciplinary team after each assessment. This was identified for one (Resident #712) of seven residents reviewed for accidents. Specifically, Resident #712 fell on [DATE] and sustained a [CONDITION(S)]. The resident was hospitalized and readmitted back to the facility on [DATE]. The CCP for falls was not reviewed and revised to address the resident's [CONDITION(S)] after the resident's return from the hospital. The finding is: The Accident prevention policy dated February 2018 documented to identify specific risk factors that may indicate the resident is at risk for falls upon admission, readmission, quarterly, annually and with any significant change. Based on the assessment the resident will have a preventative plan of care initiated as well as revised, monitored, and evaluated throughout their stay at the facility. The interdisciplinary team will collaborate in developing, evaluating, and revising the fall/injury prevention plan of care to prevent falls/injury, or to minimize injury and/or complications of a fall. Resident #712 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #712 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS documented the resident required extensive assistance of one person for transfers, dressing, personal hygiene, and toilet use. The resident was non-ambulatory and was occasionally incontinent of urine. A Fall risk assessment dated [DATE] documented the resident's score was 8 (if the total score is 10 or greater, the resident should be considered at high risk for potential for falls) indicating that the resident was not at high risk for falls. The fall risk assessment documented that the resident had a balance problem while standing/walking and was on Antipsychotics, Antianxiety Agents, Antidepressants, Hypnotics, Cardiovascular Medications, Diuretics, Narcotic Analgesics, Narcoleptic, and other Medications that also would cause lethargy or confusion. The resident's assessment did not include the resident's ambulation/incontinence status that would place the resident in a high-risk category for falls. The nursing progress note dated 8/9/2022 at 6:39 AM documented that Resident #712 stated they were standing at the bedside using the urinal when they got dizzy and fell . Resident #712 helped themselves back to bed before staff could assist. The resident complained of Left hip pain. The Physician was made aware, and X-rays were ordered. A nursing progress note dated 8/09/2022 at 1:59 PM, documented Hip, Femur and Pelvic X-ray reviewed with physician. X- ray results showed an acute impacted left femoral neck fracture. The resident was sent to Hospital emergency room (ER) for evaluation. The nursing progress note dated 8/10/2022 at 1:14 AM documented Resident #712 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The CCP for falls was reviewed on 10/28/2022 by the Surveyor. The CCP was developed on 8/2/2022 and documented Resident #712 was at high risk for Falls related to Unsteady Gait, Immobility/Limited Mobility, and Cardiac Medications. The interventions included to wear proper footwear, locking the wheelchair, keep areas clean, clutter-free, and well lit; keep bed in the lowest position; utilize low bed; keep personal items within reach; orient to environment/placement of items and call bell within reach. On 8/9/22, the CCP was updated to include slippers socks with non-skid tread to be worn in bed. On 8/18/22, the CCP was updated Sent to Hospital for evaluation, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing progress notes dated 8/19/2022 at 7:01 PM documented floor mats in place, secondary to safety; however, this intervention was not added to the resident's CCP. The Registered Nurse (RN) Manager #7 was interviewed on 10/31/22 at 10:52 AM and stated that the falls CCP interventions should have been revised upon re-admission following the resident's fall to determine if additional interventions were required to prevent the resident from falls. The Assistant Director of Nursing Services (ADNS) # 1 was interviewed on 10/31/22 at 11:30 AM and stated the resident's falls CCP should have been revised upon re-admission to ensure all prior interventions are effective to prevent further falls. 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/25/2022 and completed on 11/2/2022, the facility did not ensure each resident has the right to receive services in the facility with reasonable accommodation of resident needs and preferences. This was identified for one (Resident #307) of four residents reviewed for choices. Specifically, Resident #307 requested an extended shower hose to facilitate and maintain independence during the shower activity. Resident #307's request was not addressed by the facility. The finding is: Resident # 307 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition. The MDS indicated the resident required total assistance of one staff member for bathing. The Comprehensive Care plan (CCP) for Activities of Daily Living dated 8/1/2022 documented that Resident #307 required assistance/supervision of one staff member for bathing. Resident #307 was observed on 10/25/2022 at 11:17 AM lying in their bed. Resident #397 was interviewed on 10/25/22 at 11:17 AM and stated they have Multiple Scoliosis (MS). Resident #307 stated they know that one day they would not be able to bathe themselves, so they wanted to enjoy taking a bath by themselves as much as possible until the MS progresses. Resident #307 stated they were not able to wash their private area by themselves during the shower because the shower hose was not long enough to reach their perineal area. Resident #307 stated that their (Resident #307) Certified Nurse Assistant (CNA), the Unit Nurse Manager, and the Maintenance Director were aware of their (Resident #307) request. CNA #10 was interviewed on 11/01/2022 at 3:29 PM and stated they (CNA #10) prepare the supplies for Resident #307's shower, and they (CNA #10) stay outside of the shower stall in case Resident #10 needed something. CNA #10 stated they wash Resident #307 perineal area since the shower hose is not long enough for the Resident to use. CNA #10 stated they normally put a bucket of water on the Resident's lap and the Resident opens their (Resident #307) legs to allow the water to drain onto their perineal area. CNA #10 stated a couple of months ago they reported to Registered Nurse (RN) Unit Manager #7 that Resident #307 was requesting a longer shower hose. RN Unit Manager #7 was interviewed on 11/1/2022 at 1:13 PM and stated Resident #307 required supervision and one staff member assistance with bathing. RN Unit Manager #7 stated that a couple of months ago CNA #10 and Resident #307 requested a longer shower hose so the resident could wash their (Resident#307) perineal area themselves during the shower. RN Unit Manager #7 stated that they (RN Unit Manger #7) documented Resident #307's request for a longer hose in the maintenance order book in August 2022. RN Unit Manager #7 reviewed the maintenance order book with the surveyor; however, they (RN Unit Manager #7) could not find the documented request in the maintenance order book. The Maintenance Director was interviewed on 11/2/2022 at 11:25 AM and stated that they checked the maintenance work [order] book every morning and they do not remember a documented request for the longer shower hose. The Maintenance Director stated that they were approached by Resident #307 a couple of months ago and were asked to provide a longer shower hose. The Maintenance Director stated they did not provide the longer shower hose to the resident because they thought the longer shower hose would be an accidental hazard and infection control hazard as the longer shower hose would be touching the shower floor. The Maintenance Director stated that they did not discuss Resident # 307's request with anyone and did not explore other options to accommodate the resident's request. The Director of Nursing Services (DNS) was interviewed on 11/02/2022 at 2 PM and stated that they did not know Resident #307 requested to have a longer shower hose to wash their (Resident #307) perineal area themselves during the shower. They expected the nurses to document the resident's request in the maintenance work order book. The DNS stated they expected the Maintenance Director to communicate any concerns related to the longer shower hose with the DNS so other options could be explored to accommodate the resident's request. 415.5(e)(1)

Based on observation, record review and interviews during a COVID-19 Focus Infection Control Survey (FICS) completed on 11/22/2021, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of COVID-19 infection. Specifically, the facility staff did not follow infection control guidelines while handling dirty linen and did not perform hand hygiene to prevent the spread of infection on one of seven nursing units. The finding is: The Undated linen handling policy documented the clean and soiled linen should always be sorted and handle separately. All soiled linen must be bagged at the location used and at no time linen is to be thrown on the floor or chair before bagging. No soiled linen bags will be stored on the floor. The Current Infectious Disease Pandemic Emergency plan documented under section 10 to cohort residents to prevent the spread of the virus. The plan documented that the facility will dedicate a wing or group of rooms at the end of a unit in order to cohort residents. This area will be clearly demarcated as an isolation area. During the entrance conference on 11/22/2021 at 10:00 AM, the Director of Nursing Services (DNS) stated that the Emerald unit was designated as the COVID-19 unit. Certified Nursing Assistant (CNA) #11 was observed on 11/22/2021 at 10:20 AM, exiting from the Emerald Unit (COVID-19 positive resident unit) through the double doors to the Spring unit that was not a designated COVID-19 unit. CNA #11 was carrying an untied transparent garbage bag that contained soiled gown(s) and soiled adult brief(s) with ungloved hands. CNA #11 placed the garbage bag containing the soiled items on the floor and left the untied garbage bag unattended in the hallway on the floor of the Spring Unit. CNA #11 then returned with a housekeeper to unlock the dirty utility room on the Spring unit. CNA #11 was observed picking up the soiled garbage bag without the use of gloves and placing the garbage bag into the bin in the dirty utility room. CNA #11 did not perform hand hygiene after handling the soiled bag and returned to the Emerald unit. CNA #11 was interviewed on 11/22/2021 at 10:30 AM and stated that they (CNA #11) work on the Emerald unit, the COVID-19 unit. CNA #11 stated that they (CNA #11) bring the garbage from the Emerald unit (COVID-19 unit) to the Spring unit (a Non- COVID-19 unit) all the time. CNA #11 stated that they (CNA #11) do not need to use gloves to dispose a garbage bag into the dirty utility room. CNA #11 stated that they (CNA #11) were in a rush and refused to answer further questions. The Registered Nurse (RN) #12, who was the unit Nurse Manager on the Spring unit, was interviewed on 11/22/2021 at 11:15 AM and stated that CNA #11 should not have left the dirty linen bag on the floor unattended, and CNA #11 should have sanitized their hands after disposing the garbage bag containing soiled items before returning to the Emerald unit. The Infection Prevention (IP) Registered Nurse (RN) was interviewed on 11/22/21 at 2:48 PM and stated that CNA # 11 should not have placed the garbage bag on the floor and should have sanitized their hands after disposing the dirty bag. 415.19 (a) (1-3)

Based on observations, record reviews, and staff interviews during a Focused Infection Control Survey conducted on 12/18/2020, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of COVID-19 on two of seven units. Specifically, on 2 (Broadway and Diamond) of 7 units reviewed, staff did not perform proper hand hygiene, don (put on) and doff (take off) personal protective equipment correctly, and staff did not clean a shared resident device after use. The findings are: The Health Advisory: COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities, dated 3/13/20 and revised 7/10/2020, documented there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. Health Care Providers (HCPs) and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and face masks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. CDC guidance titled Using Personal Protective Equipment (PPE), updated 08/19/2020, documents the following first steps to doff PPE before exiting a patient's room: 1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak); 2. Remove gown.; 3. Healthcare personnel may now exit patient room. Upon exiting a patient's room, HCP should perform the following steps, per such guidance: 4. Perform hand hygiene; 5. Remove face shield or goggles; 6. Remove and discard respirator (or facemask if used instead of respirator); and 7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is [MEDICATION NAME] reuse. The Centers for Disease Control and Prevention (CDC) guidance entitled Preparing for COVID-19 in Nursing Homes dated 11/20/20 documented that universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The facility's policy titled Isolation- Categories of Transmission-Based Precautions revised 7/20/2020 documented standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking or by performance of procedure such as suctioning. Put on mask when entering the room. When possible dedicate the use of non-critical resident-care equipment items such as stethoscope, sphygmomanometer, bedside commode, or electronic rectal thermometer to a single resident (or cohort of residents) to avoid sharing between residents. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. The facility will implement a system to alert staff and visitors to the type of precaution the resident requires. The facility utilizes a signage system for identification of Contact or Droplet Precautions. The facility's policy titled Handwashing revised 11/24/2020 documented handwashing is the single most important precaution for preventing the spread of nosocomial infections. Handwashing should take place before and after resident care, immediately after gloves are removed, and between resident contacts. 1) The Registered Nurse (RN) Infection Control Preventionist (ICP)/Assistant Director of Nursing (ADON) was interviewed on 12/18/2020 at 4:24 PM and stated that the Broadway unit was placed on contact and droplet precaution because a housekeeper who worked on the unit tested positive for COVID-19. When performing care, the staff must wear a gown. If staff is administering eye drops or oral medication, staff should wash their hands before and after the medication administration. The staff should disinfect the BP (blood pressure) apparatus after each use. During an observation of Broadway unit on 12/18/2020 between 12:20 PM -12:25 LPN #1 was observed in Resident #4's room administering medication. Resident #4 was sitting in a wheelchair in her room. The room did not have signage for Contact or Droplet precautions. LPN #1 was wearing an N95 mask, a surgical mask and a face shield. LPN #1 was not wearing a gown or gloves. LPN #1 took the resident's blood pressure (BP) and then placed the BP apparatus on Resident #4's bed. LPN #1 then administered eye drops to Resident #4. LPN #1 did not wash his hands and proceeded to obtain the resident's medications from the medication cart that was in the hallway and administered the oral medications to Resident #4. LPN #1 retrieved the BP apparatus from the resident's bed and exited the room without washing his hands. LPN #1 did not clean or disinfect the BP apparatus before placing it on the medication cart. LPN #1 was interviewed on 12/18/2020 at 12:27 PM and stated Resident #4 was not on precautions and that he was not informed the Broadway unit was on contact and droplet precautions. LPN #1 stated that he did not wear a gown because the resident was not on precautions. LPN #1 stated he forgot to wash and sanitize his hands after administering eye drops and oral medications because he was rushing. LPN #1 stated that he should have washed his hands before and after administering medications and after each resident contact. He stated he was educated regarding handwashing after each resident contact. Furthermore, he stated he did not have cleaning wipes to clean the BP apparatus and that he only cleans the BP apparatus if the resident is on contact precautions. He also stated he was not certain what the facility taught him regarding cleaning medical equipment and the use of PPE. The LPN Inservice Coordinator was interviewed on 12/18/2020 at 3:37 PM and stated she is responsible for providing in-service education and competencies including infection control. The Broadway unit is on contact and droplet precaution. When administering eye drops, staff needs to wear gloves, mask, face shield, and a gown before entering the room. The gloves are used when giving eyedrops but not when giving oral medications; however, staff must wash hands after administering eye drops and oral medications. Medical equipment should be cleaned after each use. During observation of the Broadway unit with the ICP and the surveyor on 12/18/20 at 5:00 PM, the unit did not have signage indicating that the unit was on contact and droplet precautions. The ICP acknowledged that the precaution signs were missing. She stated they are printing more signs, and they will put the signs on each unit that is on transmission-based precautions. The staff is notified during morning report which units are on precaution because of potential exposure. 2) The ICP was interviewed on 12/18/2020 at 4:38 PM and stated that Diamond unit was on quarantine and on that unit the housekeepers are not required to wear a gown, however, a face mask and a face shield is required. The ICP stated hand hygiene must be performed before entering and exiting a resident's room. During an observation of the Diamond unit on 12/18/2020 at 12:48 PM Housekeeper (HK) #1 was observed in Resident #5's room cleaning. The Housekeeper was wearing an N95 face mask and gloves without eye protection. The Housekeeper #1 was observed moving the resident's bed, sweeping the resident's room, and then changing the garbage bag for the resident's garbage bin. After replacing the garbage bag, the housekeeper was observed to cleaning the sink area, the two overbed tables, and the night table. After cleaning, the housekeeper removed and discarded her gloves and did not perform hand hygiene before or after leaving the resident's room. Housekeeper #1 was interviewed on 12/18/2020 at 1:05 PM. The Housekeeper #1 stated she received COVID-19 in-service education, including the required PPE that is to be worn when cleaning a resident room. The Housekeeper #1 stated the required PPE is an N95 mask with a face shield, a gown, and gloves. The Housekeeper #1 stated she was not wearing eye protection because she did not have a face shield. She stated that she searched for a face shield but could not find one. The Housekeeper #1 also stated she should have sanitized her hands after she removed her gloves. The Housekeeping Director (HD) was interviewed on 12/18/2020 at 2:35 PM and stated the required PPE for the housekeepers includes use of an N95 respirator covered by a surgical mask, face shield or goggles, and gloves on the Diamond unit and a gown was not required because the unit is not on isolation. The HD stated hand hygiene should be performed immediately after removing gloves and before moving to the next room. The LPN Inservice Coordinator was interviewed on 12/18/2020 at 3:38 PM and stated she was responsible for providing in-service education to the Department Heads. The LPN stated the housekeepers receive in-service education from their Department Head. The LPN stated housekeepers must put on a gown, an N95 mask with a surgical mask, and eye protection when cleaning surfaces in a resident room and hand hygiene must be performed after removing the gloves. The Administrator was interviewed on 12/18/2020 at 5:15 PM and stated there are signs posted on the Broadway unit however, the surveyor informed him that there were no signs posted. The Administrator stated LPN #1 was already terminated after he became aware of the surveyor's observation because there was a gross violation and a breach of infection control practices. He stated Housekeeper #1 did not infect anything. All staff are required to wear goggles and a face shield as a precaution. Housekeeper #1 should have asked for goggles and gowns that are always available. The Administrator further stated that the reusable medical equipment should be sanitized in between use. 415.19(a)(1-2) 415.19(b)(4) 400.2

