Every finding on record at Downtown Brooklyn Nursing & Rehabilitation Center

Based on observations, record review, and interviews conducted during the onsite visit for Complaint NY00384702, it was determined that the facility failed to maintain safe and comfortable temperature levels. This was evident on four (4) of four (4) resident floors, where 55 out of 55 rooms sampled had temperatures above the Federal and State requirements in accordance with 42 CFR Part 483 and 10 NYCRR: 415.29. Specifically, room [ROOM NUMBER] was 105 degrees Fahrenheit, room [ROOM NUMBER] was 102 degrees Fahrenheit, and Resident #1 room [ROOM NUMBER] temperature reading was 96 degrees Fahrenheit. Three (3) complaints were submitted to the State Agency regarding high temperatures throughout the facility from 06/24/2025 through 06/25/2025, stating all residents were affected. The facility temperature log on 06/24/2025 at approximately 4:00 PM documented high temperatures above the regulatory range in 29 of the 36 resident rooms sampled. This resulted in Immediate Jeopardy to all resident's health and safety. The findings are: Observations during the initial tour of the facility on 06/25/2025, from 11:10 AM to 12:15 PM, included temperatures in resident rooms and corridors measuring above Federal and State required ranges of 71 to 81 degrees Fahrenheit. Temperatures were observed between 84 and 105 degrees Fahrenheit. On 06/26/2025 between 10:15 AM and 12:15 PM, 61 resident rooms were sampled with 27 resident rooms having temperatures above the regulation. Residents and staff were seen complaining to the Director of Maintenance and maintenance staff regarding the heat in their various units. On 06/25/2025 at approximately 12:14 PM, the Corporate Regional Administrator was interviewed and stated they were not aware of any complaints about malfunctioning Packaged Terminal Air Conditioner (PTAC) units or high temperatures in resident rooms until the evening of 06/24/2025. They stated that all Packaged Terminal Air Conditioner units in resident rooms were serviced on 04/29/2025, including Heating, Ventilation, and Air Conditioning (HVAC) which was serviced on 05/23/2025 in preparation for summer. A review of the facility's policy on Heat Precaution dated 07/2016 revealed that the facility shall provide information to staff, resident and family to identify and reduce adverse effects of increased heat and humidity and to prevent heat related illnesses. The policy is to ensure the safety of residents during high heat alert and to assist preventing heat illness among residents during the hot and humid weather. A review of the Maintenance Logbooks on the 2nd to 5th floors revealed that on four (4) of four (4) resident floors, there were maintenance entries indicating the air conditioning was not working, residents requested fans, rooms were reported to be hot, circuit breaker tripped off or portable air conditioners were installed in rooms. These entries were made from 06/06/2025 through 06/25/2025 and more than 36 resident rooms were affected by faulty air conditioner or hot air complaints. A review of the facility Daily Room Temperature Log Readings for 06/24/2025 and 06/25/2025 revealed that hallway and resident room temperatures on resident floors ranged from 74 to 90 degrees Fahrenheit. During an interview on 06/26/2025 at 11:06 AM, Resident #1 stated they had been in the facility for six (6) years, and had been telling the facility management, specifically the previous Administrator and maintenance staff, about the preparation for heatwaves because their experience during summer periods in the facility has not been pleasant. They stated that although the facility performed maintenance activities such as fixing the Packaged Terminal Air Conditioner units, and checking the circuit breakers, those maintenance methods did not always yield desired results. They stated that in their own opinion, centralized Heating, Ventilation, and Air Conditioning may be the solution to the high temperatures in the facility during the summer. During an interview on 06/26/2025 at 4:12 PM, in Resident #1's room, with their Family Member #1 they stated they have complained to facility staff about the high temperature in the resident's room. They stated that on one occasion, Resident #1 had a severe headache due to the high temperature in their room. Nursing Supervisor #1 was informed, and Resident #1's vital signs were taken and recorded as normal. They stated that on more than one occasion they requested a fan for the room. They further stated that on 06/18/2025 they complained to the Admissions Director, who was in the reception area at the time, and on 06/23/2025 they complained to Registered Nurse Supervisor # 1. On 6/18/2025, The admission Director called the maintenance department because the room thermostat was reading 86 degrees Fahrenheit. On 06/21/2025 and 06/22/2025, the