Every finding on record at Cortlandt Healthcare

Based on record review and interviews conducted during the abbreviated survey (2632359) the facility did not ensure that the resident's care plan was reviewed and revised timely for 1 (one) of 3 (three) residents (Resident #1) reviewed for falls. Specifically, Resident #1's care plan was not updated after a fall on 7/18/2025 to reflect a new intervention until 07/21/2025. The 09/18/2025 Facility Falls-Clinical Protocol policy documented the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. The staff and physician will identify pertinent interventions to try to prevent subsequent falls. If the individual continues to fall the staff and physician will reevaluate the situation and reconsider possible reasons for the residents falling instead of or in addition to those that have already been identified and also reconsider the current interventions. Resident #1 was admitted to the facility with diagnoses which included a history of fall, left hip fracture, and Alzheimer's disease. The 07/11/2025 Nursing admission note documented by Registered Nurse #9 documented the admission Evaluation documented the resident's diagnoses included closed left hip fracture and moderate risk for fall with a fall risk score of 15. The 07/11/2025 Baseline Care Plan documented the resident required partial / moderate assistance with sit to stand and chair/bed to chair and toilet transfers and walking 10 feet. The 07/14/2025 at risk for Falls Care Plan documented at risk for falls, history of falls related to recent change in condition requiring skilled nursing home placement, recent decrease in mobility recent fall prior to skilled nursing home placement. Fall Care Plan Interventions dated 07/14/2025 documented call light and personal items within reach, keep environment well-lit and free of clutter, non-skid socks when not wearing shoes, offer snack and or fluids when resident is attempting to self-transfer self-ambulate, resident to use call light as needed and wait for assistance. The 07/18/2025 Minimum Data Set admission Assessment documented the resident had severely impaired cognition and required partial / moderate assistance with sit to stand and chair to bed transfers and walking 10 feet and was dependent with toilet transfers. The 07/18/2025 facility incident report documented the resident sustained an unwitnessed fall in their room at 10:25 AM. The Resident was observed on the floor at side of bed by Certified Nurse Aide #2. There was no documented evidence that bed in low position was added to the care plan until 07/21/2025. The 07/18/2025 Fall Risk Evaluation documented high risk for falls, score 69.The 07/21/2025 Incident Report documented resident sustained an unwitnessed fall in their room at 07:10 PM, was observed lying on the floor next to their bed, unable to relate what happened due to cognition, denies hitting head, denies pain, no apparent injuries noted. The 07/21/2025 Fall Risk Evaluation documented high risk for falls, score 69. The 07/21/2025 Care Plan intervention documented bed in lowest position. During a follow-up interview on 10/15/2025 at 08:45 AM, the Director of Nursing stated that after the 07/18/2025 fall, the intervention to keep the resident's bed in the lowest position was not implemented until 07/21/2025. They stated the staff completes routine hourly rounding for all residents although it is not documented in resident care plans or resident care guides. During an interview on 10/15/2025 at 12:50 PM, the facility Administrator stated that their expectation is that care plan interventions are updated in real time as possible to ensure that evidence supports prevention of further falls. During an interview on 10/16/2025 at 02:08 PM, the Primary Physician stated the care plan intervention was not documented timely. 10 NYCRR 415.11 (c)(2)(i-iii)

Based on observation, interview, and record review conducted during the recertification survey from 2/25/2025 to 3/3/2025, the facility did not ensure infection prevention was maintained. This was evident for 1 (1st Floor) of 3 resident units. Specifically, Housekeeper #3 was observed in a contact/droplet precaution room without the required personal protective equipment. The findings are: On 2/26/2025 at 12:12 PM, Resident #50 and #52 were observed out of bed and in room [ROOM NUMBER] on the 1st Floor. A Enhanced Barrier Precaution sign was posted on the wall in the hallway to the left of entryway to the room. A Contact/Droplet Precaution sign was posted on the door. Housekeeper #3 was observed wearing N95 mask and mopping the floor in room [ROOM NUMBER]. Housekeeper #3 was not wearing a gown, gloves, or protective eyewear. At the time of the observation, Housekeeper #3 was interviewed and stated they received inservice from the Infection Preventionist yesterday and was told they did not have to don full personal protective equipment in rooms with certain precaution signs. The Infection Preventionist showed Housekeeper #3 a sign that was posted on another room as an example. Housekeeper #3 stated they were confused about the precautions for room [ROOM NUMBER] because there were 2 signs placed outside the room and they were unsure what personal protective equipment they should wear when entering the room. On 3/03/2025 at 12:25 PM, the Infection Preventionist was interviewed and stated Housekeeper #3 was confused by the different precaution signs outside of room [ROOM NUMBER] and made a mistake by not wearing a gown, gloves, and protective eyewear to enter the room. Resident #50 and #52 were tested and negative for COVID-19 infection but were on contact/droplet precautions due to exposure to other residents who tested positive for COVID-19. 10 NYCRR 415.19(a)(1-3) 50816

Based on record reviews and interviews conducted during an abbreviated survey (NY00351622), the facility did not ensure timely removal of discontinued medications from the narcotic cabinet. This was evident for 1 (Resident #1) out of 3 Residents reviewed for medications. Specifically, Resident #1's Oxycodone-Acetaminophen (Percocet) tablet 5-325 mg-controlled medication was discontinued as per prescriber's order on 07/11/2024. The controlled medication remained in the medication cabinet/room and narcotic records were still available from 7/11/2024 to 8/18/2024. On 8/18/2024 Licensed Practical Nurse #10 accessed and administered the discontinued controlled medication to Resident #1 without a prescriber's order. The findings are: The facility policy titled Controlled Substances dated 08/06/2024 documented that controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed. Resident #1 had diagnoses that included Malignant Neoplasm of the Colon, Emphysema (a lung condition that causes shortness of breath), and Cardiomegaly (enlarged heart). The Quarterly Minimum Data Set (resident assessment tool) dated 07/23/2024 documented resident had intact cognition and residents' pain should be assessed. Resident had no indicators of pain or possible pain in the last 5 days. The Physician Order dated 06/11/2024 documented Oxycodone - Acetaminophen tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain scale 6-10 for 30 days with start date on 06/11/2024 and end date 07/11/2024. There was no documented evidence that the order was renewed. The 30-tablet blister pack of Oxycodone-Acetaminophen (Percocet) tablet 5-325 mg-remained in the medication cabinet/room on the unit with the narcotic record from 07/11/2024 to 08/18/2024. Review of the incident report dated 08/18/2024 documented that a Narcotic Drug - Oxycodone -Acetaminophen tablet 5-325 mg 1 tablet was administered to Resident #1 on 08/18/2024 without an order. The Conclusion of the Investigation revealed that Licensed Practical Nurse #10 took the medication and administered to Resident #1 without following the policy of checking the order before getting and administering the medication. A drug diversion investigation was conducted and was unsubstantiated. Resident #1 was assessed and there was no harm to the resident. Licensed Practical Nurse #10 was suspended pending investigation. During an interview on 10/7/2024 at 1:30PM Licensed Practical Nurse #11 stated when a narcotic is discontinued it is removed from the narcotic cabinet and the sheet is removed and it is taken down to the director of nursing's office. During a follow up interview on 10/10/2024 at 9:24 AM, the Director of Nursing stated the medication should have not been in the medication room after it was stopped (discontinued). The Director of Nursing stated the procedure is that the medication nurse should have removed from the unit, the medication, and the narcotic sheet within 24 hours from discontinuation (07/11/2024). If the discontinuation occurs on a weekend the expectation is for the medication to be in their office by Monday. The Director of Nursing stated they don't know why the process was not followed and the medication was kept on the unit until 8/18/2024. 10 NYCRR 415.18(a)

Based on record reviews and interviews conducted during an abbreviated survey (NY00351622), it was determined that the facility did not ensure residents were free from medication errors. This was evident for 1 (Residents #1) out of 3 residents reviewed for medication administration. Specifically, Licensed Practical Nurse #10 administered a Narcotic Drug Oxycodone-Acetaminophen (Percocet) tablet 5-325 mg 1 tablet to Resident #1 without an order on 08/18/2024. The findings are: The facility policy titled Administering Medications dated 4/2019 documented the individual administering medications checks the physician order/label three times to verify the right resident right medications, right dosage, right time, and right method (route) of administration before giving medication. Resident #1 had diagnoses that included Malignant Neoplasm of the Colon, Emphysema (a lung condition that causes shortness of breath), and Cardiomegaly (enlarged heart). The Quarterly Minimum Data Set (resident assessment tool) dated 07/23/2024 documented resident had intact cognition and residents' pain should be assessed. Resident had no indicators of pain or possible pain in the last 5 days. The Comprehensive Care Plan for Pain dated 04/15/2024 documented administer medication as ordered by Physician and to monitor and document for probable cause of each pain episode. The Physician Order dated 06/11/2024 documented Oxycodone - Acetaminophen tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain scale 6-10 for 30 days with start date on 06/11/2024 and end date 07/11/2024. There was no documented evidence that the order was renewed. Review of the incident report dated 08/18/2024 documented that a Narcotic Drug - Oxycodone -Acetaminophen tablet 5-325 mg 1 tablet was administered to Resident #1 on 08/18/2024 without an order. The Conclusion of Investigation revealed that Licensed Practical Nurse #10 took the medicine to Resident #1 and administered it but didn't follow the policy of checking the order before getting and administering the medication. A drug diversion investigation was conducted and was unsubstantiated. Resident #1 was assessed and there was no harm to the resident. Licensed Practical Nurse #10 was suspended pending investigation. Review of the Social Worker Progress Note dated 08/23/2024 documented that the nurse reported to the supervisor that resident was complaining of pain and without reading the order Licensed Practical Nurse #10 administered pain medication that was discontinued to Resident #1. Review of the Medication Treatment Error Report dated 08/18/2024 documented an error happened but didn't cause harm or potential for harm to the resident. Education done regarding medication administration narcotic policy. During an interview on 10/08/2024 at 8:39AM, Licensed Practical Nurse # 10 stated they were passing medications, and a Certified Nurse Aide reported to them that Resident #1 was in pain. They immediately administered Resident #1 1 tablet of Percocet without checking the order. Licensed Practical Nurse # 10 stated when they went to sign off on the Percocet in the Medication Administration Record, they realized that the medication was discontinued. They immediately reported the incident to the supervisor. During an interview on 10/08/2024 at 9:00 AM, the Director of Nursing stated Licensed Practical Nurse #10 did not follow the protocol. They were supposed to check the order before administering the medication. The medication should not have been in the medication room after it was stopped (discontinued). The procedure is to take the medication and the narcotic sheet from the unit to their office. All the nurses were in serviced after the incident. During a follow up interview on 10/10/2024 at 9:24 AM, the Director of Nursing stated the medication should not have been in the medication room, after it was stopped. The procedure is the medication nurse should remove the medication and the narcotic sheet and bring them to their office within 24 hours, and if it is the weekend the expectation is the medication should be in the office of the director of nursing by Monday. The Director of Nursing stated they don't know why the process was not followed and the medication was kept on the unit for seven days. All discontinued medications are bagged and given to the driver to bring to the pharmacy. Narcotics are kept in a lock box for destruction. 10 NYCRR 415.18(a)