Based on observation, interview and record review, during a COVID-19 Focused Infection Control Survey (Complaint # NY 735), conducted on 6/15/20, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and 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 1 of 3 residents 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 out patients in individual facilities. The facility's policy entitled Isolation - Categories of Transmission Based Precautions revised 4/28/2020, documented: Droplet precautions- Resident Placement: place the resident in a private room if possible. When a private room is not available, residents with the same infection with the same microorganisms but with no other infection may be cohorted. COVID-19 positive residents who continued to test positive after 14 to 21 days may continue to remain with previously positive room cohort if both residents are asymptomatic when a private room is not available. If cohorting is not achievable use a curtain and maintain at least three feet of space between the infected resident and other residents and visitors. During an observation on 6/15/20 at 10:45 AM, a sign outside Resident # 3's room door indicated the resident was on droplet precautions. Resident #4 was observed sharing the room with Resident #3. The Lab Report for Resident #3, diagnostic results dated 6/5/20 and 6/15/20 documented COVID-19 PCR (polymerase chain reaction) detected indicating Resident#3 was positive for COVID-19. The Lab Report for Resident #4, diagnostic results dated 6/5/20 documented COVID-19 PCR (polymerase chain reaction) not detected indicating Resident #4 was negative for COVID-19. The Registered Nurse Supervisor (RNS) was interviewed on 6/15/2020 at 10:50 AM and stated Resident #3 was positive COVID-19 and Resident #4 was tested negative (could not recall when). The RNS stated that both residents (#3 and # 4) were kept in the same room as they were asymptomatic and could stay in the same room. The Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) were interviewed on 6/15/20 at 2 PM concurrently and stated that there was no other room on the unit to transfer the resident and both the residents were asymptomatic. The ADNS (who is also the Infection Control Nurse) stated she had revised the Isolation Infection Control Policy related to transmission-based precautions , as documented in the 4/28/20 revised policy. The policy was also reviewed by a Pulmonologist who found the policy to be acceptable. The ADNS stated that both residents were cohorted as per the policy. She stated since both residents were asymptomatic and a minimum space of 3 feet was maintained between the residents and these measures were adequate to limit transmission of infection. The Administrator was interviewed on 6/15/20 at 4:45 PM and stated that both residents (Resident #3 and Resident #4) were asymptomatic and remained in the same room. He stated he was unaware that the Isolation Policy documented 3 feet of space should be maintained between the infected residents and other residents and he believed the correct space to maintain between residents should be a minimum of 6 feet. 415.19(b)(1)

Based on record review and staff interviews during a Recertification survey the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident. This was identified for one (Resident #64) of eight residents reviewed for Unnecessary medications. Specifically, Resident #64 did not have a Comprehensive Care Plan (CCP) developed to address the resident's frequent refusal to take medications. The finding is: Resident #64 was admitted to the facility with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 99, indicating that the resident was unable to complete the assessment. A review of the Medication Administration Record [REDACTED]. The resident refused to take medications on the following dates: (MONTH) 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 and 29 of 2019. (MONTH) 1, 2, 3, 4, 5, 19, 22, 24, 27, 28 and 31 of 2019. (MONTH) 7, 8, 9, 21, 23, 24, 28, 29, 30 of 2019. (MONTH) 1, 3, 5, 7, 8, 19, 21, 24, 25 of 2019. (MONTH) 3, 4, 5, 7, 9, 10, 11, 16, 17, 18, 19, 21 of 2020. A review of CCPs from 9/17/19 to 1/21/20 revealed that no CCP was developed for the resident's refusal of medications. The unit Charge Registered Nurse (RN) was interviewed on 1/21/20 at 10:00 AM and stated that she was responsible for developing the CCPs. The RN stated that she did not develop a CCP for the resident's non-compliance of taking medications because she was not aware that the resident was frequently refusing medications. The Unit Desk RN was interviewed on 1/21/20 at 10:05 AM and stated that she was aware of a one-time refusal of medications by the resident through a report from the Medication Licensed Practical (LPN) when the resident was just admitted . She stated she was not aware that the resident had been refusing medications so frequently. The unit 7:00 AM-3:00 PM Medication Licensed Practical Nurse (LPN #1) was interviewed on 1/21/20 at 11:00 AM and stated that when the resident refused to take medications she informed either the Desk RN, the Charge RN, or both of them. The unit 7:00AM-3:00 PM Medication LPN #2 was interviewed on 1/22/20 at 9:51 AM and stated that when the resident refused medications he told the RN Supervisor. 415.11(c)(1)

Based on record review and interviews during the Recertification Survey, the facility did not ensure that an allegation of abuse was reported to the State Agency not later than 24 hours when the allegation determination did not involve abuse and did not result in an injury. This was identified for one (Resident #136) of one resident reviewed for Abuse. Specifically, Resident #136 made an allegation of abuse by a Certified Nursing Assistant (CNA) during a Resident Council meeting. An investigation for potential abuse was completed; however, without notification to the State Agency about the allegation. The facility Policy and Procedure on Abuse Investigation dated 10/29/19, documented that .#2- For all alleged violations, the DOH (Department of Health) should be notified two hours if the alleged violation involved abuse or results in serious bodily injury, 24 hours if it does not involve abuse and does not result in serious injury. The finding is: An interview was held with a representative from the Ombudsman program on 1/17/20 at 10:15 AM. The Ombudsman stated that during the resident council meeting held on 1/6/20 Resident #136 stated that he had been struck by a staff member, a Certified Nursing Assistant (CNA). A review of the resident council minutes dated 1/6/90 documented that Resident #136 stated that a CNA (named) tried to hit him over the weekend. Resident # 136 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) Score of 12, indicating the resident had moderate cognitive impairment. The MDS documented the resident had no behavior problems during the assessment period. A Comprehensive Care Plan (CCP) titled Psychosocial Well-Being, effective 5/19/14 and last updated on 1/9/20, documented that the resident had a potential risk for victimization related to [MEDICAL CONDITION]. The interventions included to encourage the resident to express feelings and provide emotional support. The CCP updated on 1/9/20 did not include the allegation of abuse as reported on 1/6/20. The review of the Progress Notes from 1/6/20 to 1/21/20 did not include the incident of alleged abuse. Resident #136 was interviewed on 1/17/20 at 2:11 PM. The resident stated that a CNA went to hit him by raising a hand to him. The resident stated that he had reported this to the Nurse. The Director of Nursing Services (DNS) was interviewed on 1/17/20 at 3:32 PM. The DNS stated that it seemed as though the resident was not serious. The DNS stated the accusation was investigated and it was determined that it was not abuse and therefore, it was not necessary to call it in to the Department of Health (DOH). The DNS stated that after reviewing the information and talking about the allegation with the team it was determined that this did not have to be called in. The incident was discussed and a determination was made that no contact was made. During a subsequent interview with the Ombudsman on 1/21/20 at 12:37 PM the Ombudsman stated that following the Resident Council Meeting on 1/6/20 the Ombudsman immediately reported the allegation of abuse to the Administrator, at that time, and the Assistant Administrator. The Ombudsman stated that during the resident council meeting the resident stated that he was struck by the CN[NAME] The Ombudsman stated that during a follow up meeting with the DNS and the Assistant Director of Nursing (ADNS) on 1/13/2020, the DNS stated that she had already investigated the allegation made by Resident #136. The Assistant Administrator was interviewed on 1/21/20 at 4:37 PM. The Assistant Administrator stated that they were waiting to determine whether this was an actual abuse concern before the facility called it in. He stated that the facility was going to investigate the allegation and then make the determination. 415.4(b)(2)

