Every finding on record at Champlain Valley Physicians Hosp Med CTR S N F

Based on record review and interviews during the recertification and abbreviated survey (Case #s NY00346121, NY00366317, and NY00365618), the facility did not ensure the resident's right to be free from abuse and neglect for 3 (Resident #s 1, 14, and 23) of 4 residents reviewed for abuse and neglect. Specifically, (a.) for Resident #1, a staff member grabbed their forearm and removed their call light on 6/23/2024; (b.) for Resident #14, a bed bolster was not in place when one staff member assisted in the resident's care when the resident required two staff, resulting in a fall on 12/22/2024; (c.) for Resident #23, a staff member grabbed their hand resulting in a skin tear. This is evidenced by: A policy and procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, documented the facility would actively protect the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Resident #1 Resident #1 was admitted to the facility with diagnoses of quadriplegia (paralysis of 4 limbs), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockages and breathing related problems), and essential hypertension (high blood pressure). The Minimum Data Set (an assessment tool) dated 4/05/2024 documented the resident was able to be understood, to understand others, and was cognitively intact. The comprehensive care plan titled, Behavioral Symptoms, documented the following interventions when the resident became verbally abusive to staff: Temporarily interrupt care Be sure the resident had call bell in reach The Nursing Home Investigative Report dated 7/2/2024 documented Resident #1 had reported to Registered Nurse #3 that Registered Nurse #2 had twisted their wrist and taken their call light away. Resident #1 had a reddened area to their wrist. In a witness statement dated 6/23/2024, Registered Nurse #3 documented Resident #1 had accused Registered Nurse #2 of twisting their wrist while taking the call light away. Registered Nurse #3 noted in their statement that the resident had 'some' redness to the wrist. Registered Nurse #3 notified. In a witness statement dated 6/24/2024, Licensed Practical Nurse #2 stated they did not witness the event but Resident #1 had asked not to have Registered Nurse #2 care for them because they had twisted Resident #1's wrist on their last interaction. In a progress note dated 6/24/2024, Nurse Practitioner #1 documented Resident #1 had bruising to their right wrist. Radiography was ordered and showed no fracture or dislocation. In a progress note dated 6/27/2024, Social Worker #1 met with Resident #1 who reiterated the incident to Social Worker #1. Resident #1 affirmed they felt safe at the facility. During an interview on 1/16/2025 at 1:16 PM, Director of Nursing #1 stated Resident #1 was prone to behaviors including verbal abuse of staff and making accusatory statements. The facility had developed a care plan to address these behaviors to keep both the resident and staff safe, including giving the resident space and removing themselves from the situation. They stated Registered Nurse #2 did not follow the care plan. During an interview on 1/15/2025 at 11:35 AM, Director of Nursing #1 stated Registered Nurse #2 had been a new hire and was still on probation and had chosen to resign. They stated that this incident had been reported to the Office of Professions to follow up. Resident #14 Resident #14 was admitted to the facility with the diagnoses of dementia, epilepsy (a neurological condition involving the brain that makes people more susceptible to having recurrent unprovoked seizures), and major depressive disorder. The Minimum Data Set, dated dated dated [DATE], documented the resident was rarely/never understood, rarely/never understood others, and was severely cognitively impaired. The comprehensive care plan titled, Fall Risk, reviewed 1/10/2025, documented the following intervention: staff would place posey rolls (bed bolsters) while resident was in bed. The comprehensive care plan titled, Activities of Daily Living, reviewed 1/10/2025, documented the following intervention: Bed mobility was total dependence with 2-person physical assist. The Accident/Incident report dated 12/22/2024, documented Resident #14 had a witnessed fall out of bed while personal care was being completed by a Certified Nurse Aide. The report documented Certified Nurse Aide #3 was performing personal care alone when the resident was a 2-person assist. Additionally, the bed bolster was not in place. In a written statement dated 12/22/2024, Certified Nurse Aide #3 documented they had provided care without an additional assist of another staff member. During an interview on 1/15/2025 at 11:35 AM, Director of Nursing #1 stated Certified Nurse Aide #3 had received education regarding the requirement to follow the care plan to prevent accidents and injuries. They stated Resident #14 had no injuries resulting from this incident. Resident #23 Resident #23 was admitted to the facility with the diagnosis of dementia, atrial fibrillation, and anxiety disorder. The Minimum Data Set, dated dated dated [DATE], documented the resident was rarely/never understood by others, rarely/never understood others, and was severely cognitively impaired. The comprehensive care plan titled, Behavioral Symptoms: Resists Care, effective 7/05/2023, documented the following interventions: Allow time to de-escalate and re-approach if agitated. 2 staff assist as needed for care when behavioral An Accident Report dated 12/25/2024 at 2:00 AM, documented the resident had a skin tear on the right hand caused by Certified Nurse Aide #3's failure to follow the Comprehensive Care Plan to have 2 staff present when resident was having behaviors. In a witness statement dated 12/27/2024, Registered Nurse #4 documented they observed Certified Nurse Aide #3 grab Resident #23's hands and hold them down. When told to let go, they did, and the resident's right hand was bleeding. An investigation report dated 12/26/2024 documented, upon review of the accident report on 12/25/2024 at 1:00 PM it was discovered an incident occurred on 12/25/2024 at 2:00 AM. The conclusion of the investigation was the aid failed to follow the care plan regarding the resident being resistive to care, not using the bed alarm, or treating the resident with respect. Administrator #1 notified at 2:30 PM, the Certified Nurse Aide was removed from work, and reportable incident completed. During an interview on 1/17/2025, Director of Nursing #1 stated they completed the investigation and found Certified Nurse Aide #3 to be responsible for the resident's injury and their employment was terminated. 10 New York Code, Rules, and Regulations 415.4(b)(1)(i) 43805

Based on record review and interviews during a recertification and abbreviated survey (Case #NY00366317), the facility did not ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #23) of 4 residents reviewed. Specifically, an allegation of physical abuse observed by staff on 12/25/2024 at 2:00 AM was not reported to the New York State Department of Health within 2 hours after the allegation was made. The allegation was reported to the New York State Department of Health on 12/26/2024 at 3:19 PM. This is evidenced by: The Policy and Procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, stated incidents that resulted in bodily injury must be reported within 2 hours. Resident #23 was admitted to the facility with the diagnoses of dementia, atrial fibrillation (irregular heart rate), and anxiety disorder. The Minimum Data Set (an assessment tool) dated 12/29/2024 documented the resident was rarely/never understood by others, rarely/never understood others, and was severely cognitively impaired. An Accident Report dated 12/25/2024 at 2:00 AM, documented the resident had a skin tear on their right hand caused by Certified Nurse Aide #3's failure to follow the Comprehensive Care Plan to have 2 staff members present when the resident was having behaviors. In a witness statement dated 12/27/2024, Registered Nurse #4 documented they observed Certified Nurse Aide #3 grab Resident #23's hands and held them down. When told to let go, they did, and the resident's right hand was bleeding. An investigation report dated 12/26/2024, documented, upon review of the accident report on 12/25/2024 at 1:00 PM, it was discovered that an incident had occurred on 12/25/2024 at 2:00 AM. Administrator #1 was notified at 2:30 PM, Certified Nurse Aide #3 was suspended, and an incident report was made to the New York State Department of Health. During an interview on 01/17/2025 at 10:34 AM, Administrator #1 stated they should have been made aware sooner and this incident should have been reported within 2 hours. 10 New York Codes, Rules, and Regulations 415.4 (b)(3)

Based on record review and interviews during the recertification and abbreviated survey (Case #NY00366317), the facility did not ensure the resident's right to be free from further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress for 1 (Resident #23) of 4 residents reviewed for abuse and neglect. Specifically, Certified Nurse Aide #3 was not removed immediately from resident's care when there was an allegation of physical abuse to prevent further abuse from occurring. Certified Nurse Aide #3 was allowed to work until the end of their shift. This is evidenced by: The facility policy and procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, documented the facility would actively protect the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. When an incident of alleged abuse occurs, the Administrator or designee would be responsible for assuring the resident's security, protection, and confidentiality would be maintained during the investigation. Resident #23 was admitted to the facility with diagnoses of dementia, psychotic disturbance (a mental illness that affects ability to think clearly and behave appropriately), and anxiety disorder. The Minimum Data Set (an assessment tool) dated 12/29/2024 documented the resident was rarely understood, could sometimes understand, and had severely impaired cognitive skills. An Accident Report dated 12/25/2024 at 2:00 AM documented Resident #23 had a skin tear on their right hand caused by Certified Nurse Aide #3's failure to follow the Comprehensive Care Plan to have 2 staff members present when the resident was having behaviors. In a witness statement dated 12/27/2024, Registered Nurse #4 documented they observed Certified Nurse Aide #3 grab Resident #23's hands and held them down. When told to let go, they did, and the resident's right hand was bleeding. An investigation report dated 12/26/2024, documented, upon review of the accident report on 12/25/2024 at 1:00 PM it was discovered an incident had occurred on 12/25/2024 at 2:00 AM. The conclusion of the investigation was the aide failed to follow the care plan regarding the resident being resistive to care, not using the bed alarm, or treating the resident with respect. Administrator #1 was notified at 2:30 PM, Certified Nurse Aide #3 was suspended, and an incident report was made to the New York State Department of Health. During an interview on 01/17/2025 at 10:34 AM, Director of Nursing #1 stated the accused staff was not removed from resident care by the Nursing Supervisor as they should have been, and the incident was not reported to the Administrator #1 or Director of Nursing #1. It was discovered upon daily review of the incident reports. The accused staff completed their shift. The abuse allegation was substantiated by the facility investigation and the accused staff was terminated. Education was provided to the Nursing Supervisor regarding abuse reporting and investigation procedures. During an interview on 01/17/2025 at 10:34 AM, Administrator #1 stated they were not made aware of the incident right away and when they were made aware of it, they reported it. They took immediate action and took the accused staff off the schedule. The staff should have been sent home at the time the incident was discovered, but was not. 10 New York Codes, Rules, and Regulations 483.12(c)(3)

Based on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the vision ability for 1 (Resident #28) of 2 residents reviewed for communication. Specifically, Resident #28, who had impaired vision was not assisted in obtaining optometry consultation to be evaluated for vision aids. This is evidenced by: Resident #28 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a long-term breathing problem), hypertension (high blood pressure), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The Minimum Data Set (an assessment tool) dated 11/10/2024, documented the resident was understood, able to understand others, and was cognitively intact. The Minimum Data Set documented the resident had impaired vision and used corrective lenses. Review of the medical record showed no optometry consults were documented for the resident, nor was a comprehensive care plan developed for the resident regarding their vision. During an interview on 1/13/2025 at 12:55 PM, Resident #28 stated they had not seen an eye doctor and felt they needed a new prescription. During an interview on 1/16/2025 at 1:20 PM, Registered Nurse #1 stated the resident had not seen an eye doctor since their admission to the facility. Registered Nurse #1 stated they had requested the resident be placed on the optometry list to be seen. 10 New York Codes, Rules, and Regulations 415.12(2)(b)

