Every finding on record at Cypress Garden Center for Nursing and Rehabilitati

Based on observation, record review, and interviews during the abbreviated survey (NY00375573), the facility failed to ensure a resident was protected from abuse of any kind by anyone. This was evident for one (1) out of five (5) residents (Resident #1). Specifically, on 3/19/2025 Licensed Practical Nurse (#1) pulled Resident #1 on to and off the elevator. This was witnessed by Certified Nursing Assistants # 1, #2, Security Guard #1, and Registered Nurse Supervisor #1. The findings are: The facility's Policy and Procedure titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident's Property, dated 03/20/2025, documented the purpose of the policy is to ensure a resident was protected from abuse of any kind by anyone. The policy stated abuse does not have to be intentional and can still be considered abuse if the potential for harm is present. The policy defines willful as acting deliberately, not that the individual must have intended to inflict injury or harm. The facility's Summary of Investigation dated 03/21/2025, documented that on 03/19/2025, at approximately 10:16 PM, Resident #1 was in the hallway of the first-floor lobby with the assigned Certified Nursing Assistant #1, Registered Nurse Supervisor #1 and Certified Nursing Assistant #2 who were encouraging Resident #1 to return to their floor. Licensed Practical Nurse #1, the Charge nurse on Resident #1's floor was returning from their break, and they took Resident #1's hand as Resident #1 became combative, Licensed Practical Nurse #1 pulled Resident #1 towards and into the elevator while Resident #1 remained combative. Resident #1 was admitted to the facility with a diagnosis of Hemiplegia post Cerebral Infarction, Anxiety Disorder and Depression. The Minimum Data Set (an assessment tool) dated 03/13/2025, documented Resident #1 as severely cognitively impaired. The facility's Video Surveillance Camera footage was viewed 03/31/2025 at 12:08 PM, showed the first-floor lobby of the facility on 03/19/2025. There was no audio and time on video starts at 9:13 PM, the actual time was 10:13 PM. Certified Nursing Assistants # 1, # 2, Security Guard #1, and Registered Nurse Supervisor #1 were in the lobby trying to redirect Resident #1 verbally, no touching was observed. At 9:16 PM video time (actual / real time was 10:16 PM), Licensed Practical Nurse #1 entered the lobby area, spoke to the staff that was already present, then suddenly grabs at Resident #1 who becomes combative. Licensed Practical Nurse #1 was seen pulling Resident #1 into the elevator, Resident #1 tumbled and was observed seated on the elevator floor. Certified Nursing Assistants # 1, #2 are also in the elevator. The elevator door opened on the Resident #1's floor and Licensed Practical Nurse #1 was seen helping Resident #1 up from the elevator floor and pulled Resident #1 along the floor and out of the elevator. The elevator door closes and the video ends. Care Plans for Risk for Abuse initiated on 09/16/2022 due to physical limitation and disorientation were reviewed and included interventions. Behavior Care plan updated 10/11/2024, documented increasing aggressiveness. Interventions included room changes and increase in anxiety medication in addition to non-pharmacological interventions. Physician Order dated 02/26/2025-03/21/2025, documented monitoring for altered mental status and informing the physician. As of 03/20/2025 wander-guard (wander assistive device) was ordered and visual monitoring every 30 minutes for three days. Statement of Occurrence dated 03/19/2025, documented Licensed Practical Nurse #1 was the nurse on duty on 03/19/2025. Licensed Practical Nurse #1 stated they observed Resident #1 on the first floor being aggressive and they took Resident #1's arm and escorted Resident #1 to the elevator. While in the elevator Resident #1 continued punching and kicking. On the unit Resident #1 was given some juice. During a telephone interview on 04/01/2025 at 10:56 AM, Registered Nurse Supervisor #1 stated they were one of two nurse supervisors on the evening shift on 03/19/2025. One of the Certified Nursing Assistant called them to the lobby asking for help with Resident #1. A family or a translator was not called while they were in the lobby as Resident #1 understood gestures and some English. They used gestures and a popsicle to encourage Resident #1 to cooperate. Resident #1 was just standing there, and they decided they would just wait. Licensed Practical Nurse #1 came from the outside and approached Resident #1 and held Resident #1 by the arm as Resident #1 became combative. Licensed Practical Nurse #1 started to pull Resident #1 towards the elevator, and they (Nurse Supervisor #1) were in shock, it was so fast. Licensed Practical Nurse #1 pulled Resident #1 into the elevator and closed the door. The Nurse Supervisor #2 was informed what happened and went to assess Resident #1. The Administrator was informed. The family was called, and the adult child translated. Resident #1 denied that anything happened, and that they had no pain, The family and Resident #1 refused transfer to the emergency room . Licensed Practical Nurse #1was escorted out of the building by the security guard after writing a statement and the Registered Nurse Supervisor #1 are also suspended. During a telephone interview on 04/01/2025 at 11: 58 AM, Certified Nursing Assistant # 1 stated they are still out on suspension. Certified Nursing Assistant #1 stated they knew Resident #1 from another unit and was assigned to Resident #1 on 03/19/2025 during the evening shift. Resident #1 was restless and was trying to go downstairs several times and at one point left the floor. Certified Nursing Assistant (#2) assisted them searching for the resident. The resident was found in the lobby, and we were offering food for cooperation to go upstairs. Certified Nursing Assistant (#1) called the Nurse Supervisor (#1) requesting assistance. Certified Nursing Assistant (#1) stated if we touched the resident, we knew the resident would have become combative. Also stated all staff had in services they tell us to talk calmly, not to touch them when agitated. When the Licensed Practical Nurse #1 arrived, the resident was told to go back upstairs. The nurse was trying to touch the resident, and the resident was pushing back. The nurse tried to hold the resident's arm, and the resident was being combative. The nurse held the resident and pulled the resident into the elevator. When in the elevator the resident fell on the floor. On [NAME] resident's floor the nurse was holding the resident's arm, and the resident was still fighting. The nurse pulled the resident by the arm out of the elevator along the floor. During Surveyor interview with Resident #1 via Mandarin speaking translator on 03/31/2025 at 11:45 AM, Resident #1 stated no one hurting them and did not recall the incident. During an interview on 04/01/2025 at 5:10 PM, the Administrator stated Registered Nurse Supervisor #1 informed them at about 10:21 PM on 03/19/2025, Licensed Practical Nurse #1 dragged Resident #1 into the elevator as seen on the footage. They directed the Registered Nurse Supervisor #1 to have Resident #1 assessed and remove Licensed Practical Nurse #1 immediately. The Administrator stated the Registered Nurse Supervisor #1 did not intervene and stated it was due to the shock factor. Licensed Practical Nurse #1 wrote a statement and left the facility escorted by security. The Administrator stated they called the Nurse Supervisor #2 and the Director of Nursing to ensure that everything requested was done. The police were called and responded realized Resident #1 had no capacity they asked to see the footage on 03/20/2025. The officers reviewed the footage on 03/20/2025 and spoke with their sergeant. They also requested the family contact information. Immediate interventions were started as stated in the corrective actions below. 10 NYCRR 415.11(c)(3)(i) Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement on 03/23/2025, prior to and during the time of this survey. A Plan of Correction was not required for this citation. The facility took corrective actions and was found to be in substantial compliance prior to the surveyor's onsite visit on 3/31/2025. 1. The facility immediately assessed Resident #1. There were no visible injuries. 2. Licensed Practical Nurse #1 was removed immediately from the facility and reported to New York State Office of Professions (Nursing). The Registered Nurse Supervisor #1 and Certified Nursing Assistants #1 and #2 were suspended until the investigation was completed. 3. The New York City Police Department local precinct 109 was informed on 03/19/2025. The Video footage viewed by the police officers on 3/20/2025. 4. The facility's Policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation was reviewed and no revision was needed. 5. The Facility provided in-services on Abuse/Neglect/Mistreatment, Abuse Prevention/ Prohibition and Management of Residents with Behavioral Issues started on the night shift on 03/19/2025. 6. An Ad hoc Quality Assurance Performance Improvement meeting with all department heads was held on 03/20/2025 and the video footage was shown. 7. On 03/20/2025, the in- service of all staff on abuse was initiated, any one out on vacation were called and given a brief version of the lesson plan. 8. 180 Nursing staff (100%) staff were in-serviced to date. 9. Abuse Drill was conducted on 03/23/2025, during the 7AM-3PM shift and will be ongoing. Currently on second round of drills. Since the drill Certified Nursing Assistant have been prompted to question how to handle some behavioral issues. Staff unit discussions are being encouraged. 10. The facility staff completed questionnaires on abuse after in-services and drills. 11. QAPI meetings are held quarterly, the next meeting is scheduled for the second week of April. 12. During interview on 04/01/2025, Licensed Practical Nurses and Certified Nursing Assistants stated understan

Based on observations and staff interviews during the re-certification survey, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of resident equipment layered with dirt and dust, room furniture heavily worn and torn seat cushion, room walls with streaks and stains, ice machines covered with rust stains, floor corners embedded with grime and dirt, base of dining room tables heavily worn and rust stains, nurse station area floor and walls layered with dirt and dust and entangled loose wires, torn or stained privacy curtains. This was evident for 3 of 7 units. (Units: 3, 4 and 6). The findings are: The facility policy titled, Homelike Environment, dated 06/18/24 documented, It is the policy of the facility to ensure that all residents live in an environment that is clean and neat with appropriate furnishings and in good repair. Upon the initial entrance to the facility on [DATE] at approximately 9:00 AM and subsequent observations during the recertification survey the following environmental issues were observed: A) 3rd floor: 1. Patient Toilet room located across the Day Room with the right sided over the toilet seat handle bar cracked and broken. Stained and dirty bathroom wall tiles. 2. Rusty Ice Machine located in the Day Room. Rusty Ice Machine brackets 3. Dirty and dusty base of blood pressure machines. 4. Dirty and dusty base of thermometer stand. 5. 6 dining room tables base and stand heavily worn and rusty. 6. Uneven and wobbly dining room tables. 7. Air conditioners in dining room layered with dust and dirt. 8. Floor corners in dining room area embedded with dirt and debris. 9. Corridor resident scale layered with dirt and dust. B) 4th floor: Dining Room: 1. 2 of 2 air conditioners layered with dust and dirt. 2. 1 of 2 air conditioners with broken slats and exposing the filter. 3. Floor corners embedded with ground in dirt and debris 4. Wall tiles underneath sink stained and dirty Dining room door with chipped and falling orange paint. 1. room [ROOM NUMBER] a: rusty and heavily worn base to tray table. 2. Room chair with torn cracked seating. 3. Torn wall paper. 4. Bedside two drawer bedside table heavily worn and heavily stained with built in dirt and grime. C) room [ROOM NUMBER] P: 1. Loose cable wires over the inside room door. 2. Bedside two drawer bedside table heavily worn and heavily stained with built in dirt and grime. D) room [ROOM NUMBER] b: 1. Torn mesh privacy curtains. 2. Air conditioner layered in dust and dirt. 3. Rusty base to tray table heavily. 4. Floor corners embedded with dirt and debris. E.) Base of blood pressure stand and thermometer stand layered with accumulation of dirt and dust. F.) room [ROOM NUMBER] a: 1. Cracked and dirty tiles under room sink. 2. Torn wall paper. 3. Loose cable wires at base of room end table. 4. Bedside two drawer bedside table heavily worn and heavily stained with built in dirt and grime. G.) 6th Floor: 1. room [ROOM NUMBER]b: ground in dirt on floors and corners of floors. 2. Stained dirty walls by air conditioner H.) room [ROOM NUMBER]a: 1. Walls stained and streaked. 2. Floor accumulation of dirt and dust. On 09/23/24 at 10:32 AM the 4th floor Housekeeper #1 was interviewed and stated, that they have a daily routine for completion of their assigned tasks. They sweep, mop and use the buffer machine on their assigned floors, including wiping down walls, resident equipment and dining room tables if they need cleaning. As a routine they clean all room and corridor floors. However, the dining room tables are cleaned by the nursing staff. If I notice that walls are stained or dirty I will wipe them down. The nursing station is swept and mopped if the area not occupied by the nurses. If I notice that there is an area that needs repair I will notify the maintenance department. If the privacy curtains need to be replaced I first notify my supervisor before a replacement is done. On 09/23/24 at 11:12 AM 3rd floor Housekeeper #2 was interviewed and state they report on their daily routine for cleaning their assigned units. We also have a Bathroom [NAME] who is responsible for the cleaning of the toilet bowls and replenishing paper towels. If there is a maintenance problem I will let the unit nurse know and they submit an email to the department. The nurses station gets cleaned, but it is usually busy with the nursing staff and hard to get to at times. On 09/23/24 at 12:27 PM the Housekeeping Supervisor was interviewed and stated, that their role included overseeing the Housekeeping staff to ensure that their daily assigned tasks are being done. Daily rounds are made to ensure the environment is kept clean for the residents. My staff are to be dusting high and low areas, like the bedframes and the top of overhead light fixtures. I check for dust, garbage overflow in rooms and corridors. Every month the privacy curtains are automatically changed and immediately of soiled. The nurses station is swept and spot mopped if no one is sitting at the nurses station. The IV poles and feeding pumps and blood pressure machines and scales are to be wiped and cleaned. I sometimes wipe them clean myself if I see that it is needed and speak to the staff as well. Interview with the Director of Housekeeping and Maintenance Department on 09/23/24 at 01:00 PM stated that their role is to oversee the Housekeeping and Maintenance Departments to ensure that residents and staff have a clean and safe environment. I make daily rounds to ensure staff are keeping up and completing their work assignments. I speak to residents and staff from time to time about any environmental concerns they may have. We have an electronic software system in place that the nurses have access to and submit environmental concerns. I check the software system several times a day. When I make my rounds I observe for cleanliness and safety of rooms, corridors, bathrooms, common areas and dining rooms. I am responsible for the safety of the entire facility. If there are issues that I have come across when making my rounds. I will talk to my staff to correct the problem. The nurses station is difficult to clean at times because the nurses are busy at the nurses station. Floors 3, 4 , 5 and 7 have no cable access. We have only antennas therefore the TV wires in the room are extended as close to the window as possible. I have a plan to repair or replace the Lobby floor tiles. It is a big job and needs to be done mostly at night. I have a plan to fix this and we just recently just patched it up. On 09/23/24 at 01:47 PM the Administrator was interviewed and stated that proposals are being made for concealing the TV wiring in resident rooms. We are slowly replacing or upgrading air conditioners and tray tables. There is plan to continue to repaint and repair areas of concern and will continue to keep the residents environment safe clean and homelike. 10NYCRR 415.5(h)(1) 44864