Based on observation, record review and interview conducted during the recertification survey from 10/12/23 to 10/20/23, the facility did not ensure all residents were provided the necessary care and services for 1 of 3 residents (Resident #39) reviewed for activities of daily living (ADL). Specifically, Resident #39, who had a diagnosis of aphasia (a loss of ability to understand or express speech, caused by brain damage), was not assessed and treatment was not provided to enable the resident to communicate with others more normally including speech and/or other functional communication systems. The findings are: Resident #39 was admitted with diagnoses including traumatic subdural hemorrhage (brain bleed), aphasia following other cerebrovascular disease, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The annual Minimum Data Set (MDS: an assessment tool) dated 7/7/2023 documented cognitive skills for decision making were severely impaired, hearing was adequate, they had an absence of spoken words, rarely or never made themselves understood, rarely understands verbal content, and sees adequately without corrective lenses. Section F, preferences for customary routine and activities were checked yes to indicate that an interview of the resident should be conducted, and daily preferences and activity preferences were documented. Active diagnoses included aphasia, hemiparesis, or hemiplegia. Speech therapy (ST) was last provided 3/30/2023 - 4/19/2023. Occupational therapy (OT) was last provided 3/31/2023 - 4/25/2023, and physical therapy (PT) was last provided 3/29/2023 - 4/21/2023. Resident #39's care plan dated 6/23/2023 documented the resident had a communication problem related to a cardiovascular accident as evidenced by aphasia. The goal was the resident would improve communication function. Interventions included OT/PT/Nurse to evaluate resident ability/dexterity to use communication board, writing, use computer, or use of sign language as alternate communication to speech, and to refer to speech therapy for evaluation and treatment as ordered. A policy and procedure dated 10/2022 and titled Speech Therapy Level III documented the purpose of the procedure was to identify, assess, and treat speech and language problems. General guidelines documented the speech therapist works with other rehabilitation and medical professionals and families to provide a comprehensive evaluation and treatment program for residents with aphasia, anomia (word finding), dysarthria (muscles of the lips, tongue and other body parts used for speech are weaker than normal), and apraxia (a disorder of the nervous system that affects the ability to sequence and say sounds, syllables, and words. Speech therapy treatments included working on drills and exercises to improve specific language skills affected by damage to the brain, using a communication board, exercise of speech muscles, and teaching the resident to make use of gestures and writing to express ideas. Resident #39's care Kardex (instructions for direct care staff) dated 10/19/2023, documented to use alternative communication techniques as needed, such as communication book/board, writing pad, gestures, signs, and pictures. During an observation and interview conducted on 10/12/23 at 10:34 AM, Resident #39 communicated by shaking their head to indicate yes and no to questions about eating and verbalizing, and their response was accurate when responding yes that they did not eat by mouth, and inaccurate when responding they could verbalize. No functional communication systems were observed. During an observation on 10/13/23 at 11:51 AM, 2 small dry erase white boards were observed on a bedside table. No dry erase markers or eraser were observed. Resident #39 was asked if they communicated with the dry erase boards and indicated no with a head shake. During an observation on 10/19/23 at 12:26 PM, 2 small dry erase boards stored in a plastic bag without a dry erase marker or eraser were observed on an overbed table located behind the resident. At that time, the resident was out of bed in their wheelchair with their back was to the overbed table and dry erase boards. A small picture board with the words I want and pictures was also observed on the overbed table located behind the resident. In an interview on 10/19/23 at 11:52 AM the Speech Language Pathologist (SLP) Therapist responsible for evaluation of speech for Resident #39 stated the last time they evaluated and treated the resident was 3/30 - 4/19/23 for swallowing related to dysphagia, and that they did not document anything about resident #39's communication at that time. The SLP stated that they have not specifically evaluated Resident #39 for communication. The SLP stated they were aware of the resident's communication deficits. The SLP stated that they could have done a more thorough communication exam or evaluation to determine if a picture board would be utilized more to communicate the residents' wants. In an interview on 10/19/23 at 12:31 PM, the certified nurse aide (CNA) #6 stated that Resident #39 communicated with them by nodding their head and communicating with their eyes. CNA #6 stated that they had seen a dry erase board, but no dry erase pen or eraser in the resident's room. CNA #6 stated that they had not seen an I want communication board in the resident's room when they provided care to the resident that morning. CNA #6 stated they were not told how the resident communicated or about the dry erase board or an I want board. In an interview on 10/19/23 at 12:51 PM CNA #7 stated they communicated with Resident #39 by verbalizing to them, the resident was able to understand, and the resident responded with shaking their head. CNA #7 stated the resident did not communicate with them in any other way. CNA #7 stated that they had not received any information from nursing about how to communicate with the resident. 10NYCRR 415.12(a)(2)

Based on record review and interview conducted during the recertification abbreviated surveys (NY00322999) from 10/12/2023 to 10/20/2023, the facility did not ensure that an allegation of resident neglect was fully investigated. This was evident for one of two residents (Resident #372 ) reviewed for abuse. Specifically, when it was alleged that Resident #372 was left in a chair for two shifts, including over night, the facility did not conduct a thorough investigation to rule out neglect and did not report the allegation to the New York State Department of Health (NYSDOH). The findings are: A review of the facility Policy & Procedure titled Abuse, Neglect, Exploitation or Misappropriation-reporting and Investigation dated 10/2022, documents all reports of resident abuse, neglect, exploitation are reported to local, state, and federal agencies as required by current regulations, and thoroughly investigate by facility management. Findings of all investigations are documented and reported. Resident #372 had diagnoses including metabolic encephalopathy, malignant neoplasm (cancer) of the mouth, and diabetes (uncontrolled blood sugar). The Minimum Data Set (MDS an assessment tool) dated 7/23/2023, documented the resident had severely impaired cognition, and required extensive assistance with all activities of daily living. During an interview on 10/18/23 at 10:21 AM, Resident #372's family member stated they visited the resident on 8/11/23 and when they left at 3 PM the resident was in the wheelchair. When they returned the next morning the resident was in the same position and in the same clothes as the day before. They stated they spoke to the Registered Nurse Unit Manager (RNUM) #1 that morning about the resident being left in the chair all night from 8/11/2023-8/12/2023. RNUM #1 told them that they would investigate and find out what happened. On 10/18/23, a review of facility records and Resident #372's record for the time period from 8/10/2023-8/15/2023 revealed: - No documentation in the facility morning report minutes of any incidents with Resident #372. - No documented evidence in the resident's progress notes for behavioral issues or difficulty sleeping. - The Certified Nurse Aid Tasks in the resident's electronic medical record was blank for the 3 PM to 11 PM shift on 8/11/23 and for the 11 PM to 7 AM shift for 8/11-8/12/23. There was no evidence care was provided that included bathing, bed mobility, barrier cream after incontinent episodes, bladder and bowel continence, personal hygiene, skin observation, toilet use, and transfers. - The resident's Care Plan documented the resident was at risk for potential abuse and neglect related to cognitive impairment and dependence on others for activities of daily living. Interventions included investigating all allegations of abuse neglect promptly, providing support and ensuring the resident was free from abuse and neglect. On 10/19/23 at 11:58 AM during an interview, RNUM #1 stated they remembered speaking with the family member who told him the resident had been left in the wheelchair all night. RNUM #1 stated they investigated the concern with the night shift staff and the staff said the resident kept trying to get out of bed and they were concerned about the resident's safety, so they kept the resident out of bed. RNUM #1 stated they did not document the concern or get back to the family, but they did discuss it in morning report and the Director of Nursing (DON) was there. They stated, in hindsight, it could have been considered an accusation of abuse, neglect, or mistreatment. On 10/19/23 at 12:35 PM during an interview, the Director of Nursing (DON) stated they were unaware of the allegation and if it had been brought to their attention, it would have been investigated and reported it to the NYSDOH. 415.4(b)(1)

Based on interview and record review conducted during the recent recertification survey, the facility did not ensure for 1 of 2 residents (#61) reviewed for hospitalization that the resident or resident's representative were notified in writing of transfer/discharge to the hospital, including the effective date of transfer, location of transfer, and reason for transfer. The findings include: Resident #61 had diagnoses including anemia, hypertension, and schizophrenia. The annual Minimum Data Set (MDS: an assessment tool) dated 8/22/2023 documented the residents' cognition was moderately impaired for decision making. The nursing progress notes dated 10/11/2023 - 10/13/2023 documented that Resident #61 had a very abnormal Hemoglobin of 5, the resident's medical doctor was called and ordered for the resident to go to the hospital in the morning on the day shift for a transfusion. On 10/12/2023 at 8:36am Resident #61's Hemoglobin was 5.7, their medical doctor had ordered the resident to be sent to the hospital for blood transfusion; the hospital emergency room received status report, Health Care Proxy was aware of transfer, Emergency Medical Services arrived, and Resident #61 was transferred to the emergency room via ambulance. On 10/13/2023 at 2:54PMthe facility staff nurse called the hospital emergency staff, and resident had been admitted with diagnosis anemia. There was no documented evidence in the resident's clinical record that the resident or the resident's representative, had been provided with a written notice of the transfer/discharge. In an interview on 10/18/23 at 10:36 AM Resident #61 stated they did not believe they had received a written notice of the transfer/discharge. Resident #61 stated that their nephew was their designated representative. In an interview on 10/19/23 at 9:02 AM the Social Work Director (SWD) was asked if written notification of Resident #61's transfer/discharge had been provided to the resident or the residents' representative. At that time, the SWD produced a discharge/transfer notice dated 10/12/2023 which indicated that a staff social worker had notified the resident's nephew of the transfer via phone, and the staff social worker had signed the notice. There was no evidence provided to suggest that the bed hold policy had been mailed to the resident or their representative, i.e., no return receipt was found with the transfer/discharge notice. When asked what the correct process was for notification of transfer and discharge, the SWD stated that they should have spoken with the resident, if the resident was not available, they should have spoken with the next available contact, the conversation should have been documented in the chart, and a letter should have been sent out to the resident or responsible party immediately after the phone notification. In an interview on 10/20/23 at 9:05 AM the Administrator stated that they were aware that the social worker was reaching out to families regarding discharge, transfer, and bed hold, but they were not aware that the social worker had not been providing /sending written notification to residents or their responsible party. 10 NYCRR 415.3(i)(1)

