Every finding on record at Casa Promesa

Based on observation, record review, and interviews during an Abbreviated Survey (NY00380952), the facility failed to ensure that a resident, identified as an elopement risk based on a history of previous elopement attempts, received adequate supervision to prevent elopement from the facility. This was evident for one (1) of eight (8) residents sampled (Resident #1). Specifically, on 05/16/2025 at 10:12 AM, Resident #1, who was assessed as cognitively impaired and at risk for elopement, who had a Wander Alert Device on their left ankle, exited the building undetected. Interview revealed Security Guard #1 heard a beeping sound and was not aware that it was the Wander Alert Alarm. Security Guard #1 did not investigate the beeping sound, did not identify if a resident exited the facility, did not search the lobby, and did not notify any staff. Security Guard #1 stated they were not educated on steps to be taken when the Wander Alert system was activated. Resident #1 did not return to the facility and their location remained unknown. This resulted in Immediate Jeopardy with the potential for serious harm to eight (8) residents who were at risk for elopement. The findings include: The facility's Wander Guard Policy dated 10/10/2023, documented the facility shall utilize wander management systems and devices to promote residents' safety while maintaining the least restrictive environment to protect the rights and dignity of the resident. The facility's Elopement Prevention and Missing Resident Policy dated 12/04/2024, documented the facility shall ensure the accountability and safety of each resident/client admitted to the facility while protecting their rights as a nursing home resident/client. There was no documented evidence of education for staff, including security guards, on what to do if the Wander Alert system was activated. Resident #1 was admitted to the facility from the hospital with diagnoses that included Deafness, communicable disease related Dementia, and Altered Mental Status. The Hospital Discharge summary dated [DATE], documented Resident #1 did not have capacity and was frequently requesting to go home or to go to work and Resident #1 was discharged from the hospital on [DATE] with an arm bracelet on to alert the facility of the risk for elopement. A Nursing Baseline Care Plan dated 05/15/2025 documented Resident #1 was at risk for elopement. A Comprehensive Care Plan titled Behavior Symptoms: Wandering/Elopement dated 05/15/2025, documented interventions to ensure proper placement of wander guard/ankle alert, check for any malfunction, inform the staff of resident's elopement risk, and forward the resident's picture with room and floor to the security desk. A Visual Monitoring Form dated 05/16/2025, documented Resident #1 was being monitored hourly from 12:00 AM and was last seen at 10:00 AM. The facility's investigation dated 05/20/2025 documented on 05/16/2025 at 11:00 AM, during visual checks, Certified Nursing Assistant #1 noticed that Resident #1 was not in their room or on the unit. Certified Nursing Assistant #1 was directed by Licensed Practical Nurse #1 to search the common areas. When Resident #1 was not found the Administration was notified, and Code Yellow (missing person alert) was announced at 11:30 AM. The facility's investigation summary documented that the video surveillance footage was reviewed by the Director of Nursing, the Administrator, the Director of Social Services, and the Assistant Administrator. The camera in the main lobby showed at 10:12 AM Resident #1 stepped out of the elevator and made a hand gesture to Security Guard #1 as they walked towards the front door. Security Guard #1 clicked and held the buzzer to release the door, and Resident #1 exited the building. The facility discovered Security Guard #1 pressed the buzzer before the Wander Alert device was within range to set the alarm off, therefore, the alarm would not have locked the doors. The facility concluded Resident #1 eloped. A Nursing Note dated 05/16/2025 at 9:29 AM, documented by Licensed Practical Nurse #1 indicated Resident #1 was alert and responsive, able to ambulate and use their phone or wrote on paper to communicate with staff. On 05/16/2025 at 9:29 AM, all due medications were administered. Resident #1 continued to be monitored for risk for elopement/falls, wander alert device on Resident #1's left ankle. At 11:00 AM, staff reported to Licensed Practical Nurse #1 that Resident #1 was not in their room. All staff were alerted, and code yellow was announced. A Nursing Note dated 05/16/2025 at 5:46 PM, by Registered Nurse Supervisor #2 documented at approximately 11:30 AM, staff reported Resident #1 was missing. Code Yellow was announced and a search of all the units began, including around the community and neighborhood, however, the search was unsuccessful. The video surveillance footage was reviewed, and Resident #1 was seen leaving the facility through the main lobby front door. On 05/20/2025 at 9:53 AM, the facility video surveillance footage was reviewed with the Administrator. The surveillance footage showed that on 05/16/2025 at 10:10 AM (real time), Resident #1 exited their room wearing a scarf on their head, sweatpants, a sweater and was holding a black bag. Elevator camera #1 showed that at 10:12 AM, Resident #1 entered the elevator alone, put on a mask and exited the elevator in the lobby. A camera titled Lobby Desk showed that at 10:12 AM, Resident #1 exited the elevator, waved to Security Guard #1 and exited through the main lobby of the facility. During an interview on 05/20/2025 at 1:11 PM, Certified Nursing Assistant #1 stated they were assigned to Resident #1. They monitored Resident #1 hourly and documented on the monitoring form. They stated they received a report from the outgoing nurse who informed them that Resident #1 stated they wanted to go home. Certified Nursing Assistant #1 stated they did not observe the wander alert device on Resident #1's ankle when they took Resident #1's vital signs (pulse, respiration and temperature) at approximately 9:30 AM. They stated they went to Resident #1's room to check on them at around 11:00 AM (exact time unsure) and Resident #1 was not in their room, and they were unable to locate Resident #1. They stated that they reported it to Licensed Practical Nurse #1, and a search for Resident #1 was initiated. During an interview on 05/20/2025 at 3:06 PM, Registered Nurse Supervisor #1 stated they initiated the admission process for Resident #1 on 05/15/2025 at 12:58 PM, at which time, Resident #1 expressed wanting to go home. They stated Resident #1's hospital records were reviewed by Nurse Practitioner #1, and it was documented that Resident #1 had eloped from somewhere else. Therefore, Resident #1 was placed as an elopement risk. During an interview on 05/20/2025 at 3:30 PM, the Director of Nursing stated they were informed on 05/16/2025 at 11:30 AM that Resident #1 was missing. They stated an announcement for Code Yellow was initiated and a search was conducted. They stated Resident #1 was at risk for elopement and their investigation concluded that Resident #1 had eloped from the facility. They stated the Director of Social Services spoke with Resident #1's family on 05/17/2025 at 8:00 PM and was informed by the family that Resident #1 was in New Jersey. The Director of Nursing stated as far as they knew Resident #1 remained in New Jersey and their whereabouts in New Jersey remained unknown. During a telephone interview on 05/21/2025 at 11:10 AM, Security Guard #1 stated when Resident #1 exited the elevator they thought Resident #1 was an employee because Resident #1 waved goodbye to them in the same manner the employees usually waved goodbye. Security Guard #1 stated after Resident #1 exited the building they heard a beeping sound, and they did not know what the beeping sound was. Security Guard #1 stated that they asked someone (unsure of person) if they knew what the beeping sound was and the person said no. Security Guard #1 stated that the beeping sound stopped by itself, they did not disengage the alarm. They stated they did not check the premises, they just stayed behind the desk. During an interview on 05/21/2025 at 11:12 AM, the Director of Social Services stated that on 05/15/2025 between approximately 5:30 PM and 6:00 PM, they received a call from Nurse Practitioner #1 requesting they speak to Resident #1 because Resident #1 did not want to stay in the facility. The Director of Social Services stated they spoke to Resident #1 and encouraged Resident #1 to stay. During an interview on 05/22/2025 at 11:56 AM, the Medical Director stated they received a call from Nurse Practitioner #1 on 05/15/2025 sometime during the evening (exact time unsure) stating Resident #1 expressed they wanted to go home. The Medical Director stated Resident #1 had dementia, a communicable disease, and a history of homelessness and the plan was to put Resident #1 closer to the nurse's station, place the facility's wander alert device on them, and monitor them hourly. They stated they instructed Nurse Practitioner #1 to send Resident #1 to the hospital if Resident #1 attempted to leave the facility. They stated the Psychiatrist was called to assess Resident #1's medication. The Medical Director stated they received a text message on 05/16/2025 at 11:31 AM from the Director of Rehabilitation who stated Resident #1 was missing, and law enforcement was called. They stated they were not provided with the details on how Resident #1 left the facility. They stated they spoke with the Director of Social Services, who reported to them that Resident #1's family was contacted and informed the facility that Resident #1 was in New Jersey. During an interview on 05/28/2025 at 2:01 PM, the Administrator stated Resident #1 was triggered as an elopement risk based on the documentation provided by the hospital, therefore, a wander alert device was placed on Resident #1's ankle (unsure of which ankle). They stated on 05/16/2025 at 11:30 AM, they were informed via text message that Resident #1 could not be located, and Code Yellow was initiated via the intercom at 11:33 AM. They stated that Security Guard #1 was new to the facility and was not trained on the wander Alert system. The Administrator stated Security Guard #1 reported to them that they did not see any resident leave, nor did they hear any activated door alarm. The Administrator stated Resident #1's family was contacted after Resident #1 could not be located and Law Enforcement were also notified. They stated they called Resident #1 multiple times via facetime. The Administrator stated Resident #1 answered one of the calls at 1:42 PM on 05/16/2025 then disconnected the call. They stated Resident #1's picture was not obtained because they were new to the facility. The Administrator stated they spoke with an officer from New Jersey [NAME] Police Department on 05/18/2025 and had not followed up with them since; Resident #1's whereabouts remained unknown. They stated the Director of Social Services documented that they last contacted Resident #1 or Resident #1's family on 05/17/2025. Immediate Jeopardy was identified, and the Administrator was notified on 05/23/2025 at 10:12 AM. An acceptable immediate corrective action plan from the facility was received on 05/23/2025 at 3:42 PM. Immediate Jeopardy was removed prior to survey exit on 05/28/2025 based on the following corrective actions taken by the facility: 1) Facility re-educated the Nursing staff regarding monitoring residents at risk for elopement and using the wander alert device. 2) Facility educated all staff regarding elopement prevention, which includes, adequately supervising the residents every thirty minutes and/or hourly, checking wander alert device placement and functionality, conducting head count of the residents by the nursing staff at the beginning and end of shift to ensure location of the residents who are at risk for elopement. 3) Facility educated the Security Guards on visitation and elopement policy and ensuring that staff present their identification badge before releasing the locking mechanism allowing them to leave the facility. 4) Facility has conducted chart audits of eight (8) residents at risk for elopement and using wander alert devices to ensure that the residents were assessed, and elopement care plans were updated. 5) Facility will continue to monitor and discuss residents at risk for elopement during their weekly comprehensive care plan meeting every Wednesday. 6) All Security Guards will receive in-service education on Visitation and Elopement policy. Security Guards must ensure that all visitors log in and out when visiting. Visitors are to be given a name tag sticker that must always remain in view while in the facility. Security Guards must ensure that residents who are leaving the building, for example, for out on pass, clinic visits or transfer to the hospital have their arm band on. They must also check employee's identification badge prior to buzzing the door. 7) The facility reviewed their Policies and Procedures on Elopement Prevention and Missing Resident, Visitation and Wander Guard Functioning Test and revised them on 05/23/2025. 8) The facility provided an audit tool to monitor wander alert device functionality and placement, visitors' signage, weekly alarm check, armband placement and alarm checks for the security door. As of 05/28/2025, the following staff received in services on elopement prevention, wander alert device and visitation. Security Guards- 9 of 12 =75 %, Registered Nurse-12 of 13=92%, Licensed Practical Nurses- 8 of 11 = 72%, Certified Nursing Assistants-32 of 39 =82 %, Administration staff - 13 of 15 =86 %, Housekeeping staff - 8 of 8 =100 %, Unit Clerk - 3 of 3 =100 %, Medical staff- 4 of 6 = 66 %, Dietary staff -7 of 9 =77%. Staff who are out of work will attend the in service prior to reporting to their workstation. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident in 2 (3rd and 4th Floor) of 3 units. Specifically, 1.) Expired Heparin lock flush syringes were stored in the medication room. 2.) Food items were stored together with the intravenous bags in the medication room. The findings are: The facility policy on Medication Storage and Handling with a last revision date of ,d+[DATE] documented that medications, biologicals, and intravenous sections having an expiration date are removed from storage and usage and properly disposed of after such date. On [DATE] at 11:05 AM, an observation of the 4th Floor Medication Room was conducted with Registered Nurse #2. Nineteen (19) Heparin lock flush syringes with expiration dates of [DATE] and [DATE] were observed in the Medication Room drawer. Registered Nurse #2 was immediately interviewed after the observation and stated that medications should be used by the expiration date, or it might not be effective. On [DATE] at 11:24 AM, an observation of the 3rd Floor Medication Room was conducted. Food items (plastic containers of coffee and containers of coffee creamer) were observed stored next to the intravenous fluid bags inside the cabinet. On [DATE] at 3:21 PM, Registered Nurse #3 was interviewed and stated there should be no food stored in the Medication Room. On [DATE] at 1:25 PM, the Director of Nursing was interviewed and stated that there should be no food kept in the Medication Storage areas. 10 NYCRR 415.18(e)(,d+[DATE])