Based on observation and interview, during the re-certification survey, the facility did not ensure the resident and staff physical environment was kept safe and clean. Specifically, 1.) Nurse Station 2.) Lobby Restrooms and Floor Tiles 3.) Staff Bathroom. This was evident in the Lobby area including 3 of 7 units. ( Units 3, 4 and 6). The findings are: The facility policy and procedure titled, Homelike Environment, dated 06/18/24 documented, The facility respectfully acknowledges that all residents are entitled to living in an environment that is like a homelike setting. Upon the initial entrance to the facility on [DATE] at approximately 9:00 AM and subsequent observations during the recertification survey the following environmental issues were observed: A) Lobby Area: 1. Broken floor tiles along the corridor. B) Lobby Rest Rooms: 1. Rest Room located across the out of order sign noted with unidentifiable offensive odor emitting from the bathroom. 2. Sink not firmly affixed to the wall. 3. Toilet seat loose. 4. Toilet paper dispenser broken. 5. Corners of floors embedded with dirt and dust. 6. Rest Room located across the Storage Room noted with broken toilet tank cover. C) 3rd Floor: 1. Employee Rest Room located across from the Nurse Station noted with a hole underneath the sink area surrounding the pipe running through it. D) 3rd Floor Nurse Station: 1. Accumulation of layered dirt dust and heavy debris underneath nurse desk. 2. Exposed cable wires layered with dirt dust and debris. 3. Walls behind nurse chairs with heavily streaked and stained. E) 4th Floor: 1. Employee Rest Room located across from the Nurse Station noted missing cold water faucet handle. 2. Floor tiles layered with ground in dirt dust and debris. 3. Ceramic wall tiles heavily stained and dirty. F) 4th Floor: 1. Nurse Station: a) Accumulation of layered dirt dust and heavy debris underneath nurse desk. b) Exposed cable wires layered with dirt dust and debris. c) Walls behind nurse chairs with heavily streaked and stained. G.) 6th Floor: 1. Nurse station area accumulation of dirt, dust and debris underneath the nurse desk area. 2. Accumulation of dirt and dust to the bundle of entangled wires located underneath the Nurse Station. On 09/23/24 at 01:00 PM the Director of Housekeeping and Maintenance Departments was interviewed and stated that their role is to oversee the Housekeeping and Maintenance Departments to ensure that residents and staff have a clean and safe environment. I make daily rounds to ensure staff are keeping up and completing their work assignments. I speak to resident and staff from time to time about any environmental concerns they may have. We have an electronic software system in place that the nurses have access to and submit environmental concerns. I check the software system several times a day. When I make my rounds observe for cleanliness and safety of rooms, corridors, bathrooms, common areas, dining rooms. I am responsible for the safety of the entire facility. There are issues that I have come across when making my rounds. I will talk to my staff to correct the problem. The nurse station is difficult to clean at times because the nurses are busy at the nurse station. Floors 3, 4 , 5 and 7 have no cable access. We have only antennas which need to be close to the window, therefore the TV wires in the room are extended as close to the window as possible. I have a plan to repair or replace the Lobby floor tiles. It is a big job and needs to be done mostly at night. I have a plan to fix this and we just recently just patched it up. 10NYCRR 415.29

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. Specifically, Resident #160 was observed on several occasions the hearing aid in place. This was evident for 1 (Resident #160 ) of 2 residents reviewed for Communication and Hearing Care Area. The finding is: The facility policy and procedure dated, 01/05/24 titled, Hearing Impaired and Care of, documented, 'It is the policy of the facility staff will assist hearing impaired residents maintain effective communication with clinicians, caregivers and other residents. Resident #160 has diagnoses including but not limited to Hearing Loss, Hypertension and Cerebral Vascular Accident. The Quarterly Minimum Data 3.0 Assessment Reference Date of 08/08/24 documented the resident was admitted on [DATE], with minimal hearing difficulty, hearing aid appliance in use, clear speech, usually understood, usually understands with a brief interview of mental status score of 7. The Physician's Monthly Order dated 08/22/24 documented, apply Right hearing aid in AM when resident is awake and remove at every night. Review of the Nurse Admission assessment dated [DATE] documented, under Prosthesis, Hearing Aid, and Minimal Difficulty. The Comprehensive Care Plan (CCP) dated 08/05/24 developed for Communication, documented, Use of Hearing Aids, as per MD order. Apply Right Hearing Aid in AM when resident is awake and remove every night. Review of the Resident Nursing Instructions, dated 01/05/24, for the Certified Nurse Aide documented, Apply Right Hearing Aid in AM when resident is awake and remove every night. On 09/17/24 at 12:40 PM no Hearing Aid was observed to the Right ear of the resident, while in the dining room having lunch. On 09/19/24 at 11:40 AM no Hearing Aid was observed on the Right ear of the resident while in the corridor sitting in their wheelchair. Attempted Interview with the resident on 09/19/24 at 11:49 AM made repeated statements, I can't hear, I have trouble hearing. The resident was gesturing with their hands and pointing to their ears, then talked about their arthritis. The assigned Certified Nurse Aide # 1 was interviewed on 09/19/24 12:00 PM in the room of the resident and stated, that the resident refuses the use of the hearing aide. The CNA # 1 retrieved a container which contained the Hearing Aid and stated that they are not sure if the Hearing Aide is functioning. Stated that this was reported by them to the nurses on the unit about a month ago. The resident was wheeled from the corridor back to their room and the Certified Nurse attempted to apply the Hearing Aid to the Right ear of the resident. The resident did not refuse nor attempt to remove the Hearing Aid at this time. The Certified Nurse Aide when asked about having received training on the application of a Hearing Aid, stated, Yes. On 09/20/24 at 11:15 AM the resident was observed sitting in the wheelchair along the corridor outside of the Day Room with a Right ear Hearing Aid. Resulting interview with the resident noted their response when asked if they were able to hear the State Agency talking to them. The resident responded said, Yes. On 09/19/24 at 12:10 PM Registered Nurse Unit Manager # 1 was interviewed and stated, I have not recalled having been made aware of issues with the resident and the Hearing Aid by staff. They stated I might have gotten a call from the residents son about needing to get batteries for the Hearing Aid. No follow up by Nurse Managers # 1 was made. Nurse Manager # 1 stated, I perform frequent rounds and observe residents and staff to ensure devices are in place as per medical orders. 415.12(3)(b) .

Based on observation, interviews, and record review conducted during the recertification survey from 09/16/2024 to 09/23/2024, the facility did not ensure a resident right to self-determination was honored. This was evident for 1 of 3 Residents (Resident #69) investigated for Abuse out of a total sample of 35 Residents. Specifically, Certified Nursing Assistant repeatedly attempted to render care to Resident #69 despite Resident #69 refusing care. The findings are: The facility's policy titled, Resident Rights Policy and Procedures last reviewed 6/11/2024 documented this facility is committed to assuring the rights and protection of its residents as stipulated under Federal and State Laws. Resident's rights include but are not limited to the following: Treated with respect, dignity and self-determination with care. Quarterly Minimum Data Set, dated dated dated [DATE] documents that Resident #69 is cognitively intact with a BIMS score of 15. Resident is dependent with all activities of daily living care and transfers including bed mobility. Resident is frequently incontinent of urine and bowel. Resident has active diagnosis of Aphasia, Cerebral Vascular Accident and Hemiplegia. On 09/19/24 at 11:16 AM, Resident #69 who is nonverbal was interviewed and communicated to surveyor through use of an I pad, eye movements and hand gestures. Resident #69 typed into I-Pad that Certified Nursing Assistant #9 came in to the room at 4AM waking resident up from sleep. The Certified Nursing Assistant #9 turned on the lights and did not introduce themslves. Resident #69 states they were not familiar with the Certified Nursing Assistant #9. Resident #69 was motioning with their hands for Certified Nursing Assistant #9 to leave because resident did not want care at that time. The Certified Nursing Assistant #9 attempted to move the table by the residents bedside to give care, but Resident #69 held onto the table because they did not want it to be moved. Certified Nursing Assistant #9 also attempted to pull down Resident #69 bed sheet to change residents' diaper despite Resident #69 motioning no with their hands that they didn't want care. Resident #69 typed into iPad that CNA was still trying to change me and was trying to pull down the bed sheet despite Resident #69 waving no with their hands and motioning for Certified Nursing Assistant #9 to leave. On 09/20/24 at 08:26 AM, the Certified Nursing Assistant #9 was interviewed and stated that Resident #69 was observed to be sleeping when they entered the room, turned on the lights and attempted to give care. Certified Nursing Assistant #9 stated that when Resident #69 heard Certified Nursing Assistant #9 in the room then Resident #69 woke up from sleep and opened their eyes. Certified Nursing Assistant #9 stated that they said Good morning and I am going to give care but Resident #69 did not respond and was unaware Resident #69 did not speak. Certified Nursing Assistant #9 did not review Residents' chart before entering room and was not aware that Resident #69 was nonverbal. Certified Nursing Assistant #9 stated they went to Resident #69 bedside and attempted to move the table which was by the resident's bedside which had a cup of water in it. However, Resident #69 held on to the table which caused water in the cup to be spilled. Certified Nursing Assistant #9 stated, I started to give care and she kept pushing my hands. Certified Nursing Assistant #9 tried to pull down the bed sheet to start care, but Resident #69 kept pushing Certified Nursing Assistant #9 hands away at which time Certified Nursing Assistant #9 left the room and reported it to the Licensed Practical Nurse #2 on shift. On 09/20/24 at 08:52 AM, Licensed Practical Nurse #2 was interviewed and stated that they were notified by Certified Nursing Assistant #9 that Resident #69 was refusing their diaper to be changed. Then Licensed Practical Nurse #2 went back into the room with Certified Nursing Assistant #9. Licensed Practical Nurse #2 states they asked Resident #69 why they were refusing care and Resident #69 typed into iPad that they didn't want to be changed. Licensed Practical Nurse # 2 then informed supervisor that Resident #69 refused to be changed. On 09/20/24 at 11:52 AM, the Director of Nursing Service was interviewed and stated that residents can refuse care, but it is the staff's jobs to make sure residents are tidy. If a resident refuses care, the Certified Nursing Assistants are educated to back away, reapproach and inform nurse immediately. Then the nurse will go back to resident and approach them softly. If a resident refuses care, then staff are to back away and get family and doctor involved. Every staff is given information on resident's care and CNA accountability should be reviewed by Certified Nursing Assistants before they enter a resident's room to see what care the resident should be receiving. CNA accountability will also reflect how a resident communicates. 10 NYCRR 415.5

Based on observation, record review and staff interviews conducted during the Recertification survey from 9/16/2024 to 9/23/2024, the facility did not ensure that a Comprehensive Care Plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan related to Communication: vision/hearing, was not revised based on a resident's need for a hearing aid. This was evident for 1 (Resident #207) of 3 residents reviewed for Communication' vision/hearing, out of 38 total sampled residents. The findings are: The facility's policy titled Comprehensive Care Plan, last reviewed 2/12/24, documented that each resident's comprehensive care plan shall be reviewed and updated by the interdisciplinary team as per the Minimum Data Set 3.0 schedule, quarterly, annually, significant change in condition, and if the resident's condition warrants it. Resident admitted to the facility with diagnoses that include Depression and Anxiety Disorder. On 09/16/24 at 10:58 AM, Resident #207 was interviewed and stated to the state surveyor to come closer and speak louder since Resident #207 does not hear well. Resident admitted to the facility with diagnoses that include Depression and Anxiety Disorder. The quarterly Minimum Data Set, dated dated dated [DATE] documented that resident's cognition was intact, adequate hearing, no behaviors and that resident and family participated in assessment and goal setting. A Physician's Orders dated 7/27/24 documented Audiology consult, hard of hearing, possible hearing aid. A Physician's Orders dated 8/20/24 documented Audiology consult appointment on 08/23/24 at 11:00am. A nursing note dated 7/17/24 documented that resident's family stated that they spoke with Resident #207 and noticed that hearing is more impaired and requested audiology consult. A nursing note dated 8/23/23 documented Resident #207 left the unit at 10:15AM for an audiology appointment due to hard of hearing. Audiology findings included sensorineural hearing loss with recommendations for hearing aid use to bilateral ears recommended. A Comprehensive Care Plan Titled Communication, etiology Dementia, effective 10/25/23, documented Resident #207 has a potential for alteration in communication. Goals included that Resident #207 will continue to communicate their needs with a review date of 10/22/24. Interventions included that the staff will speak slowly and clearly. A quarterly note dated 8/4/24 documented resident has no change in communication, able to verbalize needs, goals and interventions in place, plan of care continues x 90 days. There was no documented evidence that the Comprehensive Care Plan had been reviewed and revised to reflect resident's hard of hearing and the need for a hearing aid. On 09/19/24, at 11:16 AM, Certified Nursing Assistant #3 was interviewed and stated that the Resident #207 needs assistance and encouragement for activities of daily living. Certified Nursing Assistant #3 stated that Resident #207 has a hearing problem, and that Resident #207 went out last month (August) to the audiologist. Certified Nursing Assistant #3 said that Resident #207 does hear a little and that they talk loudly to Resident #207. On 09/20/24 at 10:38 AM Registered Nurse Supervisor #3 was interviewed and stated that Resident #207 is alert with periods of confusion and that when they try to speak with Resident #207, they speak closer and slower because of Resident #207 being hard of hearing. Registered Nurse Supervisor #3 stated that the doctor was notified of Resident #207 needs of the hearing aid. The Registered Nurse Supervisor #3 also stated that the communications care plan should have been updated to reflect Resident's #207 hearing loss, once they identified and saw that there was an actual hearing impairment. The Registered Nurse Supervisor #3 stated that the care plans are updated quarterly and annual, and when there is an actual change in the resident's condition. On 09/20/24 at 11:55 AM, the Assistant Director of Nursing was interviewed and stated that if the Resident #207 had gone to the Audiologist and was identified as hard of hearing, then the facility should have updated the care plan, to reflect that Resident #207 was hard of hearing. The Assistant Director of Nursing stated to the state surveyor that both the state surveyor and the Assistant Director of Nursing looked at Resident's #207 Communication care plan, and this was not addressed. On 09/23/24 at 12:22 PM, Director of Nursing was interviewed and stated that once the Registered Nurse Supervisor had identified that Resident #207 was hard of hearing, then the communications care plan should have been updated to reflect this. 10 NYCRR 415.11(c)(2) (i-iii)