Based on observation, interview and record review during an abbreviated survey (Complaint # NY 863) the facility did not ensure that the resident environment remained free of accident hazards to prevent an avoidable accident that resulted in serious injuries for one of three residents reviewed for accidents (Resident #1). Specifically, Resident #1 had severely impaired cognition and required assistance with bed mobility and transfers. The resident was found with his bed moved against the heating unit and his legs resting on the heating unit. Resident #1 sustained extensive second [MEDICAL CONDITION] partial third [MEDICAL CONDITION] both lower extremities. The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 10/11/2017 documented the resident's cognitive status as being severely impaired. He required extensive assist of two persons for bed mobility and transferring, did not walk and required total assistance with locomotion. The MDS also noted that the resident had impaired range of motion of both upper extremities. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL) dated 05/08/2014 identified that the resident had self-care deficit as evidenced by need for extensive assistance for bed mobility related to dementia. Interventions included to provide necessary assistance for completion of ADLs. The Nurse Practitioner's (NP) Progress Notes dated 12/28/2017 at 9:20 AM documented the NP received a call from nursing that the resident was found with his legs resting on the radiator emitting heat [MEDICAL CONDITION] bilateral lower extremities described as blisters and removal of epidermis. Resident reports pain on palpation and denies pain at rest. Resident with 2nd [MEDICAL CONDITION] 14% of total body surface area (TBSA estimate). The NP ordered Ringers [MEDICATION NAME] IV fluids for 5 days, Bactrim (antibiotic) every 12 hours for 7 days, administer tetanus, [MEDICATION NAME] (pain medication) every 8 hours for 5 days and Polymer silver (antimicrobial dressing with silver particles) with dry dressing for affected areas. The NP Wound Care assessment dated [DATE] at 12:07 PM documented the resident was evaluated for 2nd [MEDICAL CONDITION] from resting legs on radiator. The NP documented 6 sites of 2nd degree burns, (1) Left posterior shin measured 9.5x7cm with 100% pink wound base, (2) Back of left lower extremity measured 3x2.5cm intact blister, (3) Right lower posterior thigh measured 17x16cm with 50% loose skin and 50% pink skin, (4) Right lateral lower leg measured 24x8cm with 100% pink wound base, (5) Right lower leg measured 16x5 cm intact blister, and (6) Right Achilles area measured 2x1.5 cm with 100% pink wound base. The Nursing Progress Note (NPN) dated 12/28/2017 at 12:50 PM entered by the RN Manager documented that the RN (Manager) was called in by the nurse (LPN) to assess the resident's legs. The resident was received alert, responsive and able to make needs known. The resident was assessed by night Registered Nurse Supervisor (RNS) and Registered Nurse Manger (RNM). The RN Manager described the wounds in the NPN and noted that the Nurse Practitioner was notified, orders were received and the resident denied pain or discomfort but discomfort was noted during initial assessment. The NP notes dated 12/29/17 at 1:14 PM documented that the resident was seen for follow up of the burn affecting bilateral lower extremities. Right lower extremities noted with blistering and desquamation (peeling skin) and measurements were unchanged. Resident had an onset of fever. The NP consulted the physician and the infectious disease (ID) specialist and oral antibiotic was changed to intravenous (IV) antibiotic, intravenous fluid (IVF) was increased. The NP also noted plan for private room, supplemental oxygen, protein supplements, vital signs every 4 hours, daily and blood work. The local treatment was also changed to xeroform (petroleum impregnated gauze) and reverse isolation (used to protect the resident from contracting infection) was ordered. The facility's investigative summary dated 12/30/2017 documented that, on 12/28/2017 around 4:55 AM, a Certified Nursing Assistant (CNA) washed and changed the resident. The CNA did not notice any problem with the resident at that time and stated there was enough space for her to move between the bed and heater when she turned and positioned the resident. She covered the resident with a blanket, placed his call bell within reach and left him comfortably in bed. The room temperature was comfortable. Around 7 AM, the day shift CNA brought the resident's meal tray into his room and observed his legs on top of the radiator. She immediately moved his legs off the radiator and reported the incident to the nurse. The resident was unable to narrate how the incident happened. The resident was noted with pinkish opened areas and intact blisters to left lower leg on the posterior shin, right lateral leg, right lower leg and right Achilles. The resident denied pain and positive range of motion was noted in all extremities. The facility investigation also documented that the room felt warm when the nurse entered the room and the thermostat was on 80 degrees. It was observed that the residents' (Resident #1 and roommate) night tables were placed in between the two beds. Resident #1's roommate denied moving Resident #1's bed but the roommate had a history of [REDACTED]. The facility noted that Resident #1 was able to move his legs independently. The facility concluded that the incident was unanticipated and most likely due to the accidental contact of the resident's sensitive skin with a warm surface. The facility further concluded that it was most likely that the resident's roommate accidentally moved the resident's bed against the radiator when he was rummaging through his things inside the drawer. The facility ruled out that abuse, mistreatment or neglect occurred. The NPN by the Director of Nursing (DON) dated 12/30/2017 at 3:16 PM documented that the resident's family member met with facility staff. The family member wanted the resident to be transferred to hospital. The resident was transferred to hospital and admitted at 7:32 PM with [DIAGNOSES REDACTED]. The Hospital Burn Surgical Consult dated 12/30/17 documented the resident presented with 2-day history of lower extremity burns. [MEDICAL CONDITION] the posterior aspect of both legs with blistering. Patient was afebrile and vital signs were stable in the emergency room . Burn service was consulted for further evaluation and management. Resident with extensive second-degree and partial third-degree. The 7:00 AM - 3:00 PM Registered Nurse Manager (RNM) #1 was interviewed on 1/3/2018 at 2:22 PM and stated that, at 7:15 AM, the Licensed Practical Nurse (LPN #1) requested RNM #1 to check Resident #1 because LPN #1 was informed by CNA #3 that Resident #1 got burned from the heater. RNM #1 went with LPN #1 and the night RNS to check Resident #1. RNM #1 stated that Resident #1's bed was pushed against the radiator and there was no space between radiator and bed. RNM #1 had to push the bed away. Resident #1 was in a supine position in the middle of bed, alert and responsive and able to make his needs known. Resident #1 denied any pain. RNM #1 stated that Resident #1's legs were not on radiator when she went to the room. The 7:00 AM - 3:00 PM LPN #1 was interviewed on 1/3/2018 at 3:11 PM and stated that the 6AM- 2PM CNA reported to the 11-7 Registered Nurse Charge Nurse (RNCN) that he needed to come to room because Resident #1's legs were burned. LPN #1 went with the RNCN to Resident #1's room. Resident #1 was observed lying supine in the middle of the bed with his head elevated. LPN #1 stated the bed was close to the radiator but she did not pay too much attention to how close it was. Resident #2 was observed lying on his bed on 1/3/2018 at 4:09 PM. He was noted to be cognitively intact and stated that the CNA came in at 7:15 AM and when she pulled the curtain Resident #2 saw that Resident #1's right foot was on the window over the heater, both feet were on the heater but, the right one was more on it. Resident #2 stated he did not know how Resident #1 had his legs on the heater. Resident #2 stated that the night stand was on the left side of Resident #1's bed (in the middle of the two beds). Resident #2 stated there was a narrow space between bed and heater and it was always like that. Resident #2 stated he did not, and could not, move Resident #1's bed. The Assistant Director of Nursing (ADNS) was interviewed on 1/3/2018 at 5:24 PM and stated that, on 12/28/2017, she was notified of the incident by RNM #1. The ADNS stated she went to look at Resident #1's immediate environment and the night stands were in the middle of 2 beds and it had been like that. Even with both night stands in the middle there was still enough space for staff to move around, however, Resident #1's bed was closer to the radiator than it should have been. The ADNS stated that the facility concluded that it was possible that the roommate accidentally moved the bed. The facility concluded there was no abuse, neglect or mistreatment. The 6:00 AM - 2:00 PM CNA #3 was interviewed by phone on 1/5/2018 at 2:04 PM and stated she worked on 12/28/2017 and was assigned to Resident #1. She took report and her assignment and did her rounds, answered call bells and attended to resident needs. When she reached Resident #1's room at around 6:45 AM, she opened the door and she saw both of Resident #1's legs on the heater; the right leg was more over the heater than the left and she ran into the room and moved his legs off the heater and placed them on the bed. The foot part of the bed was closer to the heater. The night stands were in the middle of two bed at the time of incident. She went to get the night RN. CNA #3 stated Resident #1 did not complain of pain or yell when she moved him. CNA #3 stated Resident #1 could move and turn his legs. CNA #3 stated Resident #1 required staff assistance with turning but he also helped with turning. CNA #3 stated that she was knowledgeable that the bed should not be close to the heater. The 11:00 PM- 7:00 AM RN Charge Nurse (RNCN) was interviewed on 1/5/2018 at 3:19 PM and stated he worked on 12/28/2017. The night CNA (CNA#4) was in Resident #1's room around 5am and she changed him. The RNCM came in the room after 5-10 minutes to check on Resident #2's blood sugar. Resident #1 and #2 were in bed sleeping. The RNCN stated he did not notice anything unusual. CNA #3 came to the LPN and the RNCN at 7:15 AM and stated that they should come and check Resident #1. The RNCN went to Resident #1's room immediately. CNA #3 stated that she removed Resident #1's legs from the radiator. When the RNCN and LPN #3 went in the room, Resident #1's legs were already in the bed. The RNCN [MEDICAL CONDITION] both legs with bigger areas of burn on the right leg. The RNCN could not say exactly how close the bed was to the radiator. The RNCN stated the staff should know that the bed should not be close to the radiator. The 10:00 PM - 6:00 AM CNA #4 was interviewed on 1/8/2018 at 3:38 PM and stated she worked on 12/27-12/28/2017 and she was assigned to Resident #1. CNA #4 stated Resident #1 could not turn from side to side but could move his legs from side to side. Each time she checked on him that night he was in the middle of the bed. At 4:55 AM, CNA #4 washed Resident #1's perineal area and back and changed his diaper. CNA #4 did not notice any changes in his skin. Resident #1 was awake and did not complain of any pain. She left Resident #1 laying on his back in the middle of the bed, covered with the sheet and with the call bell within reach at 5:05 AM. That was the last time she attended to Resident #1. Resident #2 was sleeping. CNA #4 stated there was enough space for her to pass around the bed when she did his brief change. CNA #4 stated she did not notice the bed was closer to the radiator than usual. She did not have an idea how Resident #1 got burned and how his legs got on the radiator. CNA #4 stated she did not hear any call bells or Resident #1 calling for help after she provided care to him. 415.12(h)(2)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure that each resident's right to accept or refuse medical treatment and formulate an advance directive was maintained in accordance with State Law. The facility failed to establish mechanisms for documenting and communicating each resident's advance directive choices. Specifically, three (Residents #1, #2, #14) out of 14 residents reviewed for advance directives were not timely and accurately identified by the various indicators used by the facility for a resident's advance directive status. An additional nine residents on the pediatric unit did not have identification bracelets as per facility protocol. This failure has the potential to falsely identify a resident's directives. This resulted in actual harm and the potential for widespread serious harm that is Immediate Jeopardy. Complaint Number: NY 400 The findings are: The undated Policy and Procedure on Resuscitation Measures (PPRM) documented that all licensed nursing staff are responsible to implement basic life support measures if a resident demonstrates signs and symptoms of respiratory and [MEDICAL CONDITION]; an ambu bag will be utilized to deliver ventilations. The first licensed nurse will determine if the resident requires basic life support by checking vital signs and status. Prior to initiation of CPR (cardiopulmonary resuscitation) the licensed nurse will validate the resident's advance directive wishes for CPR/DNR (Do Not Resuscitate). The Policy and Procedure on Advance Directives (PPAD) dated [DATE] documented that all documents pertinent to Advance Directives are placed in the "Advance Directives" section of the resident's medical chart. A red dot is placed on the resident's name band and spine of the chart, if the resident is a DNR. The PPAD further documented that the social worker updates Advance Directive Lists. The PPAD dated ,[DATE] documented that residents' advance directives will be identified and honored by the facility. The social worker will be responsible to maintain advance directive and DNR list. There was no documented evidence of staff training regarding a procedure of what to do if a resident's red dot indicator is missing. During an observation on [DATE] from 2:30 PM to 3:30 PM nine residents on the pediatric unit did not have identification bracelets. 1) Resident #1 was 3 years old and admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) (an assessment tool) dated [DATE] documented that Resident #1's cognition was severely impaired. The medical record's Advance Directives section provided a Life Sustaining Treatment Order Sheet (LSTOS) dated [DATE] which documented directives that Resident #1 should not be resuscitated if cardiopulmonary arrest and order-specific measures to withhold "bag [MEDICAL CONDITION] response to [MEDICAL CONDITION]." The undated Residents' Bill of Rights/Statement of Residents' Rights signed by Resident #1's mother documented that each resident shall have the right to provide advance directives regarding important health care decisions, including the withdrawal of life-sustaining treatment. The Health Care Proxy or Surrogate's Written Consent to the Issuance of a Do Not Resuscitate Order form dated [DATE] documented consent for a DNR order. The Nursing Admission/Readmission assessment dated [DATE] documented that Resident #1 had a DNR. The Advance Directive Comprehensive Care Plan (ADCCP) dated [DATE] documented DNR in place with interventions including review Advance Directives, choices & options and include medical staff physician as designated representative's questions become specifically medical to the resident's care in relation to Advance Directives. The Pediatric Social Work assessment dated [DATE] documented a Resident Rights section for Advance Directives to be reviewed. The section was left blank. The Advance Directives Information form dated [DATE] that Advance Directives are written instructions which relate to the provision of health care when the individual is incapacitated. The resident's Advance Directives section was left blank and handwritten by the social worker, "reviewed with (father)." The Physician Assessment and Plan of Care dated [DATE] documented that there was no change in Advance Directives for Resident #1. The Pediatric [MEDICAL CONDITION] Medicine form dated [DATE] documented that Resident #1 was DNR as per [DATE] order by family. The Physician order [REDACTED]. The Medication Administration Record [REDACTED]. The Integrated Progress Notes (IPN) dated [DATE] (written by the 7:00 PM to 7:00 AM Registered Nurse Charge (RNC #1)) documented that Resident #1 was found cyanotic and oxygen saturation low 70's around 6:00 AM; proceeded to do ambu-bagging and CPR. While calling for help, suctioned resident several times with no resistance and at the same time lavaging was done. Pulse oxygen saturation and heart rate being checked frequently. Respiratory came with other staff nurses. Code Blue was called; 911 was called while other nurses checking for DNR status of the resident. Around 3 to 5 minutes 911 came; DNR was established; hence ambu-bagging and CPR was stopped. The 24 Hour Nursing Shift Report dated [DATE] for the 11:00 PM to 7:00 AM shift documented that, after 6:00 AM, the assigned aide called the nurse to the room and found Resident #1 looking cyanotic and oxygen saturation in low 70's; proceeded to do ambu-bagging & CPR. While calling for help, suctioned resident several times with no resistance and at the same time lavaging and checking for pulse. RT (Respiratory Therapist) proceeded to change trach; Code Blue was called and 911 was called while other nurses checking for DNR status of the residents. Around 3 to 5 minutes 911 came and DNR was established, hence ambu-bagging and DNR was stopped. The IPN dated [DATE] (written by the nursing supervisor) documented that Resident #1 was found unresponsive at 6:20 AM; unresponsive to painful stimuli, pupils fixed and dilated, no palpable pulse, no palpable/audible blood pressure, body shows signs of lividity and cool to touch. MD (medical doctor) made aware. Family made aware. Contacted medical examiner; medical examiner's office picked up the body at 9:00 AM. The IPN dated [DATE] (written by the Respiratory Therapist (RT #1)) documented that he was called to the resident's room at approximately 6:10 AM. Resident #1 was unresponsive and being ambu-bagged by RN (Registered Nurse). Oxygen saturation in low 70's; proceeded to change trach. Resident was being bagged, lavaged and suctioned without any resistance. During this time, 911 and Code Blue were called. After about 5 minutes it was established that the resident was DNR, at which time CPR and ambu was stopped around 6:20 AM. The IPN dated [DATE] (written by the RNC #1) documented a clarification of nurse's notes dated [DATE] that Resident #1 was found with pale face and cyanotic mottled arms; tried to suction, lavage several times and do ambu-bagging to see if there was mucus plug. No oxygen saturation noted. The team came (respiratory and other nurses), ambu-bagging was continued to help see for mucus plug; oxygen saturation reading 20's to 70's, heart rate 200's or no reading at all. One of the nurses checked the heart beat from a stethoscope; no heart beat was noted. [MEDICAL CONDITION] changed by respiratory and I alternately ambu-bagged the resident with the other nurses to try to get rid of any mucus plug. Code Blue was called; 911 was called and did chest compressions a couple of times and asking if the resident was a full code. The 3rd nurse came back with papers saying he was a DNR and hence we stopped everything; we stopped ambu-bagging and checking for mucus plug. 911 providers stopped chest compressions. I did not notice the arm band because I was so focused with what I was doing. Despite my previous documentation, I never provided any CPR on the resident. The IPN dated [DATE] (written by RT #1) documented a clarification of notes dated [DATE] that, around 6:10 AM, the resident was cyanotic and unresponsive. Nursing staff was ambu-bagging and palpating chest; proceeded to [MEDICAL CONDITION] ascertain if there was a plug. While palpating resident's heart area, 911 arrived and, within 15 seconds, it was determined that the resident was a DNR. At no time was CPR done by any staff member of Avalon Gardens. The Summary of Investigation dated [DATE] (signed by the Director of Nursing) documented that 911 responders most likely misinterpreted the nurse's actions of placing her hand on the resident's chest to ascertain chest movement as cardiac compressions. Before the resident's code status could be communicated, 911 delivered two chest compressions. Interviews revealed that the DNR identifiers were in place and the armband with a red dot was on the child's left ankle but staff did not locate this as the resident still had signs of life. As a precautionary measure, the clinical team was re-in-serviced regarding the DNR policy and procedure and all residents were rechecked to ensure that all identifiers are in place. An interview was conducted with the assigned 6:00 AM to 2:00 PM Certified Nursing Assistant (CNA #1) on [DATE] at 11:45 AM. CNA #1 stated that, on [DATE], she made rounds initial rounds and found Resident #1's face pale. CNA #1 ran to the nursing desk to tell the nurses, who went to the resident's room. CNA #1 called the front desk to page for the supervisor and call a Code Blue. She did not return to the resident's room but waited for the ambulance crew, who did not enter the resident's room because they were having a conversation with the nurses in the hallway. CNA #1 stated that Resident #1 did not have an identification bracelet. An interview was conducted with the 7:00 PM to 7:00 AM RNC #1 on [DATE] at 12:52 PM. RNC #1 stated that CNA #1 said the resident was pale looking and RNC #1 found Resident #1 not moving with eyes closed at 6:00 AM. There were no numbers on the pulse oximeter. RNC #1 stated that the resident was pulseless and without respirations. She started to ambu-bag the resident; suctioned and lavaged without resistance. Respiratory came and changed the [MEDICAL CONDITION]; there was no mucus plug. RNC #1 stated that she continued ambu-bagging the resident and kept checking for a pulse, but there was no pulse. At some point, RN #2 came into the room to say that Resident #1 was a DNR and all measures stopped. RNC #1 stated that she wrote a clarification note because she did not believe she did CPR since no compressions were performed and the Administrator wanted to know the truth. RNC #1 stated that 911 came, pushed her aside and was asking if Resident #1 was a full code while 911 personnel did one or two compressions. Later in the same interview, RNC #1 stated that 911 came, asked if the resident was a DNR and 911 did not do anything. RNC #1 further stated that she did not see an identification band on the resident and this would be the "first thing to look for. Try your best to really look for the name band and then start CPR." An interview was conducted with a 7:00 PM to 7:00 AM RN #1 on [DATE] at 2:02 PM. RN #1 stated that, on [DATE], she entered Resident #1's room after RNC #1 and Respiratory was already there. RN #1 ran out of the room to grab [MEDICAL CONDITION] and, then, again to get a portable pulse oximeter and stethoscope. Resident #1 did not have a pulse and RNC #1 was ambu-bagging the resident. Respiratory changed [MEDICAL CONDITION] RNC #1 placed the resident back on the ventilator. RN #1 stated that 911 did arrive and RN #2 told 911 that the resident was a DNR; "they (911) were at the door, nowhere near the resident." RN #1 further stated that the primary source of knowing a resident's DNR status is to check the identification band; however, "I can't remember if I checked." An interview was conducted with a 7:00 PM to 7:00 AM RN #2 on [DATE] at 2:30 PM. RN #2 stated that, on [DATE] shortly after 6:00 AM, she followed into Resident #1's room after RNC #1 and RN #1, who asked RN #2 to call Respiratory while they ambu-bagged the resident. RN #2 left the room to call Respiratory and make sure 911 was on its way. RN #2 stated that she did not check the resident's pulse but the other nurses did an assessment and said there was no pulse. RN #2 stated that she did not remember to look for Resident #1's identification, did not see a red dot on the medical record and just began preparing paperwork to transfer the resident to the hospital. "I stumbled across the DNR order and ran to announce it." RN #2 stated that 911 had just arrived and she did not see 911 personnel perform chest compressions on the resident. An interview was conducted with the 7:00 PM to 7:00 AM RN Supervisor (RNS #1) on [DATE] at 2:56 PM. RNS #1 stated that, on [DATE] around 6:15 AM, she heard a Code Blue called to the Pediatric unit. When she entered Resident #1's room, RNC #1 and RN #1 were ambu-bagging the resident. RNS #1 and 911 personnel arrived to the resident's room at the same time; RN #2 ran in behind them saying Resident #1 was a DNR. She pronounced the resident dead at 6:20 AM. RNS #1 stated that she had not checked Resident #1's DNR status but the status should have been known by the identification band. RNS #1 further stated that ambu-bagging is a part of CPR. An interview was conducted with the assigned Respiratory Therapist (RT #1) on [DATE] at 10:58 AM. RT #1 stated that, on [DATE] around 6:10 AM, he heard a call to the resident's room and, upon entering the room, saw RNC #1 and RN #1 ambu-bagging Resident #1, who was cyanotic and extremely pale. RT #1 offered help by ambu-bagging and lavaging the resident, who was not attached to the ventilator because the nurses were ambu-bagging. RT #1 changed the trach; there was no mucus plug or resistance on ambu-bagging or suctioning. RT #1 stated that, although he did not recall who it was, a staff member came in to the room to say the resident was a DNR. RT #1 stated that all measures stopped and the nursing supervisor said the resident expired. RT #1 further stated that he had not thought to question whether or not Resident #1 was a DNR. RT #1 stated that, after thinking about what happened, he decided to write a clarification note a few days later because no staff member performed CPR. An interview was conducted with the Pediatric Social Worker (PSW) on [DATE] at 10:03 AM. The PSW stated that, when Resident #1 was first admitted to the facility, she reviewed Advance Directives with the resident's mother, who wanted a DNR. Since that time, Advance Directives were reviewed annually with the family and no changes were made. The PSW stated that she had not reviewed paperwork that came with Resident #1 upon admission and is not aware of any specific directives other than a DNR. The PSW looked at the LSTOS in the Advance Directive section of Resident #1's medical record and stated that she had not reviewed the LSTOS. An interview was conducted with the Attending Physician (AP) on [DATE] at 3:34 PM. The AP stated that she was advised by nursing that Resident #1 was found unresponsive with color changes and nursing tried to resuscitate the resident until it was realized the resident was a DNR; then, CPR stopped. The AP stated, "At bedside, they (staff) don't have a great way to identify residents for DNR. In fact, I don't know how they would. "If a resident does not have a pulse, then that resident is in [MEDICAL CONDITION]. "Based on his (Resident #1) orders, he should not have been ambued." 2) Resident #2 was [AGE] years old and admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that Resident #2's cognition was moderately impaired. The Admission History and Physical dated [DATE] documented that Resident #2 declined Advance Directives on admission to the facility. The Annual Social Work assessment dated [DATE] documented that Advance Directives were discussed with Resident #2. There are no Advance Directives in place. The ADCCP dated [DATE] documented that Resident #2 had no Advance Directives in place. The Medical Assessment and Plan of Care dated [DATE] documented that Resident #2 was stable. The IPN dated [DATE] written by the Licensed Practical Nurse (LPN #1) documented that Resident #2 was found unresponsive in bed by the nurse at 4:45 AM. Supervisor made aware, CPR started. Resident transferred to hospital. The IPN dated [DATE] written by RNS #2 documented that Resident #2 was found unresponsive by the nurse at 4:45 AM. 911 called at 4:50 AM. CPR initiated immediately at 4:48 AM and last until 5:20 AM. No vitals were able to be obtained. Resident was escorted by ambulance at 5:25 AM. Then, hospital called and resident was pronounced at 5:37 AM. An interview was conducted with the 11:00 PM to 7:00 AM RNS #2 on [DATE] at 10:04 AM. RNS #2 stated that, on [DATE] at 4:45 AM, LPN #1 called her to say that Resident #2 was unresponsive. RNS #2 went to the unit and found LPN #1 standing at the resident's bedside waiting for RNS #2. No vitals had been taken. RNS #2 assessed that the resident had no pulse but the resident was not wearing an identification bracelet and LPN #1 had not looked for the resident's code status. RNS #2 left the room to review the resident's medical record, saw that the resident was not a DNR and went back in to the room to start CPR; Code Blue was called. CPR continued for about half an hour using the defibrillator but no vitals could be obtained; Resident #2 was transferred to the hospital, whose staff called to say he pronounced on arrival. RNS #2 further stated, "CPR should be started immediately and (Resident #2) should have had a bracelet that tells you what to do." An interview was conducted with the 11:00 PM to 7:00 AM LPN #1 on [DATE] at 10:11 AM. LPN #1 stated that he discovered Resident #1 unresponsive during routine rounds and walked to the nursing desk to call the supervisor. LPN #1 stated that he did not see an identification band and did not know Resident #2's CPR/DNR status. "I thought he (Resident #2) may have taken the red dot off the band." LPN #1 further stated that the resident had no pulse, no respirations and no blood pressure; "I didn't check it." An interview was conducted with the Assistant Director of Nursing/Risk Manager (ADON) on [DATE] at 1:50 PM. The ADON stated that she does investigations for incidents in the facility but was not involved in any investigation regarding Resident #1 or Resident #2, because sometimes the Director of Nursing feels she needs to handle an investigation herself. The ADON stated that, if a resident is pulseless and ambu-bagging is started, this is rescue breathing. "CPR is ambuing and chest compressions." An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:07 AM. The DON stated that she is not aware of any concerns regarding Resident #2's death. The DON started an investigation into the circumstances of Resident #1's death, because the documentation reflected that CPR was done. The DON stated, "It all boiled down to whatever was said (by involved staff) was not reflected in the documentation." The investigation is complete and no facility staff provided CPR to Resident #1. The DON further stated, "I'm not sure if she (RNC #1) said there was no pulse or erratic pulse." An interview was conducted with the Administrator on [DATE] at 12:10 PM. The Administrator stated that he is not aware of any problems surrounding Resident #2's death. He reviewed Resident #1's medical record with the DON and saw documentation that CPR was performed on the resident. All licensed staff involved were suspended pending an investigation. He stated that the investigation is complete and the conclusion was that CPR was not done on Resident #1, so there was no violation to report to the New York State Department of Health. 3) Resident #14 is [AGE] years old and was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that Resident #14's cognition is moderately impaired. The Do Not Resuscitate Order-Resident with Capacity form dated [DATE] documented Resident #14's request and consent to an order for [REDACTED]. The ADCCP dated [DATE] documented that Resident #14 had a health care proxy and DNR in place. Interventions included ensuring face sheet and armband reflect DNR. The physician's orders [REDACTED]. During an observation on [DATE] at 2:23 PM on the Broadway unit Resident #14 was observed to be wearing a white identification bracelet without a red dot indicator. An interview was conducted with the Social Worker (SW) on [DATE] at 2:53 PM. The SW stated that there is a new red book on the nursing unit with all the names of residents with a DNR but a resident's identification bracelet is the primary indicator. The SW stated that social work does not have anything to do with updating the list of DNR residents. The SW was unsure who updates the lists and further stated, "It's probably nursing every couple of weeks." An interview was conducted with the 7:00 AM to 3:00 PM charge RN #3 on [DATE] at 2:56 PM. RN #3 stated that there are chart orders and a red book that lists residents with DNR orders but the primary and fastest indicator is the red dot on a resident's bracelet to show a DNR. RN #3 stated that any resident with a DNR order should be wearing an identification bracelet with a red dot. RN #3 further stated that she thinks the DNR lists are periodically updated every few weeks but does not know who updates the lists. An interview was conducted with the In-Service Coordinator (ISC) on [DATE] at 10:55 AM. The ISC stated that, if a resident is found unresponsive, licensed staff have to check the medical record first to find out the Advance Directive status of the resident; if the resident is not a DNR, a Code Blue should be called. There is no specific method for documentation during a Code Blue. The ISC stated that the facility is in the process of changing to an electronic medical record which uses a red heart for DNR identification, so all residents' identification bracelets are being changed to red hearts rather than red dots. The staff are being in-serviced regarding this change for the past two days. During a subsequent interview on [DATE] at 11:26 AM the ISC stated that she looked into the change in identifiers as previously stated and no change to residents' identification bracelets has taken place. There has been no in-servicing regarding this change. 415.3(e)(l)(ii)