Based on interview and record review conducted during the recertification survey from 10/12/23 to 10/20/23, the facility did not ensure that to the extent practicable, each resident was offered the opportunity to participate in their plan of care, or that an explanation was included in a resident's medical record if the participation of the resident and their resident representative was determined not practicable for the development of the resident's care plan for 2 (Residents #46 and #39) of 3 residents reviewed for care planning. Specifically, Residents #46 and #39 expressed interest in attending care planning meetings and reported they had not been invited. The findings are: 1) Resident #46 was admitted with diagnoses including hemiplegia and hemiparesis, psychosis, and Diabetes Mellitus. The Annual Minimum Data Set (MDS: a screening tool) dated 8/17/2023 documented that the resident had moderate cognitive impairment for decision making, usually understands verbal content, and was usually understood. The resident was interviewed on 10/13/23 at 10:29 AM and stated they did not go to the care planning meetings, but it sounded interesting. The resident stated they did not recall being invited to care planning meetings. The Social Work progress note dated 9/7/2023 documented the Interdisciplinary Care Plan (IDCP) meeting had been held that day and the resident's daughter was in attendance at the meeting via phone. There was no documented evidence that Resident #46 had been invited to the care planning meeting, and no explanation was documented in the resident's medical record indicating if the participation of the resident was determined not practicable for the development of the resident's care plan. During an interview on 10/19/2023 at about 9:40 AM the Social Work Director (SWD) reviewed the record with surveyor and stated that the resident's daughter attended care planning on 9/7/2023. There was no documentation found that the resident was invited to attend CCP, or that their attendance at the meeting was not practicable. The SWD stated that the process was that the Social Worker or SWD would speak with the resident and ask if they would like to attend CCP, and if the resident said yes to the invitation, they would inform the resident of the date and time of the meeting. The SWD offered no explanation as to why the Resident #46 had not been invited to care planning meetings. 2) Resident #39 was admitted with diagnoses traumatic subdural hemorrhage, aphasia following other cerebrovascular disease, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The annual Minimum Data Set (MDS: an assessment tool) dated 7/7/2023 documented cognitive skills for decision making were severely impaired, hearing was adequate, they had an absence of spoken words, rarely or never made themselves understood, rarely understands verbal content, and sees adequately without corrective lenses. Section F, preferences for customary routine and activities were checked yes to indicate that an interview of the resident should be conducted, and daily preferences and activity preferences were documented. Resident #39's care plan dated 7/13/2023 documented that the resident had aphasia, was non-verbal, could answer direct yes/no questions by nodding their head, they sometimes understood, and were sometimes understood. The resident was interviewed on 10/13/23 at 11:43 AM and when asked if they had been invited to attend care planning meetings, they nodded their head no. When asked if they would like to attend care planning meetings, the resident nodded their head yes. A social work progress note dated 10/18/2023 documented that IDCP had been held on that day, and the resident's fiance was in attendance. There was no documented evidence found that the resident had been invited to the care planning meeting, and no explanation was documented in the residents' medical record indicating if the participation of the resident was determined not practicable for the development of the resident's care plan. During an interview on 10/19/23 at 9:50 AM the Social Work Director (SWD) reviewed the record with surveyor and stated that the resident's fiance had attended the care planning meeting on 10/18/2023 via telephone. The SWD offered no explanation as to why Resident #39 had not been invited to care planning meetings. 10NYCRR 415.11(c)(2)

Based on observations, record review and interviews, during a recertification survey from 10/12/23-10/20/23, the facility did not ensure the resident environment remained free of accident hazards to prevent accidents for 1 (Resident #28) of 6 residents reviewed for accidents. Specifically, Resident #28, who was assessed as needing a bed rail to promote independence, had the rail removed and when they awoke from a nap and reached for the rail, they fell and sustained a fractured (broken) shoulder and blunt head trauma. The findings are: Resident #28 had diagnoses which include atrial fibrillation, spinal stenosis, hypertension. The annual Minimum Data Set (MDS), an assessment tool, dated 7/16/23, documented the resident had a Brief Interview for Mental Status (BIMS) of 15/15 indicating they were cognitively intact. The resident required extensive assistance of two persons for bed mobility and transfers and extensive assistance for dressing. The resident's care plan for falls dated 4/20/2016, and updated 7/11/23 after a fall, documented the resident was at risk for falls and had interventions which included anticipating the resident's needs, and to re-educate to use the call bell for assistance. The physician orders dated 7/20/22 document 1/2 side rails up to both sides of bed for bed mobility and transfer participation. A side rail/grab bar review dated 7/25/23, documented the resident had demonstrated poor bed mobility and difficulty moving to a sitting position on the side of bed. The recommendation was bilateral half side rails were indicated and served as an enabler to promote independence. The Accident/Incident report dated 9/21/23 documented at 4:45 PM the resident was found on the floor next to their bed bleeding from the right side of their head. The resident stated they were trying to sit up on side of the bed and fell off bed. The box on the A/I for side rails up was not checked. The September 2023 Treatment Administration Record (TAR) documented 1/2 side rails up to both sides of the bed, check placement every shift, for bed mobility and transfer participation. The TAR was last signed for the 1/2 rails on 9/21/23 for the 7 AM to 3 PM shift. The TAR documented the resident was hospitalized [DATE] for the 3-11 PM shift. Further review of the resident's medical record revealed no documented evidence that an assessment was performed to see if the resident could safely position themselves on the side of the bed without the enabler side rail, prior to the removal. There was no documentation the resident and/or their representative received education about side rail removal. During an interview with Resident #28 and the resident's family member on 10/12/23 at 10:28 AM and 3:29 PM, both stated the side rails had been on the resident's bed for a very long time but were removed abruptly three weeks ago. The Resident stated they awoke from a nap and went reach for the rail to pull themselves up, the rail was not there, and they fell out of bed. The resident's family member stated they visited the facility every day and no one told them the rails were going to be removed. During an interview on 10/18/23 at 11:34AM, the Registered Nurse Unit Manager (RNUM) stated the facility received a letter from the State regarding side rail usage and side rails were removed. They stated all of the residents were assessed before putting rails in place but there were no plans for assessment before they were removed. RNUM#2 stated they did not provide education for staff, residents, or residents family members prior to removing the side rails. RNUM #2 stated there was a lot of confusion when the letter came out, so the facility just removed the rails without first having plans in place. During an interview on 10/20/23 at 9:23 AM, Certified Nurse Aide (CNA) #1 stated they took care of Resident #28 many times and knew the resident well. The resident was able to help staff by grabbing the rail when they were being positioned or having the bed changed. The rail gave the resident support, and they used it while they were in bed. CNA #1 stated the rails were removed on a lot of the residents' beds, there was no education or reminders to be extra cautious with the residents. During an interview on 10/19/23 at 12:24PM, the Director of Nursing (DON) stated they were at the scene on the day Resident #28 fell and the resident did not have rails on the bed. The DON stated they were not aware the resident was assessed to need the rails as an enabler, and they did not know there was a physician order for the rails. During an interview on 10/19/23 at 1:18 PM, the Administrator stated they were not aware that Resident #28 was assessed to have a need for side rails and had a physician order, but the rails were removed anyway. The Administrator stated they were unaware that assessments were not done prior to removing side rails. 10NYCRR 415.12(h)(1)

Based on observations, interviews and record review conducted during the recent recertification survey, the facility did not ensure that emergency equipment was readily available for 1 of 2 residents (Resident #35) screened for respiratory care. Specifically, a resident with a tracheostomy did not have an Ambu bag (a hand-held device that provides positive pressure to residents who are not breathing) at the bedside. The findings are: Resident #35 was admitted with a diagnosis of traumatic brain injury and tracheostomy status. The resident's orders included Oxygen at 8L/min, humidification 50% via trach mask continuously every shift for respiratory care. The annual MDS dated [DATE] documented the resident was comatose, had diagnoses including respiratory failure and a tracheostomy, and received oxygen and tracheostomy care. The resident's care plan dated 11/11/2016, and revised 7/3/2023, documented the resident had tube out procedures which included keeping an extra trach tube and obturator at bedside. If tube cannot be reinserted, monitor /document for signs of respiratory distress. If able to breathe spontaneously, elevate head of bed 45 degrees and stay with resident. Obtain medical help immediately. A policy and procedure dated 12/2/2022 and titled Tracheostomy Medical Emergencies documented: Tube Occlusion: .use an Ambu bag to ventilate, Decannulation: maintain tracheal airway and ventilation with bag tracheostomy mask as best as is possible, and If the patient is not ventilating adequately, close stoma and ventilate with bag and face mask with 100% O2 until CODE team arrives. During an observation on 10/13/23 at 9:25 AM no Ambu bag was observed at bedside. An observation and interview were conducted in the residents' room on 10/13/23 at 9:35 AM with the Licensed Practical Nurse (LPN) #4 in attendance. LPN #4 was asked to show surveyor where the Ambu bag was kept. LPN #4 proceeded to check the room storage areas and stated there was no Ambu bag. When asked what the process for ensuring the Ambu bag was accessible in the room, LPN #4 stated they would find out. During an observation on 10/16/23 at 5:55 PM no Ambu bag was observed at bedside. During an interview on 10/16/2023 at 5:58 PM, LPN #5 was asked what equipment was needed in case of a respiratory emergency for Resident #35, and they responded that they would need the suction machine, the inner cannula, and a suction catheter kit. When asked if they would need an Ambu bag for the resident in the case of a respiratory emergency, LPN #5 stated there was an Ambu bag in the dining room. In an interview on 10/19/23 at 8:50 AM the Respiratory Therapist (RT #1) stated emergency equipment that should always be in the resident's room included an oxygen tank, an Ambu bag, and a spare, smaller size trach than the one the resident has. 10NYCRR 415.12(k)(6) 41666

Based on observation, interview and record review during the recertification survey conducted from 10/12/23 to 10/20/23, the facility did not ensure that each resident had the right to make choices about aspects of their life in the facility that were significant to the resident for 1 of 3 residents (Resident #21) reviewed for choice. Specifically, Resident #21 was not provided a choice regarding whether to receive a bed bath or shower and the resident was not provided the opportunity to participate in activities they enjoyed including going to the public library. Findings include: Resident #21 had diagnoses including diabetes (uncontrolled blood sugar), generalized muscle weakness, and cervicalgia (neck pain). The Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively intact. Resident #21 required extensive assistance with 1 person for personal hygiene and was totally dependent with 1 person for bathing and required a 2 person assist for transfers. The MDS documented it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The MDS also documented that it was very important to resident to do their favorite activities. Review of the Recreation Evaluation dated 9/28/23, revealed it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath; and it was very important to the resident to do their favorite activities. Review of computerized Point of Care (POC) documentation, completed by certified nurse aide (CNA) staff from 9/1/23-10/12/23 revealed the ADL (activities of daily living) section for Bathing did not specify the resident's preference. The documentation showed the resident was bathed daily except for 9/18/23, 9/28/23, 10/1/23, and 10/5/23. During the same time period it was noted that resident did not receive a shower on their assigned shower days. There was no documentation stating showers were offered or refused. During an observation and interview on 10/12/23 at 10:40 AM, Resident #21 stated they were waiting for staff to assist with cares. The resident was in bed, wearing a gown, and the breakfast tray was on the bedside table. The resident stated that they had not had a shower and would prefer a shower instead of a bed bath. The resident stated they would like to be more involved in physical activities, missed going to the library, and felt they were declining by living at the facility. During an interview on 10/13/23 at 10:10 AM, with the Ombudsman present, the resident stated that they enjoyed attending the library and had been doing so for many years. The resident stated that they enjoyed doing research and did not want to just get books. The Ombudsman stated that they had been working since August to find a way for the resident to continue with this activity and attempted to speak with facility to facilitate library visits. The resident stated that at a care plan meeting the facility discussed getting an iPad for the resident but nothing has happened yet. Resident #21 again stated their preference for a shower instead of a bed bath, and that they were not gotten out of bed every day. During an observation later that day, 10/13/23 at 1:37 PM, Resident #21 was still in bed wearing a gown. During an interview on 10/18/23 at 12:10 PM, the Activities Director stated when residents were admitted to the facility, an assessment was completed with their hobbies, activities, religion, etc. The information was documented and an individualized care plan was created and updated quarterly. They stated there had not been any outside trips since COVID and were attempting to arrange transportation to resume trips. They stated Resident #21 was offered an iPad and refused. When requested, they were unable to provide documentation regarding the refusal. During an interview 10/18/23 at 01:08 PM, CNA #1 stated that residents were assessed for bathing preference before they entered the facility, and they accommodated preferences throughout the day. CNA #1 stated if a resident refused or care was not done, they made a note at the end of the shift, and communicated to the nurse in charge and to the staff on next shift. During interview on 10/19/23 at 11:15 AM, Nurse Manager #2 reviewed the bathing/ shower documentation provided for September and October 2023. Nurse Manager #2 stated, that based on the documentation, it appeared the resident did not receive or was not offered a shower from 9/1/23 to 10/12/23. 415.5(b)(1,3)