Based on observations, record review, and interview conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was evident during the Kitchen Task. Specifically, there were multiple cans of expired beef stew in the emergency food storage and expired frozen omelets stored past the expiration date in the kitchen freezer. The findings are: The undated facility policy titled Food Storage documented sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. Old stock is always used first, First in - First out method. Food should be dated as it is placed on the shelves. Date marking to indicate the date or day by which a ready to eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high-risk foods. An initial tour of the kitchen was conducted on [DATE] from 9:42 AM to 10:01 AM with the Assistant Food Manager. The following was observed: 14 cans of 6.63 pound cans of beef stew with a best by date of [DATE]. In the freezer, the following was observed: 2 boxes of frozen omelets with a use by date of [DATE], 15.75-pound box of frozen folded plain omelet with a use by date [DATE], a box of frozen egg patty with a use by date of [DATE], and cooked eggs dated [DATE] in the refrigerator. During an interview on [DATE] at 02:52 PM, the Assistant Food Manager stated the expired food was an oversight and that they did not look at the date when they did rounds. 10 NYCRR 415.14(h)

Based on record review and interviews conducted during the Recertification and Complaint (NY00355130, NY00355122) Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that each resident's comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect a change in resident's status. This was evident in 4 (Residents #42, #51, #50, #61) of 20 total sampled residents. Specifically, the comprehensive care plans for Residents #42, #51, #50, and #61 were not reviewed and revised following their involvement in a resident to resident altercation. The findings are: The facility titled Comprehensive Care Plan with a reviewed date of 09/2023 documented that the care plan is reviewed monthly and revised after each assessment, at least quarterly, annually, and as changes in the resident's condition dictates. The facility Investigation Summary dated 09/27/2024 documented that on 09/21/2024 at 6:30 PM, Resident #51 approached Resident #42 and accused them of sending texts with a threatening message. Staff intervened and directed Resident #51 to their room. The facility concluded that the allegations were verified. The text messages sent by Resident #42 were transphobic and referenced physical harm to Resident #51. Resident #42 was remorseful and apologetic for actions taken in anger. Mediation with both residents was made by the Director of Social Services. 1. Resident #42 had diagnoses of Bipolar Disorder and Anxiety Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #42 had intact cognition. A nurse's progress note dated 09/21/2024 at 9:53 PM documented that around 6:45 PM, Resident #42 was going up and down, screaming, cursing, calling names, was very agitated, and had a verbal altercation with another resident. There was no documented evidence that Resident #42's comprehensive care plan was reviewed and revised with new interventions following the occurrence of resident-to-resident verbal altercation on 09/21/2024. 2. Resident #51 had diagnoses of Peripheral Vascular Disease and Post Traumatic Stress Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #51 had intact cognition. A nurse's progress note dated 09/21/2024 at 9:47 PM documented that at 6:45 PM, loud voices were coming from the front lounge. Resident #51 was observed standing very close to Resident #42, while Resident #42 remained seated. Resident #51 stated the disagreement resulted from a text message received from Resident #42. A comprehensive care plan related to behavior symptoms, potential for abuse and neglect was initiated for Resident #51 on 05/14/2024. There was no documented evidence that Resident #51's comprehensive care plan was reviewed and revised with new interventions following the occurrence of resident-to-resident verbal altercation on 09/21/2024. On 12/09/2024 at 9:30 AM, the Director of Social Service was interviewed and stated that there was a misunderstanding between Residents #42 and #51. They stated that they were not on duty when the incident occurred and was made aware after the fact. The Director of Social Service stated they are responsible for updating Resident #42 and #51's care plan on behavior. On 12/09/2024 at 10:52 AM, the Director of Nursing was interviewed and stated that they were aware that Resident #42 and #51's care plan was not updated after the incident on 09/21/2024. The Director of Nursing stated it is the Social Services department's responsibility to update the care plan on resident's behavior and that the interdisciplinary team must ensure that all department heads update the care plans. 40565 The facility Investigation Summary dated 09/27/2024 documented that on 09/21/2024 at 6:00 PM, Resident #61 threw water into Resident #50's face without seeming cause. Both residents were sent to their room after the Licensed Practical Nurse intervened. 3. Resident #50 had diagnoses of Hypertension, Major Depressive Disorder, and Chronic Viral Hepatitis. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #50 had severe impairment in cognition. A nurse's progress note dated 09/21/2024 at 11:59 PM documented that at 6:00 PM, Resident #50 was in the hallway talking to Resident #61, when all of a sudden, Resident #61 threw their drinking water to Resident #50's face. Residents were asked to stay away from each other. There was no documented evidence that Resident #50's comprehensive care plan was reviewed and revised with new interventions following the occurrence of resident-to-resident physical altercation on 09/21/2024. 4. Resident #61 had diagnoses of Alcohol Dependence, Cerebral Infarction, and Other Psychoactive Substance Dependence. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #61 had intact cognition. A nurse's progress note dated 09/21/2024 at 8:17 PM documented that Resident #61 was in the hallway talking to Resident #50 when all of a sudden Resident #61 threw water onto Resident #50's place. A care plan for potential for abuse and neglect was initiated for Resident #61 on 07/05/2024. There was no documented evidence that the care plan was reviewed and revised following the 09/21/2024 incident. There was no documented evidence that Resident #61's comprehensive care plan was reviewed and revised with new interventions following the occurrence of resident-to-resident physical altercation on 09/21/2024. On 12/09/2024 at 9:44 AM, the Director of Social Services was interviewed and stated that if a resident has aggressive behaviors prior to admission, the Social Services must document and initiate the care plan on behavior. The Director of Social Services stated if a resident displayed an abusive behavior or if there is any abuse concern after the resident has already been admitted to the nursing home, either the Social Services or Nursing can initiate the care plan as a multidisciplinary approach. The Director of Social Services stated they were not aware that Resident #50's comprehensive care plan was not reviewed and care plan for behavior not initiated after their altercation with Resident #61. On 12/09/2024 at 8:53 AM, the Director of Nursing was interviewed and stated that Social Services is responsible for reviewing the comprehensive care plan after the altercation and initiating the behavioral and abuse care plan. The Director of Nursing stated nurses can also initiate and update the care plan if there is any episodic behavior or abuse incident. The Director of Nursing further stated they are not aware that Resident #50's comprehensive care plan was not reviewed after the incident and that care plan for potential for abuse was not initiated after the incident on 09/21/2024. 10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that it promoted and facilitated a resident's right to self-determination through support of resident's choice. This was evident for 1 (Resident #43) of 2 residents reviewed for choices out of 20 total sampled residents. Specifically, Resident #43's choice to refuse care was not respected. The findings are: The facility's policy titled Resident's [NAME] of Rights dated 10/2022 documented that the facility assures that all residents are guaranteed the right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care while at the facility. Resident #43 was admitted to the facility with diagnoses of Malignant Neoplasm of Endocervix, Obstructive Uropathy, and Depression. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #43 had intact cognition and was dependent on staff for personal hygiene, lower body dressing, shower, and toileting/hygiene. The assessment documented that Resident #43 had no behavioral symptoms and had not rejected care. On 12/04/2024 at 10:21 AM, Resident #43 was observed in their room. Resident #43 was interviewed and stated that some months ago, Certified Nursing Assistant #2 came in to provide care and Resident #43 told the aide they did not want to be changed at that time. Certified Nursing Assistant #2 insisted to give the care; went ahead to forcefully removed their cover and was got thrown over to the side of the bed. Resident #43 stated they reported the incident to the Administration. A comprehensive care plan for activities of daily living function, self-care deficit, was initiated on 04/12/2024. The care plan documented Resident #43 required extensive care in some areas of activities of daily living. Resident #43 required total assist for dressing, hygiene, toileting, and bathing. The facility interventions include to encourage resident to make choices associated with activities of daily living where possible. A Grievance/Complaint Report form dated 01/09/2024 documented that Resident #43 made a complaint about Certified Nursing Assistant #2. The grievance documented that on the night of 01/08/2024, Certified Nursing Assistant #2 came to Resident #43's room. Resident #43 told Certified Nursing Assistant #2 they do not want to be changed but the aide proceeded anyway. Certified Nursing Assistant #2 ripped the covers off the Resident, put them on their side and held them down, ripped their incontinence briefs off and aggressively wiped their private area with a wet cloth. Resident #43 stated they yelled at Certified Nursing Assistant #2 to stop and asked the nurse to have another aide take care of them. On 12/05/2024 at 10:50 AM, Certified Nursing Assistant #2 was interviewed and stated that they worked a double shift, from 8:00AM to 12:00 AM, on the day of the incident. They stated, on the day of the incident, Resident #43 refused care all day and would not allow any staff to do the care. Certified Nursing Assistant #2 stated Resident #43 refused care during the 8:00 AM - 4:00 PM shift and still refused care on the following shift. Certified Nursing Assistant #2 stated Resident #43 was then forced to be changed because they were concerned about the Resident's skin breaking down. Certified Nursing Assistant #2 stated they had not reported Resident #43's care refusal to the nurse. On 12/05/2024 at 11:06 AM, Licensed Practical Nurse #2 was interviewed and stated that Resident #43 will sometimes refuse care. They stated they will usually leave the resident and come back later to encourage and re-offer care. Licensed Practical Nurse #2 stated they were not on duty when Resident #43 was forced to change by a Certified Nursing Assistant, otherwise they would have not allowed it. They stated they would speak with the Resident and if they still refuse, they will report the behavior to the nursing supervisor. On 12/05/2024 at 11:13 AM, Registered Nurse #2 stated they were not on duty when the incident occurred. Registered Nurse #2 stated the Certified Nursing Assistant should have reported Resident #43's refusal for care instead of forcing the resident. On 12/06/2024 at 11:09 AM, the Director of Nursing stated Resident #43 filed a grievance against Certified Nursing Assistant #2 being rough with care. The stated they investigated the incident and Certified Nursing Assistant #2 stated they insisted on changing Resident #43 because they were worried that Resident #43's skin might breakdown if not changed for so long. On 12/06/2024 at 11:18 AM, the Administrator was interviewed and stated that Resident #43 reported that a staff was rough when they were being changed. The Administrator stated Resident #43 had history of refusing care, and they explained to the staff that residents have the right to refuse. 10 NYCRR 415.5(b) (1-3)