Based on staff interviews and record review during an abbreviated and partial extended survey it was determined that the administration failed to ensure that there were systems in place to ensure that each resident reached and maintained the highest practicable physical, mental and psychosocial well-being. Specifically, the Administration failed to have a system in place to readily identify residents' CPR (Cardiopulmonary Resuscitation)/DNR (Do Not Resuscitate) status and implement residents' advance directives; failed to ensure staff competency related to pediatric and ventilator care; failed to ensure preventative contract maintenance of ventilators and that pulse oximeter alarms were audible to staff. Additionally, the Administration failed to conduct a thorough investigation to determine the root cause of an incident and report it to the appropriate agencies. This resulted in the potential for widespread harm that is Immediate Jeopardy. Complaint Number: NY 400 Cross References: F 155 - Advance Directives F 309 - Provide Care for Highest Well-being F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: The undated Policy and Procedure on Preventative Maintenance documented that preventative maintenance is performed at 15,000 hours or annually; send out equipment to authorized dealer for maintenance as per manufacturer's specifications. The undated Policy and Procedure on Emergency Situations documented that the Registered Nurse and Respiratory Therapist will investigate any alarm sounding immediately and check that the resident is being fully ventilated. The undated Policy and Procedure on Mechanical Ventilator Program (PPMVP) documented that professional nursing will be provided 24 hours per day by a team of skilled professionals, trained specifically for long term ventilator care. The PPMVP further documented that the Respiratory Therapist and In-Service Coordinator/Designee will be responsible for orientation and training of staff appropriate to the care of ventilator dependent residents. The undated Policy and Procedure on Resuscitation Measures (PPRM) documented that all licensed nursing staff are responsible to implement basic life support measures if a resident demonstrates signs and symptoms of respiratory and [MEDICAL CONDITION]; an ambu bag will be utilized to deliver ventilations. The first licensed nurse will determine if the resident requires basic life support by checking vital signs and status. Prior to initiation of CPR (cardiopulmonary resuscitation) the licensed nurse will validate the resident's advance directive wishes for CPR/DNR (Do Not Resuscitate). The Policy and Procedure on Advance Directives (PPAD) dated [DATE] documented that all documents pertinent to Advance Directives are placed in the "Advance Directives" section of the resident's medical chart. A red dot is placed on the resident's name band and spine of the chart, if the resident is a DNR. The PPAD further documented that the social worker updates Advance Directive Lists. There was no documented evidence of staff training regarding a procedure of what to do if a resident's red dot indicator is missing. The PPAD dated ,[DATE] documented that residents' advance directive will be identified and honored by the facility. The social worker will be responsible to maintain advance directive and DNR list. An interview was conducted with the Respiratory Therapy Supervisor (RTS) on [DATE] at 3:36 PM. The RTS stated that a resident's pulse oximeter alarm is not audible to the respiratory office and is not audible to the nursing station unless the nursing unit is quiet. During a subsequent interview on [DATE] at 1158 the RTS stated that the ventilators should receive annual preventative maintenance but the facility only calls the ventilator company when something on a ventilator is broken; "the policy says 15,000 hours or annually but it's whatever comes first which would be annually." The RTS further stated, "It's their (ventilator company) responsibility to make sure everything is done with the vents." An interview was conducted with the In-Service Coordinator (ISC) on [DATE] at 10:55 AM. The ISC stated that, if a resident is found unresponsive, licensed staff have to check the medical record first to find out the Advance Directive status of the resident; if the resident is not a DNR, a Code Blue should be called. There is no specific method for documentation during a Code Blue. The facility is in the process of changing to an electronic medical record which uses a red heart for DNR identification, so all residents' identification bracelets are being changed to red hearts rather than red dots. The staff are being in-serviced regarding this change for the past two days. The ISC further stated there is no staff training for pediatrics and training regarding caring for a ventilator dependent resident is provided in a general way by respiratory therapy. "We rely on respiratory therapy for the training but it's more informal than formal. It's as needed." During a subsequent interview on [DATE] at 11:26 AM the ISC stated that she looked into the change in identifiers as previously stated and no change to residents' identification bracelets has taken place. There has been no in-servicing regarding this change. An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:07 AM. The DON stated that she is not aware of any concerns regarding Resident #2's death. The DON started an investigation into the circumstances of Resident #1's death because the documentation reflected that CPR was done. The investigation "was confusing but we concluded there was no neglect. It all boiled down to whatever was said (by involved staff) was not reflected in the documentation." The investigation is complete and no facility staff provided CPR to Resident #1. The DON further stated, "I'm not sure if she (RNC #1) said there was no pulse or erratic pulse." The DON stated that she is not sure exactly what the staffing numbers are on the pediatric unit but "staff are not designated solely to the vents." Nursing is not involved in following preventative maintenance of the ventilators. "The specialized training for them (staff) on that unit (pediatric unit) happens on the unit. It's not formalized. We educate them as things happen." An interview was conducted with the Administrator on [DATE] at 12:10 PM. The Administrator stated that he is not aware of any problems surrounding Resident #2's death. He reviewed Resident #1's medical record with the DON and saw documentation that CPR was performed on the resident. All licensed staff involved were suspended pending an investigation. The investigation is complete and the conclusion was that CPR was not done on Resident #1, so there was no violation to report to the New York State Department of Health. The Administrator further stated that the purchase of the ventilators included a preventative maintenance agreement and there should be annual preventative maintenance for each ventilator. 415.26