Based on record review and interviews conducted during the recertification and abbreviated (NY 349) survey from 6/27/22 to 7/5/22, the facility did not ensure that pharmaceutical services were provided to meet the needs of each resident. This was evident for 1 (Resident #507) of 38 sampled residents. Specifically, the facility did not ensure supply of [MEDICATION(S)] was available to available to Resident #507 in accordance with the Medical Doctor's Order (MDO). The findings are: The facility policy titled Medication: Reordering last revised 7/1/22 documented medications are reordered when supply is running low (2 days prior) to ensure all medications are available in sufficient quantity to fulfill MDOs. If medication is not received in a timely manner, the pharmacy is contacted to obtain an estimated delivery time. Nursing supervisor/manager and Medical Doctor (MD)/Nurse Practitioner (NP)will be contacted to obtain a hold order and to substitute medication from emergency stock or medication is reordered from the pharmacy. Resident #507 had diagnoses of depression and post-traumatic stress disorder ([CONDITION(S)]). The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #507 was cognitively intact, exhibited signs of depression, and had a diagnosis of opioid abuse with withdrawal. The New York State Department of Health Complaints Tracking System documented on 11/15/21 a complainant reported Resident #507 had not been receiving their [MEDICATION(S)] medications according to MDO. The Comprehensive Care Plan (CCP) related to pain dated 8/16/21 documented Resident #507 should have medications administered according to MDO and aggravating factors should be assessed. The MDO initiated 8/23/21 documented an order for Resident #507 to receive [MEDICATION(S)] 8mg-2mg sublingual film 2 times per day at 7 am and 7 pm for opioid abuse with withdrawal. A Proof of Prescription dated 10/26/21 documented 60 sublingual films of [MEDICATION(S)] 8mg-2mg were ordered for Resident #507. A Proof of Delivery Packing Slip dated 10/27/21 documented 14 sublingual films (partial order) of [MEDICATION(S)] 8 mg-2 mg was delivered on 10/27/21. The Medication Administration Record (MAR) did not document [MEDICATION(S)] 8 mg-2mg sublingual film was administered to Resident #507 on 11/3/21 at 7 pm and 11/4/21 at 7 am and documented in process at pharmacy. A Proof of Delivery Packing Slip dated 11/4/21 documented 28 films of [MEDICATION(S)] 8 mg-2 mg was delivered to the facility on [DATE]. The MAR did not document [MEDICATION(S)] 8 mg-2mg sublingual film was administered to Resident #507 on 11/18/21 at 7 pm and documented in process at pharmacy. A Proof of Delivery Packing Slip dated 11/18/21 documented 14 films of [MEDICATION(S)] 8 mg-2 mg was delivered to the facility on [DATE]. On 7/5/22 at 10:48 AM, Registered Nurse Supervisor (RN) #1 was interviewed and stated they were in training during Resident #507's stay at the facility and was responsible for administering medications per MDO. RN #1 was working on 11/4/21 at 7pm when Resident #507's [MEDICATION(S)] was not available and stated Resident #507 did not receive their [MEDICATION(S)]. The RN Supervisor was aware the [MEDICATION(S)] was not in stock at the pharmacy and and instructed RN #1 to document in process pharmacy on the MAR. Medication refill requests are submitted electronically to the pharmacy when the resident's blister pack supply is in the blue area of the pack, indicating the medication supply is close to completion. RN #1 calls the pharmacy if delivery is not made for a medication that has been reordered. If the pharmacy cannot deliver the medication, an alternative plan must be made for the resident. On 7/5/22 at 12:37 PM, the MDS Coordinator (acting Director of Nursing) was interviewed and stated the MD faxed Resident #507's prescription for a 30-day supply (60 films) of [MEDICATION(S)] to the pharmacy, but the pharmacy delivered a partial supply. The MDS Coordinator stated they do not know the reason the prescription was only partially filled by the pharmacy. When the pharmacy is unable to refill a prescription or a medication is not available, nurses must report to the MD for further orders. The MDS Coordinator was unaware Resident #507 was not administered several doses of [MEDICATION(S)]. 415.18(a)

Based on observation, record review and interviews conducted during the Recertification Survey conducted from 6/27/22 to 7/5/22, the facility did not ensure a resident was provided with the necessary services to carry out activities of daily living (ADL). This was evident for 1 (Resident #143) of 2 residents reviewed for ADLs. Specifically, there were multiple observations of Resident #143 with long uncut toenails. The findings are: The facility policy titled ADLs last reviewed 2/28/2022 documented residents' needs are met in a timely manner and the Certified Nursing Assistant (CNA) provides care and assistance in accordance with nursing instructions. Resident # 143 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 143 had mild cognitive impairment, did not reject care, and required extensive assistance of 1 person to perform personal hygiene. On 06/27/22 at 11:25 AM, Resident # 143 was observed with toenails on both feet extending a half inch in length from the tip of the toes. Resident # 143 was interviewed and stated their toenails had not been cut for more than 2 months, they require staff assistance with cutting their toenails, and would like their toenails to be cut more frequently. On 06/28/22 at 09:48 AM, 06/29/22 at 10:36 AM, 06/30/22 at 10:59 AM, and 07/01/22 at 10:01 AM, Resident # 143 was observed with uncut toenails. The Comprehensive Care Plan (CCP) related to ADL's: Personal Hygiene initiated 11/08/2021 and last revised 5/16/2022 documented to keep Resident #143's nails trim and to have Podiatry consults as ordered by the Medical Doctor (MD). The Podiatry consult documented Resident #143 was last evaluated by the Podiatrist on 4/27/2022. The Podiatry consult schedules for May 2022 and June 2022 did not document Resident # 143 was scheduled to see the Podiatrist. On 06/30/22 at 11:43 AM CNA #2 was interviewed and stated Resident #143 required extensive assistance of 1 person for personal hygiene and grooming. CNA #2 checks the toenails of residents on their assignment to see if they grow beyond the tip of the toe and informs the nurse so that a Podiatry consult can be ordered. Resident #143 was observed with long toenails a few weeks ago and CNA #2 informed Registered Nurse #3 but a Podiatrist did not come to see Resident #143. On 07/01/22 at 10:51 AM, RN #3 was interviewed and stated they were not aware Resident #143's toenails were long and uncut and could not recall staff reporting that Resident #143 needed a Podiatry consult. RN #3 observed Resident #143's toenails and stated Resident #143 needed to be referred to the Podiatrist. On 06/30/22 at 11:29 AM, RN #4 was interviewed and stated they make rounds at least twice a day and checking a resident's toenails is part of the rounds. RN #4 did not notice that Resident #143's toenails were long and was not informed by staff that Resident #143 needed a Podiatry referral. Resident #143 was last seen by the Podiatrist approximately 2 months ago. After observing Resident #143's toenails, RN #4 stated Resident #143 had long toenails and a Podiatry consult needed to be ordered. On 07/01/22 at 09:20 AM, the MDS Coordinator (MDSC) was interviewed and stated a resident's toenails were considered long if they grew beyond the tip of the toes. The Podiatrist visits the facility once a week to address consults. The CNA is responsible for reporting long toenails to the RN so a Podiatry consult can be ordered. 415.12(a)(3)

Based on interviews and record review conducted during an abbreviated survey (NY 011) on 05/12/2021, the facility did not ensure that a resident receive appropriate discharge. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, the facility discharged Resident #1 to a hotel without required assistive devices. Additionally, the facility did not contact or made referrals to local contact agencies. The findings are: Review of the facility's policy and procedure entitled Discharge Planning, last reviewed on 01/05/2021 documented that on admission, the interdisciplinary team will assist the resident in developing a customary routine as well as identifying each resident's discharge goals and needs. The facility will implement an effective discharge planning process that focuses on the resident's discharge goals, evaluates these goals throughout the resident's stay, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The discharge planning must consider the availability of as well as the capacity and capability of the caregiver/support person to perform required care, as part of the identification of discharge needs. If a resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 02/10/2021 identified Resident #1 with a Brief Interview for Mental Status (BIMS) score of 15/15, associated with intact cognition. The MDS documented that Resident #1 required extensive assistance of one-person with bed mobility, transfer, toilet use and bathing and limited assistance with personal hygiene. Wheelchair was checked off as mobility device that Resident #1 required. Section Q documented that an active discharge planning was already occurring, and Resident #1 was expected to be discharged to the community. A Discharge Planning Care Plan initiated on 02/04/2021 documented that Resident #1 will return to home/community after the resident completed physical rehabilitation treatment. The interventions were to coordinate with Rehabilitation Department regarding ordering of supplies/equipment for safe discharge home and to coordinate with Resident #1's Primary Care Physician for all necessary prescriptions prior to discharge. A Physical Therapy Progress Note dated 03/18/2021 at 08:19 AM documented that Resident #1 with inconsistent participation and fluctuating functional mobility due to complains of bilateral feet/lower extremities swelling. Resident #1 was instructed and reeducated on the importance of bilateral legs elevation when in bed. Resident #1 to continue with the bilateral ankle pumps and range of motion to improve circulation and to maintain range of motion. New orders in place for Floor Ambulation Program, 75 feet twice daily as tolerated with rolling walker and limited assistance of one staff. An Occupational Therapy Progress Note dated 03/18/2021 at 2:30PM documented that Resident #1 was observed with swelling to their lower extremities. Resident #1 reported feeling pain to lower extremities when Resident #1 was performing Activities of Daily Living (ADL) tasks (hygiene/ grooming at sink, toilet transfer and toilet tasks). Resident #1 was instructed and reeducated on using the wheelchair during ADL tasks to increase comfort and safety. A Physical Therapy Progress Note dated 03/23/2021 at 2:52 PM documented that Resident #1 had increased challenge with tasks while negotiating 3-4 steps with inconsistent participation due to complaints of [CONDITION(S)], being tired and swelling to bilateral lower extremities. A Nursing Progress Note dated 03/23/2021 at 8:19 PM documented that staff observed a small pack of white powdery substance hidden amongst the snacks that Resident #1 received from the outside. A Transfer/Discharge Notice dated 03/24/2021 documented that Resident #1 was given a Transfer/Discharge Notice on 03/24/2021. Resident #1 to be discharged to a hotel on 03/24/2021. The Transfer/Discharge Notice documented that the notice was issued in compliance with Resident #1's request. Resident #1's signature was not on the Transfer/Discharge notice. A Therapy Discharge Instructions dated 03/24/2021 documented that Resident #1 required a rolling walker and supervision for getting up from chairs/ beds and walking indoors and outdoors. Resident #1 required one-person physical assistance (both banisters) for negotiating stairs. An Occupational Therapy Discharge Instructions dated 03/24/2021 documented that Resident #1 required a shower with grab bars installed, a shower chair and assistance of one-person to assist with showers and baths. Resident #1 required the assistance of one-person for dressing. Resident #1 also required a wall mounted grab bar and supervision for toilet use. A Medical Progress Note dated 03/24/2021 at 4:08PM documented that Resident #1 was seen and examined for discharge. Medications and plan of care was reviewed with Resident #1. Resident #1 was instructed that if the resident's legs were swollen, the [MEDICATION(S)] works well but that Resident #1 should hold the [MEDICATION(S)] and follow up with their Primary Care Physician. A Nursing Progress Note dated 03/24/2021 at 5:14PM documented that Resident #1 was discharged from the facility in stable condition. Medications thoroughly explained and given to Resident #1. Resident #1 transported to the hotel by Uber. A Medical Discharge Summary created on 03/24/2021 and completed 03/25/2021, documented that Resident #1 had blood work Comprehensive Metabolic Panel on 03/24/2021 prior to discharge. The result was within normal limit. The Complete Blood Count specimen was clotted. There was no result available. Resident #1 was alert and oriented x 4, thin and was in no acute distress. Extremities 1+ bilateral pedal [CONDITION(S)]. Resident #1 was discharged to: location-patient preference living arrangements. Resident #1's vital signs-Blood pressure 121/68, Pulse 68, Respiration 18, and Temperature 97.3. A Social Services Late Progress Note dated 03/25/2021 at 12:04 PM documented that Resident #1 became agitated when the resident was asked about the white powdery substance. Resident #1 requested to be discharged as soon as possible. Resident #1 stated that they needed to make some phone calls and decide for discharge. A Social Services Late Progress Note dated 03/30/2021 at 9:15 AM documented that Resident #1 verbalized interest in returning to the community. Resident #1 was alert and oriented x 3 with ability to verbalize needs and concerns. Resident #1 stated that they previously resided in a hotel and the resident expressed interest in same. Resident #1 stated that their parent was willing to transfer money to their bank account to assist with paying for the living arrangements. Social Worker (SW) assisted Resident #1 in researching for hotels. SW confirmed resident for hotel if paperwork and picture ID was provided. SW arranged for transportation. As per rehab, resident can ambulate with assistance of rolling walker and negotiate stairs. Resident #1 was independent and self-directed in all ADLs. Resident stated that they previously resided in a hotel and expressed interest in same. Resident stated that their father was willing to transfer money to their bank account to assist with paying for the living arrangements. SW assisted Resident #1 in researching hotels in Queens. The SW confirmed Resident #1's for hotel as long as paperwork and picture ID was provided. Resident #1 declined for SW to make any other arrangements including Home Care Services and MD follow up visit. Resident #1 stated that they will follow up with their Primary Care Physician or Pain Management MD and Psychiatrist. Resident #1 was provided with rolling walker. Discharge summary was reviewed in the presence of the Registered Nurse. Resident #1 was provided with medications and signed responsibility form for medications received. Transportation was arranged by SW. Resident left facility with all personal belongings. Record review revealed that Resident #1 was discharged from the facility after staff discovered a white packet of powered substance in Resident #1's belongings that Resident #1 received from the outside on 03/23/2021. A late entry (03/25/2021) Social Worker's note documented that Resident #1 stated that they would like to be discharged as soon as possible. Record review revealed no documentation of facility reaching out to local support agencies to assist Resident #1 with appropriate accommodations, assistance and required equipment. During an interview on 05/12/2021 at 12:28 PM, the Physical Therapist Assistant (PTA) stated that on discharge, Resident #1 could transfer with supervision and was able to ambulate with rolling walker and supervision. The PTA further stated that Resident #1 required minimum assistance of 1 person for climbing 3-4 steps. During an interview on 05/12/2021 at 12:40 PM, the Certified Occupational Therapist Assistant (COTA) stated that Resident #1 had swelling to the legs and was on pain medication. The COTA further stated that Resident #1 had a wheelchair but refused to use it. The COTA also said that for discharge, they recommended a shower chair, a wheelchair, grab bar and contact guard assistance of one-person for safety during showers. During an interview on 05/12/2021 at 1:15 PM, the Director of Social Services (DSS) stated that Resident #1 had no listed emergency contact; Resident #1 told them that they had a parent but preferred not to give facility the number. After staff discovered the powdered substance, Resident #1 requested to be discharged to the hotel. The DSS stated that Resident #1 informed them that they could not take it anymore. The DSS stated that they gave Resident #1 the option to be discharged to a shelter but Resident #1 said that they did not want to wait. Resident #1 informed them that they wanted to be discharged to the hotel. The DSS verbalized that Resident #1 stated that they were going to stay at the hotel until they found somewhere else to stay. The DSS stated that they were not sure where Resident #1 was going stay after leaving the hotel. The DSS further stated that Resident #1 was given the discharge notice on the day of the discharge because it was sudden. The DSS also said that they were informed that Resident #1 was independent with her ADL needs. During an interview on 05/12/2021 at 2:00 PM, Registered Nurse Supervisor (RNS) stated that Resident #1 was back and forth about wanting to leave but on the day of discharge Resident #1 said that they would leave. The RNS further stated that Resident #1 required limited assistance with supervision for ADL needs. During an interview on 05/12/2021 at 2:15 PM, the Physician stated that they became Resident #1's Physician on 03/16/2021. The Physician stated that they completed Resident #1's discharge summary. The Physician reported being aware that Resident #1 was being discharged to a hotel. The Physician stated that they were not aware Resident #1 was not being discharged without Home Care services. The Physician also stated that they were not sure how much assistance Resident #1 needed with the ADL care. During an interview on 06/01/2021 at 4:55 PM, Resident #1 stated that they did not request to be discharged from the facility. Resident #1 stated that the DSS informed them that the facility was discharging them from the facility. Resident #1 stated that they agreed to go a hotel after being told that they were being discharged . Resident #1 verbalized that the facility did not give them a discharge notice with appeals rights. Resident #1 also said that they were not invited to and did not attend a discharge planning meeting. Resident #1 stated that they paid the hotel charges. Resident #1 stated that they ambulated with a walker. Resident #1 said that they did not bathe or took showers while in the hotel because they were unable to get in the shower. Resident #1 reported that a few days after they were discharged from the facility, a hotel staff found them unresponsive. Resident #1 stated that they were hospitalized twice since discharge from the facility and is currently residing in another nursing rehabilitation facility. During a follow up interview on 06/24/2021 at 12:36 PM, the DSS stated that Resident #1's discharge was safe. The DSS further stated that they were aware that Resident #1 required a shower chair. The DSS verbalized that they were going to order a shower chair but Resident #1 refused. The DSS added that they offered to refer Resident #1 for home care services but Resident #1 refused. 415.3(h)(1)(ii)(a)(b)