maintenance log documented the resident's room was very hot and a fan was requested. During a telephone interview on 06/26/2025 at 4:30 PM with Resident #1's Family Member #2, they corroborated Family Member #1's statement regarding the high temperature in the resident's room, as they had visited Resident #1 on 06/25/2025. During an interview on 06/26/2025 at 4:52 PM with Certified Nurse Aide #5, they stated residents had been complaining about their air conditioners not working for the past three (3) days. They said they usually take residents to a cooler place, give them water, and check their vitals. They stated that they will call the nurse if they observe anything strange with the weather or temperature. During an interview on 06/27/2025 at 12:42PM with Maintenance Staff #1, they stated their department was getting calls from nursing stations and resident family members to inform them of air conditioners malfunctioning and they were attending to the issues. They stated they were hired about three (3) weeks ago. During an interview on 06/27/2025 at 3:50 PM, the Director of Maintenance stated all Heating, Ventilation, and Air Conditioning systems in the facility were serviced and circuit breakers were checked. They stated that the maintenance of this equipment was completed on 04/29/2025 in preparation for summer. They stated their department receives calls occasionally to attend to some malfunctioned units, but they noticed an increase in calls around 06/23/2025. They stated they mobilized their staff to attend to the issues; they take the system out, wash, flush and change the filters, after which they bring the unit in and reinstall. They do Packaged Terminal Air Conditioner replacement where necessary, change parts as needed, and put portable air conditioning units where the Packaged Terminal Air Conditioner units could not be fixed. During an interview on 06/27/2025 at approximately 11:16 AM, the admission Director stated they received multiple calls on 06/23/2025 from residents newly admitted reporting that their rooms were extremely hot, with most calls coming from the 3rd floor. The admission Director stated they called Maintenance and the Nurse Supervisor to offer a room change. The admission Director stated that they sent Maintenance staff to resident rooms, to check and work on the issues raised. During an interview on 06/27/2025 at approximately 3:13 PM, the Administrator stated they are the chairman of the Quality Assurance Performance Improvement committee and are responsible for all department performance, including the Maintenance Department. The Administrator stated that on 06/19/2025, they received an email from the New York State Department of Health with a heat advisory memo. Maintenance was immediately deployed to re-check the air conditioning units in the resident's rooms, Packaged Terminal Air Conditioner and Heating, Ventilation, and Air Conditioning to ensure proper operation. The Administrator stated that no issues were reported on 06/21/2025 and 06/22/2025. The Administrator stated they contacted an electrician due to the breaker tripping. The electrician came on site on 06/24/2025 and assessed the electrical grid and contacted Con [NAME] (the energy company) and discovered that Con [NAME] had cut the voltage to the facility by 8%. They also contacted the air conditioning company on 06/24/2025 due to an abnormal number of overheated air conditioning units. The air conditioning company came to the facility on the same day and evaluated the air conditioning units and there were no significant issues, but some units failed and were replaced immediately. The Administrator stated that on 06/24/2025 at 7:58 PM, they received a phone call from the New York State Department of Health stating there is a complaint of heat in the building and requested the temperature log to be sent the following day (06/25/2025). The log was sent at 2:00 PM on 06/25/2025. The Administrator stated they were not in the facility on 06/25/2025 due to a medical appointment, but a Quality Assurance Performance Improvement meeting was held on 06/26/2025 to discuss a heat problem in the facility. Immediate Jeopardy was identified, and the Administrator was notified on 06/25/2025 at approximately 5:22 PM. An acceptable immediate corrective action plan from the facility was received on 06/25/2025 at approximately 6:12 PM. Immediate Jeopardy was removed on 06/27/2025 at 5:00 PM based on the following corrective actions taken by the facility: Observation of all units was done by the State Surveyor on 06/27/2025 between 12:15 PM and 1:02 PM. 70 resident rooms were sampled and temperatures ranged between 65 to 79 degrees Fahrenheit. Surveyors interviewed two families and five (5) alert and oriented residents who were satisfied with room temperatures. The facility held a Quality meeting on 06/26/2025 to discuss the deficiency cited for Immediate Jeopardy F584. 