Based on staff interviews and record review during an abbreviated and partial extended survey the Medical Director failed to ensure that the facility provided care to meet the needs of residents. Specifically, the Medical Director failed to ensure that policies and procedures related to residents' Advance Directives were developed and implemented and failed to ensure the coordination of medical care related to staff competency specific to pediatric care and the use of ventilators. This failure resulted in the potential for widespread harm that is Immediate Jeopardy. Complaint Number: NY 400 Cross References: F 155 - Advance Directives F 309 - Provide Care for Highest Well-being F 490 - Administration F 520 - Quality Assessment & Assurance The findings are: The undated Policy and Procedure on Preventative Maintenance documented that preventative maintenance is performed at 15,000 hours or annually; send out equipment to authorized dealer for maintenance as per manufacturer's specifications. The undated Policy and Procedure on Emergency Situations documented that the Registered Nurse and Respiratory Therapist will investigate any alarm sounding immediately and check that the resident is being fully ventilated. The undated Policy and Procedure on Mechanical Ventilator Program (PPMVP) documented that professional nursing will be provided 24 hours per day by a team of skilled professionals, trained specifically for long term ventilator care. The PPMVP further documented that the Respiratory Therapist and In-Service Coordinator/Designee will be responsible for orientation and training of staff appropriate to the care of ventilator dependent residents. The undated Policy and Procedure on Resuscitation Measures (PPRM) documented that all licensed nursing staff are responsible to implement basic life support measures if a resident demonstrates signs and symptoms of respiratory and [MEDICAL CONDITION]; an ambu bag will be utilized to deliver ventilations. The first licensed nurse will determine if the resident requires basic life support by checking vital signs and status. Prior to initiation of CPR (cardiopulmonary resuscitation) the licensed nurse will validate the resident's advance directive wishes for CPR/DNR (Do Not Resuscitate). The Policy and Procedure on Advance Directives (PPAD) dated [DATE] documented that all documents pertinent to Advance Directives are placed in the "Advance Directives" section of the resident's medical chart. A red dot is placed on the resident's name band and spine of the chart, if the resident is a DNR. The PPAD further documented that the social worker updates Advance Directive Lists. The PPAD dated ,[DATE] documented that residents' advance directive will be identified and honored by the facility. The social worker will be responsible to maintain advance directive and DNR list. There was no documented evidence of staff guidance regarding a procedure of what to do if a resident's red dot indicator is missing. An interview was conducted with the Attending Physician (AP) on [DATE] at 3:34 PM. The AP stated that she was advised by nursing that Resident #1 was found unresponsive with color changes and nursing tried to resuscitate the resident until it was realized the resident was a DNR; then, CPR stopped. "At bedside, they (staff) don't have a great way to identify residents for DNR. In fact, I don't know how they would." If a resident does not have a pulse, then that resident is in [MEDICAL CONDITION]. The AP further stated, "Based on his (Resident #1) orders, he should not have been ambued." An interview was conducted with the In-Service Coordinator (ISC) on [DATE] at 10:55 AM. The ISC stated that, if a resident is found unresponsive, licensed staff have to check the medical record first to find out the Advance Directive status of the resident; if the resident is not a DNR, a Code Blue should be called. There is no specific method for documentation during a Code Blue. The ISC stated that the facility is in the process of changing to an electronic medical record which uses a red heart for DNR identification, so all residents' identification bracelets are being changed to red hearts rather than red dots. The staff are being in-serviced regarding this change for the past two days. There is no staff training for pediatrics and training regarding caring for a ventilator dependent resident is provided in a general way by respiratory therapy. The ISC also stated, "We rely on respiratory therapy for the training but it's more informal than formal. It's as needed." During a subsequent interview on [DATE] at 11:26 AM the ISC stated that she looked into the change in identifiers as previously stated and no change to residents' identification bracelets has taken place. There has been no in-servicing regarding this change. An interview was conducted with a RT #3 on [DATE] at 11:32 AM. RT #3 stated that she is an adult respiratory therapist but does general review of respiratory with all staff at the request of the ISC. Pediatrics is different but there is no specific staff training for pediatric respiratory issues and no staff in the facility is formally trained on ventilator use; "We don't do vents. That would be up to the company." She, then, stated that the ventilator company had not provided any training on the use of the ventilators since their installation in 2011. Not all staff on the pediatric unit were trained at that time but "we address things as they come up." RT #3 further stated that she would not expect an issue with a ventilator because "they (ventilators) are work horses; they just keep going." An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:07 AM. The DON stated that she is not aware of any concerns regarding Resident #2's death. The DON started an investigation into the circumstances of Resident #1's death, because the documentation reflected that CPR was done. The investigation "was confusing but we concluded there was no neglect. It all boiled down to whatever was said (by involved staff) was not reflected in the documentation." The investigation is complete and no facility staff provided CPR to Resident #1. The DON further stated, "I'm not sure if she (RNC #1) said there was no pulse or erratic pulse." The DON stated that she is not sure exactly what the staffing numbers are on the pediatric unit but "staff are not designated solely to the vents." Nursing is not involved in following preventative maintenance of the ventilators. "The specialized training for them (staff) on that unit (pediatric unit) happens on the unit. It's not formalized. We educate them as things happen." An interview was conducted with the Medical Director (MD) on [DATE] at 3:25 PM. The MD stated that he has not signed off on any recent Advance Directive policy changes. He does not believe specific training for pediatrics is needed because "the work is the same in pediatrics and geriatrics. Fever is fever." He is aware of and agrees with the conclusion of the investigation into Resident #1's death but was unable to recall anything regarding the investigation. The MD further stated, "Everything on that unit (pediatric unit) is at the highest level." 415.15 (a)