Based on record review and interviews during a recertification and abbreviated survey (Case #NY00365618), the facility did not ensure adequate supervision and assistive devices were provided to prevent accidents for 1 (Resident #14) of 3 residents reviewed for accident hazards. Specifically, Resident #14, who required 2 caregivers for care was assisted with 1 caregiver and a bed bolster was not in place resulting in the resident rolling out of bed. Resident #14 was admitted to the facility with the diagnoses of dementia, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsion, associated with abnormal electrical activity in the brain), and major depressive disorder. The Minimum Data Set, dated dated dated [DATE] documented the resident was rarely/never understood, rarely/never understood others, and was severely cognitively impaired. The comprehensive care plan titled, Fall Risk, reviewed 1/10/2025, documented the following intervention: staff would place posey rolls (bed bolsters) while resident is in bed. The comprehensive care plan titled, Activities of Daily Living, reviewed 1/10/2025, documented the following intervention: Bed mobility total dependence with 2 person physical assist. The Accident/Incident report dated 12/22/2024, documented Resident #14 had a witnessed fall out of bed while personal care was being completed by Certified Nurse Aide #3. The report documented Certified Nurse Aide #3 performed personal care alone when the resident required a 2 person assist and the bed bolster was not in place. In a written statement dated 12/22/2024, Certified Nurse Aide #3 documented they had provided care without additional assistance from another staff member. During an interview on 1/15/2025 at 11:35 AM, Director of Nursing #1 stated Certified Nurse Aide #3 had received education on following the care plan to prevent accidents and injuries. They stated Resident #14 had no injuries resulting from this incident. 10 New York Codes, Rules, and Regulations 483.25 (d)(1)(2)

Based on observation, record review, and interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, cleaning chemicals were not stored properly, equipment was not in good repair or installed safely, equipment and floors were not clean, and the proper testing equipment was not available for checking the concentration of sanitizing solution. This is evidenced by: During observations on 01/13/2025 at 12:29 PM, the following was noted: Glass cleaner was stored above food processor. The warewashing area spay hose nozzle was hanging below the sink flood rim in water. The facility did not have correct test papers to check the sanitizing solution; the test papers presented did not show a 150 parts per million of quaternary ammonium compound graduation and a graduation above 400 parts per million of quaternary ammonium compound; and the sanitizer concentrate label stated the efficacy range was between 150 and 400 parts per million of quaternary ammonium compound. The deli station reach-down refrigerator door gasket was split and uncleanable. The underside of floor mixer, floor under bakers worktable, and floor under bakers sink were soiled with food particles or dirt. During an interview on 01/15/2025 at 1:18 PM, Administrator #1 stated that they would speak with the Dietary Department regarding the issues identified including the glass cleaner storage, the sanitizer test papers, the spray hose and potential back-siphonage, and the cleaning items. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on record review and interviews during an abbreviated survey (Case #s NY00343699 and NY00318831), the facility did not ensure that all alleged violations involving abuse was reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the State Survey Agency in accordance with State law through established procedures for 2 (Resident #s 1 and 3) of 4 residents reviewed for abuse reporting. Specifically, allegations of physical and sexual abuse that involved 2 residents was not reported by staff to facility administration within 2 hours. This is evidenced by: The Policy and Procedure titled Abuse Prevention, Investigation, and Reporting revised 8/07/2019, documented if an individual had knowledge that physical abuse had occurred, or had reason to believe so, they must notify the charge nurse, patient care coordinator, Director of Nursing, or Administrator. The Administrator or their designee, having reasonable cause would be responsible for notifying Department of Health. Incidents involving serious bodily injury must be reported within 2 hours after forming suspicion. All others must be reported within 24 hours. Resident #1: Resident #1 was admitted to the facility with diagnoses of Alzheimer's disease, diabetes, and depression. The Minimum Data Set (an assessment tool) dated 3/12/2024, documented the resident had severe cognitive impairment, could sometimes be understood, and could sometimes understand others. A document confirming the facility's submission of the Nursing Home Incident report documented the facility submitted it on 5/29/2024 at 10:59 AM. It documented the alleged incident occurred on 5/28/2024 at 9:00 PM. An email dated 5/29/2024 at 8:46 PM, written by Certified Nurse Aide #2 to Registered Nurse Manager #1 documented they reported they were working with Certified Nurse Aide #1 the evening of 5/28/2024 when Resident #1 grabbed Certified Nurse Aide #1 by their wrist. Certified Nurse Aide #1 pulled away, but then smacked Resident #1 on the top of their hand loudly and was kinda being nasty to Resident #1. The facility Investigation Report dated 6/03/2024 at 1:08 PM, documented the alleged incident occurred on 5/29/2024 at 7:00 PM (date and time differ from the facility submission of the alleged incident that documented it occurred on 5/28/2024 at 9:00 PM). It documented Certified Nurse Aide #2 reported Certified Nurse Aide #1 allegedly struck Resident #1 on the hand when the resident allegedly grabbed Certified Nurse Aide #1's wrist. Certified Nurse Aide #1 stated Resident #1 dug their hand into their wrist, and they had to pry the resident's hand off their wrist. Certified Nurse Aide #1 denied smacking the resident's hand. The Registered Nurses who was supervising had no knowledge of the incident, nor did other staff. During an interview on 6/06/2024 at 2:38 PM, Certified Nurse Aide #2 stated they and Certified Nurse Aide #1 were putting Resident #1 to bed about 8:00 PM (5/28/2024). Resident #1 grabbed Certified Nurse Aide #1's arm when they were rolling the resident to change them. Certified Nurse Aide #2 stated Certified Nurse Aide #1 pulled back hard to free their arm from the resident's grip and then slapped the resident on the top of their hand making a loud sound. They stated they waited to talk with their Union representative (Certified Nurse Aide #4) when they came in to work at 9:30 PM because they were more comfortable speaking with them about the incident and were not sure how to handle the situation. They stated the Union representative told them they had 24 hours to report abuse. They stated they sent an email to Registered Nurse Unit Manager #1 at 8:00 AM on 5/29/2024. Certified Nurse Aide #2 stated they wished they had reported the alleged abuse sooner but was overwhelmed and did not know how to handle the situation. During an interview on 6/07/2024 at 11:26 AM, Director of Nursing #1 stated they first learned of the alleged incident until 5/29/2024 at 10:30 AM and reported it to Department of Health shortly after they were told. They stated when they learned about the incident, it was reported to them Certified Nurse Aide #2 witnessed Certified Nurse Aide #1 smack Resident #1 on their hand when trying to remove their wrist from the resident's grip. Director of Nursing #1 stated Certified Nurse Aide #4 (regarding the 5/28/2024 incident) told them Certified Nurse Aide #2 did not know how to proceed and Certified Nurse Aide #4 told them to report it. Director of Nursing #1 stated it was unknown if Certified Nurse Aide #4 told Certified Nurse Aide #2 to report right then, or within a specific timeframe. They stated Certified Nurse Aide #2 should have told someone immediately about the alleged incident. They stated they could have told the charge nurse, and if they felt uncomfortable, they could have called the Patient Care Coordinator (a nursing supervisor) and management. Director of Nursing #1 stated the phone numbers were posted at the nurses' station, and the numbers were provided to staff upon hire. They stated Certified Nurse Aide #2 was worried about retaliation from their coworkers if they reported the alleged incident. Director of Nursing #1 stated abuse must be reported immediately, and administration had a 2-hour window to report it to Department of Health. During an interview on 6/07/2024 at 12:46 PM, Administrator #1 stated abuse was to be reported immediately upon happening, and within 2 hours to Department of Health. They stated they would be meeting with Certified Nurse Aide #2 and their Union Representative for verbal counseling regarding timely abuse reporting, and people to report to if they felt uncomfortable with notifying their direct supervisor. During an interview on 6/14/2024 at 1:14 PM, Certified Nurse Aide #4 stated Certified Nurse Aide #2 reported to them (on 5/28/2024) that Nurse Aide #1 had slapped another resident. Certified Nurse Aide #2 told them they were afraid of retaliation. Certified Nurse Aide #4 stated they told Certified Nurse aide #2 no matter what, Certified Nurse Aide #2 still needed to report it. Certified Nurse Aide #4 stated they did not tell anyone about it after Certified Nurse Aide #2 reported it to them. They stated they should have also reported the alleged abuse rather than taking Certified Nurse Aide #2's word that they were going to report it. Resident #3: Resident #3 was admitted to the facility with diagnoses of diabetes, high blood pressure, heart disease. The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact, could be understood, and could understand others. An untimed statement dated 6/22/2024, written by Certified Nurse Aide #2, documented Certified Nurse Aide #2 witnessed Certified Nurse Aide #3 allegedly squish their breasts together and asked Resident #3 if they liked them while moving closer to the resident. Certified Nurse Aide #2 documented they had witnessed that while working with Certified Nurse Aide #3 that week. They also documented the last time they had worked with Certified Nurse Aide #3, they were taking care of a male resident (name not provided), and Certified Nurse Aide #3 stated 3 different times that Certified Nurse Aide #2 just wanted to see the resident's penis. Certified Nurse Aide #2 documented they were afraid to report it because they were afraid Certified Nurse Aide #3 would retaliate against them. During an interview on 6/06/2024 at 3:08 PM, Certified Nurse Aide #2 stated they witnessed Certified Nurse Aide #3 squishing Resident #3's breasts together, made a kissy sound and asked Resident #3 if they liked that. They stated they reported it to Registered Nurse Unit Manager #1 the same day (this statement differs from Certified Nurse Aide #2's written statement and the following interview with Director of Nursing #1). During an interview on 6/07/2024 at 12:09 PM, Director of Nursing #1 stated they interviewed Certified Nurse Aide #2 who told them about the breast squishing incident with Resident #3. Director of Nursing #1 stated Certified Nurse Aide #2 stated they did not report it because they were afraid of what others would think and was afraid of retaliation. 10 New York Codes, Rules, and Regulations 415.4 (b)(3)

Based on observation and interviews during the recertification survey dated 10/11/2022 through 10/14/2022, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety in the main kitchen. Specifically, a toxic vapor-emitting fly strip was found in the dishwashing machine area; brooms and dust bins were stored in the cafeteria preparation area; and the floor mixer, bake shop table mixer, microwave oven, can opener holders, bake shop sugar bin, refrigerator door gaskets, cooking line floor under equipment, floor at entrance to the walk-in freezer, and fire extinguishers were soiled with food particles, food splatters, or a grease build-up. This is evidenced as follows: During main kitchen observations on 07/13/22 at 10:45 AM, a toxic vapor-emitting fly strip was found in the dishwashing machine area; brooms and dust bins stored in the cafeteria preparation area; and the floor mixer, bake shop table mixer, microwave oven, can opener holders, bake shop sugar bin, refrigerator door gaskets, cooking line floor under equipment, floor at entrance to the walk-in freezer, and fire extinguishers were soiled with food particles, food splatters, or a grease build-up. During an interview on 10/11/22 at 1:00 PM, the Supervisor for Food and Nutrition stated that the fly strip will be removed, and the cleaning items and broom storage will be addressed. During an interview on 10/13/2022 at 11:30 AM, the Administrator stated that the items found in the main kitchen will be addressed with the Food Service Director and the environmental services department. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.60, 14-1.110, 14-1.170, 14-1.172

Based on observation, record review and interviews during the recertification survey on 10/11/2022 through 10/14/2022 the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements related to F656; Development and Implementation of Comprehensive Care Plans, and F697; Pain Management. Specifically, the facility did not ensure that the approved Plan of Correction (POC) for F 656, and F 697 cited during the Recertification Survey completed on 12/19/2019 were implemented, resulting in the same deficiencies being issued during the current survey. This is evidenced by: The facility document titled CVPH Skilled Nursing Facility QAPI Plan, dated September 2019 documented, the purpose of QAPI in our organization is to take a proactive approach to improve the quality of life and quality of care of all residents. Review of the approved Plan of Correction for the Recertification Survey completed on 12/19/2019 revealed the facility identified a correction date of 1/30/2020 related to the deficient practices cited under F Tag 656 and F Tag 697. The following corrective actions were identified: For F656, A random weekly audit of 10% of care plans, or a minimum of four, will be completed to ensure completeness which includes measurable goals and objectives, comprehensive, and person centered to meet resident needs. Audit reports will be reported to QAPI until 100% compliance is obtained x3 consecutive months and then as recommended by the committee. For F697, A random weekly audit will be completed to identify residents who receive PRN pain medications. A random sample, 10% of those residents will be audited for: Effectiveness of pain medication. That a pain scale has been used per standard of practice. That a pre & post assessment of pain was documented in the chart utilizing a pain scale per standard of practice. Audit results will be reported to QAPI committee until 100% compliance is achieved for three consecutive months then as recommended by committee. During an interview on 10/14/2022 at 2:15 PM, the Administrator stated there had been many administrative changes since the last survey and they did not know why the plans of correction for F 656 and F 697 had not been maintained. They are currently working with a sister facility to get the QAPI program where it should be, we know we have work to do. 10 NYCRR 415.27(c)(3)(v)