30 Industrial sized 'Spot Coolers' were observed in operation in the facility. They were situated in the hallways throughout the eight (8) units in the facility. They were used to offset any extreme temperatures that occurred due to the heat wave. Two (2) Spot Coolers were in reserve. The Surveyor also observed 100 portable air conditioners in reserve. Invoice dated 06/25/2025, delivery date 06/26/2025, documented 100 Portable Air Conditioners were purchased. On 06/26/2025, facility staff assessed all residents for vital signs. Temperature Entry dated 06/26/2025 was reviewed and revealed that vital signs for 307 residents were taken, and no abnormal temperature was documented except Resident #7, who had 102.8 F, BP 194/106 and was taken to the hospital with suspected Sepsis. Dx Heart Failure, Obesity, Pulmonary Hypertension. Resident #7 room was not on the pool of the temperature. Their room has portable A/C, and the current room temperature was 81F. Six (6) residents were sampled for body temperature and vitals, no abnormality was reported. As per the Medical Director, all four (4) physicians were in-serviced over the phone to do more frequent rounds. Observation on 06/27/2025 on all units revealed Hydration Stations were seen on all resident units, to ensure residents remain hydrated and safe. Cooling Areas are on all units including the dining rooms, lounges and at the end of the hallways to maintain resident comfort. The maintenance staff checked for open windows and made sure blinds were drawn to prevent excessive heat from the sun. The facility changed parts and made any necessary repairs to Packaged Terminal Air Conditioners and some units were replaced. Temperatures have continuously been taken on all units, at 2-hour intervals. All staff were in-serviced on heat precautions during extreme heat events as per the Director of Nursing. The facility utilized online, phone and classroom delivery methods. This was documented with lesson plans and attendance sheets. Employees not physically present in the building for an in-person re-education were provided with an in-service module via Relias for their immediate compliance. Seven (7) employees, six (6) Certified Nursing Assistants and one (1) Nurse, who are on leave, will be re-educated on the first day that they report back to work. During an interview with interdisciplinary staff, they verbalized knowledge of heat advisory policy. Transfer agreements were reviewed and are ready to be implemented if the need should arise. The facility provided a heat wave notification advisory to the resident contacts and the Ombudsman to notify them of current conditions and what the facility is currently doing to rectify the condition. The Heat Precaution Policy dated 6/2025, was revised to include Supplemental Actions to be taken due to extreme weather . 10 NYCRR: 415.5(h)(4)

Based on observation, record review, and interviews conducted during an abbreviated and partial extended survey, complaint # NY00384702, it was determined that administration failed to ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident on four (4) of four (4) residents floors, where 55 out of 55 rooms sampled had temperatures above the Federal and State requirements. Specifically, on 06/25/2025 at 11:10 AM the temperature in room [ROOM NUMBER] was 105 degrees Fahrenheit, room [ROOM NUMBER] was 102 degrees Fahrenheit, and Resident #1 room [ROOM NUMBER] temperature reading was 96 degrees Fahrenheit. Three (3) complaints were submitted to the State Agency regarding high temperature throughout the facility from 06/24/2025 through 06/25/2025, stating all residents were affected. The facility did not an effective system in place to monitor and maintained the temperature of the facility within an acceptable range of 71 degrees Fahrenheit to 81 degrees Fahrenheit. Findings are: The facility's policy and procedure on the Quality Management Program dated 04/28/2025, documented the Quality Assurance and Performance Improvement Program of the facility supported the mission by establishing a formal, facility-wide system that strives to improve care for residents, service, and facility operations on a continuous basis. The Quality Management Program relied on a systematic, comprehensive, data-driven, proactive approach to performance management and improvement that focuses on indicators of the outcomes of care and quality of life. The program evaluates residents' and other customers' needs and expectations and involves coordination within and between the facility departments and services. The leadership team of the facility maintains overall responsibility for the implementation of the quality management program. The facility's leadership focuses on the identification and prevention of risk exposures, include the safety and security of the environment. In a temperature log dated 06/25/2025 