Based on observation, record review, and interview conducted during the Recertification Survey from 12/04/2024 to 12/09/2024, the facility did not ensure residents received necessary respiratory care consistent with professional standards of practice. This was evident for 1 (Resident #36) of 4 residents reviewed for Respiratory Care out of 20 total sampled residents. Specifically, Resident #36 received oxygen at a flow rate that was not consistent with physician's order and there was no documented evidence that oxygen tubing was being changed. The findings are: The facility's policy and procedure titled Oxygen Therapy dated 01/2021 documented that oxygen therapy must be ordered by a Medical Provider to provide resident with a concentration of oxygen that is higher than room air and to supply oxygen to body tissues that are receiving insufficient amounts from the circulating blood. The resident receiving oxygen therapy will be checked at regular intervals by the licensed nursing staff. Resident #36 was admitted to the facility with diagnosis of Chronic Obstructive Pulmonary Disease, Hypertension, and Chronic Kidney Disease. The Minimum Data Set assessment dated [DATE] documented Resident #36 had intact cognition and was receiving continuous oxygen therapy. On 12/04/2024 at 11:56 AM, Resident #36 was observed in bed with nasal cannula attached to the oxygen concentrator at bedside. Resident #36 was receiving 5 liters per minute of oxygen. There was no date noted on the oxygen tube indicating when it was last changed. On 12/05/2024 at 12:29 PM and on 12/06/2024 at 10:31 AM, Resident #36 was observed resting in bed and was receiving oxygen at 5 liters per minute. There was no date noted on the oxygen tube indicating when it was last changed. A Comprehensive Care Plan for impaired respiratory status with a last revised date of 09/19/2024 documented Resident #36 was receiving continuous oxygen via nasal cannula and had acute bronchial spasm. The facility interventions include to provide treatments per physician's order. The Physician's Order dated 10/15/2024 and was renewed on 11/15/2024 documented to administer nasal oxygen continuously at 3 to 4 liters per minute every shift for dependence on supplemental oxygen. The Treatment Administration Record for 11/01/2024 to 12/06/2024 documented Resident #36 received nasal oxygen at 3 to 4 liters per minute every shift. Review of the electronic medical record contained no documented evidence that the physician ordered to increase oxygen flow rate to 5 liters per minute. Furthermore, there was no documented evidence of when oxygen tubing was last changed for Resident #36. On 12/06/2024 at 10:21 AM, Licensed Practical Nurse #4 stated Resident #36's oxygen concentrator is checked every shift to ensure water tank is filled and working properly. They stated the oxygen is set as per physician's order and that Licensed Practical Nurse #4 had not changed the setting. Licensed Practical Nurse #4 stated they were not aware that the oxygen flow rate was increased to 5 liters per minute and was not able to tell when the tube was last changed. On 12/06/2024 at 10:26 AM, Licensed Practical Nurse #1 stated Resident #36 had an order to receive oxygen 3 to 4 liters per minute and was not able to explain why Resident #36's oxygen was set at 5 liters per minute. On 12/09/2024 at 11:12 AM, Registered Nurse #1 stated the unit nurse is responsible to ensure residents receive oxygen according to the physician's order. Registered Nurse #1 stated Resident #36's oxygen flow should have not been adjusted without proper assessments and without physician's order. Registered Nurse Manager #1 stated nurses change the oxygen tubing weekly and it must be dated. Registered Nurse #1 was not able to explain when Resident #36's tubing was last changed since they have not been documenting the tube change in the medical record. On 12/09/2024 at 11:37 AM, the Director of Nursing Service stated residents are provided with oxygen as per physician's treatment order and it must be checked daily by the unit nurse. The tubing is also changed weekly and dated by the nurse to indicate staff initials and the date it was changed. 10 NYCRR 415.12 (k)(6)

Based on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that the Infection Preventionist had completed specialized infection prevention and control training. This was evident during the review of the Infection Control Task. Specifically, the facility's designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training. The findings are: The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality Safety by Oversight Group (QSO-19-10-NH), dated 03/11/2019, documented that effective 11/28/2019, the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's infection prevention and control program. The facility's Infection Preventionist Job Description documented that the Infection Preventionist, under the direction of the Director of Nursing Services, is responsible for developing, directing, implementing, managing, and operating infection prevention in the long-term care facility. The candidate must have completed specialized training in infection prevention. The facility submitted the Infection Preventionist certificate in Infection Control and Barrier Precautions with four contact hours dated 02/28/2023. There was no documented evidence that the Infection Preventionist had completed a specialized training in infection control. On 12/05/24 at 2:32 PM, the Infection Preventionist was interviewed and stated they had been the Infection Preventionist since early 2023. The Infection Preventionist stated they were unaware of the specialized training requirement before assuming the infection preventionist role. On 12/09/2024 at 10:31 AM, the Director of Nursing was interviewed and stated the Infection Preventionist assumed the role since 2023. The Director of Nursing stated they were not aware that Infection Preventionists require a specialized training. On 12/09/2024 at 11:27 AM, the Administrator was interviewed and stated that the Infection Preventionist assumed the role in September 2023. The Administrator stated they were not aware that Infection Preventionist require specialized training before assuming the position. 10 NYCRR 415.19

Based on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that the assessment accurately reflected each resident's status. This was evident in 4 (Residents #1, #36, #42, and #54) of 20 total sampled residents. Specifically, 1.) Resident #1, #36, and #42's antiviral medication use was inaccurately documented in the Minimum Data Set assessment, and 2.) Resident #54's assessment inaccurately documented that the Resident had diagnosis of Dementia. The findings are: The facility policy Minimum Data Set Functional Coding with a revision date of 02/11/2024 documented that the policy ensures that all Minimum Data Set assessments are completed accurately, on time, and in compliance with the Centers for Medicare and Medicaid Services guidelines. Coding will be based on direct observation, medical records documentation, staff interviews, and resident input. 1. Resident #1 was admitted with diagnoses of Peripheral Vascular Disease, Hypertension, and Opioid Dependence. A physician's order with a renewal date of 11/26/2024 documented Biktarvy 50 milligram - 200 milligram - 25 milligram tablet (an anti-viral medicine) by mouth once daily for 12 months. The Minimum Data Set assessment dated [DATE] and 10/19/2024 documented that Resident #1 received antibiotics. A review of Resident #1's physician orders and progress notes from 11/01/2024 to 11/23/2024 had no documentation that Resident #1 received antibiotics. 2. Resident #36 was admitted with diagnoses of Calculus of Gall Bladder, Chronic Obstructive Pulmonary Disease, and Chronic Viral Hepatitis. A physician's order with an original date of 10/15/2024 and renewal date of 11/15/2024 documented Tivicay 50 milligram tablet (an antiviral medicine) by oral route once daily. The Minimum Data Set assessment dated [DATE] and 11/13/2024 documented that Resident #36 received antibiotics. A review of Resident #36's physician's order and progress notes dated 11/04/2024 to 11/26/2024 had no documentation that Resident #36 received antibiotics. 3. Resident #42 had diagnoses of Bipolar disorder, Unspecified Dementia, and Chronic Obstructive Pulmonary Disease. A physician's order with an original start date of 08/18/2024 and renewal date of 11/18/2024 documented Tivicay 50 milligram tablet (an antiviral) by oral route twice daily. The quarterly Minimum Data Set assessment dated [DATE] and 11/16/2024 documented that Resident #42 received antibiotics. A review of Resident #42's physician's orders and progress notes from 11/08/2024 to 11/18/2024 had no documentation that Resident #42 received antibiotics. On 12/04/2024 at 11:29 AM, Registered Nurse #1, who was the Nurse Unit Manager, was interviewed and stated that antiviral medications are considered antibiotics. Registered Nurse #1 stated their electronic medical record system classifies antivirals as antibiotics. On 12/04/2024 at 9:51 AM, the Minimum Data Set Coordinator was interviewed and stated that it is the Nurse Manager's responsibility to complete the medication section of the Minimum Data Set assessment. The Coordinator stated that antivirals were coded as antibiotics. The Minimum Data Set Coordinator stated that anti-viral medications are automatically triggered as antibiotics in the electronic medical record system. On 12/05/2024 at 11:08 AM, during a subsequent interview with The Minimum Data Set Coordinator, they stated that the Resident Assessment Instrument manual does not classify antivirals as antibiotics, it was the electronic medical record system that triggers the antivirals as antibiotics. On 12/09/2024 at 11:04 AM, the Director of Nursing was interviewed and stated that antiviral medicates fall under antibiotics in the Centers for Medicare and Medicaid Services guidelines. On 12/09/2024 at 11:59 AM, the Administrator was interviewed and stated that the Minimum Data Set Coordinator is responsible for the accuracy of each resident's Minimum Data Set assessments. 4. Resident #54 was admitted with diagnoses of Bipolar Disorder and Diabetes Mellitus. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #54 has Non-Alzheimer's Dementia. A review of Resident #54's diagnoses sheet and physician assessments had no documentation that Resident #54 had Non-Alzheimer's Dementia. On 12/06/2024 at 10:44 AM, Registered Nurse #1, who was the Nurse Unit Manager, was interviewed and stated that Non-Alzheimer's Dementia was checked off in the Minimum Data Set assessment because Resident #54 has mild cognitive impairment. On 12/06/2024 at 9:47 AM, Physician Assistant #1 was interviewed and stated that Resident #54 although cognitively impaired, is alert and oriented to person, time, and place. Physician Assistant #1 stated Resident #54 has no diagnosis of Dementia. On 12/09/2024 at 11:04 AM, the Director of Nursing was interviewed and stated that they did not see in the medical records that Resident #54 had diagnosis of Dementia. On 12/09/2024 at 11:59 AM, the Administrator was interviewed and stated that the Minimum Data Set Coordinator is responsible for the accuracy of each resident's Minimum Data Set assessments. 10 NYCRR 415.11 (b)