Based on record review and interviews during the recertification survey dated 10/11/22 through 10/14/2022, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for one (1) of 3 medical records reviewed. Specifically, Resident #84 received Medicare Part A services and did not provide notification (2-day notification) of the termination of services with the required form Notice of Medicare Non-Coverage, Form CMS -NOMNC. This is evidenced as follows: During interviews on 10/14/22 at 9:03 AM, the Administrator and Director of Nursing were requested to provide the required Notice of Medicare Non-Coverage, Form CMS -NOMNC (NOMNC) for Resident #84 and stated that though a discharge meeting with Resident #84 was held on 05/20/2022, and the resident agreed that rehabilitative services would end on 05/22/2022, the resident was not provided with a NOMNC. 10 NYCRR 415.3 (g)

Based on record review and interview conducted during the recertification survey, the facility did not ensure development of comprehensive person-centered care plans, that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for three (Residents #,s 6, 7, and #10) of sixteen residents reviewed for comprehensive care plans (CCP). Specifically, for Resident #6, the facility did not ensure a CCP was developed to address the use of oxygen and the use of anticoagulants (blood thinners), for Resident #7, a CCP was not developed to address frequent migraines and for Resident #10, a CCP was not developed to address recent antipsychotic medication. This is evidenced by: Resident #6: Resident #6 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 7/3/2022 documented the resident had no cognitive impairment, could be understood, and could usually understand others. A Medication Order dated 9/18/2022, documented to maintain oxygen saturation above 90% on 2L (liters) as needed. A Medication Order dated 4/20/2021, documented to give [MEDICATION(S)] (an anticoagulant medication) 5mg two times daily for chronic pulmonary embolism. The resident's medical record did not include documentation of a Care Plan that addressed oxygen use, or the risk of bleeding from anticoagulant use. During an interview on 10/14/22 at 3:00 PM, the Director of Nursing (DON) stated, Resident #6 has had the oxygen on since the middle of last month and there should be a care plan in place to address the use of oxygen. There should also be a care plan in place for the anticoagulant use to address the risk of bleeding. We have quarterly care plan meetings to discuss each resident's care plan needs. The DON stated they were not sure how these were missed. Resident #7 Resident #7 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident had no cognitive impairment and was usually able to make themselves understood and could understand others. A Medication Order dated 9/7/2022 (original order date 2/22/2022), documented give acetaminophen (pain reliever) 325 mg 2 tablets every 6 hours as needed for pain. Diagnosis, migraine. The Medication Administration Records (MAR) for September and October documented acetaminophen was administered 21 times in September 2022 and 12 times in October 2022 (10/1/2022 through 10/13/2022). The resident's medical record did not include documentation of a Care Plan to address migraines. During an interview on 10/14/22 at 3:00 PM, the DON stated there should be a care plan to address the resident's migraines. The DON did not know why this was not done or identified as a need in the care planning meeting. Resident #10 Resident #10 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident was understood and could be understood by others with intact cognition. A Medication Order dated 4/20/2022 (original order date 4/15/2019), documented give [MEDICATION(S)] (antipsychotic medication) 2 mg, 1 tablet (tab), 1 times a day at 8:00 AM, by mouth (PO) for major depressive disorder. Medication Administration Records (MAR) documented [MEDICATION(S)] 2 mg 1 tab was administered 30 times in September 2022 and 14 times in October 2022 (10/1/2022 through 10/14/2022). The resident's medical record did not include documentation of a Care Plan to address the antipsychotic medication added in 2019 with stated goals and interventions and possible side effects of the medication. During an interview on 10/13/22 at 10:53 am, Registered Nurse Charge Nurse (RNCN) #4 stated there were no care plans in place for the [MEDICATION(S)] and there should have been. RNCN #4 stated there were no additions to the [CONDITION(S)] care plan that would address the goals and interventions or side effects of the antipsychotic medication. During an interview on 10/13/2022 at 2:35 pm, the DON stated they expect comprehensive care plans to be developed as needed and as required. Many changes had occurred with staffing but CCPs need to be implemented and revised. 10NYCRR415.11(c)(1)

Based on observation, record review, and interviews during a recertification survey dated 10/11/2022 through 10/14/2022, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for 1 (Resident #6) of 1 resident reviewed for respiratory care. Specifically, for Resident #6, the facility did not ensure the resident's medical record included documentation of on-going administration of oxygen and monitoring of the resident's respiratory status. This is evidenced by: The Policy and Procedure (P&P) titled Oxygen Therapy Protocol for Adults last revised 3/28/22, did not address documentation or on-going monitoring of residents receiving oxygen therapy. Resident #6: Resident #6 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 7/3/2022 documented the resident had no cognitive impairment, could be understood, and usually understand others. Medication Orders dated 9/18/2022, documented maintain to oxygen saturation above 90% on 2L as needed. Nursing Progress Notes 9/18/2022 through 10/14/2022 included the following documentation related to oxygen use: On 9/18/2022 at 8:17 AM, the resident's oxygen level was 89% and oxygen was applied at 2L via nasal cannula. The Nurse Practitioner (NP) was updated and ordered to keep oxygen level above 90%. On 9/18/2022 at 3:28 PM, COVID and flu swab negative, NP (nurse practitioner) aware, oxygen 98% on 2L, decreased to 1L. On 9/21/2022 at 1:46 PM, oxygen 92% on room air. On 9/21/2022 at 10:25 PM, became short of breath, oxygen 89% on room air, oxygen on at 2L 97%. On 9/27/2022 at 2:01 PM, resident dizzy with ambulation. Oxygen 98% on 2L, decreased to 1L. On 9/30/2022 at 6:50 AM, oxygen on via nasal cannula at 1L, saturation 96%. On 10/3/2022 at 6:33 AM, complains of trouble breathing, oxygen 93% on 2L. Medication and Treatment Administration Records (MAR/TAR) for September and October 2022 did not have documentation of oxygen administration. During observations of Resident #6 on 10/11, 10/12, and 10/13/2022 during the day and evening shifts, oxygen was being administered at 2L via nasal cannula. During an interview on 10/14/22 at 2:49 PM, Registered Nurse (RN) #1 stated, if a resident requires as needed (PRN) oxygen a Progress Note should document why it was needed with a complete respiratory assessment. Oxygen administration should be signed for on the MAR. RN #1 did not know why Resident #6's oxygen was not documented on the MAR. During an interview on 10/14/22 at 3:00 PM, the Director of Nursing stated, the nurses should have documented in the Progress Notes what was going on with the resident, why oxygen was being administered, and a respiratory assessment should have been done every shift. Resident #6 has had the oxygen on since the middle of last month and there are no documented respiratory assessments and only few documentations of the administration. 10NYCRR 415.12(k)(6)

Based on record review and interviews during a recertification survey the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #'s 7 and #287) of 3 residents reviewed for pain management. Specifically, for Residents #'s 7 and #287, the facility did not ensure the resident's pain levels were assessed, did not ensure that non-pharmacological interventions for pain relief were provided and did not ensure that the effectiveness of as needed (PRN) pain medications were monitored. This was evidenced by: The Policy and Procedure (P&P) titled Pain Management, Skilled Nursing Facility dated 1/30/2020 documented pain, intensity and comfort will be assessed at least every shift after non-invasive interventions, and/or routine/PRN medications have been initiated using the designated pain scales. Resident #7 Resident #7 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 7/5/2022 documented the resident had no cognitive impairment and was usually able to make themselves understood and could understand others. A medication order dated 9/7/2022 (original order date 2/22/2022), documented to give acetaminophen (pain reliever) 325mg 2 tablets every 6 hours as needed for pain. Diagnosis, migraine. Medication Administration Records (MAR) for September and October 2022 documented acetaminophen was administered 21 times in September 2022 and 12 times in October 2022 (10/1/2022 through 10/13/2022). The resident's medical record did not include documented attempts of non-pharmacological interventions, monitoring to determine the medication's effectiveness, or consistent documentation of an assessment of the resident's pain. The resident's medical record did not include documentation of a care plan to address migraine pain relief. During an interview on 10/14/22 at 3:00 PM, the DON stated there should be a pain assessment documented in the progress notes along with the non-pharmacological interventions attempted. The pre and post medication pain scale should be documented on the MAR. Upon review of Resident #7's MAR, the DON stated the order was not entered correctly. If the order was entered correctly the system would require pre and post pain scales for each administration of a PRN medication. The DON also stated there should be a care plan to address the resident's migraines. Resident #287 Resident #287 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 9/23/2022 documented the resident was cognitively intact, could be understood and could understand others. The Comprehensive Care Plan (CCP) for pain management, initiated 9/16/2022, documented an ongoing assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain and alleviating and aggravating factor should be documented. The medication order dated 9/21/2022 documented [MEDICATION(S)]-acetaminophen 5-325 mg give 1 tablet by oral route every 12 hours as needed for pain. The Medication Administration Record (MAR) for October 2022 documented Resident #287 received [MEDICATION(S)]-acetaminophen 5-325 mg on 10/2, 10/3, 10/5, 10/6, and 10/10/2022. The record did not include documentation that the as needed pain medications administered were monitored for effectiveness. During an interview on 10/14/2022 at 8:44 AM, Registered Nurse (RN) #1 stated pain should be documented on every shift and follow up documentation for as needed medication should be entered. There is an area in the MAR to record pre and post pain levels and a progress note may be written as well. If non-pharmacological interventions are used, the interventions should be documented in the progress notes as well, especially if medications are needed as well. During an interview on 10/14/2022 at 12:32 PM, the Director of Nursing (DON) stated staff should be asking, assessing, and documenting pain levels of residents. During an interview on 10/14/22 at 3:00 PM, the DON stated there should be a pain assessment documented in progress notes along with the non-pharmacological interventions attempted. The pre and post medication pain scale should be documented on the MAR. 10NYCRR 415.12

Based on record review and interview during the recertification survey dated 10/11/2022 through 10/14/2022, the facility did not ensure the policy regarding foods brought to residents is in accordance with adopted regulations. Specifically, the facility does not provide orally and in writing, information for family and other visitors on safe food handling practices or safe reheating of food that is brought to residents. This is evidenced is as follows: The document titled Food Brought By Family/Visitors - SNF and dated 08/2019 documents that safe food handling practices will be explained to family/visitors in a language and format they understand. The facility policy for foods brought in by visitors was reviewed on 12/04/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. During an interview on 10/13/22 9:52 AM, Diet Technician #1 stated that families and visitors are not encouraged to bring food to residents; when families and visitors do bring food, it is requested that the food be only for the next immediate meal for food safety purposes; and safe food handling practices such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, and hand hygiene are not explained verbally or given in writing. During an interview on 10/13/2022 at 3:28 PM, the Administrator stated that the procedure will be updated on bringing food to residents by family and visitors.