Based on staff interviews and record review during an abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that readily identified each resident's right to accept or refuse medical treatment, formulate an advance directive in accordance with State Law and quality of care deficiencies. Specifically, the Quality Assessment and Assurance (QAA) Committee failed to review and evaluate the sequence of events preceding the deaths of Resident #1 & #2, to identify system failures and determine the root cause. The QAA Committee failed to ensure the development and implementation of policies and procedures related to residents' advance directives and staff competency specific to pediatric care and the use of ventilators. This resulted in the potential for widespread harm that is Immediate Jeopardy. Complaint Number: NY 400 Cross References: F 155 - Advance Directives F 309 - Provide Care for Highest Well-being F 490 - Administration F 501 - Medical Director The findings are: The undated Policy and Procedure on Preventative Maintenance documented that preventative maintenance is performed at 15,000 hours or annually; send out equipment to authorized dealer for maintenance as per manufacturer's specifications. The undated Policy and Procedure on Emergency Situations documented that the Registered Nurse and Respiratory Therapist will investigate any alarm sounding immediately and check that the resident is being fully ventilated. The undated Policy and Procedure on Mechanical Ventilator Program (PPMVP) documented that professional nursing will be provided 24 hours per day by a team of skilled professionals, trained specifically for long term ventilator care. The PPMVP further documented that the Respiratory Therapist and In-Service Coordinator/Designee will be responsible for orientation and training of staff appropriate to the care of ventilator dependent residents. The undated Policy and Procedure on Resuscitation Measures (PPRM) documented that all licensed nursing staff are responsible to implement basic life support measures if a resident demonstrates signs and symptoms of respiratory and [MEDICAL CONDITION]; an ambu bag will be utilized to deliver ventilations. The first licensed nurse will determine if the resident requires basic life support by checking vital signs and status. Prior to initiation of CPR (cardiopulmonary resuscitation) the licensed nurse will validate the resident's advance directive wishes for CPR/DNR (Do Not Resuscitate). The Policy and Procedure on Advance Directives (PPAD) dated [DATE] documented that all documents pertinent to Advance Directives are placed in the "Advance Directives" section of the resident's medical chart. A red dot is placed on the resident's name band and spine of the chart, if the resident is a DNR. The PPAD further documented that the social worker updates Advance Directive Lists. The PPAD dated ,[DATE] documented that residents' advance directive will be identified and honored by the facility. The social worker will be responsible to maintain advance directive and DNR list. There was no documented evidence of staff guidance regarding a procedure of what to do if a resident's red dot indicator is missing. The Policy and Procedure on Accident and Incident Report dated 2013 documented that ongoing Quality Assurance monitoring will be conducted for all incidents/accidents for improvement of the risk management program. An interview was conducted with the In-Service Coordinator (ISC) on [DATE] at 10:55 AM. The ISC stated that, if a resident is found unresponsive, licensed staff have to check the medical record first to find out the Advance Directive status of the resident; if the resident is not a DNR, a Code Blue should be called. There is no specific method for documentation during a Code Blue. The facility is in the process of changing to an electronic medical record which uses a red heart for DNR identification, so all residents' identification bracelets are being changed to red hearts rather than red dots. The staff are being in-serviced regarding this change for the past two days. The ISC stated there is no staff training for pediatrics and training regarding caring for a ventilator dependent resident is provided in a general way by respiratory therapy. The ISC further stated, "We rely on respiratory therapy for the training but it's more informal than formal. It's as needed." During a subsequent interview on [DATE] at 11:26 AM the ISC stated that she looked into the change in identifiers as previously stated and no change to residents' identification bracelets has taken place. There has been no in-servicing regarding this change. An interview was conducted with a RT #3 on [DATE] at 11:32 AM. RT #3 stated that she is an adult respiratory therapist but does general review of respiratory with all staff at the request of the ISC. Pediatrics is different but there is no specific staff training for pediatric respiratory issues and no staff in the facility is formally trained on ventilator use; "We don't do vents. That would be up to the company." RT#3, then, stated that the ventilator company had not provided any training on the use of the ventilators since their installation in 2011. Not all staff on the pediatric unit were trained at that time but "we address things as they come up." RT #3 further stated that she would not expect an issue with a ventilator because "they (ventilators) are work horses; they just keep going." An interview was conducted with the Assistant Director of Nursing/Risk Manager (ADON) on [DATE] at 1:50 PM. The ADON stated that she does investigations for incidents in the facility but was not involved in any investigation regarding Resident #1 or Resident #2, because sometimes the Director of Nursing feels she needs to handle an investigation herself. An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:07 AM. The DON stated that she is not aware of any concerns regarding Resident #2's death. The DON started an investigation into the circumstances of Resident #1's death, because the documentation reflected that CPR was done. The investigation "was confusing but we concluded there was no neglect; it all boiled down to whatever was said (by involved staff) was not reflected in the documentation." The investigation is complete and no facility staff provided CPR to Resident #1. The DON further stated, "I'm not sure if she (RNC #1) said there was no pulse or erratic pulse." The DON stated that she is not sure exactly what the staffing numbers are on the pediatric unit but "staff are not designated solely to the vents." Nursing is not involved in following preventative maintenance of the ventilators. The specialized training for them (staff) on that unit (pediatric unit) happens on the unit. It's not formalized. We educate them as things happen." An interview was conducted with the Medical Director (MD) on [DATE] at 3:25 PM. The MD stated that he has not signed off on any recent Advance Directive policy changes. He does not believe specific training for pediatrics is needed because "the work is the same in pediatrics and geriatrics. Fever is fever." The MD further stated that he is aware of and agrees with the conclusion of the investigation into Resident #1's death but was unable to recall anything regarding the investigation. "Everything on that unit (pediatric unit) is at the highest level." An interview was conducted with the Administrator on [DATE] at 12:10 PM. The Administrator stated that the purchase of the ventilators included a preventative maintenance agreement and there should be annual preventative maintenance for each ventilator. He is not aware of any problems surrounding Resident #2's death. The Administrator stated that he reviewed Resident #1's medical record with the DON and saw documentation that CPR was performed on the resident. All licensed staff involved were suspended pending an investigation. The investigation is complete and the conclusion was that CPR was not done on Resident #1, so there was no violation to report to the New York State Department of Health. The Administrator further stated that, in [MEDICATION NAME] with the investigation, a facility-wide house audit was completed by department heads to ensure DNR orders, paperwork and resident identification bands were present; there were no findings. 415.27 (a-c)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure that the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being were provided to one pediatric ventilator-dependent resident (Resident #1) of 14 residents reviewed for quality of care. The facility failed to ensure that there was a system in place to monitor and track ventilator preventative maintenance according to manufacturer's guidelines. Specifically, the facility failed to ensure that Resident #1's ventilator preventative maintenance was performed at the manufacturer ' s suggested intervals and ensure alarms were audible to staff outside a resident's room that monitor a resident's oxygen suturation (pulse oximeters). The facility failed to train and ensure staff competency specific to pediatric and ventilator care. Key staff were not able to hear alarms outside a resident's room that monitor a resident's oxygen saturation (pulse oximeters). This resulted in the potential for widespread harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint Number: NY 400 Cross References: F 155 - Advance Directives F 490 - Administration F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: The undated Policy and Procedure on Preventative Maintenance documented that preventative maintenance is performed at 15,000 hours or annually; send out equipment to authorized dealer for maintenance as per manufacturer's specifications. The undated Policy and Procedure on Emergency Situations documented that the Registered Nurse and Respiratory Therapist will investigate any alarm sounding immediately and check that the resident is being fully ventilated. The undated Policy and Procedure on Mechanical Ventilator Program (PPMVP) documented that professional nursing will be provided 24 hours per day by a team of skilled professionals, trained specifically for long term ventilator care. The PPMVP further documented that the Respiratory Therapist and In-Service Coordinator/Designee will be responsible for orientation and training of staff appropriate to the care of ventilator dependent residents. The Ventilator Vendor Service Request dated [DATE] documented that Resident #1's ventilator was provided preventative maintenance. There was no other documented evidence of preventative maintenance of the ventilator after this date. Resident #1 was 3 years old and admitted to the facility with [DIAGNOSES REDACTED]. The Admission History and Physical dated [DATE] documented that Resident #1 was admitted to the facility with a [MEDICAL CONDITION] and is ventilator dependent. The Minimum Data Set 3.0 (MDS) (an assessment tool) dated [DATE] documented that Resident #1's cognition was severely impaired. The Cognition Care Plan dated [DATE] documented that Resident #1's cognition was severely impaired related to vegetative-like state. Interventions included to maintain safe environment. The Potential for Abuse/Neglect/Mistreatment/Victimization Care Plan dated [DATE] documented that Resident #1 was a potential risk for victimization. Interventions included to anticipate resident's needs. The Advance Directive Comprehensive Care Plan (ADCCP) dated [DATE] documented DNR in place with interventions including review Advance Directives, choices & options and include medical staff physician as designated representative's questions become specifically medical to the resident's care in relation to Advance Directives. The Ventilator/Respiratory Comprehensive Care Plan dated [DATE] documented that Resident #1 was at risk for respiratory distress secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION], requiring ventilator support. The physician's orders [REDACTED]. The Physician Assessment and Plan of Care dated [DATE] documented that Resident #1 had chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] and ventilator dependent. The Pediatric [MEDICAL CONDITION] Medicine Note dated [DATE] documented that Resident #1 had no new respiratory concerns and currently stable from a respiratory standpoint; no change in ventilator support. The Neurology Progress Note dated [DATE] documented that Resident #1 was in persistent vegetative status, [MEDICAL CONDITION], on ventilation. An interview was conducted with the assigned 6:00 AM to 2:00 PM Certified Nursing Assistant (CNA #1) on [DATE] at 11:45 AM. CNA #1 stated that, on [DATE], she made rounds initial rounds and found Resident #1's face pale. CNA #1 ran to the nursing desk to tell the nurses, who went to the resident ' s room. CNA #1 called the front desk to page for the supervisor and call a Code Blue. CNA #1 stated that she doesn't recall getting any special training to work with pediatric ventilator dependent residents and has to take care of other residents on the unit besides these. An interview was conducted with the 7:00 PM to 7:00 AM RN Supervisor (RNS #1) on [DATE] at 2:56 PM. RNS #1 stated that, on [DATE] around 6:15 AM, she heard a Code Blue called to the Pediatric unit. When she entered Resident #1's room, RNC #1 and RN #1 were ambu-bagging the resident. RNS #1 and 911 personnel arrived to the resident's room at the same time; RN #2 ran in behind them saying Resident #1 was a DNR. She pronounced the resident dead at 6:20 AM. RNS #1 further stated, "I'm the supervisor for the house but I don't know anything about vents because I don't work on peds (pediatric unit)." An interview was conducted with the Respiratory Therapy Supervisor (RTS) on [DATE] at 3:36 PM. The RTS stated that a resident's pulse oximeter alarm is not audible to the respiratory office and is not audible to the nursing station unless the nursing unit is quiet. During a subsequent interview on [DATE] at 1158 the RTS stated that the ventilators should receive annual preventative maintenance but the facility only calls the ventilator company when something on a ventilator is broken; "the policy says 15,000 hours or annually but it's whatever comes first which would be annually." The RTS further stated, "It's their (ventilator company) responsibility to make sure everything is done with the vents." During an observation on [DATE] at 10:15 AM on the Petals unit a pulse oximeter alarm was triggered by RT #2 and sounding in room [ROOM NUMBER]A but was not audible at the nursing station. The Pediatric Nurse Manager was seated at the nursing station and stated that she could not hear any alarms. An interview was conducted with the assigned Respiratory Therapist (RT #1) on [DATE] at 10:58 AM. RT #1 stated that, on [DATE] around 6:10 AM, he heard a call to the resident's room and, upon entering the room, saw RNC #1 and RN #1 ambu-bagging Resident #1, who was cyanotic and extremely pale. RT #1 offered help by ambu-bagging and lavaging the resident, who was not attached to the ventilator because the nurses were ambu-bagging. RT #1 changed the trach; there was no mucus plug or resistance on ambu-bagging or suctioning. RT #1 stated that, although he did not recall who it was, a staff member came in to the room to say the resident was a DNR. RT #1 stated that all measures stopped and the nursing supervisor said the resident expired. RT #1 further stated that he had not thought to question whether or not Resident #1 was a DNR. RT #1 stated that, after thinking about what happened, he decided to write a clarification note a few days later because no staff member performed CPR. During a subsequent interview with RT #1 on [DATE] at 3:42 PM RT #1 stated that, if a ventilator alarms, it can be heard at the nursing station and in the respiratory office. He further stated that pulse oximeter alarms are not connected to ventilators and can't be heard unless staff are in a resident's room where the alarm is sounding. An interview was conducted with the ventilator vendor's Director of Product Monitoring (DPM) on [DATE] at 2:15 PM. The DPM stated that the manufacturer guidelines for the facility's ventilators recommend preventative maintenance annually. The DPM further stated that Resident #1's ventilator had not been provided preventative maintenance since [DATE]. An interview was conducted with the Pediatric Nurse Manager (PNM) on [DATE] at 9:42 AM. The PNM stated that she assigns nursing staff on the Petals unit. The PNM stated that nursing assistants and licensed nurses are not specifically assigned to ventilator residents; "They (nursing staff) all should be comfortable caring for every resident on that unit, vent and non-vent. It's a mixed assignment of vents and non-vents." The PNM stated that Resident #1 was 24 hour ventilator dependent but occasionally had a spontaneous breath. A ventilator would have to cycle through a couple of times in order to alarm. The PNM stated that, if a resident was pulseless on a ventilator, she would expect to hear a pulse oximeter alarming and, then, expect the ventilator to alarm at some point. An interview was conducted with a 10:00 PM to 6:00 AM CNA #2 on [DATE] at 4:52 PM. CNA #2 stated that all aides on the pediatric unit have ventilator dependent residents on their assignments as well as other residents to care for. CNA #2 stated that she has not had any training regarding caring for residents on ventilators; "I just ask questions if I have them." An interview was conducted with the In-Service Coordinator (ISC) on [DATE] at 10:55 AM. The ISC stated that the PNM takes care of staffing on the pediatric ventilator unit but no staff on that unit is specifically assigned just to ventilator dependent residents. There is no staff training for pediatrics and training regarding caring for a ventilator dependent resident is provided in a general way by respiratory therapy. The ISC further stated, "We rely on respiratory therapy for the training but it's more informal than formal. It's as needed." An interview was conducted with a RT #3 on [DATE] at 11:32 AM. RT #3 stated that she is an adult respiratory therapist but does general review of respiratory with all staff at the request of the ISC. RT #3 stated that pediatrics is different but there is no specific staff training for pediatric respiratory issues. RT #3 stated that no staff in the facility is formally trained on ventilator use; "We don't do vents. That would be up to the company." She, then, stated that the ventilator company had not provided any training on the use of the ventilators since their installation in 2011. Not all staff on the pediatric unit were trained at that time but "we address things as they come up." RT #3 further stated that she would not expect an issue with a ventilator because "they (ventilators) are work horses; they just keep going." An interview was conducted with the Medical Director (MD) on [DATE] at 3:25 PM. The MD stated that he does not believe specific training for pediatrics is needed because "the work is the same in pediatrics and geriatrics. Fever is fever." The MD stated that he is aware of and agrees with the conclusion of the investigation into Resident #1's death but was unable to recall anything regarding the investigation. The MD further stated, "Everything on that unit (pediatric unit) is at the highest level." An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:07 AM. The DON stated that she started an investigation into the circumstances of Resident #1's death. The investigation "was confusing but we concluded there was no neglect." The DON stated that she is not sure exactly what the staffing numbers are on the pediatric unit but "staff are not designated solely to the vents." The DON stated that nursing is not involved in following preventative maintenance of the ventilators. The DON further stated, "The specialized training for them (staff) on that unit (pediatric unit) happens on the unit. It's not formalized. We educate them as things happen." An interview was conducted with the Administrator on [DATE] at 12:10 PM. The Administrator stated that the purchase of the ventilators included a preventative maintenance agreement and there should be annual preventative maintenance for each ventilator. 415.12