Based on record review and interviews conducted during the Recertification Survey from 12/04/2024 to 12/09/2024, the facility did not ensure appropriate liability and appeal notices to Medicare beneficiaries were provided. This was evident for 2 (Residents #24 and #36) of 3 residents reviewed for Beneficiary Protection Notification Rights, out of 20 total sampled residents. Specifically, the facility did not provide residents with Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- form CMS-10055) at the termination of their Medicare Part A benefits. The residents remained in the facility. The findings are: The Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) Form CMS -10055 (2024) documented that Medicare requires Skilled Nursing Facilities to issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage to Original Medicare, also called fee-for-service, patients prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary or considered custodial. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage is a Centers for Medicare and Medicaid Services-approved model notice and should be replicated as closely as possible when used as a mandatory notice. Failure to use this notice or significant alterations of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage could result in the notice being invalidated and/or the skilled nursing facility being held liable for the care in question. The Skilled Nursing Facility must give the applicable Medicare coverage guideline(s) and a brief explanation of why the resident's medical needs or condition do not meet Medicare coverage guidelines. The reason must be sufficient and specific enough to enable the patient to understand why Medicare may deny payment. The facility's policy and procedure titled Advanced Beneficiary Notice with a review date of 11/2024 documented that the Advanced Beneficiary Notice is issued by the facility to original Medicare beneficiaries in situations where Medicare payment is expected to be denied. The facility's policy included a procedure of when to issue the Advanced Beneficiary Notice and a copy of the form CMS-10055 that must be used. Resident #24 was admitted to the facility on [DATE] and started Medicare Part A Skilled Services on 10/08/2024. Resident #24's last covered day for Medicare Part A Skilled Services was on 11/06/2024 with 69 days remaining. Resident #24 remained in the facility. There was no documented evidence that form CMS-10055 was given to the resident, informing them of their potential liability for payment. Resident #36 was admitted to the facility on [DATE] and started Medicare Part A Skilled Services on 10/15/2024. Resident #36's last covered day for Medicare Part A Skilled Services was on 11/13/2024 with 70 days remaining. Resident #36 remained in the facility. There was no documented evidence that form CMS-10055 was given to the resident, informing them of their potential liability for payment. On 12/05/2024 at 10:08 AM, the Minimum Data Set Coordinator was interviewed and stated they are responsible for informing residents of their Medicare coverage, when it takes effect and when it ends. The Minimum Data Set Coordinator stated Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage has not been issued to Residents #24 and #36 because they were not aware of this requirement. On 12/09/2024 at 11:37 AM, the Director of Nursing Services was interviewed and stated that they are not involved in the beneficiary notification process and that it is handled by the Minimum Data Set Coordinator. 10 NYCRR 415.3(h)(2)(i)

Based on record review and staff interview during the Abbreviated Complaint survey (NY00345861) conducted between 11/25/2024 and 11/26/2024, the facility did not ensure that all alleged violations involving abuse were reported immediately but not later than 2 hours after the allegation was made. This was evident for 1 resident investigated for Abuse out of 10 complaints investigated. (Resident #15). Specifically, the facility did not report an allegation of Resident Verbal or Mental Abuse to the New York State Department of Health within 2 hours after the allegation was made. The findings are: The facility's policy and procedure titled Abuse, Neglect and Mistreatment of Residents/Clients dated 01/2021 documented that The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Resident #15 was admitted to the facility with diagnoses including Persistent mood disorder, Aphasia following unspecified Cerebrovascular disease. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #15 has intact cognitive status, normally used wheelchair for mobility, and required Partial/moderate or supervision of staff for most Activities of Daily Living. The Comprehensive Care Plan for Behavior Symptoms dated 5/21/24 documented Resident has behavioral symptoms; Documented with measurable goals and interventions. The Facility Incident Report Summary dated 6/26/2024 documented that Resident #15 reported alleged verbal abuse by a Certified Nursing Assistant that occurred 6/11/24 to the Social Worker on 6/18/24; the Director of Nursing received the report on 6/20/24; and reported to the Department of Health on 6/21/24. The incident was reported late, more than 24 hours after the alleged incident. The Facility Submission Report (Intake Information) documented that the report was submitted to the New York State Department of Health on 06/21/2024; The Director of Nursing received grievance on 6/20/24 in mailbox at around 8PM regarding verbal abuse that occurred on 6/11/24. In this grievance, Resident #15 alleged that Certified Nursing Assistant was verbally degrading, and maliciously bullying the resident; Grievance was recorded on 6/11/24 by the Social Worker. On 11/26/2024 at 11:42, the Director of Social Services was interviewed and stated that the Social Worker received the grievance from Resident #15 on 6/18/24 for the incident that reportedly occurred on 6/11/24; Social Worker reportedly dropped the resident's grievance statement in the Director of Nursing's mailbox. The Director of Nursing saw the report late on 6/20/24, notified the Department of Health and started the investigation. The Director of Social Services further stated that the Social Worker supposed to have reported to them immediately, even on phone, as they can be reached 24 hours a day by phone. Director of Social Service stated that any allegation of resident abuse is supposed to be reported immediately to the Department of Health while investigation is ongoing to verify the allegations. On 11/26/2024 at 12:03PM, The Director of Nursing was interviewed and stated that Resident #15 alleged that the incident occurred on 6/11/24 but did not report to the Social Worker on time until 6/18/24. Director of Nursing stated that the Social Worker grievance incident report was received in the mailbox very late on 6/20/24 after closing and reported to the Department of Health in the early hours of 6/21/24. Director of Nursing stated that they are aware that the report was submitted late to the Department of Health, but they tried to submit it as soon as they were made aware of the incident. On 11/26/2024 at 12:13PM, the Administrator was interviewed and stated the alleged abuse was reported to the Department of Health late because their Social Worker did not report the incident to them when the alleged allegation was received from the resident; Social Worker stated that they put the grievance in the Director of Nursing's mailbox. The Administrator stated that the Social Worker could have reported in person or on phone to the Director of Nursing or to the Administrator the same day the alleged allegation of abuse was received from the resident. 11/26/2024 12:15 and 2:17PM several attempts made to speak with the social worker, via telephone unsuccessful. [10 NYCRR 415.4(b)(2)]

Based on observation, record review and interviews conducted during the Recertification Survey 9/10/23 - 9/15/23, the facility did not ensure adequate supervision was provided and equipment was available to prevent accidents. This was evident for 1 (Unit 2) of 3 units and the Main Dining Room observed for Dining. Specifically, the facility did not have suction equipment accessible in the Unit 2 common dining area, and there was no nurse staffing providing supervision during meal service on Unit 2 and in the Main Dining Room. The findings are: Policy and Procedure titled Unit Dining, last revised January in 2023, stated as follows: At least one person will be stationed in the dining room during meal service to assist individuals with eating and to handle any emergency situation that might arise. Policy and Procedures titled Nutrition Services last revised in January 2023 stated as follows: Meals will be distributed promptly with supervision as needed by nursing staff (Close supervision may be needed for those with feeding difficulties). At least one person will be stationed in the dining room during meal service to assist individuals with eating and to handle any emergencies that might arise. 1) During the meal observations on Unit 1 on 09/11/2023, 09/12/2023 and 09/13/2023 from 11:45 AM to 12:45 PM, lunch was served to 4 to 6 residents in the common area There was no licensed nurse present during the distribution and during the meals. Certified Nursing Assistant (CNAs) were observed going around distributing lunch trays to other residents in their rooms. 2) On 09/10/23 at 11:20 AM and on 09/12/23 at 11:54 AM, the Unit 2 dining area was observed during lunch. There was no suction equipment in the room, and no licensed nurse was providing supervision in the dining room. On 09/10/23 at 11:33 AM, lunch in the Main Dining Room was observed, and there was no licensed nurse providing supervision during the meal service. On 09/13/23 at 12:34 PM, an interview was conducted with Registered Nurse (RN) Manager, RN #2. RN #2 stated that either a Licensed Practical Nurse (LPN) or Certified Nursing Assistant (CNA) can observe meals however, usually a nurse must observe that the order is what is being served. Residents that need to be fed or observed will get support from a staff member. Most of the residents on this floor eat independently, only one resident needs to be observed for choking on Unit 2. Staff may have forgotten to place the suction equipment in the common area where residents are eating. On 09/14/23 at 10:50 AM an interview was conducted with the Director of Nursing (DON). The DON stated that there should be suction equipment on every unit. Resident mealtime should be observed by a Certified Nursing Assistant (CNA) and when short staffed, a Licensed Practical Nurse (LPN) can observe. The staff who observe meals are certified in Basic Life Support (BLS). 415.12(h)(2)