Based on observations,interviews and record review conducted during an abbreviated survey (NY00309932) the facility failed to provide adequate supervision/monitoring/ assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed. Specifically, Resident #1 fell forward out of their wheelchair while they were been transported by a Certified Nurse Aide (CNA#1) to their room. Resident #1 sustained a close fracture of the nasal bone and a contusion of the head. The resident's feet was not positioned on the footrest during transport. Findings include: Resident #1 was admitted on [DATE] with diagnoses including Vascular Dementia, Congestive Heart Failure and Essential Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented no Brief Interview for Mental Status (BIMS) score as the resident had severe cognitive impairment. The resident required total and extensive care for Activities of Daily Living (ADLs), including one-person physical assistance for locomotion on and off unit with a wheelchair. Resident was dependent on staff when in wheelchair to move from place to place. The comprehensive care plan (CCP) created 05/04/2022 documented that the resident requires assist with activities of daily living related to dementia. Interventions included to encourage resident to fully participate and encourage the use of call bell system for assistance. Review of security footage dated 01/14/2023 at 20:21:18 PM, Certified Nurse Aide (CNA #1) is seen pushing Resident #1 down the hall in their wheelchair. Resident #1 was seen shuffling their feet while the chair was being pushed by CNA#1. At 20:21:24 Resident #1's foot looked tangled behind the other foot and Resident #1 fell forward out of the chair to the floor face first. Resident #1's feet were not observed on the wheelchair footrest during transport. Facility incident report dated 1/14/2023 at 8:30 PM documented Resident #1 suddenly without warning put feet down on floor during active transport in wheelchair resident put their feet down on floor while wheelchair was in motion causing them to fall forward from wheelchair. Writer observed Resident #1 lying face down on the floor on their left side. Minimal bleeding noted to the nose and small break in skin at the forehead. Neuro checks initiated. Resident #1 was transferred to hospital for further evaluation. Resident #1 sustained nasal fracture because of fall however care plan was followed. Video surveillance reviewed by DON and Administrator. No environmental factors noted, no change in plan or obstructions noted in environment. No abuse, neglect or mistreatment suspected. The 1/15/23 at 2:15 PM hospital discharge record documented the resident discharge diagnosis as closed fracture of nasal bone and contusion of head. An Interview was conducted with CNA#2 on 3/15/2023 at 11:17 AM. CNA #2 stated they were following behind CNA #1 on 1/15/2023 as they transported Resident #1 to their room in a wheelchair. CNA #2 stated Resident #1 was moving their feet while CNA #1 was pushing the chair and it looked like Resident #1's foot stopped or got stuck and they fell forward out the chair. CNA #2 stated they immediately called for the nurse who came and did a head-to-toe assessment. CNA #2 stated they could not recall if CNA #1 ensured Resident #1's feet on the foot pedals but stated there were foot pedals on the residents' chair. An interview was conducted with CNA #1. on 05/25/2023 at 1:20 PM. CNA #1 stated Resident #1's wheelchair had foot pedals while they were pushing them. CNA #1 stated they believe Resident #1 moved their feet off the foot pedals during transport causing them to fall forward. CNA #1 stated they did not notice Resident #1 had removed their feet off the foot pedals otherwise they would have stopped to put them back on the pedals. During an interview conducted with the Director of Nursing (DON), on 05/25/2023 at 2:00 PM, the DON stated staff are trained on utilizing assistive devices such as ensuring breaks and foot pedals are utilized when necessary. DON stated after a review of the surveillance cameras, Resident #1 had foot pedals on their chair. DON stated Resident #1 took their feet off the pedals and the aide was unaware causing the resident to fall out the chair. DON could not tell by looking at the video if CNA #1 ensured Resident #1's feet were properly placed on the foot pedals prior to moving the resident. 415.12(h)(2)

F 656 CORTLANDT # 2 COMPREHENSIVE CARE PLAN Based on interview and record review conducted during an abbreviated survey (NY 072), the facility did not ensure that it fully implemented a Comprehensive Person-Centered Care Plan (CP) for Activities of Daily Living (ADLs) 1 of 3 residents reviewed for Accidents. Resident #1's CP for ADLS dated 7/9/2019, noted that Resident #1 required extensive assistance of 2 persons for bed mobility, dressing, and personal hygiene. The findings are: Resident #1 was a [AGE] year old resident admitted to the facility on [DATE] from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Minimum Data Set (MDS; a resident assessment tool) dated 12/9/2020 documented that the resident was severely cognitively impaired; totally dependent requiring the assistance of 2 persons for bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #1 also used a wheelchair as a mobility device and was always incontinent of bowel and bladder. The CP for ADL related to Chronic Pain, Moderate Dementia was initiated on 7/9/2019, had been reviewed and revised with a goal that Resident #1's ADLs will improve through the review date. The CP interventions included that for 1) eating, Resident #1 was totally dependent on 1 staff or tube fed; 2) locomotion on unit, totally dependent on 1 staff; 3) locomotion off unit, totally dependent on 1 staff; 3) personal hygiene, total assistance of 2 staff (resident does not participate in activity at all) and; 4) transfers, totally dependent on 2 staff while utilizing a mechanical lift. During in an interview with the Director of Nursing (DON) on 6/16/2021 at 9:00am, she/he stated that CNA #1 had admitted that she/he cared for Resident #1 by him/herself on the 11:00pm to 7:00am shift on 1/9/2021. During in an interview with a Licensed Practical Nurse (LPN #1) on 6/16/2021 at 3:47pm, he/she stated that on 1/10/2021 at approximately 7:15pm, CNA #2 requested that he/she examine Resident #1's hand. LPN #1 stated that he/she went to see the resident, reported the hand discoloration to the supervisor and notified the Medical Doctor (MD). The MD ordered a stat (immediate) X-Ray of Resident #1's fingers. Results were received by the facility the next morning (1/11/2021) and showed that Resident #1 sustained a fracture of the left first finger. During in an interview on 6/17/2021 at 9:54am with LPN #2, he/she stated that he has no recollection of an event regarding resident on 1/10/2021. During in an interview on 6/17/2021 at 10:02am with CNA #2, she/he stated that she/he was performing cares with Resident #1 at around 7:00pm and she/he saw the bruise to his/her left hand. CNA #2 reported it to LPN #1. CNA #2 does not recall if an additional staff person was assisting with Resident #1 at the time and stated that the resident required extensive assistance from 2 people. During in an interview on 6/17/2021 at 10:44am with CNA #1, he/she stated that she/he worked on the 3:00pm to 11:00pm shift and the 11:00pm to 7:00am shift. She/he was assigned to Resident #1 for the 11:00pm to 7:00am shift on 1/9/2021. CNA #1 further stated that she/he changed Resident #1's diaper and turned and positioned him/her. CNA #1 stated that Resident #1 is unable to turn by him/herself. CNA #1 added that he/she could not recall if another staff person assisted him/her provide care to Resident #1. CNA #1 stated that if he/she was working by him/herself, he/she would call the nurse who would usually come and help. During in an interview with CNA #3 on 6/18/2021 at 11:48am, she/he stated that she worked in the facility for [AGE] years. CNA #3 stated that he/she worked on 1/8/2021 and 1/9/2021 on the 7:00am to 3:00pm shifts. CNA #3 explained that CNA #4 assisted him/her to provide care for Resident #1. CNA #3 stated that there was no discoloration of the left hand and there was nothing there. CNA #3 stated that he/she worked from 3:00pm to 11:00pm on 1/9/2021 and assisted another CNA with Resident #1's care. CNA #3 stated that on 1/10/2021 she/he worked from 7:00am to 3:00pm, was assigned to Resident #1 and was assisted by CNA #4. CNA #3 explained that both noticed a light purplish discoloration on the top of Resident #1's left hand. CNA #3 stated that they both thought it was from a blood draw and did not report it to the nurse. The next day (1/11/2021) CNA #3 worked the 7:00am to 3:00pm shift and noted the discoloration of the left hand was more pronounced. CNA #3 then reported it to LPN #1 who said that it had already been reported. During in an interview with CNA #4 on 6/18/2021 at 11:57am, she/he explained that he/she has been employed at the facility since 2013. CNA #4 went on to explain that he/she worked from 7:00am to 3:00pm on 1/8/2021 and 1/9/2021. During those shifts, CNA #4 assisted CNA #3 to provide care for Resident #1 and did not notice anything on the left hand. He/she stated that he/she from 7:00am to 3:00pm on 1/10/2021 and that was when he/she and CNA #3 noticed a discoloration on the top of Resident #1's left hand. However, CNA #3 not CNA #4 did not report it to the nurse as they thought the discoloration was a result of a recent blood draw. 483.21(b)(1)