Based on staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure that each resident was provided with medically related social services to attain or maintain her or his highest practicable physical, mental and psychosocial well-being, for 1(#1) of 19 residents reviewed. Specifically, the facility failed to obtain a complete admission psychosocial assessment of a resident (Resident #1) with psychiatric illness and a history of running away from his group home. The resident was not assessed as an elopement risk. Subsequently, on 7/13/13 Resident #1 eloped from the facility undetected by staff and was found by police in another town 5 hours later. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint Number: NY 032 Cross References: F 323 - Accidents & Supervision F 490 - Administration F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) assessed the resident to have moderately impaired cognition. On 7/13/13, the resident eloped undetected by staff and was found by police in another town 5 hours later. The Policy and Procedure on Elopement dated 10/10 documented that each resident will be assessed for the risk of unsafe wandering and elopement. Information from a family member or prior provider is a vital part of this process; the social worker plays a crucial role in researching a resident's past patterns and routines so that risk of unsafe wandering is properly addressed and understood upon the resident's admission to the facility. The Social Work Psychosocial assessment dated [DATE] documented that Resident #1 did not have a history of elopement/wandering and does not wander. An interview was conducted with a 7:00 AM to 3:00 PM charge Registered Nurse (RN #1) on 7/17/13 at 11:36 AM. RN #1 stated that she didn't know that Resident #1 had a prior history of leaving his group home until after the resident eloped from the facility. RN #1 further stated, "Usually the social worker will have contact with the caregiver, get the history and tell us (staff). I was never told of that (Resident #1's history)." An interview was conducted with the Director of Social Work (DSW) on 7/18/13 at 9:03 AM. The DSW stated that a resident's wandering/elopement behavior is part of the psychosocial assessment of a resident upon admission to the facility. The DSW stated that, at the time of Resident #1's admission, the DSW did not speak with the resident's care providers at the group home. The DSW called the resident's group home providers after Resident #1 had eloped from the facility and was advised that the resident had run away from the group home in the past when the resident was under stress. The DSW stated that a team meeting was held with the resident alone the day before Resident #1 eloped; the resident's group home providers were not invited to the meeting. There is speculation that a discussion of discharge may have triggered the elopement. The DSW stated that his thought was to have the resident involved since "there are people in the community who live like that (with mental illness/mental retardation)." When asked whether or not this statement was comparable to the resident ' s living situation, the DSW further stated, "No. He's (Resident #1) been institutionalized for many years." An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse Manager (RNM) on 7/18/13 at 12:30 PM. She stated that she did not know of the resident's elopement history. "The social worker gets the history on admission. He (social worker) wouldn't interview the resident. He'd get the history from the case manager (at the group home)." The RNM further stated, "If we (staff) knew he ran from the group home, he probably would have been an elopement risk." An interview was conducted with the Administrator on 7/19/13 at 9:33 AM. The Administrator stated that a wanderer should be identified by staff on admission and a wander guard should be applied. 10 NYCRR 415.5 (g)(1)(i-xv)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure a safe environment, providing adequate supervision and monitoring to protect the health and safety for one (Resident #1) of 19 residents reviewed with a history of unsafe wandering/elopement behavior. Specifically for Resident #1 the facility failed to obtain a complete psychosocial history from his group home providers, which included a history of prior elopement. The resident was not assessed to be an elopement risk. He wandered within the facility daily and was observed by staff pacing to/from an exit door for which 20 minute monitoring was started but was not carried over to the resident's plan of care. On 7/13/13 staff was alerted by a visitor that the resident was unusually quiet and a curtain was drawn around his bed. Resident #1 eloped on 7/13/13 undetected by staff and was found by police 5 hours later in another town 16 miles away. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for 23 residents at risk for unsafe wandering/elopement. Complaint Number: NY 032 The findings are: The Policy and Procedure on Elopement dated 10/10 documented that each resident will be assessed for the risk of unsafe wandering and elopement. Information from a family member or prior provider is a vital part of this process; the social worker plays a crucial role in researching a resident's past patterns and routines so that risk of unsafe wandering is properly addressed ...If a resident is missing initiate a Code Amber; a systemic search of the facility and surrounding grounds ...Upon resident's return to the facility the Registered Nurse will perform an assessment of the resident, noting any injuries, change in condition, monitor vital signs, neurological assessment. Nurse will contact Attending Physician and report findings and condition of the resident; follow orders as indicated. Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated 6/18/13 assessed that the resident's cognition is moderately impaired. The Elopement Risk assessment dated [DATE] and updated 7/8/13 assessed that Resident #1 was at low risk for elopement. The Comprehensive Care Plan (CCP) titled, Potential for Elopement, dated 6/12/13 documented that Resident #1 was at risk for elopement secondary to independent mobility and psychiatric [DIAGNOSES REDACTED]. Interventions included monitoring the resident for wandering behavior, psychiatric follow-up as needed and monitoring the environment for hazards. The CCP titled, Potential for Abuse/Neglect/Mistreatment/Victimization, dated 6/13/13 documented Resident #1's "risk" related to mental retardation. Interventions included monitoring the resident and psychiatry consult as needed. The CCP titled, Mood Indicators, dated 6/13/13 documented Resident #1's psychiatric diagnosis. Interventions included to monitor the resident more frequently. The Social Work Psychosocial assessment dated [DATE] documented that Resident #1 does not have a history of elopement/wandering and did not wander. The Integrated Progress Notes (IPN) dated 6/15/13 documented that Resident #1 was showing "some signs of psych behaviors; becomes paranoid at times." The medical record lacked documented evidence that Resident #1 was evaluated by Psychiatry. The IPN dated 6/21/13 documented that 20 minute watch initiated due to wandering behavior. All appropriate staff were made aware. The CCP titled, Behavioral Symptoms, dated 6/21/13 documented Resident #1's pacing from room to guard desk, appears to be anxious. The interventions section included choices of analyzing key times, places, circumstances and triggers but was not checked as an intervention on the CCP. The Twenty Minute Watch Form (TMWF) dated 6/21/13 documented that Resident #1 was visually monitored every 20 minutes from 2:00 PM to 10:00 PM. There was no documented TMWF that the resident was visually monitored on any additional shifts or dates. The IPN dated 7/9/13 documented that Resident #1's behavior remains paranoid and has displaced anger. Will continue to closely monitor. The Therapeutic Activities/Recreation Progress Assessment Review Date 7/11/13 documented that Resident #1 walks on/off the unit. The IPN dated 7/12/13 documented that Resident #1 had increased agitation and anxiety. Resident on 20 minute watch. The Certified Nursing Assistant Accountability Record (used by the aides to provide direct care) lacked documented evidence that Resident #1 was an elopement risk or on 20 minute watch. The IPN dated 7/13/13 at 8:30 PM documented that a family member of another resident stated, "He (Resident #1) disappeared." Nurse notified supervisor who initiated a building-wide search, a head count of each unit and a search of the grounds. Upon not finding the resident, 911 was called. The Occurrence Report dated 7/13/13 at 7:00 PM documented that Resident #1 eloped. Police notified; building-wide search; search of grounds; Code Amber called; department heads notified. The physician was notified at 9:00 PM; no orders at this time. The Occurrence Report did not include the last time the resident was seen by staff members. The IPN dated 7/13/13 documented that Resident #1 returned with police at 11:45 PM, verbally disruptive running up/down the hallway screaming; orders to place for C-PEP (Comprehensive Psychiatric Emergency Placement) in progress; refuses to take medication; security informed resident became less agitated; escorted to secured unit with 1:1 (one to one supervision) in progress. The 911 call was cancelled. The IPN dated 7/14/13 documented that a body check of Resident #1 was done at around 12 Noon. No visible injuries noted. The undated Summary of Investigation documented that there is no evidence of a system failure. Resident #1's working background, strong desire to go back to the group home and running away as a way of coping with stressful situations facilitated the elopement. The policy on elopement was found compliant and elopement risk assessments of all residents in the facility were reviewed and found compliant. All facility windows were checked and were reinforced to prevent raising more than 6 inches. On 7/17/13 at 10:43 AM Resident #1's room was observed with the Director of Nursing (DON). The DON stated that, on 7/13/13, the resident was able to dislodge a screw on the frame of the window; the window opens above a cement staircase descending to the basement. The DON tested the window to see if the screw had been replaced. She was not able to open the window but stated, "As of yesterday it wasn't fixed yet." An interview was conducted with a 6:00 AM to 2:00 PM Certified Nursing Assistant (CNA #1) on 7/17/13 at 11:11 AM. CNA #1 stated that he also cared for Resident #1 from 2:00 PM to 10:00 PM at times. CNA #1 stated that the resident seemed cognitive "but would make up stories and be very paranoid about things." The resident wandered around and could usually be found by the security desk at the exit door because "he wanted to go home." CNA #1 stated that he did not think Resident #1 was at risk for elopement because the resident did not have a wander guard; sometimes a resident might be put on 20 minute watch. When asked if the resident was on 20 minute watch, CNA #1 further stated, "No. He (Resident #1) was never on that." An interview was conducted with a 7:00 AM to 3:00 PM medication Licensed Practical Nurse (LPN #1) on 7/17/13 at 11:23 AM. LPN #1 stated that Resident #1 would walk around to different parts of the building, and she did not recall him ever being on 20 minute watch. LPN #1 stated, "I only remember hearing that he (Resident #1) was on 20 minute watch after he left and came back." LPN #1 further stated, "He definitely wasn't on that (20 minute watch) before (eloping)." An interview was conducted with a 7:00 AM to 3:00 PM charge Registered Nurse (RN #1) on 7/17/13 at 11:36 AM. RN #1 stated that, on 6/21/13, she placed Resident #1 on 20 minute monitoring; "he (Resident #1) was anxiously pacing back and forth towards the outside door." She does not know why the resident's monitoring did not continue. RN #1 stated that a resident is reassessed for elopement risk annually and when a change would occur; "a change is if a resident goes to an exit, wants to leave or put on 20 minute monitoring." She further stated that she did not reassess the resident. RN #1 stated that she didn't know that Resident #1 had a prior history of leaving his group home until after the resident eloped from the facility. RN #1 further stated, "Usually the social worker will have contact with the caregiver, get the history and tell us (staff). I was never told of that (Resident #1's history)." An interview was conducted with a 3:00 PM to 11:00 PM RN #2 on 7/17/13 at 12:37 PM. RN #2 stated that, around 7:00 PM on 7/13/13, CNA #3 told her that the family of Resident #1's roommate said that Resident #1 had disappeared and there might be a problem. The roommate's family said that the resident's curtain had been pulled and it was unusually quiet. RN #2 went to the resident's room, pulled the window blinds open and saw the window opened with no visible screen. RN #2 stated that the resident should not have been able to open the window; "he could have killed himself." RN #2 stated that the resident was often seen on different units and she had seen him on the other side of the building. RN #2 stated that she never questioned Resident #1's wandering because she doesn't remember him talking about leaving. RN #2 further stated that Resident #1 was never monitored. An interview was conducted with a 6:00 AM to 2:00 PM CNA #2 on 7/17/13 at 1:01 PM. CNA #2 stated that she had not been assigned to care for Resident #1 more than a couple of times but does not "remember (the resident) being at risk for anything." CNA #2 stated that Resident #1 was never on 20 minute watch. An interview was conducted with a 3:00 PM to 11:00 PM Registered Nurse Supervisor (RNS #1) on 7/17/13 at 1:26 PM. RNS #1 stated that, around 7:00 PM on 7/13/13, RN #2 advised her that Resident #1 was missing. A Code Amber (missing resident alert) was called and the facility searched. The resident was not found, so the police were notified. RNS #1 stated she notified the doctor of the resident's elopement but Resident #1 had not returned to the facility by the end of her shift. RNS #1 further stated, "I didn't really know him (Resident #1). I don't think there was any monitoring involved." An interview was conducted with a 6:00 AM to 2:00 PM CNA #3 on 7/17/13 at 1:44 PM. CNA #3 stated that Resident #1 "always wandered back and forth to the security desk. I just let him do his own thing." An interview was conducted with a 2:00 PM to 10:00 PM CNA #4 on 7/17/13 at 2:14 PM. CNA #4 stated that Resident #1 was seen all over the building but very often near the door by security. CNA #4 stated that he didn't think the resident was supposed to be watched and did not think that the resident had a wander guard. An interview was conducted with the Director of Building Services (DBS) on 7/17/13 at 2:22 PM. The DBS stated that screws were put into window frames about 2 ? years ago after the elopement of another resident to prevent windows from opening more than six inches. He stated that there has been no maintenance log of the windows since that time. The DBS further stated, "It's my thought to start some kind of log in September." An interview was conducted with a 2:00 PM to 10:00 PM CNA #5 on 7/17/13 at 2:37 PM. CNA #5 stated that, although she was never assigned to Resident #1, she "always saw him wandering around on the other units." With regard to recognizing a resident who might be at risk for elopement, CNA #5 stated, "You have put a wander guard. That's all I know." An interview was conducted with the Director of Social Work (DSW) on 7/18/13 at 9:03 AM. The DSW stated that a resident ' s wandering/elopement behavior is part of the psychosocial assessment of a resident upon admission to the facility. The DSW stated that, at the time of Resident #1's admission, the DSW did not speak with the resident's care providers at the group home. The DSW called the resident's group home providers after Resident #1 had eloped from the facility and was advised that the resident had run away from the group home in the past when the resident was under stress. The DSW stated that a team meeting was held with the resident alone the day before Resident #1 eloped; the resident's group home providers were not invited in the meeting. There is speculation that a discussion of discharge may have triggered the elopement. The DSW stated that his thought was to have the resident involved since "there are people in the community who live like that (with mental illness/mental retardation)." When asked whether or not this statement was comparable to the resident's living situation, the DSW further stated, "No. He's (Resident #1) been institutionalized for many years." An interview was conducted with an 11:00 PM to 7:00 AM RN #3 on 7/18/13 at 11:00 AM. RN #3 stated that, when she came on duty on 7/13/13, Resident #1 had not yet been found. The police came into the facility around Midnight with the resident, who was found in another town. RN #3 stated that, after the police left, the resident started throwing chairs and screaming; security was keeping watch of the resident. The resident was told he was going to go to the psychiatric emergency room and 911 was called. RN #3 stated that the resident soon calmed down after hearing about being sent out and staff transferred the resident to a locked unit with one to one supervision. The 911 call was cancelled. RN #3 stated that she knew that the physician was contacted after the resident eloped but the physician was not contacted after the resident returned to the facility. RN #3 further stated, "A body check was never attempted." An interview was conducted with the Attending Physician (AP) on 7/18/13 at 11:52 AM. The AP stated that Resident #1 had a long psychiatric history and should have been seen by Psychiatrist no more than two weeks after admission to the facility. Resident #1 was "very anxious, always wanted to leave and was seen coming in and out all the time." The AP stated that he was called by nursing on the evening the resident eloped, but "I don't really know when he came back. They (nursing) called me sometime midday the next day." The AP further stated that Resident #1 must be in a supervised setting and should have been considered an elopement risk. An interview was conducted with the Security Guard (SG) on 7/18/13 at 12:10 PM. The SG stated that he monitors the three alarmed exit doors by viewing the security camera. The SG stated that there is a Risk Book for residents at risk for wandering and elopement. He opened the book and pointed out that the last updated entry of wanderers was on 3/22/13; "it's not updated on any regular basis." The SG further stated, "If a resident doesn't have a wander guard, I wouldn't know if they're at risk (for wandering/elopement)." An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse Manager (RNM) on 7/18/13 at 12:30 PM. The RNM stated that she does not know why Resident #1 was not seen by the Psychiatrist but the resident should have been seen. Pending consults for the Psychiatrist are left for the Psychiatrist's discretion of when to see a resident. She is not sure if the resident ever had a pending consult for the Psychiatrist. The RNM stated that she does not know if the resident had been on 20 minute watch previously but Resident #1 should have been on 20 minute watch since 7/12/13 when the resident was showing increased agitation. The RNM was uncertain regarding documentation of this 20 minute watch but stated that it should have been documented by CNAs on a TMWF. The RNM stated that Resident #1 would often sit near the door by the security guard. She stated that she did not know of the resident's elopement history. "The social worker gets the history on admission. He (social worker) wouldn't interview the resident. He'd get the history from the case manager (at the group home)." The RNM further stated, "If we (staff) knew he ran from the group home, he probably would have been an elopement risk." An interview was conducted with the Assistant Director of Nursing (ADON) on 7/18/13 at 1:50 PM. The ADON stated that she investigated Resident #1's elopement and did not find any systemic concerns or break in policy. The ADON stated that she does not know if the resident was physically assessed upon return to the facility and thinks the doctor was called the next day. She was uncertain about whether or not issues of assessment and notification of the physician are addressed in the elopement policy. The ADON further stated that, following the elopement, she had asked nurse managers to make sure all residents' elopement assessments were current in date; residents were not reassessed for their elopement risk. The ADON stated that she is also the In-Service Director for the facility. Staff are in-serviced annually on what to do if an elopement occurs as per policy. The ADON stated that, after Resident #1's elopement, staff was rein-serviced on the policy but not on identifying resident triggers for elopement. An interview was conducted with the Medical Director (MD) on 7/18/13 at 2:32 PM. The MD stated that he was notified of Resident #1's elopement, but has had no other involvement. The MD stated that he is not aware of any concerns regarding psychiatric consultations. The MD further stated, "I haven't been involved in any policy review at current." An interview was conducted with the Director of Nursing (DON) on 7/19/13 at 9:04 AM. The DON stated that Resident #1 was on psychotropic medication upon admission to the facility and should have been seen by a Psychiatrist. She is not aware of a time frame for psychiatric consults or the reason for which the resident was not seen by Psychiatrist. The DON stated that she is not aware of any behaviors Resident #1 exhibited to trigger a reassessment of his elopement risk. The DON stated that, after Resident #1 eloped, she believes staff followed the facility's policy on elopement and there is no other policy on elopement prevention. An interview was conducted with the Administrator on 7/19/13 at 9:33 AM. The Administrator stated that the ADON made her aware of Resident #1's elopement on the evening of 7/13/13. The Administrator stated that she told the ADON to follow the Code Amber protocol. The resident was not physically reassessed and the Administrator performed a body assessment of the resident the next day. The Administrator stated that a wanderer should be identified by staff on admission and a wander guard should be applied. 10 NYCRR 415.12 (h) (1) (2)