Based on observation, interviews, and record review conducted during the recertification survey on 09/10/23 - 09/15/23, the facility did not ensure that a resident's room was adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. This was evident for 2 (Resident #12 and Resident #62) of 20 sampled residents. Specifically, the emergency call device located in Resident #12's bathroom was not working on multiple observations during the survey. The emergency call device in Resident #62's bathroom was missing a pull cord. The findings are: The Policy and Procedure titled Resident Call System, last revised in January 2021, documented it is the facility policy to ensure that resident care systems are operational, at all times. Support Services are responsible for the ongoing testing and maintenance of the resident call system. 1) During an observation on 09/10/23 at 10:19 AM, Resident #12 pulled the call bell cord in their bathroom, and there was no light activated above Resident #12's room door. No response from staff was observed. On 09/10/23 at 10:34 AM, Resident #12 pressed the call bell again, and there was no light activated. On 09/10/23 at 10:42 AM, the Surveyor observed Licensed Practical Nurse (LPN) LPN #2, came into the resident room to administer scheduled medication. There was no inquiry about the previous calls for assistance. On 09/11/23 at 09:31 AM, the Surveyor observed Resident #12 pulling the emergency cord in the bathroom, there was no light activated above the room door. On 09/13/23 at 12:15 PM, an interview was conducted with the Certified Nursing Assistant (CNA) CNA #5 regarding the call device in Resident #12's room. CNA #5 stated they were not aware the emergency call device not working, and Resident #12 usually comes to the nursing station for assistance. CNA #5 stated there was no work order for the call bell, and they have not noticed any environmental concerns in the room. On 09/15/23 at 10:08 AM an interview was conducted with Licensed Practical Nurse (LPN), LPN #2 regarding the concerns in Resident #12's room. LPN #2 stated they never witnessed Resident #12 refusing any repairs in the room. During an interview on 09/13/23 at 01:58 PM, Maintenance staff (Other Staff #10) stated that in the beginning of July, Resident #12 refused to allow staff to complete repairs in the room. Resident #12 did not want to come out of the room to allow repairs to be done because Resident #12 wanted to oversee the work due to concerns regarding their personal property. When Resident #12 refused the repairs, the supervisor was informed. Today, when they went to the room, Resident #12 refused the repairs because Resident #12 was going out. The Maintenance staff member stated that a reset of the call bell was done about 2 days ago after a nurse informed them of the issue. There was no work order for Resident #12's call bell. A housekeeper was present when the call bell was reset, but the Maintenance staff could not remember their name. The Maintenance staff member stated they repaired the bathroom door and took pictures for the supervisor after Resident #12 left. 2) On 09/13/23 at 09:23 AM, the Surveyor observed that the emergency call device located in a resident (Resident #62) was missing a pull cord. On 09/15/23 at 09:37 AM, the Surveyor observed a new cord attached to the Emergency Call device in the resident (Resident #62) bathroom. On 09/13/23 at 12:24 PM, an interview was conducted with Certified Nursing Assistant (CNA) CNA #5 regarding the call device in Resident #62's room. CNA #5 stated they were not aware the emergency call device was missing a pull cord. During an interview on 09/13/23 at 11:49 AM, the Facility Supervisor (FS) stated the broken call bell in Resident #12's room was not reported prior to yesterday. All staff can email environmental concerns to the facility department or create a work order at the nursing station. The FS stated they did not have a work order for Resident #12's room. The FS stated they did not know the call bell in Resident #62's room was missing a pull cord. They did not receive a work order or report about this concern from staff, but they were in Resident #62's room recently to address a bedrail concern. On 09/13/23 at 01:58 PM, an interview was conducted with the Maintenance staff (Other Staff #10) regard the concerns in the resident (Resident #12), Other Staff #10 stated that in the beginning of July the resident (Resident #12) refused to allow staff to complete repair because the resident (Resident #12) does not want to come out of the room to allow repair can be done. Wants to oversee work with concern for personal property. When resident (Resident #12) refused supervisor was informed. Other Staff #10 stated that went there today, but because resident (Resident #12) was going out of the facility, refused work. Other Staff #10 stated that after resident left the facility, went into repair bathroom door and took pictures for supervisor. Other Staff #10 stated that a reset of the bathroom call bell was done about 2 days ago after made aware buy a nurse, there was no work order, could identify the nurse. Other Staff #10 stated that the housekeeper was present during the time of the reset, however could not identify the staff member. On 09/14/23 at 10:43 AM, and interview was conducted with the Facility Administrator (FA) regarding the environmental concerns in the resident (Residents #12) room. The FA Stated that a work order was conducted during rounds when the resident verbalized concerns about the smell of onions and that the resident (Resident #12) always has a concern. The FA stated that was told by staff that the resident denies access to her room. The FA stated that was not aware that the emergency call device was not working. 415.29

Based on observation, record review, and interviews conducted during the recertification survey from 09/10/2023 to 09/15/2023, the facility did not ensure sufficient nursing staff to provide nursing or related services to assure resident safety and to attain or maintain highest practicable well-being of each resident. This was evident for 3 of 3 resident units (Unit 1, 2, and 3). Specifically: 1) During meal observations, there was no Licensed Professional Nurse or Certified Nursing Assistant available to monitor the residents in the common dining areas. 2) Actual nurse staffing was less than projected staffing on multiple occasions, based on the Facility Assessment Tool document submitted to the survey team. The findings are: The Facility Assesment tool provided to the survey team dated 8/30/2023 did not include a breakdown of who many staff are required per unit on each shift. The Facility Assessment Tool dated 9/13/2023 documented the facility assessment is utilized to support decision -making regarding staffing and other imminent requirements to retain the safety of the residents and staff. The Staffing Plan describes the number of staff available to meet residents' needs. Nursing, nutrition services and housekeeping staffing is evaluated at the beginning of each shift and adjusted as needed to meet the care needs and acuity of the resident population. The Staffing Plan for Nursing the following: 12 AM - 8 AM: 1 Registered Nurse (RN) Supervisor, 4 Licensed Practical Nurses (LPN), 7 Certified Nursing Assistants (CNA) 8 AM - 4 PM: 2 RN Managers, 2 LPNs, 16 CNAs 4 PM - 12 AM: 1 RN Supervisor, 4 LPNs, 13 CNAs There was no staff breakdown documented in the facility assessment. 1.) During the meal observations on Unit 1 on 09/11/2023, 09/12/2023 and 09/13/2023 from 11:45 AM to 12:45 PM, lunch was served to 4 to 6 residents in the common area There was no licensed nurse on the unit during the meal distribution and the duration of the meals. Certified Nursing Assistant (CNAs) were observed going around distributing lunch trays to other residents in their rooms. 2) On 09/10/23 at 11:20 AM and on 09/12/23 at 11:54 AM, the Unit 2 dining area was observed during lunch. There was no licensed nurse providing supervision in the dining room. On 09/10/23 at 11:33 AM, lunch in the Main Dining Room was observed, and there was no licensed nurse providing supervision during the meal service. On 09/13/23 at 12:34 PM, an interview was conducted with Registered Nurse (RN) Manager, RN #2. RN #2 stated that either a Licensed Practical Nurse (LPN) or Certified Nursing Assistant (CNA) can observe meals however, usually a nurse must observe that the order is what is being served. Residents that need to be fed or observed will get support from a staff member. Most of the residents on this floor eat independently, only one resident needs to be observed for choking on Unit 2. On 09/14/23 at 10:50 AM an interview was conducted with the Director of Nursing (DON). The DON stated that there should be suction equipment on every unit. Resident mealtime should be observed by a Certified Nursing Assistant (CNA) and when short staffed, a Licensed Practical Nurse (LPN) can observe. The staff who observe meals are certified in Basic Life Support (BLS). 2.) The Actual Staffing Sheets from 09/01/2023 to 09/13/2023 documented that for 117 total shifts, there were 73 scheduled CNAs that did not work and were not replaced. Many night shifts only had 1 CNA per unit scheduled for a total of 3 CNAs, which is under the required 7 CNAs per the Facility Assessment. The staffing sheets also documented some of the day shift CNAs are assigned to be escorts, meaning they were not be available to provide care for a portion of the day because they were assigned to take residents to appointments. On 09/12/23, 09/13/23, 09/14/23 and 09/15/23, the actual staffing sheets documented 1 LPN was assigned to Unit 1 on the 8AM to 4 PM shift. On 09/13/2023 at 2:45 PM, Licensed Practical Nurse (LPN) # 5 was interviewed and stated the facility is always short of nursing staff. The assigned CNAs on the Unit are used as escort first and then when they come back, they will be on the unit. With the breaks and all, by the time that is over, it is time to go home. Some days, we will have 2 to 3 actual CNAs on Unit 1. During an interview on 09/15/23 at 2:35 PM, the Director of Nursing (DON) stated the staffing breakdown on each unit is as follows: Night Shift (12:00 AM to 8:00 AM) - Units 1, 2, and 3 required 1 LPN and 2 CNAs per unit. Day Shift (8:00 AM to 4:00 PM) - Units 1, 2, and 3 required 1 LPN each, and Unit 1 required 4 to 6 CNAs, Unit 2 required 5 CNAs, and Unit 3 required 4 CNAs. Evening Shift (4:00 PM to 12:00 AM) - Units 1, 2, and 3 required 1 LPN and 3 CNAs per unit. The DON stated staffing is a challenge. The facility supplements the staffing with overtime and giving out some freebies to our staff. The facility has arrangements with agencies, but they cannot always supply the staff. The CNAs on the schedule are also used to escort residents to outside medical appointments or dialysis if there is no available escort. The surveyor pointed out to the DON that on the Night shift, there is usually only 1 CNA per unit instead of 2. The DON sated that unfortunately, the CNAs call in sick, and the agency cannot provide a replacement and no one volunteers to stay over. 415.13 (a)(1)(i-ii)