Based on interview and record review conducted during an Abbreviated Survey (NY 135), the facility did not ensure that it fully implemented a Comprehensive Person-Centered Care Plan (CP). Specifically, the facility did not fully implement a CP for Activities of Daily Living (ADLs) for 1 of 3 residents (Resident #1) reviewed for accidents. The CP for Transfers dated [DATE], noted that Resident #1 required assistance with ADLs and was totally dependent for transfers, requiring the assistance of 2 staff while utilizing a mechanical lift. The findings are: Resident #1 was a [AGE] year-old resident who was admitted to the facility on [DATE] from a long-term care facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 expired in the facility on [DATE]. The Minimum Data Set (MDS; a resident assessment tool) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] which suggested that the resident was cognitively intact. The MDS also noted that Resident #1 required extensive assistance of 2 staff with bed mobility, transfers, toilet use and personal hygiene. Resident #1 used a wheelchair as a mobility device and was frequently incontinent of bowel/bladder. The CP for ADLs related to [CONDITION(S)], initiated on [DATE], has been reviewed and revised with goals including that Resident #1's ADL status will improve through the review date. The CP interventions included 2 staff to assist with transfers utilizing a mechanical lift as Resident #1 was totally dependent. Review of the Documentation Survey Report dated [DATE] showed that Resident #1 was determined to need extensive assistance of 2 staff for bathing, bed mobility, dressing, personal hygiene, and toileting. Resident #1 was totally dependent on 2 staff for transfers while utilizing a mechanical lift. During an interview with the Director of Rehabilitation (DOR) on [DATE] at 11:43am, he/she stated that Resident #1 should utilize Hoyer lift (a type of mechanical lift). Should a patient require total assistance with transfers, the notes will reflect TD (totally dependent). However, while in rehabilitation, the therapists practice standing with the residents. Specifically, there were several factors against Resident #1, most importantly, after he/she got sick with COVID-19, he/she didn't recover fully. Also, Resident #1 had arthritic knees which could buckle at any time. Resident #1 required 2 Physical Therapists (PTs) to stand him/her with precautions including a chair behind him/her. The DOR further stated that Resident #1 always utilized a Hoyer lift after readmission from the hospital admission for COVID-19. During in an interview with the Licensed Practical Nurse (LPN #1) on [DATE] at 12:50pm, he/she stated that he/she has worked Full Time at the facility for 4 years, primarily during the 7:00am - 3:00pm shift. LPN #1 then stated that he/she worked on the 7:00am - 3:00pm shift on [DATE]. At approximately 11:15am, LPN #1 asked the Certified Nursing Assistant (CNA #1) to get Resident #1 out of bed because he/she a tele-appointment with the Cardiologist at 1:15pm. As another CNA went to get the Hoyer lift, Resident #1 told CNA #1 not to use the Hoyer lift on him/her. LPN #1 stated that he/she was called to Resident #1's room but does not remember who called. LPN #1 went to the room and he/she saw blood on the floor. LPN #1 stated that he/she called the Nurse Manager and the Nurse Practitioner (NP). The NP examined Resident #1 and he/she was sent to the emergency room (ER). LPN #1 stated that Resident #1 had thin skin and sustained a laceration that was about 3 inches long. LPN #1 added that the Hoyer lift for transfers was in Resident #1's CP. During in an interview with the Director of Nursing (DON) on [DATE] at 2:11pm, he/she stated that after the incident he/she called CNA #1 to get a statement to which CNA #1 refused. CAN #1 told the DON that he/she had left the facility at approximately 3:00pm. The DON stated that CNA #1 listened to Resident #1 regarding not using the Hoyer lift. During in an interview with CNA #1 on [DATE] at 9:56am, he/she stated that he/she was assigned to Resident #1 on [DATE] for the 7:00am - 3:00pm shift. He/she stated that the unit was short staffed that morning as there were 2 CNAs at the time. CNA #1 reported that at some time between 12:00pm - 12:45pm a nurse (CNA #1 could not recall which one) was yelling and screaming that Resident #1 had to get up for his/her appointment and told CNA #1 to get him/her up. CNA #1 stated that he/she went to the room and he/she got Resident #1 dressed. CNA #1 stated that the nurse said that he/she did not know how Resident #1 was transferred when he/she got out of bed. CNA #1 stated that Resident #1 told him/her that they did not use the Hoyer lift and he/she refused to use the Hoyer lift. CNA #1 stated that Resident #1 cut his/her leg on the side of the wheelchair. CNA #1 stated that he/she did not notice the cut at that time. Resident #1 moved his/her leg and CNA #1 saw that he/she was bleeding. CNA #1 stated that he/she reported the cut to the nurse and to the supervisor. CNA #1 stated that the DON told him/her that resident was to be transferred utilizing a Hoyer lift. CNA #1 further stated that he/she wrote a statement, but the DON wanted him/her to change his/her statement. CNA #1 stated that he/she wrote in the statement that he/she got the resident out of bed into the wheelchair and bruised his/her leg. CNA #1 stated that he/she did not have a chance to check the computer to verify how Resident #1 is transferred. CNA #1 stated that he/she had worked with Resident #1 in the past, but he/she had never assisted him/her out of bed before. During in an interview with the DON on [DATE] at 10:59am, he/she stated that he/she spoke with CNA #1 in his/her office on [DATE] after the incident with Resident #1. The DON stated that CNA #1 told her that he/she did not utilize the Hoyer lift when transferring Resident #1 because he/she said that he/she did not use it. CNA #1 told the DON that the nurse told him/her to get Resident #1 out of bed and CNA #1 did so alone without utilizing the Hoyer lift. The DON stated that he/she asked CNA #1 to write a statement to which CNA #1 refused. The DON explained that he/she told CAN #1 that he/she will be suspended pending the outcome of the investigation at which time CNA #1 exited the DON's office and left the facility. The DON denied that CNA #1 gave him/her a statement and that he/she told CAN #1 to change the statement. During an interview with LPN #1 on [DATE] at 11:41am, he/she stated that on [DATE], CNA #1 was working another resident and at about 12:00pm, LPN #1 was rushing her for Resident #1 to get him/her get Resident #1 out of bed. LPN #1 stated that the other aide was retrieving the Hoyer lift from the other side of the hallway. Meanwhile, CNA #1 was in Resident #1's room where the he/she told CNA #1 to not use the Hoyer lift. LPN #1 denied yelling at CNA #1 and stated that sometimes she has a loud voice. 483.21(b)(1)