Based on observation and staff interviews during recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, potentially hazardous cold foods (sandwiches) were not maintained at the proper temperature (at or below 41 degrees Fahrenheit), and equipment used to slice meat for sandwiches was not properly cleaned after use. This was evident during the Kitchen Observation facility task. The findings are: 1) The policy and procedure titled Sandwich preparation last reviewed 6/19/18, documented: All items for sandwiches, for example Egg salad/Tuna salad and any deli meats, are held under refrigeration at 40 degrees or less prior to assembly. Sandwiches will be assembled on an appropriate cutting board, and upon completion, each sandwich is wrapped and dated. They are then placed back into the refrigerator. Sandwiches are assembled for same day use and discarded at end of the day. The policy and procedure titled Hot and Cold food holding effective 4/20/16 and reviewed 4/18/19, documented the purpose to hold food safely for resident consumption. The policy documented all cold foods (milk-juices-etc) will be held at 41 degrees or colder. On 09/20/2019 at 10:17 AM, a Dietary Aide (DA # 9) was observed making salami sandwiches for the day. The meat for the sandwiches was stored in an open metal pan on the table. DA #9 borrowed a thermometer from the Cook to take the temperature of a sandwich. At 10:33 AM, the temperature was 65.1 degrees Fahrenheit (F). At 10:40 AM, after 20 sandwiches were made, the sandwiches were placed on a ceramic plate, wrapped with plastic wrap, and dated with a label reading 9/20. The sandwiches were put on a rack and placed in the refrigerator at 10:43 AM. On 09/20/19 at 12:48 PM, the Cook (staff #13) took the temperature of the salami sandwiches stored in refrigerator. Surveyor noted that the refrigerator internal temp was 40 F. There was 1 sandwich left in the refrigerator from the salami sandwiches prepared earlier. At 12:52 PM, the temperature of the sandwich was 58.8 degrees Fahrenheit. The Cook asked the state agent (SA) if the temperature should be 40 degrees or less. After the SA nodded yes, the Cook discarded the leftover sandwich. An interview was conducted with DA #9 during the observation on 09/20/19 at 10:17 AM. The DA stated that they make 22 to 25 sandwiches per day, and this process takes her 2 to 3 ½ hours to complete. She further stated that sandwich making started at 7 o'clock this morning, and the sandwiches were for the 11 o'clock meal. DA #9 stated she takes temperatures of sandwiches sometimes. She stated she does not have a thermometer, but she borrows a thermometer from the Cook. DA #9 stated that she does not record the temperature of the sandwiches, and she was not sure what the temperature should be. 2) On 09/23/19 at 09:32 AM, a Dietary Aide (DA # 10) was observed making ham and cheese sandwiches for the day. The sandwiches were placed in the refrigerator with an internal temperature of 38 degrees F at 09:44 AM. On 9/23/19 at 1:06 PM, the Dietary Supervisor (DS #11) took the the temperature of a ham and cheese sandwich in the refrigerator. The temperature registered 62.6 degrees F. DS #11 calibrated the thermometer and took a repeat temperature of 61.2 degrees F at 01:08 PM. A second sandwich was tested , and the temperature was 60.1 F at 1:09 PM. The repeat temperature, after thermometer calibration, was 60.4 F at 1:10 PM. DS #11 then put the sandwiches in the freezer. An interview with DA #10 was conducted on 09/23/19 at 10:06 AM. DA #10 stated he did not know if temperatures of the sandwiches were taken. An interview was conducted with the Dietary Supervisor (DS #11) on 09/23/19 at 10:08 AM and. She stated that the sandwiches are refrigerated as soon as they made, and the temperatures are taken before the tray line starts. It takes about a half hour to prepare the sandwiches, on average. An additional interview with DS #11 was held at 1:12 PM after the temperatures were taken. DS #11 stated the remaining sandwiches would be thrown out and new sandwiches would be made after she checked with her supervisor. 3) The policy and procedure titled Sanitizing and cleaning slicer effective 04/20/16 and reviewed 4/18/19, documented the purpose of the policy was to maintain and sanitize the slicer in a way to ensure no cross contamination or bacteria growth. Duties include Using soapy water, clean cradle and all exposed area of the machine, use sanitizing solution on all areas of the machine, reassemble machine, and place cover over machine which indicates it is cleaned and sanitized. A kitchen observation of equipment cleaning of the meat slicer was conducted on 9/23/2019 at 09:45AM. Surveyor observed DA #10 cleaning the meat slicer after making ham and cheese sandwiches for the day. Staff wiped down table with cloth soaked in sanitizing solution (bleach, soap, water) after he unplugged the machine and he continued to break down the machine for cleaning. Surveyor noted that old food debris (dried meat) fell out of the carriage tray when the carriage tray knob was loosened. When the latch knob in the sharpener area was loosened, dried meat also fell out of the machine. There was also old dried meat debris underneath the machine on the table. The Meat slicer machine cleaning was finished at 09:53 AM, and the machine was covered with plastic bag. There was still noticeable meat debris remaining on the sharpener and carriage tray handle groove areas of the machine after cleaning. The table also still had old food debris on it. An interview was conducted with (DA #10) on 09/23/19 at 09:55 AM. He stated the meat slicer is used daily, and whoever makes the sandwiches is supposed to clean the meat slicer. He stated that when staff finish cleaning the machine, plastic is placed on top of it. The SA pointed out areas that were not clean on the meat slicer. DA #10 cleaned the table underneath the machine after the machine was moved to the right. The DA also stated that he did not know how to take off the sharpener on the meat slicer. An interview was conducted with the Dietary Supervisor (DS #11) on 09/23/19 at 10:11 AM. During the interview, the supervisor removed the plastic covering from the meat slicer and the sharpener knob fell off, exposing food debris underneath the sharpener knob. Surveyor noted there was still food debris (dried meat) left under machine, and the counter under the machine had to be wiped down again. DS #11 stated the staff has to make sure they clean the machine completely all the times. 415.14(h)

Based on observation and interview during the recertification survey, the facility did not ensure that a homelike environment was provided. Specifically, resident rooms were observed with bare white walls and lacking decor, creating a colorless, dull environment. This was observed for 3 residents (Resident #s 110, 218, and 204) on one (1) of six (6) resident units (Unit 3). The findings are: A review of the facility's policy and procedure for, 'Homelike Environment, documented: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These include: inviting color and decor. 1.) Resident #110 was admitted on [DATE]. The resident was alert and oriented to person, place and time, with moments of confusion. During the initial unit tour, on 09/17/19 at 9:10 AM, the resident's room was observed. The room walls were painted off white and the wall space facing the resident was bare. An Activities, calendar was posted on the wall between the beds in the room. There were no other wall hangings or colors contrasting the bare walls. Resident #110, was interviewed during the observation. Resident #110 stated that yes the walls are bare, but she would not expect anything more from an institutional setting. The resident stated, it does not matter. On 09/20/19 at 08:33 AM, Resident #110 was observed having breakfast in her room. Two wall hangings with the depiction of flowers were on the wall facing her. The resident was interviewed. She stated that she that she did not realize what a big difference it made, to have something of life she can now look at. She stated that yesterday (09/19/19), she was asked how she felt about having a bare wall by staff. She said she told them that because she is in an 'institutional setting, that she doesn't expect much, and doesn't expect her room to be homelike. She stated she had not ever been asked about how she felt about her walls being bare before. She stated that having pictures of flowers on the wall really made a difference. She said she chose the flower hanging because it reminded her of life and something growing. She said it made her feel very happy, and it was better than having bare walls. 2.) Resident # 218 was admitted on [DATE]. The resident was alert and oriented with periods of confusion. On 09/17/19 at 9:45 AM, the resident's room was observed during the initial tour. The wall space in the single bedded room was bare. An off white paint color covered the walls. Resident #218 was interviewed during the observation. The resident stated she would like something colorful on her walls to look at. She stated that she had not been asked about how she felt about the bare walls by facility staff. On 09/20/19 at 8:50 AM, the resident was observed sitting on her bed eating breakfast. The room wall was decorated with two pictures depicting colorful fishes. The resident was smiling from ear to ear. The resident stated that seeing these pictures on her wall made her very happy. She again stated that this makes her room bright, and it made her very happy to see something colorful on her walls. 3.) Resident # 204 is alert, oriented with periods of confusion. On 09/17/19 at 11:23 AM, during the initial tour of the resident's room, the entire wall space was bare. The resident was asked about how she felt about her bare walls. The resident stated that she would like to have some wall decorations. She stated that having decorations or pictures on her wall is good for the soul and spirit, and it looks good too. The resident added that she has no family in this country. On 09/20/19 at 12:10 PM, the resident was observed in her room sitting in a wheelchair and staring at the wall. The resident's wall were still bare. The unit registered nurse #1 was interviewed immediately after the initial tour on 9/17/19 and on 09/23/19 at 10:42 AM. The RN stated that many rooms are bare, and it was just something she assumed that the residents liked. She stated that she would not normally ask residents about how they felt about the bare walls. On 09/23/19 at 10:45 AM, the Social Worker (Staff #4) was interviewed. She stated that residents are encouraged to bring in personal items from home. This is also mentioned in the Care Planning Meetings. She stated that she understood that not all residents attend the care plan meeting. She stated she noticed the bare walls, but had not asked residents about how they feel about having bare room wall. On 09/23/19 at 10:12 AM, the Admissions Director was interviewed. She stated that once a bed is accepted by the resident or family, she contacts them and and gives them an introduction to the facility. This introduction includes: activities, staffing, personal property, and personal belongings. She informs residents and families that they are allowed to bring personal photos, blankets and accent furniture. On 09/23/19 at 08:44 AM, the Administrator was interviewed. She stated that her role included the assurance that policies are implemented and that residents are safe and receive quality of care and quality of life services. She ensures that the policies are implemented by providing inservice's, having discussions during resident council meetings, and making rounds to ensure that residents are satisfied with their environment. She stated she asks residents about their level of satisfaction concerning the environment, specifically about safety, appearance, odor and cleanliness. The administrator stated that the first and second floor renovations began in (YEAR). The renovations included lots of upgrading, including creating a homelike environment. The facility staff encourage residents and families to bring in personal items from home. We also encourage residents and families to create their own personal items. It is a team effort that begins during the admission process and continues with other staff encounters. 415.29(e)(1)