Based on interview and record review during the Recertification Survey, the facility did not ensure each resident was screened for a mental disorder or intellectual disability prior to admission for 4(Resident #s 2,3,12 and 34) of 20 residents reviewed for DOH-695 (Department of Health) Pre-Admission Screening and Record Review (PASRR, a federal requirement to ensure that residents were not inappropriately placed in a skilled nursing facility). Specifically, there was no documentation the facility reviewed and maintained DOH-695 PASRR screens prior to admission to the facility for Resident #s 2,3,12 and 34. The findings include but are not limited to: The facility policy on Pre-Admission Screening and Record Review approved in 2021 stated as follows: The Admission Coordinator then generates an identification card and initiates a PASRR form and an admitted corresponding to the medical orders. 1) Resident #3 was admitted to the facility on [DATE] with diagnoses which include Bipolar Disorder, Mood Disorder, and Hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified the resident as alert and oriented to person, place and time with a score of 15 on the Brief Interview For Mental Status (BIMS) and independent with most Activities of Daily Living (ADLS). On 09/13/2023 at 12:30P, there was no PASRR in Resident #3's medical record. On 09/13/2023 at 1:00PM, a request for a printed copy of the PASRR was made to the Director of Social Services. The Director provided a PASRR dated 9/6/2023. There was no documented evidence the resident was screened prior to admission. 48931 2) Resident #12 was admitted [DATE], and the PASARR was completed 9/7/23. 3) Resident #2 was admitted [DATE], and the PASARR was completed 8/25/14. 4) Resident #34 was admitted [DATE], and the PASARR was completed 8/2/10 On 09/15/23 at 11:21 AM, an interview was conducted with the Unit Case Manager (Other staff #8). The Case Manager stated that they are responsible for completing the PASARR screens for the residents. The Case Manager stated that residents are usually admitted with a screen. They complete the screen upon admission or within 72 hours if the resident is alert and oriented and does not come with a screen. On 09/15/23 at 11:29 AM, the Administrator was interviewed and stated that the facility recently revamped the admission process in the past month. Consultants are in the facility to provide training. A supervisor was completing the screens, but there was a concern. 415.11(e)

Based on observations, record review and interview conducted during the recertification survey from 9/10/23 to 9/15/23, the facility did not ensure that the results of the most recent survey report and any plan of correction in effect were posted in a place readily accessible to residents, and family members and legal representatives of residents. This was evident for all residents, including 10 of 10 attendees of the Resident Council Meeting. Specifically, the results of the most recent state survey were not posted. The findings are: Policy and Procedure dated 8/1/2, titled Posting of Nursing Home Inspection documented: Notice of the reports are posted for all residents and/or visitors in the lobby area (entrance) of the facility, and the binder of the complete list of deficiencies and corrective plans implemented is kept and readily accessible at the security station. On 9/10/23 at 10:54 AM, the lobby area was observed with a sign posted inside a locked glass bulletin board located on the wall by the main lobby elevators, directing people that survey results were available by request at the security desk. There were no survey results posted. On 09/12/23 at 10:32 AM, during the Resident Council meeting, 10 out of 10 residents stated that there was a sign posted by the elevator in the main lobby that informs them survey results are available upon request. On 09/13/23 at 12:55 PM, the surveyor requested the survey results according to posted instructions. Security personnel presented a binder with survey results dated 5/13/2022. The survey binder was kept on the counter behind the security desk. On 09/15/23 at 10:53 AM an interview was conducted with the Facility Administrator (FA). The FA stated that there is a posted in the main lobby with directions to request survey results from any staff member or security. The FA understood survey results should be available, however, they were not aware that survey results should not have to be requested. 415.3(d)(1)(v)

Based on observations, interviews, and record review conducted during the recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure that food was stored according to professional standards for food safety. This was evident for 1 (2nd Floor) of 3 units. Specifically, the pantry refrigerator on the 2nd Floor was used to store staff food items, contained undated resident food, contained unlabeled, undated, and uncovered bowls of ice, and was not within acceptable temperature range. The findings are: The facility policy titled Unit Pantries and Food Safety dated 08/15/2023 documented staff will refrigerate the labelled and dated prepared items in the pantry refrigerator. Staff are prohibited from storing their personal food items within the pantry at any time. On 09/10/2023 at 09:28 AM, the 2nd Floor pantry was observed with 1 full-sized refrigerator at 50 F internal temperature containing an undated sandwich for Resident #62, an undated package of food for Resident #55, an unlabeled and undated package of food for Licensed Practical Nurse (LPN) #2, and an undated, unlabeled cup of apple sauce. A supplement refrigerator was observed with an internal temperature of 45 F. On 09/11/2023 at 11:03 AM, the 2nd Floor pantry full-sized refrigerator was observed with undated food packages for Resident #62, #55, and #33, 2 unlabeled and undated breakfast sandwiches, 7 undated and unlabeled bowls of ice, and 1 uncovered bowl of ice. On 09/15/2023 at 10:11 AM, an interview was conducted with LPN #2 who stated the 2nd Floor pantry contains a refrigerator for nourishment and supplement refrigerator for resident food, juice, milk, and apple sauce for medication administration. Items should be labeled with resident name and dated. Staff are not supposed to store food there. LPN #2 stated they worked overtime and stored their personal food in the refrigerator because it would have gone bad. LPN #2 did not date their food because they did not store it for a long period of time. On 09/13/2023 at 12:40 PM, an interview was conducted with Registered Nurse (RN) #2 who stated supplements, juice, and ice are stored in the unit pantry refrigerators and discarded after 3 days. Food with mold and bubbles needs to be discarded. Name and dates are labeled on the food. Temperatures of the refrigerators should be between 35 F and 42 F. Staff food should not be stored in pantry refrigerator. On 09/14/2023 at 10:50 AM, an interview was conducted with the Director of Nursing (DON) who stated the pantries contain 1 refrigerator for supplements and 1 refrigerator to store resident food. Food should be labeled, dated, and discarded after 2 days. Staff food should not be stored in the pantry refrigerators. 415.14(h)

Based on observation, record review and interview during the Recertification/Complaint survey, the facility did not ensure that drug records are in order and that an account of all controlled drugs is maintained as per standard of practice. Specifically recount and reconciliation of Narcotics and Controlled Medications were observed not being done by two (2) Licensed Nurses. This was evident for 1 of the 3 units observed for medication storage and labelling. The findings are: The facility Policy and Procedure for Narcotics and Controlled Medications dated May 2022 documented: Two (2) Licensed or registered nurses should always be present to conduct a handoff when shifts are changed, or in the case of an emergency - resulting in an early departure from the facility. On 09/11/23 at 08:29 AM, One (1) nurse, (LPN #2) was observed counting the Control medications in the medication room alone. LPN #2 was interviewed and stated that the night Nurse, (LPN #3) left earlier before they could get to the unit to count the narcotics. LPN # 2 stated that they worked previous shift on another unit, and they were waiting for the incoming nurse to take over before coming down to the unit to count the narcotics. On 09/13/23 at 07:58 AM, an interview was conducted with the Licensed Practical Nurse, LPN #3. LPN #3 stated that the incoming nurse, LPN #2 worked overnight on another unit upstairs, came down to collect the key and went back up without counting the control medications together. LPN #3 stated that they know that narcotics counting should be done by 2 nurses, but they thought the counting will be done by LPN #2 with the Supervisor because they needed to leave on time for another job. LPN #3 further stated that most of the time there is no nurse on the unit to hand over to when it is time to go, and sometimes it is difficult to wait indefinitely when they need to get to other job on time. On 09/11/23 at 09:02 AM, an interview was conducted with the supervisor, RN #1. RN #1 stated that Narcotic Counting is supposed to be done by 2 Nurses as per protocol. RN #1 stated that they are not aware that the Night Nurse did not count with the incoming Nurse when they were doing handing over. On 09/13/23 at 11:47 AM, the Director of Nursing, DON was interviewed and stated that if the outgoing LPN is to go before the arrival of the incoming Nurse, they have to do narcotic count with RN Supervisor. DNS stated that the LPN counting the control medication alone did not follow proper procedure. DNS also stated that they are not aware that the counting of control meds is not done by 2 nurses due to late arrival of the incoming nurse. DNS stated the problem has not been brought to their attention before. 415.18(a)

Based on observation, record review and staff interview the facility did not ensure prompt efforts were made to resolve a resident's grievance. This was evident for 1 (Resident #3) of 20 sampled residents. Specifically, the facility did not complete their investigation and respond to Resident #3's grievance that a fanny pack was taken from their room. The finding is: The facility policy titled Grievance/Complaint dated 11/01 documented residents are encouraged to verbalize any grievances or complaints without retaliation. Designated staff are assigned to intervene in resolving the issues. Resolution should be attempted immediately but should not take longer than fourteen days. Procedure # 2 documented, the resident /Significant other has the right to present a grievance or complaint directly to administration or to any other staff member. Staff at any level upon hearing a grievance or complaint, will be responsible to respond immediately and try to resolve the issue at the lowest level. Staff member will notify the Nursing Supervisor of the complaint. The Director of Social Services (DSS) is responsible for assigning a resolution date which should not take longer than 14 days. Resident # 3 was admitted to the facility with diagnoses which include Hypertension, Osteoporosis, and bipolar disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition and was independent with most Activities of Daily Living (ADLS). During the initial tour of the facility on 09/11/2023, Resident #3 stated someone took their fanny pack from their room. Resident #3 stated they reported it to the Social Worker, and they have not received a response regarding the investigation. Review of the Grievance /Complaint report submitted by the resident documented that the report was initiated on 08/01/2023 and written by the Director of Social Services (DSS). Resident #3 reported they went to bed on 7/31/2023 at 6:00 PM, and when Resident #3 woke up on 8/1/2023 at 2:00 AM, they noticed the fanny pack was missing from the wheelchair in their room. There was no documented evidence the grievance investigation was fully completed, and no resolution was communicated to Resident #3. During an interview on 09/14/23 at 12:36 PM, the DSS stated Resident #3 told them about the missing fanny pack, and they emailed the Head of Security (HOS) on 8/1/2023 to request video footage. The HOS responded to the request on 8/15/2023, but when the DSS reviewed the video, they realized the HOS provided camera footage from the wrong angle. The DSS stated they requested additional footage, but they did not receive it yet. The DSS acknowledged grievances should be resolved in 14 days, and it had been 42 days since the grievance was reported. The DSS stated they were relying on the video footage to help with the investigation. The DSS stated no staff interviews or statements were completed. During an interview on 09/14/23 at 12:51 PM, the HOS stated they oversee the camera footage for the entire organization, not just the facility. The length of time it takes to respond to requests depends on the priority. The HOS stated they receive 6 to 10 requests per day, and some are related to a subpoena and take priority. The footage was provided 8/15/2023. 415.3(c)(1)(ii)