Based on record review and interviews during abbreviated surveys (Case #s NY 377 and NY 652), the facility did not ensure there was evidence that all alleged violations were thoroughly investigated for 2 (Residents #s 2 and 3) of 3 residents reviewed. Specifically, there was no evidence of an investigation to rule out abuse, neglect or mistreatment after Resident #2 reported that a male shook Resident #2. Additionally, there was no evidence of a thorough investigation to rule out abuse, neglect or mistreatment after Resident #3 was documented to have a bruise of unknown origin to the right lower flank (the area between the ribs and hip). This was evidenced by: The Policy and Procedure (P&P) titled Incident/Accident Report Policy/Skilled Nursing Facility, last revised 8/6/19, documented the charge nurse, unit manager, and/or manager on call was to be promptly notified and was then responsible for assessing, reviewing, documenting, and reporting of the incident and/or accident. Regardless of how minor an incident or accident was, it must be reported to a nurse manager, and any unwitnessed incident or accident must be investigated for potential abuse. The supervisor was to be notified of all incidents or accidents, and anyone that had contact with the resident in the past 24 hours was to be interviewed. Resident #2: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-standardized assessment tool) dated 12/2/19 documented the resident had moderately impaired cognition, was usually able to be understood, and was sometimes able to understand others. A Nursing Progress Note dated 12/14/19, documented Resident #2 alleged a male came into the room and shook Resident #2. LPN #1 documented there were no marks identified on Resident #2's arms or body. The progress note did not include documented evidence that a Registered Nurse (RN) or manager was notified of the allegation. Review of the Electronic Medical Record dated 12/14/19 did not include documented evidence that an RN assessment was completed for Resident #2. The facility was not able to provide documented evidence that facility staff were interviewed or that an investigation was initiated for the allegation of abuse on 12/14/19. During an interview on 12/18/19 at 11:30 AM, Registered Nurse Clinical Operations Supervisor (RN COS) #1 stated Resident #2 was alert but very confused, did not display behaviors and did not have a history of accusatory behavior towards others. She stated that when there was an allegation of abuse, an RN full-body assessment was expected to be completed, and the victim and all staff members present on the unit were supposed to be interviewed. RN COS #1 stated she expected the charge nurse to review all progress notes daily and would have expected LPN #1 to have reported the allegation immediately to an RN. RN COS #1 stated that an investigation should have been completed for Resident #2. She also stated LPN #1 should have notified the RN on duty and that the Director of Nursing (DON) or the Administrator should have been notified. During an interview on 12/18/19 at 12:00 PM, Assistant Administrator stated he would have expected that an investigation would have been completed for Resident #2's allegation of abuse. During an interview on 12/27/19 at 12:00 PM, LPN #1 stated Resident #2 reported the allegation of abuse to her, and the allegation was reported to the charge nurse on 12/14/19. LPN #1 stated that she had not provided a statement until she was called into the facility on [DATE]. Resident #3: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had moderately impaired cognition, was rarely/never able to make his/herself understood and was usually able to understand others. The Activities of Daily Living (ADL) Comprehensive Care Plan (CCP) dated 11/26/19 documented Resident #3 required two staff assist for bed mobility, toileting, transfers, and ambulation. An Admission assessment dated [DATE] did not document evidence that Resident #3 had a bruise to the right lower flank. A Nursing Progress Note dated 11/28/19, documented Resident #3 had a 9-centimeter (cm) circular, hazy blue colored bruise to the right lower flank. A Facility Accident/Incident (A/I) Report dated 11/28/19 RN #1 documented a hazy blue bruise was identified to the right lower flank of Resident #3. The resident was unable to state what had happened and the resident's family was unaware of how the bruise happened. The Report included a written statement by the DON dated 12/9/19, two staff written statements dated 12/18/19, one staff written statement dated 12/19/19 and one undated staff statement. A Facility Summary (undated) documented that on 11/28/19 at approximately 7:45 PM, RN #1 assessed a 9 cm bruise to the right flank of Resident #3. That an A/I Report was filed, the family and physician were notified. The summary included that the A/I report was brought forward to the attention of the DON on 12/9/19. During an interview on 12/18/19 at 1:04 PM, the DON stated that when she returned from out of town, the investigation did not include statements from the staff that were working that shift and she felt that it was too late to obtain statements at that time, and that all staff present on the unit should have written statements when the bruise was identified. The DON stated she assumed the bruise was from the injection of [MEDICATION NAME] due to seeing a bruise to the right lower abdomen but was not aware the nurse progress note documented a bruise to the right lower flank. During an interview on 12/18/19 at 12:00 PM, Assistant Administrator stated he would have expected interviews to have been obtained from staff regarding the bruises on Resident #3. 10 NYCRR 483.12(c)(2)

The facility did not ensure person-centered comprehensive care plans were developed and implemented that included measurable objectives and timeframes to meet the residents needs for 5 (Resident #'s 6, 17, 23, 33, and #286) of 12 residents reviewed. Specifically, for Resident #23, the facility did not ensure that a comprehensive care plan (CCP) was developed for the use of a wound vac and did not ensure the CCP for [MEDICAL CONDITION] (MS) included person centered interventions, for Resident #33 the facility did not ensure that a care plan was developed to include the visitor warning sign on the door to the resident's room, for Resident #286, the facility did not ensure the resident's CCP titled High Risk for Falls included the use of alarms, for Resident #6, the facility did not ensure the resident's care plan for pain included the use of the physician ordered narcotic pain medication and that the care plan included interventions to address the effectiveness of and the resident's response to the pain medication and for Resident #17, the facility did not ensure a CCP was developed that addressed the need for and use of isolation precautions. This is evidenced by: The Policy & Procedure titled Care Planning on Residents dated 8/6/2019 documented that comprehensive person centered care plans will be implemented and include measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs. Hazards and risks for residents will be identified and interventions will be put in place to alleviate these risks as much as possible. Resident #23: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 11/5/19, documented the resident was cognitively intact, was able to make himself understood and usually able to understand others. The physician orders [REDACTED]. The comprehensive care plan (CCP) titled Skin Integrity dated 10/25/19 documented the resident has skin breakdown related to immobility located on the left coccyx, unstageable. The CCP did not include documentation regarding the use of a wound vac. The CCP titled [MEDICAL CONDITION], documented the [DIAGNOSES REDACTED]. The CCP's goal documented the resident will not have complications related to MS and the intervention documented to monitor for signs and symptoms of an MS flare. During an interview on 12/19/19 at 11:00 AM, the Director of Nursing (DON) stated the wound vac should have been documented in the care plan. Resident #23 should have had interventions for his MS documented in the care plan. Resident #33: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 11/27/19, documented the resident had moderate cognitive impairment, was able to understand others and make himself understood. During an observation on 12/17/19 at 09:22 AM, there was a sign on the resident's room door that read - Not to enter until speaking with Nurse. During an interview on 12/17/19 at 9:30 AM, Registered Nurse #1 stated the sign was on the door because one day a visitor brought food into him one which he ate so fast he almost choked. A nursing progress note dated 11/21/19, documented; resident vomited, had eaten all of his lunch, friends brought him Taco [NAME] and the residnt ate that meal also. New sign on door for visitors to see nurse prior to entering due to all the food visitors are bringing in. Resident stated he ate too much, his blood glucose was elevated. During a review of the CCP there was no documentation of the sign on the residents door to alert visitors to see the nurse due to food brought in by visitors. During an interview on 12/18/19 at 1:00 AM, the Assistant Administrator stated on 11/21/19, the resident had eaten all of his lunch, then friends from came in to visit and brought him Taco [NAME]. The resident ate that too, then proceeded to vomit. A decision was made to put a sign on the door for visitors to see the nurse before entering the room, to monitor his food intake. Resident #33 is diabetic and developmentally delayed. His care plan should have included the sign on the door for visitors and why. During an interview on 12/19/19 at 11:00 AM, the DON stated Resident #33's sign on the door for visitors should have been documented in the care plan. Resident #286: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE]. documented the resident had severe cognitive impairment with moderately impaired decision making skills. A 48 hour care plan dated 11/25/19 indicated the resident was at risk for falls. Both bed and chair alarms were indicated as safety measures at this time. The Certified Nurses Aide (CNA) care plan instructions documented bed alarm and chair alarm on 12/12/19, and mag alarm (a magnetic alarm clipped to resident's clothing) discontinued on 12/6/19. The Incident and Accident Report (I&A) dated 12/7/19, documented the resident stood up from a Geri-chair, bent over to pick up a blanket and fell backwards on his/her buttocks. Under detail of fall, it documented that alarms were in place at the time of the fall. The I & A dated 12/10/19, documented the resident slid out of the chair. The chair alarm was sounding at the time of incident. The corrective actions documented to continue the use of the chair alarm and mag sensor. The CCP titled High Risk for Falls, dated 11/25/19, documented interventions to evaluate pattern of falls and ensure call bell within reach. The interventions did not include use of alarms for safety. During an interview on 12/19/19 at 11:00 AM, the DON stated the alarms documented on the 48 hour care plan should also be placed in the comprehensive care plan. Both alarms should have been care planned when initiated. 10NYCRR415.11(c)(1)