Based on observation, record review, and interview during the re-certification survey, the facility did not ensure that each resident was treated with dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life. Specifically, a resident was observed wearing oversized soiled and tattered sneakers with no socks. This was evident for one (1) of one (1) resident reviewed for Dignity (Resident # 1). The finding is: The facility policy for Resident Funds - Personal Shopping dated 08/2019, documented that, The facility must ensure that all residents' personal needs are met and that their rights and dignity are respected. If a resident lacks capacity and has family .involved in his/her care, the family should be encouraged to make purchases for the resident directly. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 09/10/19, documented that the resident had clear speech and was sometimes understood and sometimes understands. The resident had a brief interview mental status score of 3 out of 15, indicating severely impaired cognition. No rejection of care behaviors were identified. The resident required supervision to limited staff assistance for activities of daily living needs. On 09/17/19 at 1:08 PM, the resident was observed sitting in the dining room eating lunch. The resident got up from his seat, and began to walk out of the dining room. A thumping sound was heard as he walked, and the back of his heels lifted up from the back of the sneakers as the resident walked out of the dining room and into the corridor. His sneakers were heavily soiled, tattered and large for his feet. He wore no socks. Nursing staff were present when the resident got up and walked out of the dining room. The resident was observed again on 09/18/19 at 9:45 AM in the dining room, wearing the same soiled, tattered, and loosely fitting sneakers with no socks. Again, he was heard making a thumping sound when he walked, and the heels lifted up from the back of the sneakers. He wore no socks. Nursing staff were present in the dining room at the time. On 09/19/19 at 10:05 AM, the assigned Certified Nurse Assistant (CNA #2) was interviewed. The assigned CNA stated that he has been assigned to the resident for more than a year. The CNA stated that the resident needs help in retrieving his clothing, but he can put them on himself. The CNA stated that he also gives him his sneakers to put on. When asked about socks for the resident, the CNA stated that the resident wears socks whenever he wants to but not all the time. The SA accompanied the CNA to inspect the resident's clothing closet. There were no socks to be found in the drawers. The CNA recanted his statement about socks and stated that the resident has not had any socks. He further stated that he is supposed to inform the nurse when a resident needs any items of clothing so that they can contact the family or housekeeping for donated clothing items. He stated that he should have reported the oversized sneakers to his nurse because poor fitting shoes can result in a fall. He also stated that better fitting footwear is important because it looks good and feels good and could prevent foot problems. The Social Worker (SW) was interviewed on 09/19/19 at 10:29 AM. The SW stated that the resident does not have a personal fund account, and his family visits occasionally. The facility has a system in place where they collect clothing, shoes, and socks and distributes them as needed. This should have been reported to her by the nurse or CNA so she could follow-up. The SW stated that she had not noticed the resident's footwear before because he is usually sitting down. When clothing items are needed, she would contact the family to ask for needed items first. She would also contact the housekeeping department and ask if any of the needed items are available from the donated stock. Many times, the facility absorbs the cost of purchasing needed items. On 09/19/19 at 10:35 AM, the Registered Nurse (RN) Unit Manager, (UM) # 1 was interviewed. The UM stated that if a resident is in need of any clothing items, they contact the SW or the housekeeping department and family. She further stated the assigned CNA should communicate with the nurse to report a need for items of clothing or footwear. The facility has donated clothing that is managed and kept by the Housekeeping Department. The unit manager # 1 stated that she makes rounds and notices how residents are dressed and groomed. She stated that she had not noticed the condition of the resident's sneakers. 415.5(a)

Based on observation and interview, the facility did not ensure that medically related social services to attain and maintain the highest practicable physical, mental and psychological well - being of each resident were provided. Specifically, a resident observed wearing oversized, soiled, and tattered sneakers without socks was not assisted with obtaining new footwear and socks. This was evident for one (1) of one (1) residents reviewed for Dignity (Resident # 1). The finding is: The facility policy for Resident Funds - Personal Shopping dated 08/2019, documented that, The facility must ensure that all residents' personal needs are met and that their rights and dignity are respected. If a resident lacks capacity and has family .involved in his/her care, the family should be encouraged to make purchases for the resident directly. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 09/10/19, documented that the resident had clear speech and was sometimes understood and sometimes understands. The resident had a brief interview mental status score of 3 out of 15, indicating severely impaired cognition. No rejection of care behaviors were identified. The resident required supervision to limited staff assistance for activities of daily living needs. On 09/17/19 at 1:08 PM, the resident was observed sitting in the dining room eating lunch. The resident got up from his seat, and began to walk out of the dining room. A thumping sound was heard as he walked, and the back of his heels lifted up from the back of the sneakers as the resident walked out of the dining room and into the corridor. His sneakers were heavily soiled, tattered and large for his feet. He wore no socks. Nursing staff were present when the resident got up and walked out of the dining room. The resident was observed again on 09/18/19 at 9:45 AM in the dining room, wearing the same soiled, tattered, and loosely fitting sneakers with no socks. Again, he was heard making a thumping sound when he walked, and the heels lifted up from the back of the sneakers. He wore no socks. Nursing staff were present in the dining room at the time. On 09/19/19 at 10:05 AM, the assigned Certified Nurse Assistant (CNA #2) was interviewed. The assigned CNA stated that he has been assigned to the resident for more than a year. The CNA stated that the resident needs help in retrieving his clothing, but he can put them on himself. The CNA stated that he also gives him his sneakers to put on. When asked about socks for the resident, the CNA stated that the resident wears socks whenever he wants to but not all the time. The SA accompanied the CNA to inspect the resident's clothing closet. There were no socks to be found in the drawers. The CNA recanted his statement about socks and stated that the resident has not had any socks. He further stated that he is supposed to inform the nurse when a resident needs any items of clothing so that they can contact the family or housekeeping for donated clothing items. He stated that he should have reported the oversized sneakers to his nurse because poor fitting shoes can result in a fall. He also stated that better fitting footwear is important because it looks good and feels good and could prevent foot problems. The Social Worker (SW) was interviewed on 09/19/19 at 10:29 AM. The SW stated that the resident does not have a personal fund account, and his family visits occasionally. The facility has a system in place where they collect clothing, shoes, and socks and distributes them as needed. This should have been reported to her by the nurse or CNA so she could follow-up. The SW stated that she had not noticed the resident's footwear before because he is usually sitting down. When clothing items are needed, she would contact the family to ask for needed items first. She would also contact the housekeeping department and ask if any of the needed items are available from the donated stock. Many times, the facility absorbs the cost of purchasing needed items. On 09/19/19 at 10:35 AM, the Registered Nurse (RN) Unit Manager, (UM) # 1 was interviewed. The UM stated that if a resident is in need of any clothing items, they contact the SW or the housekeeping department and family. She further stated the assigned CNA should communicate with the nurse to report a need for items of clothing or footwear. The facility has donated clothing that is managed and kept by the Housekeeping Department. The unit manager # 1 stated that she makes rounds and notices how residents are dressed and groomed. She stated that she had not noticed the condition of the resident's sneakers. 415.5(g)(1)(i-xv)