Based on observation, record review and staff interview the facility did not ensure a safe, clean, comfortable, and homelike environment was provided or exercise reasonable care for the protection of the resident's personal property from loss or theft. This was evident for 2 of 20 sampled residents (Resident #3 and Resident #12). Specifically, Resident #3 had a fanny pack taken from their room, and Resident #12's room was observed with missing wall paint, a rusty door, missing wall plaster, dirty floors, and other concerns. The findings are: 1) Resident # 3 was admitted to the facility with diagnoses which include Hypertension, Osteoporosis, and bipolar disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition and was independent with most Activities of Daily Living (ADLS). During the initial tour of the facility on 09/11/2023, Resident #3 stated someone took their fanny pack from their room. Resident #3 stated they reported it to the Social Worker, and they have not received a response regarding the investigation. Review of the Grievance /Complaint report submitted by the resident documented that the report was initiated on 08/01/2023 and written by the Director of Social Services (DSS). Resident #3 reported they went to bed on 7/31/2023 at 6:00 PM, and when Resident #3 woke up on 8/1/2023 at 2:00 AM, they noticed the fanny pack was missing from the wheelchair in their room. There was no documented evidence the grievance investigation was fully completed, and no resolution was communicated to Resident #3. During an interview on 09/14/23 at 12:36 PM, the DSS stated Resident #3 told them about the missing fanny pack, and they emailed the Head of Security (HOS) on 8/1/2023 to request video footage. The HOS responded to the request on 8/15/2023, but when the DSS reviewed the video, they realized the HOS provided camera footage from the wrong angle. The DSS stated they requested additional footage, but they did not receive it yet. The DSS acknowledged grievances should be resolved in 14 days, and it had been 42 days since the grievance was reported. The DSS stated they were relying on the video footage to help with the investigation. The DSS stated no staff interviews or statements were completed. During an interview on 09/14/23 at 12:51 PM, the HOS stated they oversee the camera footage for the entire organization, not just the facility. The length of time it takes to respond to requests depends on the priority. The HOS stated they receive 6 to 10 requests per day, and some are related to a subpoena and take priority. The footage was provided 8/15/2023. 48931 2) On 09/10/23 at 10:19 AM, Resident #12's room was observed. The bathroom door was rusty and had missing paint. The walls had paint peeling and missing plaster. The floor in the corner by the closet was dirty and stained. The light fixtures dusty, and a water stain was observed on the bulletin board. On 09/13/23 at 12:15 PM, an interview was conducted with the Certified Nursing Assistant (CNA) CNA #5 who stated they did not notice any environmental concerns in Resident #12's room. On 09/15/23 at 10:08 AM an interview was conducted with Licensed Practical Nurse (LPN), LPN #2 regarding the concerns in the resident (Resident #12) room. LPN #2 stated that every morning the resident complains about the room being dirty. When the housekeepers go in to clean, Resident #12 tells them what to do. LPN #2 stated that they have not witnessed or heard of the resident refusing cleaning or repairs in the room. LPN #2 stated that the Housekeeper goes in when the resident is present to give directions only because the resident will not be satisfied with how it is done. During an interview on 09/13/23 at 01:58 PM, Maintenance staff (Other Staff #10) stated that in the beginning of July, Resident #12 refused to allow staff to complete repairs in the room. Resident #12 did not want to come out of the room to allow repairs to be done because Resident #12 wanted to oversee the work due to concerns regarding their personal property. When Resident #12 refused the repairs, the supervisor was informed. Today, when they went to the room, Resident #12 refused the repairs because Resident #12 was going out. The Maintenance staff member stated they repaired the bathroom door and took pictures for the supervisor after Resident #12 left. During an interview on 09/13/23 at 11:49 AM, the Facility Supervisor (FS) stated all staff can email environmental concerns to the facility department or create a work order at the nursing station. The FS stated they did not have a work order for Resident #12's room. On 09/14/23 at 10:43 AM, and interview was conducted with the Facility Administrator (FA) regarding the environmental concerns in Residents #12's room. The FA Stated that a work order was completed during rounds when the resident verbalized concerns about the smell of onions, and Resident #12 always has a concern. The FA stated that staff informed then Resident #12 denies access to the room, at times. 415.5(h)(2)

42 CFR 483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. 10NYCRR 415.29 Physical environment. The nursing home shall be designed, constructed, equipped, and maintained to provide a safe, health, functional, sanitary, and comfortable environment for residents, personnel, and the public. Based on staff interview and document review conducted during the Life Safety Code recertification survey, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Reference is made to the following: 1. It could not be verified that the building's backflow devices on the domestic water supply and Sprinkler system (devices that stop the undesirable reversal of flow of liquids, gases, or suspended solids into the potable water supply) were inspected annually. The finding is: During document review on 09/22/2023 between 09:00AM - 01:00PM, it was noted that annual inspection and testing records were missing for two backflow preventer devices installed on domestic and sprinkler system. In an interview on 09/22/2023 at approximately 01:45PM, the Assistant Administrator Facilities stated they would provide the annual inspection reports. Facility did not provide any additional documents. 42 CFR 483.90(d)(2) 415.29(f)(4)