Based on observation, record review and interview during a recertification survey the facility did not ensure adequate pain management was provided to a resident who required such services, consistent with professional standards of practice for one (1) (Resident #6) of one (1) residents reviewed. Specifically, the facility did not ensure that circumstances for when pain could be anticipated were identified and communicated, did not ensure the resident's existing pain was routinely evaluated for the management and prevention of pain, and did not ensure the use and administration of an as needed (PRN) medication was adequately monitored for effectiveness with the use of a pain scale per standard of practice. Additionally, the facility did not ensure the resident's care plan for pain included the use of the physician ordered narcotic pain medication and interventions to address the effectiveness of and the resident's response to pain medication. This is evidenced by: A Pain Rating Scale shall be completed and documented to identify and monitor the level of pain and/or the effectiveness of treatment modalities until the resident achieves consistent pain relief control AHRQ, National Guideline Clearinghouse. Health Care Association of New Jersey (NCANJ): 18.23. Pain Management Policy and Procedure revised 7/26/19, documented the purpose was to assure resident quality of life by assessing their pain, implementing pain control initiatives and evaluating the resident's response and comfort level. Interventions included: - Pain assessment will be done on an ongoing basis whenever the need arises throughout the resident's stay. - The Pain Rating Index utilized for the pre medication, must also be utilized and mentioned in the post medication note. - Pain/intensity/comfort will be reassessed at least every shift, after non-invasive interventions, and/or routine/PRN medications have been initiated using the designated pain scales. Finding #1: The facility did not ensure that circumstances for when pain could be anticipated were identified and communicated, did not ensure the resident's existing pain was routinely evaluated for the management and prevention of pain, and did not ensure the use and administration of an as needed (PRN) medication was adequately monitored for effectiveness with the use of a pain scale per standard of practice. Resident #6: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident is a Hospice patient. The Minimum Data Set (MDS - an assessment tool) dated 9/13/19, documented the resident was moderately impaired for cognition and was able to understand others and was able to be understood others. physician's orders [REDACTED]. Place 0.75 milliliter (15 mg) by sublingual route 4 times per day and 15 mg every 1 hour PRN for pain. Scheduled every day at 6:00 am, 10:00 am, 2:00 pm, 6:00 pm 10:00 pm for malignant neoplasm of brain and low back pain. On 10/23/19 [MEDICATION NAME] concentrate 15 mg increased to 5 times per day. The Electronic Medication Administration Record [REDACTED] October 2019 - on 18 occasions. November 2019 - on 6 occasions. December 2019 - on 6 occasions from 12/03/19 to 12/16/19. Per Nursing Progress Notes, PRN [MEDICATION NAME] was given on the following dates: 10/26/19 at 2:49 AM - the resident was noted with her brow furrowed and was grimacing. [MEDICATION NAME] 15 mg given at 02:40 AM. 10/28/19 at 12:15 PM - resident was crying out in pain during transfers. PRN [MEDICATION NAME] given at 12:00 PM. 11/02/19 at 2:06 PM - resident was crying out in pain when getting up for lunch. Given PRN [MEDICATION NAME] at 12:32 PM. 11/05/19 at 9:35 PM - resident was medicated with [MEDICATION NAME] 15 mg at 7:20 PM for perceived pain related to resident rubbing her leg and weeping. Effect noted. 11/06/19 at 10:52 PM - resident was crying out in pain while being transferred to bed, given [MEDICATION NAME] at 7:16 PM. Good effect. 11/28/19 at 3:33 PM - resident received PRN [MEDICATION NAME] at 08:25 AM for visible pain. Patient was grimacing, scooting around in her chair and moaning. Had good effect. 11/29/19 at 4:46 AM - resident was given PRN [MEDICATION NAME] 15 mg at 3:02 AM for pain. Resident grimacing and calling out. 12/3/19 at 8:20 AM - resident was moaning and had facial grimacing during transfer. PRN [MEDICATION NAME] given at 08:20 AM. 12/06/19 at 3:34 PM - PRN [MEDICATION NAME] administered at 12:24 PM for pain during lunch. 12/07/19 at 3:38 PM - resident was medicated with PRN [MEDICATION NAME] 15 mg at 12:18 PM for moaning and crying out during lunch. 12/11/19 at 12:43 pm - resident was hollering out when moving her legs up in her chair. PRN [MEDICATION NAME] 15 mg given at 12:19 PM. 12/11/19 at 10:48 PM - resident with increased pain, tensing up and grimacing at dinner. Resident medicated with PRN [MEDICATION NAME] at 15 mg at 6:38 PM. 12/15/19 at 9:50 PM - resident medicated with PRN [MEDICATION NAME] 15 mg at 6:05 PM for pain related to resident grimacing and rubbing her leg. Good effect noted. 12/16/19 at 10:22 pm - PRN [MEDICATION NAME] 15 mg was given at 7:49 PM. Resident was moaning and screaming in pain and crouched over to one side when staff tried to move her. 12/18/19 at 9:30 PM - [MEDICATION NAME] 15 mg given at 6:42 PM, resident was leaning in her recliner and grimacing. Attempted to reposition with little effect. She had a poor appetite at supper. In bed appears more comfortable, sleeping without grimacing. On the following ten occasions from 10/26/19 - 12/16/19, a medication pain scale was not utilized post administration of PRN [MEDICATION NAME]. - 10/26/19 at 02:40 AM - no post medication documentation - 10/28/19 at 12:15 PM - no post medication documentation - 11/05/19 at 07:20 PM - charted as effect noted - 11/06/19 at 07:16 PM - charted as good effect - 11/28/19 at 08:25 AM - charted as had good effect - 12/06/19 at 12:24 PM - no post medication documentation - 12/07/19 at 12:18 PM - no post medication documentation - 12/11/19 at 12:19 PM and 6:38 PM - no post medication documentation - 12/15/19 at 06:05 PM - charted as had good effect - 12/16/19 at 07:49 PM - no post medication documentation Medical Note dated 12/19/19, documented Hospice called Nurse Practitioner (NP) #4 today regarding the resident's poor pain control. Hospice would like resident to be started on a low dose [MEDICATION NAME] and to continue with every hour PRN [MEDICATION NAME] 15 mg. During an interview on 12/18/19 at 01:18 PM, Licensed Practical Nurse (LPN) #1 stated the resident is sometimes in pain when transferred or when care is being provided. The resident's legs hurt when she is put back to bed or when she is turned and positioned. When the resident is experiencing pain during care, the Certified Nurse Assistants (CNAs) will come to get her before they are finished caring for the resident and the LPN will give the resident PRN [MEDICATION NAME]. The resident can experience pain when she is due for a routine dose of [MEDICATION NAME] but this is not always the case. During an interview on 12/18/19 at 1:26 PM, the Administrator stated on 12/13/19, Hospice staff reported pain better controlled. The resident's pain issues were not mentioned during Interdisciplinary Team Meeting (IDT). During an interview on 12/18/19 at 1:26 PM, Clinical Operations Supervisor/Registered Nurse Manager (RNM) #2 was not aware that the resident was in pain when care was being provided. She also was not able to find documentation that the physician or Hospice had been notified. Upon reviewing the nursing progress notes, she stated a non-verbal pain scale was not being used post- medication. Effectiveness of the medication should be assessed one hour after administration for non-verbal signs such as moaning or grimacing. She also stated the LPNs should check with the RN before holding the medication. Interdisciplinary Team (IDT) Meetings are held as needed for change of condition. During an interview on 12/18/19 at 02:32 PM, NP #4 stated she had not been told the resident was having pain with care and during transfer. Hospice follows up every 2 weeks to see the resident who has a brain mass. NP #4 would have wanted to know the resident was having breakthrough pain, stating this was a very important occurrence. Either the resident needs an increase in medication dose or the nurses need to give PRNs appropriately. Not everyone is good with reporting. When the nurses hold an around the clock dose of [MEDICATION NAME]. it should be reported to the chain of command. The nurses need education on pain management. During an interview on 12/19/19 at 08:51 AM, Hospice Case Manager #3 stated Hospice was not aware but would absolutely want to know that the resident was having pain with care. They definitely would follow up with the NP #4 or the physician to adjust the medication. Hospice could not see how many PRNs were given as they just got computer access 2 weeks ago. The use of PRNs had not been reported to hospice. If the system had been up, Hospice nurse #9 would have reviewed nursing notes. Case Manager #3 will talk to the hospice nurse to let her know she needs to be more thorough. Since Hospice just got hooked up to the computer the nurse was pretty much dependent on what nursing hold her. Case Manager #3 also stated she would want to know if a nurse held the medication. The point of [MEDICATION NAME] is to give it even if sleeping in order to keep the resident comfortable. During an interview on 12/19/19 at 10:00 AM, Charge RN #5 stated since the resident is non-verbal, the pain scale showing faces should be used to determine effectiveness one hour after giving the medication. Or any symptoms should be noted such as moaning, facial grimacing, smiling, eating/not eating. The nurses absolutely should be documenting if the medication was effective using the pain scale. The staff have not reported to her that the resident was having breakthrough pain. During an interview on 12/19/19 at 10:56 AM, Assistant Administrator #2 stated hospice recently obtained access to the facility's computer system. He had been working with IT and the university that would enable Community Hospice to see only the medical records of hospice patients. Finding #2: The facility did not ensure the resident's care plan for pain included the use of the physician ordered narcotic pain medication and that the care plan included interventions to address the effectiveness of and the resident's response to the pain medication. Pain Management Care Plan related to metastatic [MEDICAL CONDITION] with brain metastases and chronic low back pain with an effective date of 4/01/19, documented a goal: the resident will exhibit decrease in nonverbal signs and symptoms of pain as evidenced by no facial grimacing, moaning, or calling out. Intervention was an ongoing assessment of the resident's pain with emphasis on onset, location, description, intensity of pain and alleviating and aggravating factors. Use non-pharmacological interventions for discomfort: back rub, meditation, breathing techniques, soothing music and document patient's response. A Note dated 7/04/19 documented care plan reviewed. Pain medication available if necessary. During an interview on 12/19/19 at 10:00 AM, Charge RN #5 stated the RNs initially start the care plans and update them as needed. Because the resident is having pain, non-verbal signs of how to assess for the pain should have been in the careplan. Also, during Care Plan meetings, the management team updates careplans as needed. Specifics concerning the resident's pain should have been contained in the care plan. If the resident was yelling out in pain, a medication change may be necessary. It had not been reported to her in a couple of months that the resident was having pain issues. During an interview on 12/19/19 at 10:09 AM, RNM #2 stated changes in condition are discussed during IDT meetings and care plans are updated at that time. 10NYCRR415.12

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #23) of one resident observed for dressing changes. Specifically, for Resident #23, the facility did not ensure infection control measures were maintained during a wound vac dressing change. This is evidenced by: Resident #23: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 11/4/19, documented the resident was cognitively intact, was able to make himself understood and was usually able to understand others. The physician orders [REDACTED]. The Wound/Ostomy Note dated 12/16/19 documented the wound vac dressing was removed from the left buttocks area. Measurements: 5 centimeters (CM) x 1.8 CM x 1.6 CM depth with undermining from 11 to 12 o'clock for distance 3.9 CM. On 12/18/19 at 8:45 AM, the Wound, Ostomy, Continence Nurse (W[NAME]N) was observed during the wound vac dressing change on Resident #23. This surveyor met the W[NAME]N outside the resident room and donned gowns and gloves. This surveyor dropped a glove during the process of donning gloves. The W[NAME]N who was gowned and gloved bent down and picked the glove off the floor, stepped into the room and discarded the dirty glove in a trash can. She did not change gloves and wash her hands. She pulled the resident's sheet off, removed the wound vac dressing and tubing, discarded the dressing and tubing in the trash can and removed and discarded her gloves. She did not wash her hands prior to donning another pair of gloves and applied the new wound vac dressing and tubing. During an interview on 12/18/19 at 10:20 AM, the W[NAME]N stated she was employed by the hospital, and changed all wound vac dressings in the nursing home. She did not realize that she did not change her gloves and washed her hands after picking up the glove off the floor. She normally changes her gloves and washes her hands after every task. After removing the dirty dressing she would normally have used the hand sanitizer between the glove change. Going from dirty to clean she should have washed her hands in between changing her gloves. During an interview on 12/18/19 at 10:35 AM, the Nursing Home Educator and MDS Coordinator stated the nursing home conducts spot auditing of dressing changes, handwashing and the use of PPE (personal protective equipment) on random staff members, but does not oversee the wound staff from the hospital. The nursing home staff do not do the wound vac changes ever. Nursing home staff will cover the wound with an alternate dressing if needed, and call the wound vac people. The W[NAME]N should have changed gloves and washed her hands after picking up the glove from floor and after removing the dirty dressing. During an interview on 12/19/19 at 11:00 AM, the Director of Nursing (DON) stated the W[NAME]N is employed by the organization and received education in handwashing and infection control through the same system the nursing home used. The W[NAME]N should have changed her gloves and washed her hands after picking the glove off the floor and disposing of it and after removing the dirty dressing and starting the clean portion of the dressing change. 10NYCRR415.19(b)(4)