Based on observations, interviews, and record review during the Re-Certification Survey, the facility did not ensure that residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition. Specifically, a resident with wandering and elopement risk behaviors was prescribed [MEDICAL CONDITION] medications without an appropriate diagnosis. In addition, the facility did not attempt any non-pharmacological interventions targeted to address the psychosocial stressors of loss of home and family moving away that contributed to the behavior prior to starting the medication. This was evident for one (1) of five (5) residents investigated for Unnecessary Medication (Resident # 51). The finding is: The policy for, [MEDICAL CONDITION] Drugs & GDR (Gradual Dose Reduction), dated 03/20/19, documented the following: That residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the medical record. Psychopharmacological medications will never be used for the purpose of discipline or convenience. Resident #51 is an [AGE] year, admitted to the facility on [DATE], who is alert, pleasant and approachable, with [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3.0 (MDS) Assessment reference Date (ARD) dated 03/12/19 documented an admission date of [DATE]. The resident was assessed as having clear speech, usually understands and usually understood, with a Brief Interview Mental Status (BIMS) score of 5 out of 15, indicating the resident had severely impaired cognition. No wandering behaviors were identified, and the resident required extensive assistance for activities of daily living needs, (adl). The [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 07/13/19 documented a BIMS score of 7 out of 15, indicating the resident had severely impaired cognition. No wandering behaviors were identified, and the resident required limited assistance for ADL's. [DIAGNOSES REDACTED]. The resident received Antipsychotic medication (AP) on a routine basis, with no Gradual Dose Reduction (GDR) attempted because the Physician documented it was clinically contraindicated on 06/10/19. Resident #51 was observed at different intervals throughout the survey, including but not limited to the following: On 09/19/19 at 08:14 AM, the resident was observed in the dining room area seated in a wheelchair (w/c) and dressed appropriately. The resident was quiet and had both hands on lap. There were no outbursts or inappropriate behaviors noted. The resident was able to wheel himself in and around the unit, and he used both feet to propel his wheelchair. When greeted, the resident smiled and nodded his head. On 09/19/19 at 09:37 AM, the resident was observed in his room. He was walking around his side of the room and closed his privacy curtains. His wheelchair was nearby. When spoken to, he nodded his head, smiled, and in broken English said ok, ok. The resident was approachable, seemed calm, and had a friendly and gentle demeanor. On 09/20/19 at 09:37 AM, the resident was observed in the dining room sitting in his w/c. A Chinese newspaper was folded next to him. No behaviors or outbursts were observed by the state agent (SA) during the survey. Review of Hospital records dated 02/24/2019 documented that the resident had a history of [REDACTED]. Medications included: Donepezil ([MEDICATION NAME]) 10 milligrams (mg) by mouth (po). The Initial Admitting Physician's History and Physical note dated 03/06/19 documented the resident was an [AGE] year old with [DIAGNOSES REDACTED]. Current medications included Donepezil 10 mg po at bedtime. A Nursing Progress Note dated 03/07/19, timed at 11:41 PM, documented that the resident verbalized that he wanted to go home. Monitoring every 30 minutes was ongoing. A Nursing Note dated 03/08/19, timed at 12:11 AM, documented that the resident was wandering on the unit. When re-directed, stated, I am going home. A wander guard was applied. Nursing Notes entered 03/08/19 at 7:18 AM and 03/13/19 at 12:21 PM, documented that the resident was adjusting to unit, stays mostly in his room, and had no behaviors problems. Monitoring every 30 minutes. A Nursing Note entered 03/13/19 at 11:31 PM documented that the resident had episodes of blocking the room with his wheelchair and was difficult to re-direct. The initial Psychological evaluation documented that on 03/13/19 the resident was seen. The resident was diagnosed with [REDACTED]. The evaluation was ordered on [DATE] as a routine consult completed upon admission. A Care Plan Note on the Behavioral Symptoms Comprehensive Care Plan (CCP) dated 4/18/19 documented that Nursing notified Social Work (SW) about the resident's constant wandering behaviors. The resident was attempting to leave the building and refusing to wear the wanderguard. the resident was on q 30 minute monitoring for high elopement risk. The family was aware. SW spoke to the resident on 4/18/19 regarding the behavior. The resident stated his house is close by so he wishes to visit home. The resident was informed by his son that the house would be sold soon, and the family was moving. SW was supposed to provide further support if needed. An additional CCP note dated 4/22/29 documented the resident was not able to adjust to the facility's life and routines. The resident continued to wander on the unit and attempted to leave the building. The resident was also continuing to refuse to wear the wanderguard. The note documented the team was waiting for the psychiatrist to see the resident. SW would provide further support if needed. A Nursing Note entered 04/28/19 at 1:50 PM documented that the resident was found on the main floor between the inner and outdoors. The resident stated, I am going home, my home is nearby, I need to see my family. Staff told the resident that he cannot go out, and the resident became very upset. The resident was not listening and screaming at staff. The doctor was called and informed about the wandering behavior, and Quetiapine 25 mg po twice a day was ordered. The physician's interim order dated 04/28/19 documented an order for [REDACTED]. [MEDICATION NAME] is a medication used to treat [MEDICAL CONDITION] and Bi-Polar Disorder. The Physician's Monthly renewal orders dated 5/1/19 documented orders for Quetiapine 25 mg PO BID. The Psychiatry Consult dated 05/08/19 documented the resident was being seen for an initial evaluation for capacity of medical and discharge decisions and agitation and screaming to staff. The resident's current medication was [MEDICATION NAME] 25 mg po BID. The chart was reviewed, and the consultant discussed the case with a nurse who reported the resident sleeps and eats good. During the exam, the resident was alert and superficially cooperative. The resident's mood was euthymic with labile and [MEDICATION NAME] affect. The resident was distracted, and had limited insight and judgment. The resident had poor cognitive function and impulse control. There was no overt agitation or irritability noted. The resident was diagnosed with [REDACTED]. The psychiatrist documented the resident could not understand the consequence of his decisions regarding medical issues and discharge planning. The Plans/Recommendations were to add [MEDICATION NAME] 250 mg po twice a day, labs in 1 week (Complete Blood Count, Liver Function Test, and [MEDICATION NAME] level, monitor for mood and behavioral changes, and support and direct for proper ADL. There was no documentation in the psychiatry note regarding what specific targeted behaviors were being treated by the [MEDICAL CONDITION] medication and should be monitored. Also, the evaluation did not include any information regarding the psychosocial stressors occurring with the resident that could be contributing to the resident's behaviors (loss of his home and proximity to his family). There is also no documented evidence that the psychiatrist attempted to get a psychiatric history from the resident and family. The physician's interim order dated 05/08/19 documented orders for [MEDICATION NAME] Acid ([MEDICATION NAME]) 250 mg po twice a day for Mood Disorder. The Pharmacy Drug Regimen Review dated 05/20/19 documented, currently on Quetiapine, use is for a [DIAGNOSES REDACTED]. Please evaluate. An approved [DIAGNOSES REDACTED]. Medical response dated 05/20/19 documented, I agree, psych consult.' A Medical Note dated 05/20/19 documented the physician was called regarding the pharmacist's recommendation. The resident was seen and examined. The resident denied any history of psychiatric issues. The physician further documented they would call psychiatry to follow-up and specify the psychiatric disorder and attempt to taper/discontinue psych meds. The note further documented the resident had dementia with no abnormal behavior and was on [MEDICATION NAME]. An interim physician's orders [REDACTED]. The [DIAGNOSES REDACTED]. Review of psychiatry consult dated 06/10/19 documented, follow up for medication change, current medications: [REDACTED]. Specific (Targeted) Behaviors to be monitored,: last seen on 05/08/19. [MEDICATION NAME] was added. Chart reviewed. Discussed with a nurse. He is better. Says he is sleeps and eats good. The plan was to continue with current medications. There was no documentation regarding what specific targeted behaviors should be monitored. The physician's monthly renewal orders dated 6/27/19 documented the dosages for [MEDICATION NAME] Acid and Quetiapine remained unchanged. The Pharmacy review dated 07/14/19 documented, currently on [MEDICATION NAME] 25 mg po twice a day for behaviors associated with dementia. No recent behavior problems noted. Please evaluate, consider taper to once daily or document inability to do so. Physician response dated 07/16/19 documented, I agree. An interim physician's orders [REDACTED]. The Medical Note entered by the Nurse Practitioner (NP) dated 07/18/19 documented the NP was called to evaluate the resident regarding the pharmacy recommendations. The resident had mood disorder with mixed features for which he was placed on [MEDICATION NAME]. Psychiatry saw the patient and recommended to continue with [MEDICATION NAME] po daily for mood disorder. The bottom of the consult documented the plan to continue [MEDICATION NAME] 25 mg BID and [MEDICATION NAME] 250 mg twice a day. The physician's monthly renewal orders dated 07/29/19 documented orders for Quetiapine 25 mg once daily for Mood Disorder. The physician's monthly order dated 08/30/19 documented, Quetiapine 25 mg po daily for Mood disorder and [MEDICATION NAME] Acid 250 mg twice a day for Mood disorder. The Medical Note entered by the Nurse Practitioner (NP) dated 09/18/19, documented the NP was called to review the pharmacy recommendations. The NP documented the resident was currently on [MEDICATION NAME] and Quetiapine. The plan was to discontinue Quetiapine, start [MEDICATION NAME] 2.5 mg daily, continue [MEDICATION NAME] Acid 250 mg BID, and a psychiatry consult secondary to medication changes. There was no documentation in the NP note regarding psychiatric symptoms or behaviors observed. The physician's orders [REDACTED]. [MEDICATION NAME] Acid was decreased to 250 mg once daily from twice a day. The Psychiatry note dated 09/18/19 documented that the reason for the consult was to evaluate efficacy of regimen. Current medications: [REDACTED]. Specific (Targeted) Behaviors to be monitored: .has a history of Dementia. Mental Status Examination: poor impulse control, inappropriate affect and anxious mood, disoriented to time, poor insight. Plan: lower [MEDICATION NAME] Acid to 250 mg po daily. There was no mention of the [MEDICATION NAME] 2.5 mg po daily in the psychiatry consult. The Medical note entered by the primary physician dated 09/18/19 documented the resident was currently on [MEDICATION NAME] acid for mood disorder. The plan documented the resident would continue [MEDICATION NAME] acid 250 mg po qd and [MEDICATION NAME] 2.5 mg daily. There was no documentation from the physician regarding psychiatric symptoms and behaviors observed. There was no documentation regarding which targeted behaviors should be monitored. On 09/19/19 at 08:15 AM, the assigned Certified Nurse Aide (CNA #1) was interviewed. The CNA stated that she is familiar with the resident and has been assigned to him for the month of September. The resident at times gets around on the unit with his w/c, and when in his room, he walks. The only concern with the resident is that he, wants to go home. She stated the resident has displayed no behavior problems. The resident comes and goes as he likes on the unit. He may stay to watch activities, but he mostly keeps to himself. On 09/19/19 at 09:00 AM, the Registered Nurse Unit Manager (RNUM #1) was interviewed. The RNUM stated that the resident is mostly quiet and calm. He tends to suddenly want to leave to go home see his family. The resident can become upset and agitated when staff are attempting to prevent him from leaving the unit or facility. One time, the resident went to the lobby carrying a bag containing some clothing and had to be redirected by staff. The resident has also had to be escorted out of the elevator by staff when he gets onto it to in an attempt to leave the facility. The resident tends to wander, but he is not aggressive or abusive to others. The resident likes to keep to himself. The resident alternates between using a w/c and walking with the w/c to get around. The main issue with the resident is that he wants to go home. He is allowed to leave the unit and is monitored closely as he has refused to wear a wanderguard. The resident becomes agitated when the staff try to stop him from leaving the floor, which is why they have staff watch him in the lobby. The security guard was made aware of the resident's desire to leave, and they also keep an eye on him. The resident is in and out of activities, and, at times, they have called his son on the phone to help calm him down. The current psychiatrist was interviewed on 09/19/19 08:42 AM. He stated that the previous psychiatrist stopped working at the facility in the beginning of (MONTH) 2019. He stated that yesterday (09/18/19) was his very first visit with the resident. He stated that he decreased the resident's [MEDICATION NAME] Acid from twice a day to daily, and the resident has no signs of psychotic behaviors and was very calm and quiet. He would not prescribe Antipsychotic medications as he did not see signs of aggression, violence, hallucinations or delusions. He further stated he lowered the [MEDICATION NAME] Acid with a plan to discontinue it altogether. Antipsychotic medications are mostly prescribed for residents with a [DIAGNOSES REDACTED]. The dangers of prescribing AP medications to older people without an appropriate medical [DIAGNOSES REDACTED]. On 09/19/19 at 09:39 AM, the Nurse Practitioner (NP) was interviewed. She stated that she has been following the resident for roughly a month. The resident is mostly calm and is on AP medications due to agitation or impulsiveness at times, as he wants to leave to go home. She changed the medications yesterday, discontinuing Quetiapine and starting [MEDICATION NAME] 2.5 mg daily. She made the medication change because Quetiapine was no longer going to be covered by the resident's insurance, and the insurance company requested an alternate medication be used. The resident does not have [MEDICAL CONDITIONS] disorder, or [MEDICAL CONDITION]. The potential gross side effects of prescribing AP medications for residents with Dementia, include falls, an increase in mental status changes, parkinsonism-like tremors. In hind sight, and in the absence of an appropriate diagnosis, the resident should not be on AP medications. The resident's main issue was wanting to go home. On 09/20/19 at 08:37 AM, the Social Worker was interviewed and stated that she spoke to the family about the resident's desire to go home and see his grandchildren. The family may visit on weekends, and they have stated that they cannot take him back. The only behavior exhibited by the resident was attempting to go home. The resident was stopped from leaving once, while in the lobby, with a bag of clothing items in his hand. He does not exhibit aggression, [MEDICAL CONDITION], or abusive behaviors. She stated she makes rounds, and she takes about 5 minutes to speak with the resident about his need to leave. The resident stated that he just wants to see his family and that these thoughts are spontaneous. As for activities, he does not like to attend activities and has no hobbies. I have not explored further with him to try to create ideas and activities he may like. On 09/20/19 at 09:20 AM, the Recreation staff member was interviewed and stated that activity programs last 45 minutes. The resident likes musical based programs, like karaoke, name that tune, musical strolls, guitars, arts and craft, balloon throwing and volleyball. The resident also likes the newspaper. The resident is friendly, not abusive or aggressive. He knows when he wants to participate and when he wants to leave. She stated that the recreation staff receives Dementia Care inservice. There is no one special program developed for the resident. The activities are for all of the residents, and they do not offer activities designed specifically for Dementia residents. On 09/20/19 at 09:38 AM, the primary physician was interviewed. She stated that she first saw the resident upon admission to the facility, and she is able to speak his dialect. He was on [MEDICATION NAME] for dementia and exhibited no behavior problems, is calm. A wanderguard was placed because he wanted to go home. He knows his name and where he lives. He was started on AP medications on 04/28/19 when he became agitated and started screaming at the staff for trying to prevent him from leaving the facility. We need a valid [DIAGNOSES REDACTED]. He is not aggressive or psychotic. The black box warning for AP medications means there is a risk of death if the medications are used by elderly residents, and antipsychotics are not approved for dementia related cases. She stated that she went along with the psychiatrist's recommendations and understands that she is the one who ultimately makes decisions about a resident's medication regimen. The only behavior concern with the resident was his wanting to go home. On 09/23/19 at 11:12 AM, the Medical Director was interviewed. He stated that referrals are made to the psychiatrist for behaviors such as, combativeness, aggression, loss of appetite, and agitation. The psychiatrist makes recommendations, but the primary care physician has to agree or disagree. The Medical Director stated he conducts monthly board meetings with his doctors, and they discuss residents who are AP and follow-up with psychiatry. There ought to be a proper [DIAGNOSES REDACTED]. Attempts to interview the physician who initially ordered Quetiapine and the psychiatrist who followed the resident upon admission were unsuccessful because they no longer work at the facility. 415.12(m)(1)

Based on observation and staff interviews during the recertification survey, the facility did not ensure the infection prevention and control program desgned to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections was maintained. Specifically, the consultant eye doctor did not properly clean the overbed table used or perform hand hygiene prior to completing an eye exam. This was evident for 1 random observation (Resident #199) on 1 out of 6 resident units (2nd floor). The finding is: The facility policy titled Handwashing, reviewed and revised on 7/2017, documented that handwashing should be done before and after resident contact. Proper handwashing technique includes the following steps: Wet hands with running water. Apply soap and throughtly distributed over hands. Vigorously rub hands together for 20 seconds covering all surfaces of the hands and fingers. On 09/19/19 at 10:09 AM, the Eye Doctor was observed preparing to see residents on the 2nd floor. The Eye Doctor borrowed an overbed table from a resident's room to use during the exams. He wiped off the table top with a paper towel and placed his bag containing eye exam equipment on it. The State Agent (SA) observed stains on the overbed table after it was wiped down. The Eye Doctor then wheeled the table into a resident room. After exiting one room, the Eye Doctor went to see Resident #199. He did not perform hand hygiene prior to entering the room or performing the eye exam. The Eye Doctor placed eye drops into the resident's eyes during the exam. On 09/19/19 at 10:24 AM, the Eye Doctor was observed performing hand hygiene after completing the eye exam for Resident #199. The eye doctor washed his hands for less than 10 seconds. On 09/19/19 at 11:06 AM, the Eye Doctor was interviewed. He stated that he used the overbed table to move around his equipment. He uses alcohol prep wipes to clean the overbed table tops, which are sometimes filthy. He stated that he usually sees 5 to10 patients on multiple floors. After he finishes with a patient, he washes his hands with soap and water or hand sanitizer and moves on to the next patient. He further stated that he washes his hands for 2 to 3 minutes before or after the patient is seen. If the patient has an infection or oozing eyes, he washes hands during the examination if doing a two-part exam. The Eye Doctor further stated he uses gloves when residents' eyes are oozing, or they are on contact isolation. 415.19 (b) (4)