F689 Based on observation, record review, and interview, conducted during an Abbreviated Survey (Complaint # 2), the facility did not ensure that the resident received adequate supervision to prevent elopement for 1 of 4 residents reviewed for elopement (Resident #1). Specifically, Resident #1 who was identified as an elopement risk upon admission, successfully eloped on the morning of 3/24/2021. Resident #1 who had a Wanderguard in place, exited the facility undetected through an open, unlocked loading dock curtain door. The findings are: The Facility Policy and Procedure on Elopement dated November 2019, documented that the facility would ensure that its residents were secure from the potential of elopement, becoming a missing person, or being harmed due to wander risk. The facility would safeguard the health and welfare of residents who were cognitively impaired, emotionally disturbed, and were at risk to wander or leave the facility without staff notification/authorization. The facility would ensure that staff immediately responded to the code for Elopement (Code Doctor Travel), follow elopement procedures for a resident suspected of, or found to have been missing from the facility, and would ensure a safe environment for all residents. Wanderguard Logs which documented each resident's name, bracelet site, functional status as well as serial number and expiration date of each Wanderguard, were located at every nurse's station, the reception desk, and in the Nursing Supervisor's office. The Facility Assessment (FA) dated 12/2020 documented that the resident profile included impaired cognition, depression, anxiety, and behaviors that need intervention. The FA documented the identification and implementation of services and care the facility offered as well as interventions to help support individuals with issues such as anxiety, care of individuals with cognitive impairment and care of individuals with depression. The FA documented that all residents will be evaluated and/or assessed for elopement potential. Resident #1 is an [AGE] year-old who was admitted to the facility on [DATE] with diagnoses including but not limited to Dementia, Depression, and Anxiety. The Quarterly Minimum Data Set (MDS; a resident assessment tool) dated 02/01/2021 documented that Resident #1 had a Brief Interview for Mental Score (BIMS) of 3/15, indicating severely impaired cognition. The MDS assessment documented that Resident #1 wandered daily and exhibited verbal outbursts. MDS assessment also documented that Resident #1 required limited assistance for ambulation and transfers. Resident #1's Admission assessment dated [DATE], documented that Resident #1 had a memory problem, was disoriented, alert, had the presence of delusions, had behaviors that put him/her at risk and has had no history of elopement or exit seeking behaviors. Resident #1's Care Plan (CP) for Activities of Daily Living (ADLs) dated 10/23/2020 documented that Resident #1 required assistance with ADLs related to dementia. The CP goal was that Resident #1 would improve in ADL status through the review date. The CP interventions included for staff to provide supervision for transfers and ambulation with extensive staff assistance of one person provided for locomotion off the unit. Resident #1's Elopement Risk assessments dated 10/23/2020, 02/09/2021, 03/24/2021 all identified/documented Resident #1 as at risk for elopement. Resident #1's CP for Elopement Risk dated 11/02/2020 documented goals including that Resident #1 would have fewer episodes of exit seeking behaviors. The CP interventions included: 1) acknowledging Resident #1's feelings; 2) negotiation of an agreement (11/06/2020); 3) praise and reinforcement for appropriate behaviors (11/06/2020); 4) provide Resident #1 an opportunity to express him/herself (11/06/2020); 5) redirect negative behaviors (11/06/2020); 6) face time calls to resident's son to facilitate adjustment (02/04/2021); 7) son to bring in personal items from home such as plants, a quilt, decorative plates (02/11/2021); 8) care givers to stop and talk to resident (03/26/2021); 9) offer pleasant diversions such as tending to plants, particularly orchids, fold clothing and put in drawers (03/24/2021); 10) care givers to provide opportunities for positive interaction (03/26/2021); 11) offer tasks which divert attention such as folding clothes, caring for plants, assisting with wiping tables or sorting (03/26/2021). Review of a Facility Investigation dated 03/24/2021 documented that at approximately 7:30 AM Resident #1 was observed outside. Video footage that was reviewed revealed that Resident #1 got onto the elevator at 7:18 AM and exited through the back door of the elevator, went the door to the loading dock and climbed over the loading dock while holding a large garbage container. Resident #1 was observed on the video to have sustained a fall, got up and subsequently picked up the garbage container which had fallen over. Facility staff intervened at that time and returned Resident #1 to the building. The Registered Nurse Supervisor (RNS) documented that Resident #1's Wanderguard was in place and functioning at the time and that vital signs were taken upon return to the unit. A Certified Nursing Assistant (CNA) documented that Resident #1 was seen on the unit at 7:15 AM. Review of a Nursing Progress Note dated 10/24/2020 documented that Resident #1 was attempting to leave the facility while carrying his/her belongings. The Wanderguard was noted to be in place. The Physician was made aware that Resident #1 did not sleep all night and the responsible party will be notified. Review of a Physician's Order dated 10/24/2020 documented that staff were to check the Wanderguard every shift for placement and every Wednesday night for function. Review of the Certified Nursing Assistant (CNA) Kardexes (record of services provided) dated October 2020, November 2020, December 2020, January 2021, February 2021, March 2021, April 2021, May 2021 and June 2021 documented that CNAs were to check the placement of the Wanderguard, provide a safe environment free from spills and/or clutter, provide supervision for transfers and ambulation, and provide extensive assistance for locomotion off the unit. Review of the CNA Accountability records dated February 2021 and March 2021 documented that Resident #1 required supervision for transfers and ambulation in the corridor. Review of Resident #1's Medication Administration Records (MARs) dated October 2020 through March 2021 documented that Resident #1's Wanderguard was checked every shift for placement. Review of Nursing Progress Note dated 10/26/2020, 10/29/2020, 10/30/2020, 11/04/2020, 11/07/2020, 11/08/2020, 11/10/2020, 11/13/2020, 11/17/2020, 11/22/2020, 11/25/2020, 11/26/2020 and 11/27/2020 all documented that Resident #1 was ambulating back and forth on the unit, confused and wanting to go home. Resident #1 expressed that he/she wanted to go home and wandered looking for exit doors. Review of a Nursing Progress Note dated 11/26/2020 documented that Resident #1 was at the elevator for an extended period of time and refused to leave. Resident #1 eventually returned to her hallway and the Supervisor was made aware. Review of Nursing Progress Notes dated 11/27/2020 and 11/28/2020 documented that Resident #1 was out of bed and wandering throughout the shift, going into other residents' rooms. Review of a Physician's Progress Note dated 10/27/2020 documented that Resident #1 was repeatedly asking to go home. The Physician discussed the concern with the Resident's son, the psychologist and requested that psychiatry evaluate the resident. Review of a Physician's Progress Note dated 11/29/2020 documented that Resident #1 spent most of the past few nights pacing the hallways and not sleeping much. The Physician's plan was to increase Resident #1's dose of [MEDICATION(S)] and to have Psychiatry follow-up regarding depression and [CONDITION(S)]. Review of a Nursing Progress Note dated 12/01/2020 documented that Resident #1 had displayed increased agitation and was screaming at staff. Also, Resident #1 went onto the elevator but was redirected with safety maintained. Review of a Behavior Note written by the Psychologist dated 1/11/2021 documented that Resident #1 was standing in an elevator on the main floor lobby, confused and disoriented. He/she was redirected back to the unit and the nursing staff was notified about the incident. The Psychologist noted that if possible, Resident #1's Wanderguard should be recalibrated to set off if and when the resident leaves the unit instead of the building. Review of a Plan of Care Note dated 1/20/2021 documented that the resident repeatedly packs up her belongings and walks on the unit. Review of a Physician's Progress Note dated 1/26/2021 documented that the resident stated he/she is not happy at the facility and wants to go home. Resident #1 was eating and sleeping well and was medically stable. Review of a Nurse's Progress Note dated 2/03/2021 documented that Resident #1 was awake and out of bed at night, stating that he/she wants to go home. Resident #1 refused to go back to bed despite encouragement so he/she continued ambulating up and down the hallway. Review of a Plan of Care Note dated 2/11/2021 documented that the Registered Nurse Manager (RNM) spoke with the Resident's son regarding Resident #1's wandering behavior and elopement risk. Resident #1 has been actively making attempts to leave. The Resident's son brought in clothes from home, decorative plates, an old quilt, and plants which the son stated to the RNM would make him/her feel more at home. Review of a Nurse's Progress Note dated 2/13/2021 documented that Resident #1 was very anxious and kept crying saying that he/she wanted to go home. Resident #1 kept going into other residents' rooms and was redirected to his/her own room by staff where he/she laid down for a nap. Review of a Social Service Progress Note dated 3/05/2021 documented that Resident #1's appears to enjoy the personal touches that his/her family brought in and has been spending more time in his/her room. Resident #1's family expressed that they were very happy with his/her care. Review of a Nurse's Note dated 3/13/2021 document that the resident was confused and crying, getting on the elevator with another resident, trying to go onto other floors. Staff will continue to monitor and keep resident safe. The Wanderguard was noted to be on Resident #1's ankle. Review of the Psychiatrist Evaluation dated 3/18/2021 documented that Resident #1 had a long history of depression, agitation, anxiety, and dementia with behaviors. The evaluation also noted that Resident #1 was presenting as confused and labile with frequent disruptive vocalizations. A Nurse's Note dated 3/20/2021 documented that Resident #1 was observed walking in the hallway stating that he/she wants to go home. Review of a Nurse's Note dated 3/24/2021 documented that the resident was awake throughout the night, walking up and down the hallways, very weepy with occasional crying. Resident #1 stated that he/she wanted to go home and had multiple attempts to go on the elevator. Redirection was applied and the resident's safety was maintained. On 6/15/2021 at 9:30AM, an interview was conducted with the Certified Nursing Assistant (CNA #1). CNA #1 stated that he/she was walking past a window in the day room and saw Resident #1 outside. CNA #1 then ran outside with another CNA and a nurse to check on the resident and bring him/her back inside. CNA #1 stated that there were no alarms on the elevators, no alarms sounded and nobody noticed the resident was missing. On 6/15/2021 at 11:45AM, an interview was conducted with the Licensed Practical Nurse (LPN #1). The LPN stated that as he/she was getting morning report at the nurse's station, he/she heard an alarm and the staff immediately began to look for the resident. He/she stated that Resident #1 had a history of wandering and exit seeking and that the staff redirects him/her. He/she stated that at the time of the incident, there was no alarm on the elevator, but the exterior doors were alarmed. LPN #1 also stated that he/she thinks the alarm rang because staff ran through the alarmed exterior door when they went to assist the resident in the parking lot, after seeing the resident through the window. On 6/15/2021 at 7:45AM, an interview was conducted with Receptionist #1. The Receptionist stated that if he/she saw a resident in the lobby he/she checked the elopement list (a binder of residents who are at risk for elopement) to see if the resident was at risk for elopement and notifies the nurse immediately. Receptionist #1 shared that after the incident with Resident #1 a new alarm system was activated where he/she can see on a computer screen if any Wanderguards have gone through an alarmed exit. The screen also shows the name assigned to the Wanderguard. On 6/15/2021 at 8:00AM, an interview was conducted with the Registered Nurse Supervisor (RNS #1). RNS #1 stated that when Resident #1 eloped, the elevators were not alarmed. RNS #1 stated that the resident was able to go onto the elevator, through the back door of the elevator and go outside through the loading dock curtained door. RNS #1 stated that it had never happened before in all the years he/she had worked at the facility. RNS #1 further stated that now the elevator's back door and loading dock curtained door have been locked. Also there were alarms enabled on the elevators. On 6/15/2021 at 10:30AM, an interview was conducted with the Assistant Director of Nursing (ADON #1). ADON #1 stated that at the time of the incident, the elevators and the loading dock curtain door were not alarmed, and the back door of the elevator was not alarmed or locked. ADON #1 added that after the elopement incident with Resident #1, alarms were installed in the elevators as well as the elevator back door and that the loading dock curtain doors were locked. ADON #1 stated that a resident could go to another floor, but the exterior doors were alarmed. ADON #1 also added that there was no specific documentation for frequency of safety checks, and that the nurses were responsible to document resident behaviors and methods of redirection in the Nurse's Notes. On 6/15/2021 at 8:30AM, an interview was conducted with the Director of Nursing (DON #1). DON #1 stated that prior to the incident, the elevator back door and the loading dock curtain door were not alarmed. However, after the incident they were locked, and alarms were placed on the elevators. On 6/15/2021 at 11:00AM, an interview was conducted with the Director of Building Services (DBS #1). DBS #1 stated that the previously existing alarms included both exterior lobby doors, the exterior clock-in door, the exterior clock-out door, stairway #1, stairway #2, stairway #3 on the first, second, and third floors, kitchen/loading dock door and the first floor dining room exterior doors. He/she stated that the back door to the elevator was not previously locked, the loading dock curtain door was not previously alarmed, and there were no Wanderguard alarms on the elevators. DBS #1 stated that he/she installed a temporary alarm to the elevator and locked the loading dock curtain door as well as locked the elevator back door. DBS #1 stated that the alarm company installed permanent alarms to the elevators, the exterior door to the parking lot and the interior doors to the first floor dining room., DBS #1 stated that all the doors and elevator alarms in the facility are checked daily for functioning. On 6/15/2021 at 10:45AM, an interview was conducted with the facility Administrator. The Administrator stated that prior to the incident, the exterior front doors and first floor dining room exterior doors were alarmed but there were no alarms on the elevators or to the loading dock curtain door. The Administrator further stated that the back door of the elevator was not locked. He/she stated that after Resident #1's elopement incident, temporary alarms were placed on the elevators. The Administrator assed that the alarm company installed strobe lights and alarm panels at the loading dock curtain door as well as Wanderguard alarms on the elevators. The back door of the elevator was to be locked. An interview was conducted with the ADON #1 on 7/01/2021 at 2:45PM. ADON #1 stated that the staff were unaware of the Psychologist's recommendation to recalibrate the resident's wander guard to set off when [he/she] leaves the unit perimeter instead of the building 415.12(h)(1)