Based on record review and interview during a recertification survey, the facility did not ensure that written notification was sent to the resident, the resident's representative, and a representative of the Office of the State Long-Term Care Ombudsman of the resident's transfer or discharge and the reasons for the move for six (6) (Residents #'s 12, 13, 18, 25, 27, and #31) of six (6) residents reviewed for hospitalization . Specifically, the facility did not ensure there was documented evidence the resident, the resident's representative, or the Ombudsman were notified in writing by the facility when the residents were admitted to a hospital. This is evidenced by: Resident #13: The resident was initially admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was had moderately impaired cognition, could be understood and could understand others. A Discharge MDS dated [DATE], documented the resident was discharged to the hospital on [DATE]. A Progress Note dated 6/30/18, documented the resident was transferred to the hospital from the facility for respiratory distress. A Progress Note dated 7/2/18, documented the resident returned to the facility from the hospital acute care setting. An entry MDS dated [DATE], documented the resident was returned to the facility on [DATE]. The facility was unable to provide documentation showing the Resident, Resident's Representative, or the Ombudsman were notified in writing of the Resident's discharge to the hospital. During an interview on 9/26/18 at 11:30 AM, the Director of Social Work (DSW)/ Supervisor of Resident Services stated he was responsible to notify the ombudsman of the resident's transfer and discharge to the hospital from (MONTH) (YEAR) to (MONTH) (YEAR), while the Social worker was out on maternity leave. However, he did not do this. Also, he did not notify the residents or residents representative in writing because he was not aware this needed to be done. He thought the bed hold notification given to the residents was sufficient to comply with the regulation on transfer and discharge. During interview on 9/26/18 at 12:26 PM the Social Worker stated she was out on a medical leave from (MONTH) to (MONTH) (YEAR) and left instructions with the DSW on how to notify the ombudsmen when a resident was transferred to the facility. This was not done for the resident's that were transferred to the hospital during that period. In reviewing the regulation for notifying residents and residents representatives about transfer and discharge to the hospital in writing, from the period on (MONTH) (YEAR) to present, the SW stated she wasn't doing it correctly. They would have to develop another policy and procedure, on how to notify residents and residents family of the resident's discharge and transfer. Resident #27: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was moderately impaired for cognition, was able to understand others and was usually understood. A medical note dated 8/02/18 at 10:59 AM, documented the resident was found in her recliner incontinent of a large amount of foul smelling stool, and that blood was on the soaker pad. Stool for occult test is positive. Labs and ammonia level ordered. A medical note dated 8/02/18 at 11:42 AM, documented the resident had critically low lab values. Resident to be transfused with 2 units of packed red blood cells. Resident has a history of chronic gastrointestinal (GI) bleeding, this is an acute episode. A medical note dated 8/02/18 at 12:51 PM, documented the resident was lethargic. Resident will need a higher level of care due to large amount of blood loss in stool and altered level of consciousness. Resident sent to the Emergency Department. A medical note dated 8/07/18 at 11:11 AM, documented the resident was discharged from the hospital without further GI bleeding. Resident #25: The resident was admitted to on 2/21/13, with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE], documented the resident usually understands and is understood by others. The resident has mild cognitive impairments. A discharge summary dated 9/10/18 at 11:01 AM, documented the resident was admitted to the hospital on [DATE] at 06:06 AM, with [DIAGNOSES REDACTED]. The resident was treated and deemed medically stable on 9/10/18 at 11:01 AM and readmitted back to the nursing home. During an interview on 9/26/18 at 12:41 PM, the Social Worker reported the transfer and bed hold notice was not completed because the resident went to the hospital on a Friday and returned to the facility on Sunday, therefore she did not complete it. 10NYCRR415.3 (h)(1)(iii)(a-c)

Based on observation, and staff interview during the standard recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Foods time/temperature controlled for safety (TCS foods), formerly identified as potentially hazardous foods, are to be stored at 41 degrees Fahrenheit (F), food temperature thermometers shall be calibrated, and kitchen surfaces are to be cleaned. Specifically, TCS foods were not stored at 41 F and food-contact surfaces were not clean. This is evidenced as follows. The main kitchen was inspected on 09/24/2018 at 10:13 AM. A bottle of lemon juice, warm to the touch, was found under the work counter by the windows; though the lemon juice is a food, no labels on the bottle indicated that it was to be used solely for cleaning The dishwasher ' s thermometer, used to check the temperature of a sample sanitizing solution before verifying the concentration of chemical sanitizer, was found out of calibration when checked by the standard ice-bath method as follows: 28 F. The can opener, table mixers, microwave oven, blast chiller filter, and dishwashing machine area wall fan were soiled with food particles or grease. The Director of Nutrition Services stated in an interview conducted on 09/24/2018 at 12:00 PM that he did not know why lemon juice was not labeled for cleaning only, the dishwasher's thermometer should have been calibrated, and he will discuss more frequent cleaning equipment with staff. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.40(b), 14-1.40, 14-1.60, 14-1.85, 14-1.110, 14-170

Based on medical record review and interviews during an abbreviated survey (Case #NY 353), it was determined that the facility failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the facility failed to ensure that a system was in place and followed for assessing residents, monitoring residents, and for notification to the physician of incidents or changes in resident conditions', for five (5) of five (5) residents (#'s 1, 2, 3, 4 & #5) reviewed. This resulted in Immediate Jeopardy and Substandard Quality of Care to resident's health and safety. This is evidenced by the following: The facility policy titled Falls, Care of At Risk Patient and Care of Fallen Patient, with a revision date of 7/1/14, documented that a fall assessment is completed on admission, after each fall, with a change in condition, and quarterly per MDS (Minimum Data Set). After a fall, complete an Incident Report and forward the Quality Assurance (QA) Investigation Form to the Director of Nursing (DON). The facility Interdisciplinary Team (IDT) will review all resident falls/interventions, will update the resident care plan and assure that the CNA (Certified Nursing Assistant) Care Card has been revised to reflect the approved intervention. For an unwitnessed fall, neuro (neurological) vital signs (NVS) will always be completed, minimally every 30 minutes twice, every hour twice, then every two hours twice; Notify the Physician, the Director and the family. Document on the CCP (Comprehensive Care Plan), and in the resident's record. Resident #1: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident with severe cognitive impairment. Review of the facility form titled Neurological Assessment Form dated 5/15/15, documented that at 4:15 am an assessment had been initiated. The NVS was completed four times (4:15 am, 4:45 am, 5:15 am and 7:15 am). The next documented NVS due at 9:15 am, documented the resident was sleeping. There were no further NVS documented, no orders to discontinue the NVS checks, or Progress notes related to the NVS. Review of the Twenty-Four (24) Hour Report dated 5/15/15 at 4:00 am, documented the resident was found by the CNA on the floor, beside the bed. Vital signs obtained (see the NVS sheets). Resident has a reddened area on the left hip. Resident had pulled off all clothes, so the mag sensor (alarm attached to the clothing to alert staff that the resident is moving) was not alarming. Resident denies any pain. Daughter notified. There was no documented evidence that the physician was notified. The facility was unable to provide documentation of an assessment by a Registered Nurse (RN) regarding this fall, or any care plan interventions to prevent recurrence, or that a fall assessment was completed, per policy. There was no documented evidence that the physician was notified, or that the resident was being monitored after the fall. Review of a facility form titled Accident dated 5/18/15 at 12:00 pm, documented the resident was found on the floor in his room, was Incontinent of stool and had a left eyebrow skin tear. Resident's left abdominal area was red. This form also documented that the Patient Care Coordinator #1 (PCC) was notified. The section of the Accident form titled Measure to Prevent Recurrence documented: review in IDT with a Physical Therapy (PT) Assessment; Review with pharmacy regarding medications; and discuss with the physician. Review of the facility's Twenty-Four (24) Hour Report on 5/18/15 at 1:36 am, documented that the resident was found on the floor in the room, near the closet at 12:00 pm, by the CNA, with the mag sensor going off. The resident was incontinent of a large amount of stool, had a left eyebrow and left elbow skin tear, left knee red, and NVS stable. The PCC (Patient Care Coordinator) was made aware. Resident up in wheelchair with lap buddy, and the physician was made aware. The facility was unable to provide documentation of an assessment by an RN regarding this fall, or any care plan interventions to prevent recurrence, or a PT assessment, contrary to documentation, or that a fall assessment was completed, per policy. There was no documented evidence that the resident had been monitored since the fall on 5/15/15, or from the fall on 5/18/15. Review of the Progress note and Twenty-Four Hour Report dated 5/21/15 at 6:25 am, revealed documentation that a CNA noted a red rash on the resident's left leg which was warm to touch. The resident's temperature was 99.5 degrees (normal 98.6). There was no documented evidence that an RN assessment was completed, or that the physician was notified. Review of a facility Progress note dated 5/22/15 at 1:06 pm, documented that the writer was called to the room when it was noted that the resident had a large purple bruise to the left lateral abdomen (14 by 13 1/2 centimeters (cm) extending down into the groin area (measuring) 12 cm., and a 6 cm by 6 cm palpable, non-tender like area, on the left lateral (abdominal) bruise. The area near the top right of the bruise had a 3 cm by 2 cm abraded (to scrape away the surface of a part) area. The physician was notified. Review of the facility Progress notes dated 5/22/15 at 2:33 pm, documented that a message was left on the physician's answering machine of the need to update him on the abdominal assessment of the resident. Review of the facility Progress notes dated 5/22/15 at 11:13 pm, documented RN aware of bruise by day charge nurse. The Progress note also documented: that the physician on call was reached; gave an order to do an ultrasound resulting of a hematoma; blood work to be done in the morning; the physician examined the resident; the resident denies pain; and is wheeling around in his wheel chair. The facility was unable to provide any documentation regarding monitoring this resident from 5/15 through 5/30/15. Review of a Progress note on 5/30/15 at 7:55 pm, documented that the resident complained of left knee pain, red and warm to touch. The physician was notified, and an order was received for [MEDICATION NAME] 600 milligrams (mg.) three times a day, use [MEDICATION NAME] (narcotic pain medication) for pain management and an ice pack. The facility was unable to provide documentation that an RN assessment was completed at this time. Review of the Progress note dated 5/31/15 at 4:00 am, documented the resident's left knee is swollen, compared to the right knee. There was no documentation that the ice pack was entered as an order, or placed on the treatment administration record (TAR), Review of the facility's Twenty-Four Hour Report dated 5/31/15 at 4:00 am, documented resident complained of left knee pain, and knee was noted to be swollen, compared to the right knee. Review of the Progress note dated 5/31/15 at 8:15 am, documented the resident complained of left knee pain and swelling, the physician was made aware, and had ordered an x-ray. Review of an x-ray report dated 5/31/15 at 9:01 am, documented an impacted comminuted (reduced to minute particles or fragments) [MEDICAL CONDITION] femur. The Director of Nursing (DON) was interviewed on 8/6/15 at 11:00 am, and stated there was no documentation of monitoring since the 5/5/15 fall, but there should have been. The NVS on 5/15/15 should have been completed, despite the resident sleeping, and should not have been discontinued without a physician's orders [REDACTED]. The DON additionally stated that there wasn't an incident report for the bruising noted on 5/22/15, as it was assumed the bruising was from the fall on 5/18/15. Resident #3: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessed the resident on 7/6/15, to be cognitively intact. Review of the CCP (Comprehensive Care Plan) titled Falls initiated on 12/2/14, documented the resident was independent with transfers, and ambulated with supervision, using a rolling walker. Review of a facility form titled Accident dated 6/1/15 at 3:00 pm, documented that on 6/2/15 at 11:50 pm, the resident complained of right lower extremity (RLE) pain with swelling noted, difficulty bearing weight, and ambulation. The resident stated she fell , and reported it to the nurse. The section of the form titled Corrective Actions documented: assessment of right lower extremity; physician notified; and orders obtained. The section titled to Prevent Reoccurrence documented: reviewed need to ask for assistance before attempting to get up alone unassisted; and will review in the IDT (Interdisciplinary Team). The facility was unable to provide documentation that any changes were made to the CCP. Review of the Progress notes revealed no documented evidence regarding a fall, or an assessment on 6/1/15. A Progress note dated 6/3/15 at 2:39 am, documented that the resident stated she fell yesterday, injured her RLE (right lower extremity), and was helped up by a nurse. The Progress note documented: RLE is swollen; difficulty bearing weight; and difficulty walking. It also documented: complained of pain, 8 out of 10 (10 being the worst); and medicated with Tylenol 650 mg. An additional note on 6/3/15, documented the resident was ambulated to the dining room with the walker without difficulty, and had no complaints of leg pain. There were no additional Progress notes regarding the RLE, until 6/11/15 at 12:13 am, when it was documented that the resident was given Tylenol 650 mg (milligrams) for right knee pain. A progress note dated 6/12/15 at 4:11 am, documented that the resident complained of right leg pain, had stated it really hurts, and was medicated with Tylenol 650 mg. Review of the facility form titled Accident dated 6/12/15 at 7:05 am, documented that the resident was found sitting against the wall in front of the toilet. It also documented resident stated she dropped her comb, bent to pick it up, started to slip, and slid down onto the floor. The resident stated she did not hit her head, or hurt herself, that her body was examined, and that there were no bruises, or injuries noted. PCC #2 and Acting DON were made aware and there was no injury, so the physician was not notified. The section of the form titled Prevent reoccurrence, documented to encourage to call for help when in high risk situation, and PT (Physical Therapy) input regarding the need for evaluation. A Progress note dated 6/12/15 at 7:51 am, documented the resident was found sitting on the floor with (her) back against the wall facing the bathroom door. She stated she was not injured, she just wanted to get up. It documented resident was assessed by the RN, and had no apparent injuries. The facility was unable to provide documentation that any changes were made to the CCP, or that PT was consulted. Review of the facility form titled Accident dated 6/12/15 at 6:00 pm, documented the resident missed a chair while sitting, and fell to the floor on her buttocks. It documented the fall was observed, did not hit head, NVS (neuro vital signs), and physician aware. The section of the form titled Prevent reoccurrence documented review of proper mechanics of staff assistance, and PT to review with resident safety when sitting. The Progress notes dated 6/12/15 at 9:36 pm, documented resident complained of right knee pain, no redness or warmth noted, and given Tylenol 650 mg. The facility was unable to provide documentation that any changes were made to the CCP or that PT was consulted. The review of a facility form titled Accident dated 6/13/15 at 3:15 am, documented the resident was found sitting on the bathroom near the toilet. The section of this form titled Outcome, documented assessment by charge nurse. The section of the form titled Prevent occurrence documented review mag sensor, review in IDT (Interdisiplinary Team) with PT consult for input. The facility was unable to provide documentation that an RN assessment was completed, or that any changes were made to the CCP at that time. Review of a PT assessment dated [DATE] (untimed), documented that the resident had three falls over a twenty-four hour period, and determined the resident required the assist of one, and a mag sensor for safety. The PT assessment determination for assist of one, and a mag sensor was not documented on the CCP. The DON (Director of Nursing) was interviewed on 8/6/15 at 1:50 pm, and stated that she was unable to find any documentation that the resident was monitored after the 6/1/15 fall, or that any changes to the care plan were made, but that there should have been. Resident #2: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 6/20/15, assessed the resident to have moderately impaired cognition. Review of the facility form titled Accident dated 5/17/15 at 3:25 pm, documented the resident was found on the floor, lying on his back. The resident stated he hit his head, and there was a quarter sized bump, a bruise( measuring) 5 cm (centimeter) by 3 cm on the lateral aspect of the left wrist, with a skin tear measuring 1 cm in the middle, minimally bleeding, and that NVS (neuro vital signs) were started. The physician was notified, and monitoring will continue. The section titled Measure to Prevent Recurrence, documented a PT (Physical Therapy) assessment for safety, mag sensor, call bell within reach, and a reminder to call for assistance. Review of the progress notes dated 5/17/15, documented that at 3:25 pm, the resident was found on the floor lying on his back, in the lounge. The Progress notes also documented there is a quarter size bump with skin intact. A bruise 5 cm by 3 cm was noted on the lateral aspect of the left wrist with a skin tear in the middle (1 cm). It is minimally bleeding. NVS started. Pupils react irregularly with no response to light, facial muscle, hand grasps, and foot push symmetrical. Resident states head is slightly sore, skin tear cleansed, and protected with dressing. The physician was notified and will continue to monitor. An additional note added at 10:21 pm, documented there was no further injury, NVS (neuro vital signs) check complete, and resident in bed. Review of the resident's care plan titled Risk for falls initiated 12/13/14, was not updated after the 5/17/15 fall. Review of the Progress notes from 5/17 through 5/20/15, revealed no documentation, or assessment that the resident's status was being monitored after the fall. Review of a PT assessment documented on 5/19/15, that the resident was screened and at last screen resident required supervision with a rollator walker, but had been documented as independent. Recommend resident continue with one assist and continue using a mag sensor. Review of the care card that is used by CNAs (Certified Nursing Assistants) to provide personal care, revealed that locomotion was changed on 6/17/15, to supervision with a walker, but was not specific as to what type of walker. There was no documentation that a mag sensor was needed for safety. The DON (Director of Nursing) was interviewed on 8/6/15 at 1:50 pm, and stated that she was unable to find any documentation that the resident was monitored after the fall, or that any changes to the care plan were made, but that there should have been. The Medical Director (MD) was interviewed on 8/6/15 at 5:00 pm, and stated that he believed falls and changes in residents' condition were being reported, and monitored. He stated that he believed that suggested changes that were made at the IDT meetings, were being made. The MD's response, when given specific examples regarding Resident #'s 1, 2, & 3, was that it was very unusual that he was not notified of those situations, because he gets called all the time. The MD also stated he believed that the residents were being monitored after falls, and that suggested IDT changes were being followed through on. 10 NYCRR 415.12