Based on record reviews, and staff interviews during the recertification survey, the facility did not ensure that a resident's care plan for Nutrition was reviewed and revised. Specifically, facility staff did not complete a timely review, and/or revision of the plan of care for a resident who a had an identified and recorded significant weight loss of 24 pounds (lbs) within 30 days. This was evident for 1 resident reviewed for Nutrition out of a Sample of . (Resident # 241) Findings are: The facility's policy titled Weight Monitoring documents that the nursing staff will identify resident's at risk for weight changes. Weights will be obtained weekly for four weeks for all new and readmissions and monthly thereafter unless other wise recommended. Nursing assistants will document weights on flow sheets. The dietitian/dietician assistant will transpose the weight into the EMR in the weight monitoring section and will review and evaluate the resident's weight pattern monthly. The The Dietician will review the monthly weights to identify any resident with a significant weight loss. Resident # 241 an [AGE] years old re-admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The Nurse's admission note dated 10/27/17 documented that the resident was admitted [MEDICAL CONDITION], UTI, increased Shortness of Breaths (SOB), Foley catheter 18F (French). The resident was also noted with generalized [MEDICAL CONDITION]. The resident's weight records documented that his admission weight on 10/27/17 was 113 lbs. The resident had a 3 lb wight gain by 11/19/17 when is weight was recorded at 118 lbs. On 12/5/17 the resident had a recorded weight of 93 lbs. This reflected a weight loss of 24 lbs (20%) in less than 30 days. The hospital discharge record also revealed that the resident was receiving a diuretic ([MEDICATION NAME] 25mg) prior to discharge from the hospital. The discharge records dated 10/27/17 documented the following orders for medication: aspirin, 81mg , [MEDICATION NAME], 75mg 1 tab by mouth (po), metroprolol 25mg po daily , Ramipril 1.25mg 1 tab po daily, [MEDICATION NAME] 5mg po daily, [MEDICATION NAME] 0.4mg 1 tab(po) daily at hour of sleep (hs), Metronidazone 500mg 500mg 1 tab po daily . The resident's medical record documents that the resident's weight was being measured on a monthly basis after 11/9/17 where his weight was recorded at 118lbs. This reflected a weight gain of 5 lbs since the admission weight of 113 lbs on 10/27/17. On 12/13/17 at 10:00 AM, the resident was observed in the room, alert and awake. Resident was also observed with a Foley Catheter bag hanged to the left side of bed. The resident unable to make conversation, unable to make needs known. The resident also has a limited range of motion to both upper and lower extremities. On 12/19/17 at 12:19 PM resident was observed during lunch being fed by staff with a meal that consisted of pureed items and thickened liquids. The resident ate approximately 80 % of the meal . The Nutrition assessment dated [DATE] documents that the resident requires a puree diet, and honey thickened liquids and consumes between 50 and 75% of meals. The assessment also notes that the resident is receiving a diuretic. The assessment further documents that the resident is noted with swollen lower extremities, generalized [MEDICAL CONDITION], pressure ulcer, septic shock. The Assessment noted that the resident has the potential for weight loss fluctuations. There was a request for a return weight. A protein supplement was recommended (LPS 30 milliters) and a double egg at breakfast. There was a note to monitor weight, but no indication of frequency. The Minimum Data Set Assessment (MDS) admission assessment dated [DATE] documented that the resident cognitive status is severely impaired. The MDS further documented that the resident required total assistance with Activity of Daily Livings (ADLS) including eating. The resident is incontinent of bowel, admitted with Foley catheter for urination due to [MEDICAL CONDITION]. The MDS also documented that the resident weighed 113 pounds (lbs) upon admission. The Comprehensive Care plan (CCP) for nutrition was revised on 10/28/17. The CCP identified that resident as being at risk for weight loss and dehydration. The CCP identified that the resident had generalized [MEDICAL CONDITION], and the potential for weight loss and fluctuations. Interventions were put into place, such as puree diet, supplements for protein, and to be fed all meals by staff. At this time the resident's weight was 113 lbs. The CCP was reviewed on 11/15/17 there was no mention of weight gain or loss. It was recorded on 12/5/17 that the resident experienced a weight loss of 24 lbs within a month. The CCP was not updated again until 12/15/17 where the weight loss of 12/5/17 was identified. The CCP noted that the [MEDICAL CONDITION] has resolved. That was 10 days between the weight loss being recorded on the weight record and the CCP being reviewed and revised. In addition there was no documented evidence that the nursing staff informed the dietician or attending physician of the resident's weight loss. The CCP documented that the resident's BMI is 17.1 and is Ideal Body Weight (IBW) ranges between 90-106. There was a note to see revised weight goal, but no other notation in the CCP was noted. It said, No goals exist for this focus, no interventions exits for this focus, no notes exist for this focus. On 12/20/17 02:30 PM an interview with the RN Supervisor was conducted. The RNS stated that the resident was admitted with generalized [MEDICAL CONDITION] and used to be on diuretic from the hospital, although the discharge record from the hosp dated 10/27/17 documented [MEDICATION NAME] 25mg po daily but never continued in the nursing home. She stated that noted the weight loss on 12/5/17, and did the re-weight around 12/17/17 and cannot recollect when she notified the dietician. The RNS further stated that the protocol for weight monitoring is to weigh new admitted residents weekly x 4 weeks, then monthly. She stated that Nursing puts the weight record in and it's the responsibility of the dietician to review weight records. We can tell them about a significant change but we are not mandated to do so. 12/20/17 03:06 PM an interview was conducted with the Registered Dietician (RD). The RD stated that the resident was admitted with 113.5 lbs, also sated that the resident had generalized [MEDICAL CONDITION], stated that she believed the resident was admitted with diuretic in the hospital . stated that the wt loss potential was not related to poor intake. The RD stated that they were informed of the weight loss on 12/14/17. 12/20/17 05:56 PM an interview was conducted with the DNS. She stated that nursing staff conduct weekly weight monitoring for 4 weeks upon admission. Then after it is done monthly. The weekly is done by the nurses and monthly is done by the dietary staff. If there are concerns such as weight loss the dietary will come and discuss with nursing staff. The staff needs to communicate effectively. 415.

Based on observation, record reviews, and staff interviews, the facility did not ensure that a resident maintained acceptable parameters of nutritional status. Specifically, The facility did not effectively monitor a resident at risk for weight loss and weight fluctuations. The facility did not identify the resident's poor intake, and 24 lb weight loss. The failure to identify the weight loss resulted in the resident's plan of care not being reviewed and revised in a timely manner. As a result there were no interventions put in place to prevent a further decline in the resident's weight. This was evident for 1 resident reviewed for Nutrition out of a Sample of . (Resident # 241) Findings are: The facility's policy titled Weight Monitoring documents that the nursing staff willl identify resident's at risk for weight changes. Weights will be obtained weekly for four weeks for all new and readmissions and monthly therafter unless other wise recommended. Nursing assistants will document weights on flow sheets. The dietitian/dietician assistant will transpose the weight into the EMR in the weight monitoring section and will review and evaluate the resident's weight pattern monthly. The The Dietician will review the monthly weights to identify any resident with a significant weight loss. Resident # 241 an [AGE] years old re-admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The Nurse's admission note dated 10/27/17 documented that the resident was admitted [MEDICAL CONDITION], UTI, increased Shortness of Breaths (SOB), Foley catheter 18F (French). The resident was also noted with generalized [MEDICAL CONDITION]. The resident's weight records documented that his admission weight on 10/27/17 was 113 lbs. The resident had a 3 lb wight gain by 11/19/17 when is weight was recorded at 118 lbs. On 12/5/17 the resident had a recorded weight of 93 lbs. This reflected a weight loss of 24 lbs (20%) in less than 30 days. The resident's medical record documents that the resident's weight was being measured on a monthly basis after 11/9/17 where his weight was recorded at 118lbs. This reflected a weight gain of 5 lbs since the admission weight of 113 lbs on 10/27/17. The Nutrition assessment dated [DATE] documents that the resident requires a puree diet, and honey thickened liquids and consumes between 50 and 75% of meals. The assessment also notes that the resident is receiving a diuretic. The assessment further documents that the resident is noted with swollen lower extremities, generalized [MEDICAL CONDITION], pressure ulcer, septic shock. The Assessment noted that the resident has the potential for weight loss fluctuations. There was a request for a return weight. A protein supplement was recommended (LPS 30 milliters) and a double egg at breakfast. There was a note to monitor weight, but no indication of frequency. The Minimum Data Set Assessment (MDS) admission assessment dated [DATE] documented that the resident cognitive status is severely impaired. The MDS further documented that the resident required total assistance with Activity of Daily Livings (ADLS) including eating. The resident is incontinent of bowel, admitted with Foley catheter for urination due to [MEDICAL CONDITION]. The MDS also documented that the resident weighed 113 pounds (lbs) upon admission. The Comprehensive Care plan (CCP) for nutrition was revised on 10/28/17. The CCP identified that resident as being at risk for weight loss and dehydration. The CCP identified that the resident had generalized [MEDICAL CONDITION], and the potential for weight loss and fluctuations. Interventions were put into place, such as puree diet, supplements for protein, and to be fed all meals by staff. At this time the resident's weight was 113 lbs. The CCP was reviewed on 11/15/17 there was no mention of weight gain or loss. It was recorded on 12/5/17 that the resident experienced a weight loss of 24 lbs within a month. The CCP was not updated again until 12/15/17 where the weight loss of 12/5/17 was identified. The CCP noted that the [MEDICAL CONDITION] has resolved. That was 10 days between the weight loss being recorded on the weight record and the CCP being reviewed and revised. In addition there was no documented evidence that the nursing staff informed the dietician or attending physician of the resident's weight loss. The CCP documented that the resident's BMI is 17.1 and is Ideal Body Weight (IBW) ranges between 90-106. There was a note to see revised weight goal, but no other notation in the CCP was noted. It said, No goals exist for this focus, no interventions exits for this focus, no notes exist for this focus. On 12/20/17 02:30 PM an interview with the RN Supervisor was conducted. The RNS stated that the resident was admitted with generalized [MEDICAL CONDITION] and used to be on diuretic from the hospital, although the discharge record from the hosp dated 10/27/17 documented [MEDICATION NAME] 25mg po daily but never continued in the nursing home. She stated that noted the weight loss on 12/5/17, and did the re-weight around 12/17/17 and cannot recollect when she notified the dietician. The RNS further stated that the protocol for weight monitoring is to weigh new admitted residents weekly x 4 weeks, then monthly. She stated that Nursing puts the weight record in and it's the responsibility of the dietician to review weight records. We can tell them about a significant change but we are not mandated to do so. 12/20/17 03:06 PM an interview was conducted with the Registered Dietician (RD). The RD stated that the resident was admitted with 113.5 lbs, also sated that the resident had generalized [MEDICAL CONDITION], stated that she believed the resident was admitted with diuretic in the hospital . stated that the wt loss potential was not related to poor intake. The RD stated that they were informed of the weight loss on 12/14/17. 12/20/17 05:56 PM an interview was conducted with the DNS. She stated that nursing staff conduct weekly weight monitoring for 4 weeks upon admission. Then after it is done monthly. The weekly is done by the nurses and monthly is done by the dietary staff. If there are concerns such as weight loss the dietary will come and discuss with nursing staff. The staff needs to communicate effectively.

Based on interviews and record review conducted during an abbreviated survey, the facility did not ensure that a resident receives adequate supervision and assistance devices to prevent accidents. This was evident in 1 of 3 resident sampled (Resident #1). Specifically, Resident #1 Comprehensive Care Plan (CCP) dated 04/07/2016, identified Resident #1 at High Risk for falls. The interventions documented provide bed alarm. The Nursing Quarterly/Annual/Significant Change Assessment-Fall Risk Assessment/Safety Measures dated 05/17/2016 documented chair alarm. On 06/05/2016 at 2:30AM, Resident #1 was observed on the floor in the hallway. Resident #1 sustained abrasions to the forehead and left forearm. Resident #1 did not have a bed or chair alarm in place at the time of the fall. Complaint # NY 767 The findings include: Resident #1 is [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 05/14/2016 identified Resident #1 with long-short term memory impairments. He requires limited assistance of one staff with walking in room and corridor. The Fall Risk Assessment form dated 05/06/2016, identified Resident #1 with a score of 14 points. Per the instructions on the form if the total score is 10 or greater, the resident should be considered at High Risk for potential falls. The fall CCP dated 04/07/2016, identified Resident #1 at risk for falls/injury/fracture related to impaired balance, impaired gait, medications, and Alzheimer's disease. The interventions included provide bed alarm. The Nursing Quarterly/Annual/Significant Change Assessment - Fall Risk Assessment/Safety Measures, created on 05/08/2016 and completed 05/17/2016, documented under title Safety Measures Implemented or Presently in Use: Cross Reference with Safety Care Plan revealed that the box for chair alarm was checked. Review of the Resident CNA Documentation Records from 04/2016 - 06/2016 revealed that there was no instruction for bed and chair alarm. Review of the Resident Nursing Instructions from 04/06/2016 - 06/20/2016 revealed that there was no instruction for bed and chair alarm. Review of the facility Post Fall Investigation, revealed that Resident #1 was observed lying on the floor on 06/05/2016 at 2:30AM. Question 10 of the investigation states, what mechanical devices were in use? The bed and chair alarm boxes were left blank. The nurse's note dated 06/05/2016 at 10:35PM, documented, noted with 2cm superficial abrasion on left side of forehead and in multiple sites on the left forearm. Skull x-ray is negative. No complaints of pain or any discomfort. The Nurse's Progress Notes dated 06/05/2016 at 2:30AM, documented call to assess resident, as per the Charge Nurse, Resident observed lying on the floor in the hallway in front of Room 209 and Hoyer Lift. When asked, resident unable to state what happened, denies pain when asked, body assessment done. Superficial abrasion to forehead area, able to move both upper extremities and both lower extremities without pain and discomfort. Doctor made aware, ordered stat x-ray for the skull, MD ordered treatment for [REDACTED]. Tylenol 325mg by mouth every 6 hours as needed for pain management. The physician's orders [REDACTED]. Cleanse left forearm superficial abrasion with Norma Saline pat dry, apply Bacitracin and dry protective dressing daily times 10 days. Cleanse forehead area superficial abrasion (left side) with Normal Saline pat dry, apply Bacitracin Ointment with dry protective dressing daily times 10 days. Bed sensor alarm when in bed for safety and visual monitoring every 30 minutes for resident safety. The Resident Treatment Administration Record dated 06/05/2016, documented, Cleanse forehead area superficial abrasion (left side) with Normal Saline, pat dry apply Bacitracin Ointment and dry protective dressing daily times 10 day for superficial abrasion. On 08/03/2016 at 1:25PM, a telephone interview was conducted with Resident #1's assigned CNA #2 on the 11-7 shift. She stated that on 06/05/2016 at 1:30AM when she made rounds on the unit, Resident #1 was in bed without a bed alarm. In addition, she stated, if a resident has instructions on the CNA Accountability Record to have safety devices such as bed/chair alarm, I make sure that the alarm devices are in place as per the instructions. On 06/28/2016 at 10:40AM, the Registered Nurse Manager (RNM) was interviewed. She stated that Resident #1 wanders around the unit, sleeps and urinates everywhere. She further stated that Resident #1 had no bed or chair alarm prior to the incident. In a follow-up telephone interview on 08/12/2016 at 10:15AM, she stated that she is responsible for updating Resident #1 's plan of care and the Resident Nursing Instructions as needed. She explained that the bed alarm was implemented after the fall. The RNM responded to a question regarding the updating of the Resident Nursing Instructions to reflect the bed alarm that was implemented on 06/05/2016 post fall incident. She stated that it was not done. On 08/03/2016 at 1:13PM a telephone interview was conducted with the Registered Nurse Supervisor (RNS) on the 11-7 shift. He stated that Resident #1 had no bed or chair alarm prior to the incident. He further stated that the Licensed Practical Nurse (LPN) paged him to the unit for Resident #1 who was found lying on the floor in the hallway. She also stated, assessment revealed that Resident #1 had a superficial abrasions on the forehead and left forearm. In a subsequent telephone interview on 08/18/2016 with the RNS, he stated that he might have overlooked Resident #1's CCP for bed and chair alarm. In addition, he stated that the alarm devices were not documented on the Resident Nursing Instructions. On 09/28/2016 at 9:48AM, a telephone interview was conducted with the Director of Nursing. She stated that the admitting RN is responsible for initiating the residents CCP, the Resident CNA Documentation Record and the Resident Nursing Instructions. She further stated that any RN can update the CCP and the Resident Nursing Instructions. She also stated that when Resident #1 was admitted on [DATE], the fall CCP intervention documented bed alarm. She also stated that the bed alarm instruction was not documented on the Resident Nursing Instructions. In addition, the DON affirmed that after the occurrence, the bed alarm was applied but the Resident Nursing Instructions was not updated. She also stated that Resident #1 did not need a bed or chair alarm upon admission. She stated that it was an error made by the admitting nurse. Although, the DON stated that the admitting nurse made an error, record review revealed that the error was never identified or corrected by facility staff. The facility's Policy and Procedure on Safety Alarms, documented: Resident with history of fall or identified at risk for fall will be assessed by the clinical team for use of bed and chair alarm. Use of alarm is at the discretion of the Interdisciplinary Team, therefore, a physician's order [REDACTED]. CNA must notify charge nurse/RNS for any missing or malfunctioning of alarms for immediate replacement. CNA has to sign every shift for use of bed/chair alarm in the accountability record. §483.25(h)(2)