Based on record review and staff interviews conducted during an abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that functioned to develop and implement appropriate plans of action to readily identify issues with the potential to cause serious harm to the health and safety for 1 (#1) of 19 residents identified to be at risk for elopement/wandering behaviors . Specifically, the Quality Assessment and Assurance (QAA) Committee failed to review and evaluate the undetected elopement incident for Resident #1 on 07/13/2013, to determine the root cause. The QAA Committee failed to ensure the development and implementation of policies and procedures for the prevention of elopement, and the monitoring and supervision of residents with a known history of elopement/wandering. The QAA Committee also failed to identify system failures related to residents who are at risk for elopement/wandering. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy. Complaint Number: NY 032 Cross References: F 250 - Medically Related Social Services F 323 - Accidents & Supervision F 490 - Administration F 501 - Medical Director The findings are: Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) assessed the resident to have moderately impaired cognition. On 7/13/13, the resident eloped undetected by staff and was found by police in another town 5 hours later. The undated Summary of Investigation documented that there is no evidence of a system failure. Resident #1's working background, strong desire to go back to the group home and running away as a way of coping to stressful situations facilitated the elopement. The policy on elopement was found compliant and elopement risk assessments of all residents in the facility were reviewed and found compliant. All facility windows were checked and reinforced to prevent raising more than 6 inches. An interview was conducted with the Attending Physician (AP) on 7/18/13 at 11:52 AM. The AP stated that Resident #1 had a long psychiatric history and should have been seen by a Psychiatrist no more than two weeks after admission to the facility. Resident #1 was "very anxious, always wanted to leave and seen coming in and out all the time." The AP stated that he was called by nursing on the evening the resident eloped, but "I don't really know when he came back. They (nursing) called me sometime midday the next day." The AP further stated that Resident #1 must be in a supervised setting and should have been considered an elopement risk. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/18/13 at 1:50 PM. The ADON stated that she investigated Resident #1's elopement and did not find any systemic concerns or break in policy. The ADON stated that she does not know if the resident was physically assessed upon return to the facility and thinks the doctor was called the next day. She was uncertain about whether or not issues of assessment and notification of the physician are addressed in the elopement policy. The ADON further stated that she had asked nurse managers to make sure all residents' elopement assessments were current in date; residents were not reassessed for their elopement risk. The ADON stated that she is also the In-Service Director for the facility. Staff are in-serviced annually on what to do if an elopement occurs as per policy. The ADON stated that, after Resident #1's elopement, staff was rein-serviced on the policy but not on identifying resident triggers for elopement. An interview was conducted with the Medical Director (MD) on 7/18/13 at 2:32 PM. The MD stated that he was notified of Resident #1's elopement, but has had no other involvement. The MD stated that he is not aware of any concerns regarding psychiatric consultations. The MD further stated, "I haven't been involved in any policy review at current." An interview was conducted with the Director of Nursing (DON) on 7/19/13 at 9:04 AM. The DON stated that Resident #1 was on [MEDICAL CONDITION] medication upon admission to the facility and should have been seen by Psychiatry. She is not aware of a time frame for psychiatric consults or the reason for which the resident was not seen by Psychiatry. The DON stated that she is not aware of any behaviors Resident #1 exhibited to trigger a reassessment of his elopement risk. The DON stated that, after Resident #1 eloped, she believes staff followed the facility's policy on elopement and there is no other policy on elopement prevention. An interview was conducted with the Administrator on 7/19/13 at 9:33 AM. The Administrator stated that the ADON made her aware of Resident #1's elopement on the evening of 7/13/13. The Administrator stated that she told the ADON to follow the Code Amber protocol. The resident was not physically reassessed and the Administrator performed a body assessment of the resident the next day. The Administrator stated that a wanderer should be identified by staff on admission and a wander guard should be applied. The Administrator further stated that wander guards are checked weekly and, other than this, she is unaware of any other QA on elopement. 10 NYCRR 415.27(a-c)

Based on staff interviews and record review during an abbreviated and partial extended survey it was determined that the administration failed to ensure that there was a system in place to ensure that each resident reached and maintained the highest practicable physical, mental and psychosocial well-being for 1 (#1) of 19 residents reviewed with wandering/elopement behaviors. Specifically, Resident #1 was admitted to the facility with a history of elopement from his group home and was known to wander within the facility. The facility did not complete a comprehensive assessment inclusive of the resident's known history for wandering and did not provide supervision to protect his health and safety. Resident #1 dislodged a screw in the window frame and eloped from the facility on 7/13/13 undetected by staff. He was found 5 hours later in another town 16 miles away. The Administration failed to perform a thorough investigation to determine the root cause of the incident, to prevent further instances of unsafe wandering, and failed to identify system failures related to residents at risk for unsafe wandering/elopement. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy. Complaint Number: NY 032 Cross References: F 250 - Medically Related Social Services F 323 - Accidents & Supervision F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) assessed the resident to have moderately impaired cognition. On 7/13/13, the resident eloped undetected by staff and was found by police in another town 5 hours later. An interview was conducted with the Director of Building Services (DBS) on 7/17/13 at 2:22 PM. The DBS stated that screws were put into window frames about 2 ? years ago after the elopement of another resident to prevent windows from opening more than six inches. He stated that there has been no maintenance log of the windows since that time. The DBS further stated, "It's my thought to start some kind of log in September." An interview was conducted with the Director of Social Work (DSW) on 7/18/13 at 9:03 AM. The DSW stated that a resident's wandering/elopement behavior is part of the psychosocial assessment of a resident upon admission to the facility. The DSW stated that, at the time of Resident #1's admission, the DSW did not speak with the resident's care providers at the group home. The DSW called the resident's group home providers after Resident #1 had eloped from the facility and was advised that the resident had run away from the group home in the past when the resident was under stress. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/18/13 at 1:50 PM. The ADON stated that she investigated Resident #1's elopement and did not find any systemic concerns or break in policy. The ADON stated that she does not know if the resident was physically assessed upon return to the facility and thinks the doctor was called the next day. She was uncertain about whether or not issues of assessment and notification of the physician are addressed in the elopement policy. The ADON further stated that she had asked nurse managers to make sure all residents' elopement assessments were current in date; residents were not reassessed for their elopement risk. The ADON stated that she is also the In-Service Director for the facility. Staff are in-serviced annually on what to do if an elopement occurs as per policy. The ADON stated that, after Resident #1's elopement, staff was reinserviced (educated) on the policy but not on identifying resident triggers for elopement. An interview was conducted with the Director of Nursing (DON) on 7/19/13 at 9:04 AM. The DON stated that Resident #1 was on [MEDICAL CONDITION] medication upon admission to the facility and should have been seen by a Psychiatrist. She is not aware of a time frame for psychiatric consults or the reason for which the resident was not seen by a Psychiatrist. The DON stated that she is not aware of any behaviors Resident #1 exhibited to trigger a reassessment of his elopement risk. The DON stated that, after Resident #1 eloped, she believes staff followed the facility's policy on elopement and there is no other policy on elopement prevention. An interview was conducted with the Administrator on 7/19/13 at 9:33 AM. The Administrator stated that the ADON made her aware of Resident #1's elopement on the evening of 7/13/13. The Administrator stated that she told the ADON to follow the Code Amber protocol. The resident was not physically reassessed and the Administrator performed a body assessment of the resident the next day. The Administrator stated that a wanderer should be identified by staff on admission and a wander guard should be applied. 10 NYCRR 415.26

Based on staff interviews and record review during an abbreviated and partial extended survey the Medical Director failed to ensure that the facility provided care in accordance with current standards of practice to meet the needs of residents for 1 (#1) of 19 residents reviewed with wandering/elopement behaviors. Specifically, the Medical Director failed to ensure that policies and procedures were developed and implemented to prevent elopement of residents and to monitor and supervise residents with a history of elopement or wandering behavior. The Medical Director also failed to coordinate the medical care of a resident with a known history of psychiatric illness. This failure resulted in Resident #1's undetected elopement from the facility. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy. Complaint Number: NY 032 Cross References: F 250 - Medically Related Social Services F 323 - Accidents & Supervision F 490 - Administration F 520 - Quality Assessment & Assurance The findings are: Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) assessed the resident to have moderately impaired cognition. On 7/13/13, the resident eloped undetected by staff and was found by police in another town 5 hours later. The Physician's Orders did not include an order for [REDACTED]. An interview was conducted with the Attending Physician (AP) on 7/18/13 at 11:52 AM. The AP stated that Resident #1 had a long psychiatric history and should have been seen by a Psychiatrist no more than two weeks after admission to the facility. Resident #1 was "very anxious, always wanted to leave and seen coming in and out all the time." The AP stated that he was called by nursing on the evening the resident eloped, but "I don't really know when he came back. They (nursing) called me sometime midday the next day." The AP further stated that Resident #1 must be in a supervised setting and should have been considered an elopement risk. An interview was conducted with the Medical Director (MD) on 7/18/13 at 2:32 PM. The MD stated that he was notified of Resident #1's elopement, but has had no other involvement. The MD stated that he is not aware of any concerns regarding psychiatric consultations. The MD further stated, "I haven't been involved in any policy review at current." An interview was conducted with the Director of Nursing (DON) on 7/19/13 at 9:04 AM. The DON stated that Resident #1 was on [MEDICAL CONDITION] medication upon admission to the facility and should have been seen by a Psychiatrist. She is not aware of a time frame for psychiatric consults or the reason for which the resident was not seen by Psychiatry. The DON stated that she is not aware of any behaviors Resident #1 exhibited to trigger a reassessment of his elopement risk. The DON stated that, after Resident #1 eloped, she believes staff followed the facility's policy on elopement and there is no other policy on elopement prevention. 10 NYCRR 415.15 (a)

Based on observation, record review, resident and staff interviews during the abbreviated survey, the facility was not administered in a manner to ensure that each resident reached or maintained his/her highest practicable level of physical, mental and psychosocial well-being. Specifically, during a period of high temperatures the air conditioning on the Broadway unit was not functioning. One (Resident #3) of five residents reviewed was clammy, sweaty, running a fever of 100 degrees Fahrenheit (F) and sitting in a room with a registered air temperature reading of 96 degrees F. Administration did not develop policies and procedures or protocols for the current heat situation. This resulted in actual harm that is not Immediate Jeopardy. Additional deficiencies cited under actual harm: F309 - Provide Care/Services For Highest Well Being Complaint ID Number: NY 484 The finding is: An interview was conducted with the Attending Physician (AP) on 6/9/11 at 3:20 PM. The AP stated, "the resident's fever is due to the excessive heat in the facility. "I'm glad you are here. This happens all the time." An interview was conducted with the Director of Nursing (DON) on 6/9/11 at 4:16 PM. The DON stated that the air conditioning system went down in the evening on 6/8/11 and has not been optimally restored. The DON stated that she is not aware of a policy regarding heat-related emergencies but the she has started to in-service staff. An interview was conducted with the Administrator on 6/9/11 at 4:50 PM. The Administrator stated that the air conditioning had not been working properly since last evening, 6/8/11 and all staff are presently being in-serviced on keeping residents hydrated. The Administrator stated that he did not think there was a policy or protocol in place for "heat-related emergencies but nursing may have one. You could ask them." The Administrator stated that he believes all air conditioning units are up and running but has not seen the temperature come down yet. There was no documented evidence of a policy or procedure regarding heat-related emergencies. During a subsequent interview with the Administrator on 6/9/11 at 5:10 PM, the Administrator stated that he was new to the facility, starting approximately one year ago and was unaware of a Dear Administrator Letter from the New York State Department of Health (NYSDOH) regarding Heat Advisory. The Administrator stated that the facility does not have a heat emergency protocol and he had not advised the NYSDOH of the loss of air conditioning in the facility. 415.26

Based on observation, record review, resident and staff interviews during an abbreviated survey, the facility did not ensure that each resident received the necessary care and services to maintain the highest practicable well-being. Specifically, one resident (Resident #3) of nine residents with a temperature range of 98.2 to 98.4 reviewed for quality of care was observed clammy and sweaty with a body temperature of 100 degrees Fahrenheit (F) in a room where the temperature reading of the air was 96 degrees F. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 484 The finding is: Resident #3 is [AGE] years old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) (an assessment tool) documented that the resident's cognition is severely impaired. The Comprehensive Care Plan (CCP) dated 6/7/11 documented that the resident is at risk for respiratory distress secondary to [MEDICAL CONDITION]. Interventions included administer oxygen, assist resident to avoid exertion, head of bed elevated as needed and respiratory consult as needed. The resident is at risk for dehydration and interventions included monitoring for signs and symptoms of dehydration including poor skin turgor, dry mouth and thirst. The District Nurse Assignment Record for the Broadway Unit dated 6/9/11 documented the resident's temperature as follows: 12 Midnight: 98.2, 4:00 AM: 98.2, 8:00 AM: 98.4, 12 Noon: 98.2, 4:00 PM: 100. The Medical Assessment and Plan of Care (MAPC) dated 6/9/11 documented that the resident had an exacerbation of [MEDICAL CONDITION] and an axillary (armpit) temperature of 100 degrees F. The physician progress notes [REDACTED]. The resident's temperature was rechecked and found to be 100 degrees F axillary and rectally. The PPN documented that the etiology (origin) of the fever as high room temperature due to surrounding temperature and ordered GT (Gastrostomy) Tube (a medical device used to provide nutrition for someone who cannot swallow) fluids increased to avoid dehydration. On 6/9/11 at 3:01 PM, the surveyor observed Resident #3 lying in bed, clammy, sweating and nonverbal. The resident's room temperature on the Broadway Unit was observed to be uncomfortable and the wall thermometer read 96 degrees F. An oscillating fan was on the wall across the room facing the ceiling fixed in one position and did not move. At 3:03 PM, the 7:00 AM to 3:00 PM Licensed Practical Nurse Charge (LPN) entered Resident #3's room and stated "Wow it's hot" and read the wall thermometer and stated "It's 96 degrees F." The LPN took Resident #3's axillary temperature which LPN stated was 100 degrees F. The LPN left the room to report to the Attending Physician. An interview was conducted with the Attending Physician (AP) on 6/9/11 at 3:20 PM. The AP stated that he was just informed by the charge nurse that Resident #3 has a fever of 100 degrees F. He ordered GT fluids be increased due to the excessive heat. The AP stated, "The resident's fever is due to the excessive heat in the facility. I'm glad you are here. This happens all the time." An interview was conducted with the 7:00 AM to 3:00 PM Broadway Unit LPN on 6/9/11 at 3:30 PM. The LPN stated that Resident #3 is monitored for dehydration; she did not believe that anyone checked on the resident during the day and was not sure how long the resident was sweating like that. The LPN stated that the air conditioning on the unit has not been working since last night and it has been very uncomfortable. An interview was conducted with the Director of Nursing (DON) on 6/9/11 at 4:16 PM. The DON stated that if a resident's room is hot or a resident is sweating/clammy, the resident should be moved to a day room where the air conditioning is functioning. She is not aware of any resident problems. 415.12