br>Based on record review and interview during an abbreviated survey (Case # NY 3), it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: The facility did not ensure that residents who sustained a change in condition (falls, bruises, etc) were appropriately assessed, monitored, and that care plans were appropriately updated. This resulted in no actual harm but had the potential for more than minimal harm that was Immediate Jeopardy and Substandard Quality of Care to residents' health and safety. This is evidenced by: Refer to F- 309 Provides Care/Services/ Highest Well Being - Scope/Severity L During an interview on 8/6/15 at 4:00 pm, the Administrator stated he started working at this facility on 6/3/15, and had started to identify areas of concern. The Administrator stated that he had identified issues with falls, and was attempting to develop corrective measures, specifically, environmental factors. The Administrator stated that there hasn't been any leadership oversight for many months, if not years. 10 NYCRR 415.26

br>Based on record review and interview during an abbreviated survey (Case # NY 3), it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not ensure that residents who sustained a change in condition (falls, bruises, etc) were appropriately assessed, monitored, and that care plans were updated appropriately. This resulted in no actual harm but had the potential for more than minimal harm that was Immediate Jeopardy and Substandard Quality of Care to residents' health and safety. This is evidenced by: Refer to F- 309 Provides Care/Services/ Highest Well Being - Scope/Severity L During an interview on 8/7/15 at 10:00 am, the Quality Assurance (QA) Manager stated they have been using the electronic progress note (sigma care) for their Incident and Accident reports. The QA Manager stated that they have seen a decrease in the number of resident falls. The QA Manager was asked how there could be a decrease in the number of falls, when not all falls had been recorded in the Progress notes. The QA Manager stated that he was unaware that all falls were not recorded in the electronic record, and therefore had not captured an accurate number of falls. During an interview on 8/7/15 at 11:00 am, the DON stated that in their QA, they were following falls since she started working there (October 2014), but they were not specifically looking at falls to ensure measures were in place or whether there was following up regarding falls. 10 NYCRR 415.27(a-c)