Based on staff interviews and record review conducted during an abbreviated survey, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident in 1 of 3 residents sampled for Accidents (Resident # 1). Specifically, Resident #1's Comprehensive Care Plan (CCP) dated 04/07/2016, identified Resident #1 at High Risk for falls. The CCP documented provide bed alarm. The Nursing Quarterly/Annual/Significant Change Assessment - Fall Risk Assessment/Safety Measures dated 05/17/2016, had the box for chair alarm checked. Resident #1 was observed on the floor on 06/05/2016 at 2:30AM in the hallway. Neither bed nor chair alarm was in place at the time of the fall. Complaint # NY 767 The findings include: Resident #1 is [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 05/14/2016 identified Resident #1 with long-short term memory impairments. He requires limited assistance of one staff with walking in room and corridor. The Fall Risk Assessment form dated 05/06/2016, identified Resident #1 with a score of 14 points. Per the instructions on the form, if the total score is 10 or greater, the resident should be considered at High Risk for potential falls. The Fall CCP dated 04/07/2016, identified Resident #1 at risk for falls/injury/fracture related to impaired balance, impaired gait, medications, and [MEDICAL CONDITION]. The interventions included provide bed alarm. The Nursing Quarterly/Annual/Significant Change Assessment - Fall Risk Assessment/Safety Measures created on 05/08/2016 and completed on 05/17/2016, had the box for chair alarm checked. Review of the Resident Nursing Instructions from 04/06/2016 - 06/20/2016 revealed that there was no instruction for bed and chair alarm. The Nurse's Progress Notes dated 06/05/2016 at 2:30AM, documented call to assess resident, as per the Charge Nurse Resident observed lying on the floor in the hallway in front of room [ROOM NUMBER] and Hoyer Lift. When asked resident unable to state what happened, denies pain when asked, body assessment done. Superficial abrasion to forehead area, able to move both upper extremities and both lower extremities without pain and discomfort. Doctor made aware, ordered stat x-ray for the skull, MD ordered treatment for [REDACTED]. Tylenol 325mg by mouth every 6 hours as needed for pain management. Review of the POS [REDACTED]. Question 10 of the investigation form states, What mechanical devices were in use? The bed and chair alarm boxes were left blank. The updated CCP dated 06/05/2016 documented bed sensor alarm when in bed for safety. This intervention for bed sensor alarm was not documented on the Resident Nursing Instructions for 06/2016. On 06/28/2016 at 10:40AM, the Registered Nurse Manager (RNM) was interviewed. She stated that Resident #1 had no bed or chair alarm prior to the fall of 06/05/2016. She explained that the alarm was provided after the fall. In a subsequent interview with the RNM on 08/12/2016, she stated that she initiated the CCP of 04/07/2016 identifying Resident #1 with bed alarm. On 08/03/2016 at 1:13PM, a telephone interview was conducted with the Registered Nurse Supervisor (RNS) on the 11-7 shift. He stated that Resident #1 had no bed or chair alarm prior to the incident. He stated that Resident #1 received the bed alarm after the fall. In addition, he stated prior to the incident, he might have overlooked Resident #1's CCP for bed alarm. He asserted that the bed alarm was not documented on the Resident Nursing Instructions. On 08/03/2016 at 1:25PM, a telephone interview was conducted with Resident #1's assigned CNA #2 on the 11-7 shift. She stated that on 06/05/2016 at 1:30AM when she made rounds on the unit, Resident #1 was in bed, but did not have a bed alarm. In addition, she stated, if a resident has instructions on the CNA Accountability Record to have safety devices such as bed/chair alarm, I make sure that the alarm devices are in place as per the instructions. On 09/28/2016 at 9:48AM, a telephone interview was conducted with the Director of Nursing. She stated that the admitting RN is responsible for initiating the residents' CCP, the Resident CNA Documentation Record and the Resident Nursing Instructions. She further stated that any RN can update the CCP and the Resident Nursing Instructions. She also stated that when Resident #1 was admitted on [DATE], the fall CCP intervention documented bed alarm. However, the bed alarm instruction was not documented on the Resident Nursing Instructions. In addition, the DON affirmed that after the occurrence, the bed alarm was applied, but the Resident Nursing Instructions was not updated. She also stated that Resident #1 did not need a bed or chair alarm upon admission. She stated that it was an error made by the admitting nurse. Although, the DON stated that the admitting nurse made an error, record review revealed that the error was never identified or corrected by facility staff. The facility Policy and Procedure on Prevention of Falls, documented on page 2 The admitting nurse will identify any safety measure to be implemented for the resident on safety task under CNA assignment. The RN completing the risk assessment and evaluating plan of care will review CNA assignment to ensure safety task reflects all current measures/plan. §483.75 (I)

Based on observation, interviews and record review during an abbreviated survey, the facility did not provide adequate supervision to a resident to prevent accidents. This was evident for 1 of 3 sampled residents (Resident #1). Specifically, Resident #1, who was identified as at risk for elopement, was able to leave the facility unnoticed by the security guard. The resident left the facility at around 5:34PM and was not identified as missing until 8:05PM when the resident ' s family notified the facility. Complaint # NY 067 The findings include: Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 5/28/15 documented that the resident had severely impaired cognitive skills for daily decision making with long and short term memory impairments. The Elopement Risk assessment dated [DATE] documented that the resident was not at risk for elopement. The Elopement Risk assessment dated [DATE] documented that the resident was at risk for elopement. The resident was observed wandering in the hallway and redirected by the staff. The Comprehensive Care Plan (CCP) dated 5/22/15 documented that the resident had a wander guard on the left arm. The facility ' s interventions included conducting 30- minute monitoring, providing psychiatric evaluations and social service counseling, and checking for functioning of the wander guard. The Social Services Admission Note dated 5/22/15 documented that the resident was wandering on the unit. The resident was placed on monitoring for behavior and safety. The note documented that the resident will be moved to the Korean unit for a better placement. The Room Change Note dated 5/22/15 documented that the resident was transferred from the 5th floor to the 4th floor. The family was informed. The 24-Hour Report dated 5/23/15 at 12:00AM documented that the resident was transferred from another unit. The report documented that the resident appeared confused and constantly asked for his wife. The Wanderer Monitoring Form dated 5/24/15 documented that the resident was monitored every 30 minutes from 3:45PM to 5:45PM. At 5:45PM, the form documented that the resident was eating supper. The monitoring form had no documentation from 6:00PM to 11:00PM. The Accident/Incident Report dated 5/24/15 at 8:05PM documented that the resident ' s son notified the facility that the resident took a taxi and went to his home. The son called the New York Police Department (NYPD). The resident was taken to the hospital and returned to the facility. The report documented that the resident had no injury and that his wander guard was functioning. The resident was placed on one to one monitoring. The Facility Investigation Summary dated 5/29/15 documented that the resident followed another family towards the front door when the security guard was present. The security guard intentionally silenced the alarm and continued talking to his co-worker, without investigating the cause of the alarm sounding. The facility concluded that the security failed to follow the facility elopement prevention policy. On 6/16/15 at 11:30AM the video surveillance at the front desk was viewed. Prior to viewing the surveillance video, the Administrator stated that the time shown on the surveillance camera was 15 minutes behind the actual time. The video revealed that on 5/24/15 at 17:19PM (5:19PM) + 15 minutes (actual time: 5:34PM), the security guard was talking to the receptionist at his post. A male visitor came to the lobby followed by Resident #1. The alarm system's red light flashed. The security guard was observed entering a code on the alarm panel. The male visitor opened the door and exited the building without signing out. Resident #1 followed the visitor. Outside of the building, the visitor went to the left direction and Resident #1 went to the right direction. The receptionist pointed out Resident #1 to the security guard. The security guard briefly went outside and returned without the resident. On 7/3/15 at 4:18PM a telephone interview was conducted with Certified Nursing Assistant (CNA) #1, who was on duty during the 3PM-11PM shift on 5/24/15. CNA #1 stated that Resident #1 was nicely dressed and looked like a visitor. She stated that he had a wander guard. CNA #1 stated that at around 5:00PM, the food truck came for supper, but the resident ' s tray did not come. CNA #1 stated that another CNA called the kitchen for his tray. CNA #1 stated that she made her rounds for monitoring at 5:45PM and saw the resident sitting in the hallway near the day room where he ate his dinner. At 6:00PM, she was waiting at the elevator for her break, and still saw the resident sitting in the hallway. She stated that she returned from her break at 6:45PM. She stated that she did not make rounds for monitoring at 6:45PM because she had to provide care to two other residents at that time. CNA #1 stated that at 7:30PM, she started doing the 30-minute monitoring, but did not finish because there were residents in the hallway who were at high risk for falls. CNA #1 stated that she could not leave those residents. She stated that she did not see Resident #1, so she assumed that the resident was in his room. CNA #1 stated that at around 8:00PM she heard that the resident's son called to notify the charge nurse that the resident was at home with him. On 6/16/15 at 4:00PM and on 7/13/15 at 3:36PM interviews were conducted with CNA #2, who was on duty during the 3PM-11PM shift on 5/24/15. CNA #2 stated that the resident was new on the unit and looked like a visitor. She stated that the resident was crying for home, always talking about his wife. CNA #2 stated that the resident knew his address. She stated that between 5:00PM and 5:15PM, she called the kitchen to get the dinner tray for Resident #1. She stated that dinner finished between 5:30PM and 5:45PM. She stated that she saw the resident sitting outside the day room around 6:45PM. When the surveyor informed her that the video surveillance revealed the resident leaving the facility around 5:34PM, CNA #2 stated that that was impossible because his dinner tray came late and he ate his dinner. CNA #2 continued to state that she saw the resident at 6:45PM. On 7/3/15 at 2:57PM an interview was conducted with the charge Licensed Practical Nurse (LPN). The LPN stated that it was her first day as the charge nurse on the 4th floor. The LPN stated that she found out that the resident was on monitoring for behavior when she checked the 24 hour report. The LPN stated that CNA #1 was aware of the monitoring of Resident #1. The LPN stated that she last saw the resident at 5:00PM for the medication pass. Around 8:00PM, she received a call from the resident ' s son, who reported that the resident was at his home in Brooklyn. The LPN stated that she immediately notified the Registered Nurse Supervisor (RNS). The LPN stated that the resident ' s family brought the resident back to the facility via an ambulette around midnight. The LPN stated that the resident was still wearing a wander guard and it was functioning when he returned. On 7/8/15 at 10:00AM an interview was conducted with the RNS. The RNS stated that on 5/24/15 the LPN notified her that the resident left the facility and went to his home in Brooklyn. The RNS stated that the resident ' s son asked how his father got out of the building undetected. The RNS stated that the resident had a wander guard and his picture was in the Wanderer Log Book. The security guard told her that he did not hear the wander guard alarm when the resident left. On 7/3/15 at 9:43AM an interview was conducted with the Security Guard (SG), who was on duty on the evening of 5/24/15. The SG stated that he was speaking to the receptionist at his post when a male visitor who does not speak English walked out of the building. The SG stated that he was not sure if the wander guard alarm disarmed at that time. When the man left the building, the receptionist pointed at the door and asked him if the man was a resident. The SG stated that he went outside to check. He stated that he walked about 15 feet away from the front door. The SG stated that on the right side he saw a Korean guy, but he did not stop him because he did not look the same as he did when he was first admitted to the facility. The SG stated that the man did not look like the man he saw in the Wanderer Log Book. The SG stated that the picture in the book should have been updated. The SG further stated that the resident who left looked too sane to be in a nursing home. On 6/16/15 at 4:35PM an interview was conducted with the Receptionist. The Receptionist stated that on 5/24/15, sometime after 5:00PM, she walked over to the security desk to get a form. She stated that she saw a man walking out of the door, so she pointed him out to the SG to go after him because he did not look like a visitor. She stated that the SG went outside and looked around for 3-4 minutes. The SG returned to the facility and stated nothing wrong. On 6/16/15 at 5:45PM an interview was conducted with the Director of Nursing (DON). The DON stated that the resident was at risk for elopement. She stated that on 5/24/15, she got a call from the Assistant Director of Nursing (ADON) that the resident left the facility and went to Brooklyn. The DON stated that the SG failed to ensure the visitors sign in and out as per protocol. She stated that the SG let the resident go out of the building without checking why the alarm went off. The DON stated that the resident was supposed to be on 30-minute monitoring, but the CNA did not look for the resident until 7:30PM. 415.12(h)(2)