Based on interviews and record reviews conducted during an Abbreviated Survey (NY 635) it could not be ensured that the facility staff followed a resident's advanced directives. Specifically, 1 of 8 residents (Resident #1) reviewed for advance directives had Do Not Resuscitate (DNR) and Do No Intubate (DNI) orders in place which was not executed when the resident was found unresponsive without vital signs. The facility staff performed CPR which contradicted the resident's/representative's DNR wishes. The findings are: Resident #1 was a [AGE] year old who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the [DATE] 5-day Minimum Data Set (MDS; a resident assessment tool), the resident had a Brief Mental Interview Status (BIMS) score of ,d+[DATE] which indicated severe impaired cognition and required extensive assistance of staff support with Activities of Daily Living (ADLs). Review of a Medical Orders for Life-Sustaining Treatment (MOLST) consent dated [DATE] and signed by the physician on [DATE], documented specific instructions for DNR (Do Not Resuscitate - do not begin Cardio-Pulmonary Resuscitation (CPR) to make the heart or breathing start again if either stops; allow natural death); DNI (Do Not Intubate - do not place a tube down the patient's throat or connect to a breathing machine that pumps air into and out of lungs); no tube feeding, send to hospital if necessary, use a trial of IV fluids, and the use of antibiotics to treat infections, if medically indicated. Check ID band every shift. Review of Resident #1's Medication Administration Records (MARs) dated ,d+[DATE]-,d+[DATE] revealed staff signatures on all shifts from ,d+[DATE]-,d+[DATE], indicating that the Resident #1's ID band was checked according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of an Advanced Directives Care Plan initiated [DATE] documented that the resident had a health care proxy, MOLST directives included DNR/DNI, no feeding tube, trial of IVs, use of antibiotic (ABT), and send to hospital. A copy of each advance directive is to be in the resident's record. The directives are to be reviewed quarterly as to the continuation of the directives executed. Re-education of directives to be done as needed. Review of the facility's Policy/Procedure for New Admissions from the Hospital revised [DATE] included the following actions: 1. check hospital records for signed DNR directives on admission. If present place in front of the chart x 72 hours or until signed facility DNR is obtained. If resident is competent, initiate the MOLST. 2. Obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Place an orange dot sticker on the resident's name label on the side/spine of the chart (indicative of DNR). 4. Place an orange bracelet on the resident (indicative of DNR). 5. Document the hospital DNR on the 24-hour report and verbally communicate it to the on-coming nurse during shift report. An Advanced Directives Policy/Procedures revised [DATE] documented specific actions for the social worker to meet with the resident/representative after admission to review and confirm any existing Advance Directives/MOLST. Communication of Advanced Directives involved: If the resident has a DNR, an identifier in the form of an orange band will be placed on the resident. This signifies advance directive of DNR. An orange dot will be placed on the resident's chart. This signifies advance directive of DNR. On the hard paper chart, the DNR will be located on the face sheet. The MOLST is located in the Social Service section of the chart. This signifies advance directive of DNR. If the resident has a DNR, electronic identifiers will be placed in the electronic medical record (EMR). According to an investigative report signed by the Administrator, at approximately 8:45AM on [DATE] a code blue (indicating an emergency) was announced for a unit. A Registered Nurse Supervisor (RN #1) reported to the unit and upon arrival, inquired if the resident was full code to which she was told yes. Upon RN #1's arrival to the resident's room, LPN #1 had already retrieved the crash cart and initiated CPR with the assistance of LPN #2. RN #1 did not check the resident's code status. LPN #1, who had called the code, related to RN #1 that Resident #1 was not breathing. LPN #1 stated that she checked the paper chart for the DNR dot but did not see one. The report stated LPN #2 also stated that there was no dot on the resident's room indicating DNR. She also did not recall seeing a DNR bracelet on the resident. Upon arrival of the Emergency Medical Service (EMS), in less than five minutes, LPN #2 went to gather paperwork for the hospital transfer, and at that time it was recognized that Resident #1 was DNR. The report further stated that upon review of the MOLST and that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff did not follow facility Policy/Procedure for a resident with a DNR status. There was no orange bracelet on Resident #1 or orange dot on the spine of the resident's chart. Staff did not review the Electronic Medical Record (EMR) for code status. Resident #1 had Advanced Directives Do Not Resuscitate (DNR) and Do No Intubate (DNI) orders in place which was not executed when the resident was found unresponsive without vital signs. The facility performed CPR which contradicted the resident's/representative's DNR wishes. There was no documented evidence that a DNR arm bracelet was applied to the resident, nor was there documented evidence that a DNR dot sticker was affixed to the resident's cart to communicate the resident's DNR status. The ,d+[DATE]-,d+[DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired in the facility on [DATE]. In an interview with Certified Nursing Assistant (CNA #1) on [DATE] at 2:09PM, she stated that she was on the unit the day the resident expired but was not involved in CPR/Emergency Medical Service (EMS) process. She stated she was unsure if Resident #1 wore an orange bracelet or if he was DNR. CNA #1 stated that residents who are DNR wore orange color bracelets to signify DNR status which means do not resuscitate. If a resident was not breathing, she would call for the nurse right away. CNA #1 stated orange dots are also placed on the residents' charts if they are DNR. During an interview with the Administrator on [DATE] at 2:35PM, he stated that LPN #1 found Resident #1 without vital signs on the morning of [DATE]. The Administrator explained that Resident #1 was new to facility as he was admitted on [DATE]. He stated that a resident's code status is to be established on admission, no later than the next day. If a resident was admitted after hours, the admitting Registered Nurse (RN) is responsible to establish a resident's code status and apply the applicable DNR identifiers. During working hours, the Social Worker is responsible to ascertain residents' DNR status and apply the applicable DNR identifiers. The Administrator stated criteria used to communicate DNR status involved the MOLST, an orange arm bracelet and an orange dot sticker on the chart. He stated when Resident #1 was found unresponsive without vital signs, he did not have an orange bracelet in place nor was there an orange dot sticker on the chart to indicate that Resident #1 was DNR. The Administrator stated that he was unsure if Resident #1 was capable of removing his arm bracelet. He explained that there was no documented evidence that the orange bracelet or orange dot sticker were applied to the resident or the chart respectively. The Administrator stated the social worker told him that she applied the orange bracelet to Resident #1 on [DATE] but did not know how it came off. The Administrator stated that the facility did not follow the facility protocol. During an interview with the Social Worker (SW) on [DATE] at 3:05PM, she stated that she was assigned to Resident #1 who was admitted sometime in [DATE]. The SW stated that Resident #1 was lethargic and was unable to provide information. She stated that on the day of admission, she spoke to Resident #1's daughter, who was his health care proxy, about his condition and advanced directives. The SW further stated that she was responsible for initiating advance directives. The SW stated that Resident #1's daughter wanted him DNR; telephone consent was obtained and witnessed by another staff member. The SW stated that after she had obtained the resident's DNR status, she put the information in the computer for the resident's physician to sign. She also stated that she flagged the chart for the doctor to sign the consent form, then wrote her admission note. The SW stated that she was responsible for applying the orange bracelet to Resident #1's arm which signified that he was DNR status. She stated that it was a nursing responsibility to apply the orange dot sticker on the chart. The SW stated that she applied the orange bracelet to Resident's #1 arm on the same day she obtained the orders. The SW said that she did not know how the bracelet as Resident #1 was not capable of removing it. In a telephone interview with the Attending Physician (AP) on [DATE] at 4:51PM, she stated the resident was admitted from the hospital related to new onset of [CONDITION(S)], and dementia and that she did not know the resident prior. The AP stated when she saw the resident initially, he was unable to answer questions, he was lethargic, but she had no baseline information to compare his status. The AP stated the resident was also evaluated by a Nurse Practitioner (NP) and there was nothing outstanding. The AP stated that she received a call on [DATE] that Resident #1 had passed from [CONDITION(S)]. The AP stated that Resident #1 was DNR. She was unaware that the facility attempted CPR. In a telephone interview with LPN #1 on [DATE] at 5:03PM, she stated that she had discovered Resident #1 unresponsive and without vital signs on the day he expired. LPN #1 stated that on [DATE], prior to his death, the resident was lethargic. LPN #1 was asked if she knew the resident was DNR prior to his death to which she stated she was not aware he was DNR. LPN #1 stated on [DATE], Sunday, at 7:30AM she arrived for duty. LPN #1 stated that at about 8:30AM she went to Resident #1's room to obtain his vital signs. When she checked the pulse, it was absent. She ran out of the room to call a code and to check the chart for DNR. LPN #1 stated there was no orange dot sticker on the chart, and there was no MOLST in the advanced directive section of the chart. LPN #1 stated she did not check other areas for identifiers because of wasted time that would have affected the CPR process. LPN #1 stated she went back to perform CPR on the resident. LPN #1 stated shortly after that a co-worker said the resident was DNR. LPN #1 was asked if the resident had a DNR ID band in place prior to and on the day of his death to which she responded that she did not recall. In a telephone interview with Registered Nurse Supervisor (RN #2) on [DATE] at 10:13AM, she stated that she conducted Resident #1's admission assessment. RN #2 stated that she was unsure if Resident #1 was admitted in DNR status. She stated when a resident is admitted and the RN receives a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 stated the Social Worker is responsible for obtaining advanced directives. RN #2 stated she did not receive DNR information or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did not apply any DNR information to the resident. 415.3 (e) (1) (i)

Based on interviews and record reviews conducted during an Abbreviated Survey (NY 635) it could not be ensured that the facility staff followed a resident's advanced directives. Specifically, 1 of 8 residents (Resident #1) reviewed for advance directives had Do Not Resuscitate (DNR) and Do No Intubate (DNI) orders in place which was not executed when the resident was found unresponsive without vital signs. The facility staff performed CPR which contradicted the resident's/representative's DNR wishes. The findings are: Resident #1 was a [AGE] year old who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the [DATE] 5-day Minimum Data Set (MDS; a resident assessment tool), the resident had a Brief Mental Interview Status (BIMS) score of ,[DATE] which indicated severe impaired cognition and required extensive assistance of staff support with Activities of Daily Living (ADLs). Review of a Medical Orders for Life-Sustaining Treatment (MOLST) consent dated [DATE] and signed by the physician on [DATE], documented specific instructions for DNR (Do Not Resuscitate - do not begin Cardio-Pulmonary Resuscitation (CPR) to make the heart or breathing start again if either stops; allow natural death); DNI (Do Not Intubate - do not place a tube down the patient's throat or connect to a breathing machine that pumps air into and out of lungs); no tube feeding, send to hospital if necessary, use a trial of IV fluids, and the use of antibiotics to treat infections, if medically indicated. Check ID band every shift. Review of Resident #1's Medication Administration Records (MARs) dated ,[DATE]-,[DATE] revealed staff signatures on all shifts from ,[DATE]-,[DATE], indicating that the Resident #1's ID band was checked according to the physician's orders [REDACTED]. Review of an Advanced Directives Care Plan initiated [DATE] documented that the resident had a health care proxy, MOLST directives included DNR/DNI, no feeding tube, trial of IVs, use of antibiotic (ABT), and send to hospital. A copy of each advance directive is to be in the resident's record. The directives are to be reviewed quarterly as to the continuation of the directives executed. Re-education of directives to be done as needed. Review of the facility's Policy/Procedure for New Admissions from the Hospital revised [DATE] included the following actions: 1. check hospital records for signed DNR directives on admission. If present place in front of the chart x 72 hours or until signed facility DNR is obtained. If resident is competent, initiate the MOLST. 2. Obtain an order for [REDACTED]. 4. Place an orange bracelet on the resident (indicative of DNR). 5. Document the hospital DNR on the 24-hour report and verbally communicate it to the on-coming nurse during shift report. An Advanced Directives Policy/Procedures revised [DATE] documented specific actions for the social worker to meet with the resident/representative after admission to review and confirm any existing Advance Directives/MOLST. Communication of Advanced Directives involved: If the resident has a DNR, an identifier in the form of an orange band will be placed on the resident. This signifies advance directive of DNR. An orange dot will be placed on the resident's chart. This signifies advance directive of DNR. On the hard paper chart, the DNR will be located on the face sheet. The MOLST is located in the Social Service section of the chart. This signifies advance directive of DNR. If the resident has a DNR, electronic identifiers will be placed in the electronic medical record (EMR). According to an investigative report signed by the Administrator, at approximately 8:45AM on [DATE] a code blue (indicating an emergency) was announced for a unit. A Registered Nurse Supervisor (RN #1) reported to the unit and upon arrival, inquired if the resident was full code to which she was told yes. Upon RN #1's arrival to the resident's room, LPN #1 had already retrieved the crash cart and initiated CPR with the assistance of LPN #2. RN #1 did not check the resident's code status. LPN #1, who had called the code, related to RN #1 that Resident #1 was not breathing. LPN #1 stated that she checked the paper chart for the DNR dot but did not see one. The report stated LPN #2 also stated that there was no dot on the resident's room indicating DNR. She also did not recall seeing a DNR bracelet on the resident. Upon arrival of the Emergency Medical Service (EMS), in less than five minutes, LPN #2 went to gather paperwork for the hospital transfer, and at that time it was recognized that Resident #1 was DNR. The report further stated that upon review of the MOLST and that physician's orders [REDACTED]. Staff did not follow facility Policy/Procedure for a resident with a DNR status. There was no orange bracelet on Resident #1 or orange dot on the spine of the resident's chart. Staff did not review the Electronic Medical Record (EMR) for code status. Resident #1 had Advanced Directives Do Not Resuscitate (DNR) and Do No Intubate (DNI) orders in place which was not executed when the resident was found unresponsive without vital signs. The facility performed CPR which contradicted the resident's/representative's DNR wishes. There was no documented evidence that a DNR arm bracelet was applied to the resident, nor was there documented evidence that a DNR dot sticker was affixed to the resident's cart to communicate the resident's DNR status. The ,[DATE]-,[DATE] MAR indicated [REDACTED]. The physician's orders [REDACTED]. The resident expired in the facility on [DATE]. In an interview with Certified Nursing Assistant (CNA #1) on [DATE] at 2:09PM, she stated that she was on the unit the day the resident expired but was not involved in CPR/Emergency Medical Service (EMS) process. She stated she was unsure if Resident #1 wore an orange bracelet or if he was DNR. CNA #1 stated that residents who are DNR wore orange color bracelets to signify DNR status which means do not resuscitate. If a resident was not breathing, she would call for the nurse right away. CNA #1 stated orange dots are also placed on the residents' charts if they are DNR. During an interview with the Administrator on [DATE] at 2:35PM, he stated that LPN #1 found Resident #1 without vital signs on the morning of [DATE]. The Administrator explained that Resident #1 was new to facility as he was admitted on [DATE]. He stated that a resident's code status is to be established on admission, no later than the next day. If a resident was admitted after hours, the admitting Registered Nurse (RN) is responsible to establish a resident's code status and apply the applicable DNR identifiers. During working hours, the Social Worker is responsible to ascertain residents' DNR status and apply the applicable DNR identifiers. The Administrator stated criteria used to communicate DNR status involved the MOLST, an orange arm bracelet and an orange dot sticker on the chart. He stated when Resident #1 was found unresponsive without vital signs, he did not have an orange bracelet in place nor was there an orange dot sticker on the chart to indicate that Resident #1 was DNR. The Administrator stated that he was unsure if Resident #1 was capable of removing his arm bracelet. He explained that there was no documented evidence that the orange bracelet or orange dot sticker were applied to the resident or the chart respectively. The Administrator stated the social worker told him that she applied the orange bracelet to Resident #1 on [DATE] but did not know how it came off. The Administrator stated that the facility did not follow the facility protocol. During an interview with the Social Worker (SW) on [DATE] at 3:05PM, she stated that she was assigned to Resident #1 who was admitted sometime in [DATE]. The SW stated that Resident #1 was lethargic and was unable to provide information. She stated that on the day of admission, she spoke to Resident #1's daughter, who was his health care proxy, about his condition and advanced directives. The SW further stated that she was responsible for initiating advance directives. The SW stated that Resident #1's daughter wanted him DNR; telephone consent was obtained and witnessed by another staff member. The SW stated that after she had obtained the resident's DNR status, she put the information in the computer for the resident's physician to sign. She also stated that she flagged the chart for the doctor to sign the consent form, then wrote her admission note. The SW stated that she was responsible for applying the orange bracelet to Resident #1's arm which signified that he was DNR status. She stated that it was a nursing responsibility to apply the orange dot sticker on the chart. The SW stated that she applied the orange bracelet to Resident's #1 arm on the same day she obtained the orders. The SW said that she did not know how the bracelet as Resident #1 was not capable of removing it. In a telephone interview with the Attending Physician (AP) on [DATE] at 4:51PM, she stated the resident was admitted from the hospital related to new onset of [MEDICAL CONDITION], and dementia and that she did not know the resident prior. The AP stated when she saw the resident initially, he was unable to answer questions, he was lethargic, but she had no baseline information to compare his status. The AP stated the resident was also evaluated by a Nurse Practitioner (NP) and there was nothing outstanding. The AP stated that she received a call on [DATE] that Resident #1 had passed from [MEDICAL CONDITION]. The AP stated that Resident #1 was DNR. She was unaware that the facility attempted CPR. In a telephone interview with LPN #1 on [DATE] at 5:03PM, she stated that she had discovered Resident #1 unresponsive and without vital signs on the day he expired. LPN #1 stated that on [DATE], prior to his death, the resident was lethargic. LPN #1 was asked if she knew the resident was DNR prior to his death to which she stated she was not aware he was DNR. LPN #1 stated on [DATE], Sunday, at 7:30AM she arrived for duty. LPN #1 stated that at about 8:30AM she went to Resident #1's room to obtain his vital signs. When she checked the pulse, it was absent. She ran out of the room to call a code and to check the chart for DNR. LPN #1 stated there was no orange dot sticker on the chart, and there was no MOLST in the advanced directive section of the chart. LPN #1 stated she did not check other areas for identifiers because of wasted time that would have affected the CPR process. LPN #1 stated she went back to perform CPR on the resident. LPN #1 stated shortly after that a co-worker said the resident was DNR. LPN #1 was asked if the resident had a DNR ID band in place prior to and on the day of his death to which she responded that she did not recall. In a telephone interview with Registered Nurse Supervisor (RN #2) on [DATE] at 10:13AM, she stated that she conducted Resident #1's admission assessment. RN #2 stated that she was unsure if Resident #1 was admitted in DNR status. She stated when a resident is admitted and the RN receives a physician's orders [REDACTED]. and one to the resident's door, indicating DNR status. RN #2 stated the Social Worker is responsible for obtaining advanced directives. RN #2 stated she did not receive DNR information or a physician's orders [REDACTED].#1 on the day of admission. She stated she did not apply any DNR information to the resident. 415.3 (e) (1) (i)