Based on medical record review and staff interview during the standard recertification survey and complaint investigation (NYS # 171), the facility did not ensure that the resident received adequate supervision and assistance devices to prevent accidents for two (#s- 43 and 51) of five residents reviewed. Specifically, the facility did not ensure that one resident (#51)received adequate supervision and interventions to prevent falls. The Physical Therapy (PT)recommendation upon discharge from the therapy program and prior to the occurrence of repeated falls was for hand hold assistance with ambulation and transfers for this resident. The facility interdisciplinary team instead opted to then change the resident to independent ambulation with distant supervision in order to respect family wishes for the resident's right to be independent despite potential risks. As a result, repeated falls were documented in the Nurse's Progress Notes without increased supervision or new interventions having been added and this resulted in the resident ultimately having a fall on 7/9/12 that resulted in a fractured left hip. Additionally, the facility did not ensure that one resident (#43) received adequate supervision to prevent an elopement from the building. This resulted in actual harm that is not immediate jeopardy for Resident #51 and the potential for more than minimal harm that is not immediate jeopardy for Resident #43. This is evidenced by the following information: Resident #51 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #51 was assessed as having no mood symptoms and as having rejection of care one to three days a week. The resident was noted to require extensive one person physical assist with transfers and walking and had impairment on one side for upper extremity and lower extremity range of motion. The MDS documented the resident had a fall in the month prior to the assessment, had a fracture related to a fall in the six months prior to the assessment and had a major injury from one fall since the last assessment entry. The admission MDS dated [DATE] assessed the resident usually understood and usually was able to understand with severe cognitive impairment. She required extensive one person physical assist with transfers and walking. The MDS assessed the resident had impairment on one side for upper extremity range of motion, had a fall in the month prior to admission and had a fracture related to a fall prior to admission. A Nurse's Progress Note dated 5/11/12 at 4:00 am documented that the resident was found sitting on her buttocks on the floor with the magnetic sensors attached and alarming. It documented that the residents pajamas were damp and she had on non-gripper socks with no shoes. The resident did complain of pain in her right arm, a previous fracture site. A facility Analysis of Incidents & Accidents ( A I/A) form dated 5/11/12 documented that the root cause of the fall was that the resident had slippery socks on and was incontinent of urine. In response to this fall, the resident's black socks were removed by staff and replaced with gripper socks, the magnetic sensor alarms were to continue and landing strips were not initiated due to their risk of being a trip hazard to the resident. A PT Initial Evaluation dated 5/30/12 documented that the resident had a right humeral fracture that was previously in a sling for conservative treatment with a history of impulsive and resultant falls. It documented that the resident was assessed for Merry Walker use but that the patient was confused and required direct supervision to use the device. It noted that it was not safe for the patient to use on the unit. A PT Discharge Summary dated 6/2/12 documented a recommendation for the patient to ambulate with hand hold assist with nursing on the unit. There were no further PT evaluations or screenings of this resident's ambulation and transfer abilities after 6/2/12. A Nurse's Progress Note date 6/8/12 at 10:30 pm documented that the resident had a shuffling gait whenever she walked around and was found sitting on the floor at 7:45 pm. It documented that she had no injuries and that the resident was brought to a chair, but was then back up and walking with no more falls. There was no facility A I/A form provided to the surveyor for the 6/8/12 fall, only staff investigation statements that recapitulated the Nurse's Note. A Nurse's Progress Note dated 6/11/12 at 6:30 pm documented that the resident was walking down the hallway from supper and was found sitting upright in the hall with her back against the wall. It documented there was no apparent injury. A facility A I/A form dated 6/11/12 at 6:30 pm recapitulated the information documented in the Nurse's Notes for the fall at this time. It also documented that the resident was coming down the hall with an incline and noted that the resident had a tendency to try and bend over to pick up something real or imagined from the floor. A late entry Nurse's Progress Note dated 6/11/12 documented that at 4:45 pm, the resident went to sit down in an unoccupied Merry Walker, missed the seat and sat on the floor with no injury. It was noted that the entire episode was witnessed by a Certified Nursing Assistant. The facility A I/A form dated 6/11/12 at 4:45 pm recapitulated the information documented in the Nurse's Notes for the fall at this time. A Nurse's Progress Note dated 6/15/12 at 4:00 pm documented that the resident attempted to sit in an empty Gerichair in the south hall and apparently missed the edge of the seat and sat on the floor. It documented that she was found sitting upright in front of her Gerichair with no injury detected. There was no facility A I/A form provided to the surveyor for the 6/15/12 fall. A computerized facility tracking form for this fall was provided to the surveyor for review. It recapitulated the information documented in the Nurse's Notes for the fall at this time. A Nurse's Progress Note dated 6/21/12 at 7:20 pm documented that the resident fell while walking in hallway and was found sitting upright with her back against the wall. It noted that she had been wandering frequently on this date and that she had no apparent injury. A facility A I/A form dated 6/21/12 recapitulated the information documented in the Nurse's Notes for the fall at this time. There was no documented evidence of facility assessments or intervention having been completed in follow-up to these falls that occurred on 6/8/12, 6/11/12, 6/15/12, and 6/21/12 in an attempt to prevent future falls and/or injury from falls. A Nurse's Progress Note dated 7/9/12 at 6:20 pm documented that the writer witnessed the resident fall in the center lounge after hearing her stumble. It noted that the resident fell to her left hip/buttock and then lowered her upper body to the floor. It noted that her left hip was externally rotated. A later note on this date at 7:30 pm documented that a new order was obtained for a stat x-ray to be done on the left hip and then at 10:00 pm, it was documented that the physician was in and that the x-ray was positive for acute intertrochanteric fracture. It was noted that the daughter and the family were agreeable to surgery. A Nursing Home Transfer form dated 7/10/12 at 11:20 am then documented that the resident was transferred to the operating room for repair of the fractured left hip. A care plan titled "At Risk for Falls" related to history of falls with fracture, new environment, psychotropic medications and cognitive status was dated 4/25/12. The resident's transfer and ambulation status on this care plan was documented as one assist with a gait belt prior to 7/9/12. The only fall documented on the care plan was the fall that occurred on 7/9/12. It documented that the resident had a fractured left hip on 7/9/12. There were no revisions or new interventions added to this care plan to prevent repeated falls until after the fall that occurred on 7/9/12. During an interview on 7/25/12 at approximately 2:30 pm, the Director of Nursing stated that the Interdisciplinary Team (IDT) met every morning except on Tuesdays when doctors are making rounds. She stated that resident falls are discussed at these IDT meetings. She stated she, the Registered Nurse Unit Managers (RNUMs), the MDS Coordinator, activity staff, social work, and sometimes Certified Nursing Assistants (CNAs) attended these meetings. She stated that the MDS coordinator took the notes from these IDT meetings at which time resident falls were included for discussion and that he was then responsible for updating both the care cards and care plans with any new interventions discussed by the IDT. She stated that Therapy staff for the facility were not always able to attend these morning IDT meetings and that this might occur once a week, if that. During an interview on 7/25/12 at 3:05 pm, the Registered Nurse Unit Manager (RNUM) and the MDS Coordinator stated that after the fall on 5/11/12, gripper socks were added as an intervention in an attempt to prevent future falls. It was then stated that it was on 6/6/12 that the IDT discussed trialing a magnetic sensor alarm with the resident only when she was in her room/bed, and discontinued its use in the wheelchair in the lounge and trialing the resident as independent in ambulation everywhere with supervision only and no magnetic sensor in the lounge in an attempt to increase her independence. They stated the IDT decided to trial this increased independence with the resident because the daughter clearly verbalized to them in a care plan meeting on 6/5/12 that she and the family wished only for her mother's right to be independent in her mobility to be respected despite the risks involved, which they were well informed. There was no documented evidence of this discussion that was held with the resident's daughter, just a signature that the residents daughter had attended the initial care conference on 6/5/12. The RNUM and the MDS coordinator on 7/25/12 at 3:05 pm, both concurred that despite notation by the IDT team of each of the falls that occurred in June 2012, there was no documented discussion about them by the IDT team or new interventions put into place by the facility in an attempt to prevent repeated falls. They stated this was because they were respecting the wishes of the family for the resident's right to be independent despite the potential risks that could result. During a follow up interview on 7/26/12 at 7:25 am, the RNUM stated that the resident was discontinued from PT on 6/1/12 as hand hold assist with nursing during ambulation. She stated the resident's sling came off on 5/25/12, but had been very agitated when staff was with her and when she was not able to be independent in ambulation. She stated she recalled the daughter coming in to walk with the resident and not holding her hand. She stated she clearly recalled the discussion with the IDT and the resident's daughter when the resident's daughter verbalized the desire for her mother to be able to walk freely about the unit and without staff assistance in an attempt to respect the resident's independence. She stated that the facility chose to respect the daughter's and the resident's wishes for this increased independence despite the potential. She stated she did not know what else the facility could have done to prevent the resident from falling without restricting her. During an interview on 7/26/12 at 10:30 am, a senior PT stated that someone from the therapy staff tried to go once a week to the morning IDT meetings for the skilled nursing unit. She stated they typically attended these meetings as needed. She stated that they were not always able to make the meetings. She stated the only consult the therapy department received for this resident after being discharged from therapy on 6/1/12 was after the resident came back from surgery after the fall with a fracture that occurred on 7/9/12. She stated the therapy department was not always involved in IDT discussions about changing resident ambulation and transfer status, but that it would be a good idea to have them included in such discussion since they were technically the mobility experts at the facility. She stated that if the PT who treated this resident for her initial therapy services had recommended hand hold assist with ambulation after she was discharged from program on 6/1/12, then she would need to stand by this recommendation. She stated that she has known of times where the IDT will decide on alternative mobility status for residents based on family requests/wishes, but also stated that she also recognized how resident safety always came first. She stated all they could do was make the recommendations based on their assessments and expertise. Resident #43 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] assessed the resident usually understood and usually was able to understand with severely impaired cognition. The resident was assessed as feeling down, depressed or hopeless on several days and as wandering daily. He was assessed as independent in transfers and required supervision with no physical help in ambulation in the corridor. He was assessed as steady at all times during transitions and walking. He was noted to have had a fall with no injury since the prior assessment. A Nurse's Progress Note dated 6/21/12 at 7:00 am documented that the resident was wandering and exit seeking all night long. It was documented that he was continually setting off door and elevator alarms. It noted that he was very easy to redirect. A Nurse's Progress Note dated 6/21/12 at 2:10 pm documented that the resident was wandering around the unit trying to get out of doors and that alarms were sounding throughout the morning, but that the resident was easily redirected. A Nurse's Progress Note dated 6/22/12 at 11:45 pm documented that the resident was awake on the 11:00 pm to 7:00 am shift and fast walking down the North to South corridor. It was noted that he was hard to redirect to bed, that he was up multiple times to the bathroom to toilet, and that a snack with milk was given to him. It was noted that he was medicated with Ativan one milligram at 11:50 pm with an effect pending. At 1:30 am, it was noted that the resident remained awake in the lounge near the nurse's station eating a snack and was then redirected to his room with his bed mat and motion sensor alarm on in the room. A Nurse's Progress Note dated 6/22/12 at 2:00 am documented that the resident was reported missing on the unit after being redirected several times. It was documented that the Patient Care Coordinator and Security was called to start a search with the staff. It was noted that the resident was returned to the unit by security at 2:10 am and was brought to the emergency room for evaluation. The 24 hour report for the skilled nursing facility dated 6/21/12 documented that the resident had made several attempts to get out of doors on the 7:00 am to 3:00 pm shift, that he was at the doors many times on the 3:00 pm to 11:00 pm shift and that he had eloped at 2:00 am out the West Fire Door on the 11:00 pm to 7:00 am. An internal investigation dated 6/22/12 documented that on this date, the resident was found to have exited the west fire door on the sixth floor. It was documented that the resident was found outside the building by the Medical Office Building on the hospital campus. It documented that the Patient Care Coordinator, Security, and the Administrator of Skilled Nursing were notified. It noted that an internal investigation was immediately initiated and a report was filed with the New York State Department of Health. It documented that a full body assessment was completed with no injuries noted, and a new Elopement Risk Assessment was completed. It was documented that the resident was immediately placed on one to one observation. The conclusion to this investigation dated 6/22/12 documented that the resident independently ambulated on the unit. It documented that the resident had been exit seeking during the evening of 6/22/12 and staff attempted interventions including redirection, television, returning the resident to his room, offering snacks, and medication with little effect. It noted that on 6/22/12 at approximately 2:00 am, the resident entered the stairwell in the west corridor. It noted that staff responded to the west alarms but did not see anyone. It documented that the staff began searching the unit and attempted to access the west stairwell. It was then noted that after several attempts to access the fire door, the staff caused the mechanism to delay from opening. It noted that Security staff were able to reset the doors and enter the stairwell. It documented that security assisted in the search and returned the resident to the unit. It noted that the resident was then evaluated in the emergency room and had a scrape over his left eye and on his right knee. The resident was then noted to be placed on one to one observation immediately with all door alarms reassessed and found to be in working order. During an interview on 7/24/12 at 6:50 am, the 11:00pm-7:00am Registered Nurse Supervisor (RNS) stated that the resident was very restless on the evening of 6/22/12 when the elopement occurred. She stated she was given report from the prior shift and was told he was pacing between the north and south corridors. She stated that night the staff had tried many interventions with him that did not calm him down, including a final effort of giving him a dose of Ativan (an antianxiety medication) in attempt to decrease his restlessness. She stated this administration of the Ativan had no effect on him. She again stated that the previous two shifts had reported the resident was both restless and exit seeking. She stated she recalled the resident to have been very restless and fast paced that night and that no interventions to settle him were effective. During an interview on 7/25/12 at 6:15 am, a Certified Nursing Assistant who had worked the night shift of 6/22/12 stated she was at the Nurse's station when she heard a door alarm sound. She stated she was at the Nurse's Station desk within eyesight of the electronic board that identified the door that was alarming and saw that it was the West fire door alarm. She stated she immediately responded by going over to the West Fire Door, but could not get the door open because she did not know it had a 30 second delay before it would open when it was pushed. She stated she looked through the window on the fire door and did not see anyone in the stairwell so she reset the alarm. She stated that as she turned away to return to the nurse's station, she realized that this resident had been up and walking around. She stated she quickly then proceeded through the hall to his room and discovered that this resident was no where she could see. She stated she then went right to the nurse's station to tell the licensed nurse's at the desk that this resident was missing and that they then started a search for the resident. She stated the nurses immediately convened the CNAs to start a search and that she and the two nurse went back to the door, but still could not open it. She stated as they got to the door, the heard another door alarm on a lower floor going off in the stairwell and that security was immediately called for assistance because they knew then that a resident had gotten into the stairwell. During a follow-up interview on 7/25/12 at 6:30 am, the RNS stated she was at the Nurse's Station charting. She stated a CNA at the Nurse's station could see the door that was alarming from where she was so she directed the CNA to go down to check the door immediately. She stated that this resident had been up and down the halls all night pushing the doors and setting off alarms so she thought that it had likely been this resident that had set it off. She stated she expected the CNA to find this resident near the door alarming and to bring him away from it. She stated that when the CNA came back and told her she didn't see anyone and that this resident was missing, she jumped up in a panic and ran down to the West Fire door with the LPN and the CNA. She stated that when the got there, they heard another alarm going off in the stairwell and immediately called security. She stated that they kept trying to push the door to open it, but it would open because they did not know they could open it only by pushing on it for 30 seconds. She stated when the pushed the door, the alarm would go off and they kept just resetting the door alarm to stop it from going off. During an interview on 7/25/12 at 8:40 am, the CNA assigned to this resident's hallway stated that she got report when she started working and was told this resident had been active that night. She stated the staff tried to get him to stay in his room, but he was constantly coming out. She stated that she went on her break around 1:45 am and left another CNA on the unit. She stated after 15 minutes the aide came in to the break room stating this resident had gone out the door. She stated that they then started looking for him everywhere. She stated that the previous shift had said this resident was up and active, but did not know how intense his behaviors were. She stated that at one point the aides asked the nurses if they could get more help because of him. She stated she told the charge nurse this sometime after midnight at which time they gave him some medication. During an interview on 7/25/12 at 8:45 am, the Director of Nursing stated that the resident was extremely restless on 6/22/12 (the day the elopement occurred), constantly looking to leave, pushing the fire doors and setting off alarms. She stated she was not physically present around the time of this elopement, but heard about it afterward. She stated her expectation would have definitely been that resident should have had increased, closer, one to one supervision from the staff during this time if he was that restless. She stated the staff should know that charting can wait and be put aside so that safety was assured and so that the resident received adequate supervision at that time. She stated the staff panicked and did not remember to hold the door down for 30 seconds to get it to open. She stated the staff had been educated on this previously, but thought they were just in panic mode and had not remembered. She stated the staff responded appropriately to the alarms and she was just so thankful the resident did not hurt himself. 10 NYCRR 415.12(h)(1)