Based on observation, record review and interview conducted during the Recertification Survey, the facility failed to have an effective system in place to monitor and supervise residents who smoke. Specifically, the facility allowed residents to smoke at all times in smoke lounges located on all three resident units. Smokers assessed as being unsafe were observed smoking without supervision and without wearing protective equipment as ordered. Facility staff were aware that unsafe smokers could enter the smoking lounge at any time to smoke unsupervised, obtained smoking materials from other residents, and did not always wear ordered protective equipment. Staff also demonstrated inconsistent knowledge of the supervision needs for unsafe smokers. In addition, a non-smoker using oxygen was observed inside the smoking room while smoking was in progress. This was evident for 6 of 9 residents reviewed for Smoking Accidents. (Resident #s 33, 62. 70, 89 and 93). The lack of supervision of unsafe smokers put residents at risk for injury, harm, impairment, or death. This resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care to resident health and safety. The findings include but are not limited to: The facility policy titled No Smoking Policy dated 3/1995, revised 11/2001, documented the following: -Each unit has a smoking lounge that is equipped with a TV monitor to allow nursing staff supervision of the area at all times. -Each resident will be assessed by the Licensed Nurse upon admission, quarterly, and as needed thereafter to identify residents who may be an unsafe smoker utilizing the Smoking Assessment Form. -If a resident is classified as an unsafe smoker, a red shaded area will be placed on the resident's identification card (ID). The Registered Nurse (RN) or Social Worker will notify Admissions to issue the ID. -The residents who are classified as unsafe smokers shall not be permitted to retain any type of smoking articles, which include cigarettes, tobacco, etc. either on his/her person or within sleeping areas at any time. -Unsafe smokers will be allowed to smoke in the smoking lounge only under supervision of a staff member or significant other. -Cigarettes and/or other smoking articles will be stored in the nursing station for such unsafe smokers and provided as scheduled by the interdisciplinary team. -Smoking schedules will be prepared to allow unsafe smokers to smoke under the direct supervision of staff or significant other for the entire smoking period. The facility shall provide reasonable means of providing direct supervision to those residents wishing to smoke. Staff members, guardians, visitors, and volunteer workers may assist in providing this service to residents. Any persons providing supervision to unsafe smokers must be instructed in smoking regulations prior to rendering such service. Each unit in the facility had a smoking room that was left open 24 hours to all residents. Each smoking room had a glass window by the door, providing visibility to a quarter of the room. 1) Resident #62 has a [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition and received oxygen therapy. There was a No Oxygen Allowed sign posted by the smoke room. During an observation on 11/15/19 at 4:43 PM, Resident #62 was observed inside the Unit 3 smoke room. There was an oxygen tank attached to the resident's wheelchair (w/c), and the resident was receiving oxygen via nasal cannula. There was another resident in the room actively smoking. No staff member was observed in the smoke room. The resident opened the smoke room door and exited smoke room, wheeling himself into the hallway. The Licensed Practical Nurse (LPN #4) and the day shift charge nurse, Registered Nurse (RN #1), were observed sitting at the nursing station across from the smoke room. When the resident exited the smoke room, the staff did not speak to the resident. During an interview on 11/115/19 immediately after the observation Resident #62 was interviewed. The resident stated that he knows that he should not go into the smoke room with oxygen in use because it is dangerous. Resident #62 stated that he does not smoke, but he went into the smoke room to speak to another resident. During an interview, on 11/15/19 at 5:28 PM, LPN #4 he stated that he did not notice that Resident #62 went into the smoke room with oxygen. He stated no resident should ever be allowed inside the smoke room with oxygen, and residents are reminded that oxygen should not be inside the smoke room. 2) Resident #70 was admitted to the facility with [DIAGNOSES REDACTED]. The most recent Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The resident was independent with most Activities of Daily Living (ADLs). The resident's [DIAGNOSES REDACTED]. The most recent smoking assessment dated [DATE] documented the resident was a safe smoker. There was a Physician's Clinical Monthly Evaluation dated 10/23/19 that documented the resident had involuntary limb movements and tremors. The resident had [MEDICAL CONDITION]/[MEDICAL CONDITION] Disorder being treated with multiple psychoactive medications, Neurocognitive Disorder being treated with [MEDICAL CONDITION] Therapy (ART), and Tremors/Dystonic movements being treated with [MEDICATION NAME]. Based on the physician's evaluation, the resident should have been assessed as an unsafe smoker. The facility's smoking assessment template includes upper extremity tremors among the disabilities that would make a resident unable to safely handle cigarettes or matches. The Facility Accident/Incident report, initiated 10/27/19, documented that Resident#70 reported a burning sensation on her left upper inner thigh. The resident reported that she dropped a cigarette onto her lap and burned her upper left thigh. The recommendations included wearing a smoking apron, resident education on smoking hazards, and staff ensuring the apron is on before the resident enters the smoke room. The Comprehensive Care Plan (CCP) dated 10/14/19 identified the resident as Smoking Unsafe Smoker. The CCP documented no interventions at that time. The CCP documented that on 10/28/19, one day after the resident burned herself in the smoke room, interventions were implemented. The interventions included keeping cigarettes by the nursing station, supervision while smoking in the smoking area, and wearing a smoking apron while smoking. The CCP noted that the resident was educated regarding the interventions and the updated care plan. There was no evidence that a new smoking assessment was done after the physician's evaluation or the incident on 10/27/19. During interview on 11/15/19 at 6:46 PM and 11/26/19 and followed up at 4:01 PM, the Director of Nursing (DON), acknowledged the incident concerning Resident #70. The DON investigated the incident. The resident was informed that she needs to wear a smoking apron, and the CCP was updated. A new smoking assessment was not completed. The DON stated that anytime there is an incident, a resident should be reassessed for a change in condition that could affect their ability to safely smoke. According to the DON, the MDS Coordinator should have completed the assessment. During an interview with LPN #4 on 11/15/19 at 6:21 PM, LPN #4 stated that he was aware that Resident #70 was assessed as an unsafe smoker. LPN #4 stated that the resident is supposed to wear an apron while smoking and should be supervised while smoking in the smoke room. During the interview the LPN stated that because of other work duties and time constraints nursing staff don't always monitor the unsafe smokers. During observations of the Unit 2 smoking room, on 11/18/19 at 12:22 PM, no staff member was by the entrance. A nurse was observed seated at the nursing station documenting on the computer. Resident #70 was observed seated in a chair with her back against the wall. Resident #70 had a lit cigarette in her hand, and she was not wearing a smoking apron. The TV monitor that provides a view of the smoking room was not monitored by nursing staff. During an interview on 11/18/19 at 12:22 PM, Resident #70 stated that a few weeks ago she burned herself while smoking in the smoke room. She said that earlier on the day of the incident the nursing staff did provide her with a smoking apron. Later in the day they didn't offer her an apron and she didn't wear one. The resident stated that she dropped the cigarette onto her lap and burned her upper left thigh. Staff did not assess her [MEDICAL CONDITION] she exited the smoke room. She informed staff of the burn later in the evening. 3) Resident #93 had [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition and moderately impaired vision. A physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) for Smoking dated 5/21/19 included the interventions of supervision while smoking, provide assistance when smoking, provide smoking apron, and provide education on risks of unsafe smoking behavior. The CCP noted that the resident was non-compliant with wearing the smoking apron despite education, and the staff were continuing to monitor for compliance. There was no documented evidence that the resident had a quarterly or annual smoking assessment from 5/1/19 to 11/5/19. The Smoking assessment dated [DATE] documented that the resident was an unsafe smoker, visually impaired, and monitored while smoking. The assessment noted the resident refused to wear the smoking apron. During an interview of the Licensed Practical Nurse (LPN #5) on 11/15/19 at 5:38 PM, Resident #93 exited his room, at 5:38 PM, and wheeled himself to the smoke room. The resident's room and the unit smoke room door were both within full view of LPN #5. LPN #5 did not get up to offer Resident #93 a smoking apron. The smoking aprons were hanging near the entrance. Resident #93 passed the smoking aprons and turned the corner where he was no longer visible to LPN #5. The TV that monitors the smoke room was positioned on the other side of a wall behind LPN #5's back. LPN #5 continued with the interview and did not look at the TV monitor or smoke room door to observe Resident #93. After a few seconds of Resident #93 being out of view, the surveyor asked LPN #5 to pause the interview. The Surveyor went to the smoke room door. LPN #5 got up to follow the Surveyor. Resident #93 was not visible from the smoke room door, so the surveyor entered to observe him. There was no staff member in the smoke room at this time. During the observation Resident #93 had another resident light a cigarette for him. At this time, LPN #5 grabbed an apron from the wall and offered it to Resident #93. Resident #93 refused to wear the apron. The resident continued smoking. LPN #5 went back to back to the nursing station, but did not position himself in front of the TV monitor to observe Resident #93 while he was still smoking. LPN #5 continued the interview with the Surveyor without any further monitoring of Resident #93 in the smoke room. No staff member was observed going into the smoke room. Resident #93 refused to be interviewed. On 11/18/19, the physician re-ordered the resident be monitored during smoking every hour from 7 AM to 9 PM and use a smoking blanket (original order date 4/3/18) and monitor every 60 min (minutes) for aggressive behavior and unsafe smoking. During an interview on 11/19/19 at 4:20 PM, LPN #5 identified Resident #93 as an unsafe smoker. LPN #5 stated there are 2 nurses on the unit during the evening shift. The smoke rooms are open 24 hours per day, and there is no smoking schedule for any residents. The nurses observe smoking via the TV monitor or through the glass by the smoke room door. Nursing staff do not watch residents the entire time they are smoking. When unsafe smokers want to smoke, the nursing staff should offer an apron and monitor closely. Close monitoring is not constant supervision. He glances at the TV monitor as much as possible. If a resident refuses to wear an apron, the nursing staff will encourage them, write a progress note, refer them to the Social Worker (SW), and provide close monitoring. The nursing staff checks the unsafe smoker after smoking to make sure they haven't incurred any burns. The nursing staff do not assist unsafe smokers with lighting cigarettes; the safe smokers can light the cigarettes for the unsafe smokers. If unsafe smokers are found keeping their own cigarettes and lighters, they are referred to the SW. He does not know if safe smokers give cigarettes and lighters to unsafe smokers. He stated that the nursing staff cannot control that. During an interview on 11/18/19 at 1:08 PM, the Certified Nursing Assistant (CNA #4) stated that she was assigned to provide care to Resident #93 in (MONTH) 2019, and he is not a smoker. CNA #5 further stated that there are no unsafe smokers on the unit (Unit 3). CNA #4 stated that there are regular in-services provided to the staff regarding smoking. CNA #4 stated that if a resident goes into the smoke room, and emerges without [MEDICAL CONDITION] other incidents occurring, then it shows that they are safe to go in there without supervision. The CNAs are not responsible for monitoring a resident's clothing for burn holes or looking for any signs of burns. The residents are alert and can tell the staff if they burn themselves. There are only two CNAs assigned to the unit, and it would be too difficult for them to monitor the residents in the smoke room continuously. For example, right now, the other CNA is on break and she is the only CNA tasked with monitoring the entire unit and addressing residents' needs. CNA #4 stated the only rules that apply to the smoke room are that residents should be wearing aprons, however not every resident agrees to wear the smoke apron. The LPN is responsible for giving residents cigarettes if they are being held at the nursing station. CNA #4 stated the nurses hold cigarettes for the residents who cannot physically hold onto the cigarettes. She does not know if there is a set schedule for residents to smoke. During an interview on 11/19/19 at 3:56 PM, the Physician's Assistant (PA) assigned to the resident stated that the order for a smoking blanket should refer to a smoking apron. This is an error. Resident #93 requires a smoking apron because he is an unsafe smoker. The PA stated that the resident was deemed an unsafe smoker, because he was found [MEDICAL CONDITION] his clothes in the past. The PA stated that he is unsure how the resident burned his clothing, but the resident has visual impairment in the form of [DIAGNOSES REDACTED]. An interview was conducted with the Director of Social Work (DSW) on 11/18/19 at 2:15 PM. The DSW stated that Resident #93 and Resident #70 burned themselves in the past; that is why they are considered unsafe smokers. The interdisciplinary team assesses whether a resident is an unsafe or safe smoker. The team consists of Registered Nurses and Social Workers. Unsafe smokers either have physical disabilities or cognitive impairments that prevent them from being able to conduct themselves in a safe manner while smoking. Social Work coordinates with the nursing department to ensure that the unsafe smoker has a smoking schedule that is manageable. Depending on how many cigarettes a resident has and how busy the LPN may be, the resident may be able to smoke hourly or every two hours. The DSW stated that when any staff member believes that a resident may be unsafe, a team meeting is held to discuss the resident's smoking status. Unsafe smokers are required to wear an apron and have their cigarettes held by nursing. The staff does not keep any lighters. The nursing staff should dispense the cigarette and ask the unsafe smoker to wear an apron. The DSW corroborated that the unsafe smokers are assisted by the safe smokers with lighting their cigarettes. The LPN or CNA are supposed to directly supervise the unsafe smoker until the cigarette is lit. Then, they supervise through the door or TV monitor. The nursing staff checks the resident afterwards to ensure that he or she does not have [MEDICAL CONDITION] burn holes in their clothing. Sometimes, unsafe smokers obtain cigarettes from safe smokers, but this is discouraged and not allowed. Residents are educated regarding the smoking policy upon admission. Behavior contracts and/or smoking contracts are not utilized if a resident is non-compliant with the smoking rules. If a resident is non-complaint with the rules, it is documented in the record and the resident is re-assessed to determine their smoking status. During an interview on 11/18/19 at 5:07 PM, the Director of Nursing (DON) stated that there are times when unsafe smokers may sneak by the staff and go into the smoke room unsupervised and without their smoke aprons. No one stands at the door of the smoke room to monitor, and the TV monitor is used for supervision. The security personnel can also observe residents in the smoke rooms from the security camera monitor at the front desk. During an observation of the front desk security camera on 11/18/19 at approximately 5:15PM it was noted that the security monitor is used to view the inside and outside of the building, including the smoke room. It was observed that the security guard often switches between screens and does not monitor the smoking room. Immediate Jeopardy (IJ) was identified, declared, and the facility Administrator and DON were notified on 11/19/19 at 5:26 PM. The survey team declared the immediacy of the IJ had been abated after receiving an acceptable corrective action plan from the facility on 11/19/19 at 10:39 PM. On 11/26/19 at 3:20 PM, the survey team declared the IJ was removed as of 11/25/19 based on the following corrective actions taken by the facility: 1. The facility implemented a revised Resident Smoking Policy on 11/21/19. The policy included that residents assessed as unsafe smokers will be monitored continuously during smoking by an assigned CN[NAME] All smoking materials for unsafe smokers will be held by nursing staff in a locked cart. The CNAs will assist unsafe smokers by assisting them with donning smoking aprons and lighting their cigarettes. In addition, the LPNs will intermittently monitor the TV monitor at the nursing station. A list of all smokers in the facility will be kept on each unit with a smoking log book. The CNAs will document all cigarettes given to unsafe smokers in the log book. 2. The facility implemented education on the revised policy. Per documentation submitted by the facility, 98% of staff were trained by 11/25/19. This includes all nursing staff. The survey team also conducted interviews with staff on different shifts to verify their education on the new policy. A total of 14 CNAs, 11 LPNs, 3 RNs, 2 Social Workers, and 3 Security Guards were interviewed. All persons were knowledgeable on the revised policy. 3. Daily smoking observations on all units, during different shifts, were conducted from 11/21/19 to 11/25/19. Unsafe smokers were observed smoking under supervision and wearing aprons. Each unit also had a binder that contained the list of all smokers with their pictures inside. All units had a CNA assigned to the smoke room for monitoring. 415.12(h)(2)