Based on observations, interviews and record review conducted during a recertification survey the facility did not ensure a person-centered comprehensive care plan was developed and/or implemented to meet the resident's medical, physical, mental and psychosocial needs. Specifically, 1) a care plan was not developed for 1 of 3 residents (#53) reviewed for range of motion (ROM), and 2) the care plan was not implemented as per physician's orders [REDACTED].#35) reviewed for respiratory care. The findings are: 1. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] and Quarterly MDS dated [DATE] indicated that Resident #53 had cognitive impairment, received extensive assist by 2 staff for bed mobility, transfers, eating and toilet use. Furthermore, Resident #53 had an impairment on one side upper extremity, no lower extremity impairment and received occupational as well as physical therapies. Care Plans reviewed revealed there were no care plans in place to address the upper extremity impairment for resident #53. The 7/24/2020 physician's orders [REDACTED]. Interview on 10/2/20 at 12:15PM with the Registered Nurse Unit Manager (RNUM #2), she indicated she was responsible for development of care plans to address the limited range of motion care area. After checking the resident medical record she indicated a limited range of motion care plan had not been developed. The September 2020 Certified Nursing Assistant (CNA) task record indicated for Resident #53 to weight bear as tolerated on the right wrist and hand. Range of motion (ROM) is permitted on the right upper extremity (RUE). 2. Resident #35 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/19/20 Significant Change and 8/18/2020 MDS indicated that Resident #35 had severe cognitive impairment. Review of the 8/19/2020 Physician order [REDACTED]. If SP02 is measured to be less than 92%, apply oxygen (O2) at 2 liters per minute (LPM). The 8/2/2018 Care Plan titled, Altered Respiratory Status Related to Asthma had a 3/3/2020 intervention for the use of O2 at 2LPM via nasal cannula (n/c) if SPO2 less than 92%. The 8/19/2020 Care Plan titled, Resident Will Be Monitored for Shortness of Breath (SOB) and Desaturation related to asthma and as needed (PRN) oxygen use had an intervention for monitoring SPO2 and administration of O2 as per MD order. Review of the Treatment Administration Record (TAR) indicated that staff are to check SP02 every shift. If the SPO2 is less than/equal to 92%, apply O2 at 2LPM via N/C. Documentation on 9/29/2020 and 10/2/2020 indicated oxygen via N/C at 2LPM was administered with an oxygen saturation above 92%. Observation on 9/29/20 at 08:41AM, 12:00PM and 2:30PM and 10/2/20 at 10:00AM revealed resident #35 receiving oxygen via n/c at 2LPM. During an interview on 10/2/20 at 10:05AM with Licensed Practical Nurse (LPN #1), she stated she had not yet checked the resident O2 sat this tour. When asked why the resident was using O2 for a sat above 92% she stated the resident would like to use the oxygen and can make simple needs known. She stated she should have let the nurse manager or physician know that the resident is requesting to use oxygen have the order changed. During an interview on 10/2/20 at 10:10AM with the Registered Nurse Unit Manager (RNUM #1), she stated the resident should not use oxygen unless the O2 saturation is lower than 92%. She further stated she continues to educate the nurses on the importance of checking physician's orders [REDACTED]. 415.11(c)(1)

F919 Based on observation, record review and interview conducted during a recertification survey, it could not be ensured that the facility maintained the resident call bell system in proper working order. Specifically, the call bell system on the 1st floor was unable to be heard clearly at the nurses' station when the call bells were activated from residents' rooms. Findings are: Review of the facility's Policy and Procedure for Call Bell System dated 10/2019 indicated that a system can be accessed on each unit. Items identified for correction will be entered onto TELS (Maintenance Management Program) so it can be identified and fixed. During observation on 10/2/2020 at 9:55am and 10:08am on the 1st floor, the call bell was activated in rooms [ROOM NUMBERS] by staff and could not be heard clearly in all areas of the nurse's station. Subsequently, the Director of Maintenance activated the call bell in room [ROOM NUMBER]A, and could not be heard clearly in all areas of the nurse's station. During surveyor interview with the Director of Maintenance at 10:10am, he indicated that the call bell usually rings louder. He further explained that the facility does not conduct any preventive maintenance on the call bells. He stated that if the call beels malfunction, the company is contacted. He explained that he will contact the company to initiate repair of the call bells. Interview with the LPN 10:12am and 10:28am indicated that the auditory indicator of the call bell system cannot be heard clearly. She explained that that she usually uses the lights to identify when a resident activates the call bell. She further indicated that if she is on one side of the unit she can't hear or see if a resident on other side has activated the bell until she returns to the nurse's station or walks down to that side of the hall. 415.29

F657 Based on record review and interview conducted during a recertification survey, it cannot be ensured that the facility reviewed and revised Comprehensive Care Plans with measurable objectives, timeframes and appropriate interventions for 1 of 1 residents (#44) reviewed for prevention of further decline and/or potential restoration of urinary continence to the extent possible. The findings are: Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/3/2020 Annual and 8/26/2020 Quarterly Minimum Data Set Assessment (MDS) indicated that Resident #44 had severe cognitive impairment, required supervision for toileting and had occasional incontinence of bladder. The 11/19/2019 Bowel and Bladder evaluation indicated that Resident #44 is continent of bladder. The 07/23/2020 Bowel and Bladder evaluation indicated that Resident #44 is incontinent of bladder. The 08/26/2020 Bowel and Bladder evaluation indicated resident #44 is continent of bladder. The Patient-Centered Care Plan dated 2/8/2018 and titled Resident has Potential for Bladder Incontinence Related to Disease Process, Impaired Mobility, Medication Side Effects, But Resident is Mostly Continent had a goal for the resident to be continent at all times, through the review date. The plan notes interventions including to notify nursing if incontinent during activities, ensure unobstructed path to the bathroom and the resident is to inform staff of toileting needs on the overnight shift. The care plan did not show interventions to promote continence/and or prevent further decline in continence. An interview was conducted on 10/2/2020 at 10:18AM with the Registered Nurse Unit Manager (RNUM #1) where she indicated that she thought the resident knew when she had to go to the bathroom. She stated she had not updated the bladder incontinence care plan to include individualized interventions to restore bladder function and/or to prevent further urinary function decline. An interview was conducted on 10/2/2020 at 11:15AM with Certified Nursing Assistant (CNA #3). She indicated that the resident was incontinent of urine at times. She indicated the resident wets the protective undergarments and the floor. CNA #3 also stated that sometimes Resident #44 knows when she needs to be toileted. She stated that the resident is not currently on a toileting schedule. 415.11(c)(2)(i-iii)