at 11:10 AM, documented the temperature in the sampled 55 residents' rooms on all eight units, which ranged from 83 degrees Fahrenheit to 105 degrees Fahrenheit. Seven rooms were over 100 degrees Fahrenheit. In a temperature log dated 06/26/2025 at 10:15 AM, the documented temperature in the 61 sampled residents' rooms on all eight units, which ranged from 71 degrees Fahrenheit to 89 degrees Fahrenheit. During an interview on 06/27/2025 at approximately 11:16 AM, the admission Director stated they received multiple calls on 06/23/2025 from residents who were newly admitted reporting that their rooms were extremely hot, with most calls coming from the 3rd floor. The admission Director stated they called Maintenance and the Nurse Supervisor to get the residents room changed. The admission Director stated Maintenance staff went to the resident rooms to correct the air conditioning issue. During an interview on 06/27/2025 at approximately 3:13 PM, the Administrator stated they are the chairman of the Quality Assurance Performance Improvement committee and are responsible for all department performance, including the Maintenance Department. The Administrator stated that on 06/19/2025, they received an email from the New York State Department of Health with a heat advisory memo. Maintenance was immediately deployed to re-check the air conditioning units in the resident's rooms, the Packaged Terminal Air Conditioner and the Heating, Ventilation, and Air Conditioning to ensure proper operation. The Administrator stated there were no issues reported on 06/21/2025 and 06/22/2025. The Administrator stated they contacted an electrician due to the breaker tripping. The electrician came on site on 06/24/2025 and assessed the electrical grid and contacted Con [NAME] (the energy company) and discovered the energy company had cut the voltage to the facility by 8% (eight percent). They also contacted the air conditioning company on 06/24/2025 due to an abnormal number of overheated air conditioning units. The air conditioning company came on the same day and evaluated the air conditioning units and there were no significant issues, but some units failed and were replaced immediately. The Administrator stated that on 06/24/2025 at 7:58 PM, they received a phone call from the New York State Department of Health stating there is a complaint of heat in the building and requested the temperature log to be sent the following day (06/25/2025). The log was sent at 2:00 PM on 05/25/2025. The Administrator stated they were not in the facility on 06/25/2025 due to a medical appointment, but a Quality Assurance Performance Improvement meeting was held on 06/26/2025 to discuss a heat problem in the facility. During an interview on 06/27/2025 at 11:55 AM, the Assistant Director of Nursing /Staff Educator stated no family or residents complained to them on 06/23/2025, 06/24/2025, or 06/25/2025. The Assistant Director of Nursing /Staff Educator stated on 06/23/2025, during rounds, some areas of the hallway felt warm, and they called maintenance staff, who responded. The Assistant Director of Nursing/Staff Educator stated they notified the Director of Maintenance that it was warm. The Assistant Director of Nursing /Staff Educator stated that they did not notify the Director of Nursing or Administrator, and they did not check the residents' rooms. During an interview on 06/27/2025 at 12:34 PM, the Director of Nursing stated that they first became aware that someone had made a complaint of being uncomfortable with the room temperature on 06/25/2025 from the State Surveyor at 5:00 PM. The Director of Nursing stated that the State Surveyor told them that the room temperature was above the acceptable range. The Director of Nursing stated they did rounds after that, and it was warm in the units and rooms. During an interview on 06/27/2025 at 3:34 PM, the Medical Director stated they are aware of the elevated temperatures in the facility and will monitor the medical status of residents. 10 NYCRR 415.26

Based on observation, record review, and interviews conducted during the Recertification survey from 04/03/2025 to 04/10/2025, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 (Resident #274) out of 4 residents reviewed for Respiratory Care out of 38 sampled residents. Specifically, Resident #274 was observed receiving oxygen via nasal cannula at a rate of 3 liters per minute without a Physician's order. The findings are: The facility's policy titled Transcription and Order Entry into PCC (Point Click Care) with effective date 6/15 documented that all resident orders must be entered into the electronic medical record to appear in the resident's medication profile. Resident #274 had diagnoses that included Cancer, Chronic Obstructive Pulmonary Disease, Pneumonia, and shortness of breath. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #274 was moderately cognitively impaired and was not on oxygen therapy. On 04/03/2025 at 10:22 AM, 04/04/2025 at 10:23 AM and multiple occasions on 04/03/2025 and 04/04/2025, Resident #274 was observed receiving oxygen via nasal cannula at a rate of 3 liters per minute via a concentrator. On 04/03/2025 at 10:25 AM, Resident #274 was interviewed and stated they returned to the facility the day before and had been receiving oxygen since their return. The Skilled Observation Note dated 04/02/2025 documented Resident #274 had Oxygen Saturation at 94.0 % on 04/02/2025 at 21:13. The Skilled Observation Note also documented Resident #274 received oxygen via nasal cannula. The Nursing note dated 04/04/2025 documented Resident #274 was on oxygen at 2 liter/minute and had no complaint of shortness of breath. The MD (Medical Doctor) History and Physical Note-V 4 dated 04/02/2025 documented Resident was on oxygen via nasal cannula at 4 liters/minute. There was no documented evidence that a physician's order for oxygen was entered into the medical record for Resident #274 until 04/06/2025, which was four days after Resident #274 was readmitted to the facility. On 04/08/2025 at 11:31 AM, Registered Nurse #1 was interviewed and stated Resident #274 was receiving oxygen when readmitted on [DATE]. Registered Nurse #1 also stated that the Registered Nurse Supervisor was responsible for entering the orders for newly admitted residents. On 04/08/2025 at 12:38 PM, Registered Nurse #2 was interviewed and stated that as the Registered Nurse Supervisor for the floor where Resident #274 resided they are responsible for assessing all newly admitted residents and entering the orders for the physician to sign. Registered Nurse #2 also stated that Resident #274 was receiving oxygen on admission on 04/02/2025, and a physician's order was required for a resident to receive oxygen. Registered Nurse #2 reviewed Resident # 274's medical record and was unable to find a physician's order for oxygen for Resident #274 that covered the period 04/02/2025 to 04/05/2025. Registered Nurse #2 stated it was an error that the order had not been entered prior to Resident #274 receiving oxygen. On 04/09/2025 at 09:21 AM, the Director of Nursing was interviewed and stated that all Registered Nurses on the unit were able to enter the medical orders for residents after obtaining the verbal orders from physicians. The Director of Nursing also stated that there should be an order in place before oxygen is providing to residents. On 04/09/2025 at 11:12 AM, the Medical Director was interviewed and stated the physician's review the hospital discharge papers for all new residents. The Medical Director also stated that the nurses assess the newly admitted residents and obtain orders from the attending physicians. The Medical Director further stated that oxygen was considered a medication and therefore there should be an order in place before it is administered to residents. The Medical Director stated that it was an error to administer oxygen to Resident #274 without a physician's order. 10 NYCRR 415.12(k)(6)

Based on record review and interviews conducted during the Recertification survey from 1/3/2023 to 1/10/2024, the facility did not ensure that Minimum Data Set 3.0 assessments were submitted and transmitted within 14 days of completion. This was evident for 4 (Residents #70, #145, #226 and #110) of 38 total sampled residents. Specifically, the Minimum Data Set 3.0 assessments for Residents #70, #145, #226, and #110 were not submitted and transmitted within 14 days of completion. The findings are: The facility policy titled Minimum Data Set 3.0 assessment dated ,d+[DATE] documented assessments will be submitted at least weekly 14 days of the Care Plan date. Resident #70's Minimum Data Set 3.0 assessment with reference date 11/13/2023 and completion date 12/15/2023 documented a submission date of 01/05/2024, more than 14 days after the completion date. Resident #145's Minimum Data Set 3.0 assessment with reference date 11/22/2023 and completion date 12/14/2023 documented a submission date of 01/05/2024, more than 14 days after the completion date. Resident #226's Minimum Data Set 3.0 assessment with reference date 11/27/2023 and completion date 12/14/2023 documented a submission date of 01/05/2024, more than 14 days after the completion date. Resident #110's Minimum Data Set 3.0 assessment with reference date 12/2/2023 and completion date 12/13/2023 documented a submission date of 01/05/2024, more than 14 days after the completion date. There was no documented evidence the Minimum Data Set 3.0 assessments for Residents #70, #145, #226, and #110 were submitted within 14 days of completion. On 01/08/2024 at 12:03 PM, an interview was conducted with the Minimum Data Set Coordinator #1 who stated the computer system alerted them when assessments were ready for submission. The batch of assessments for Residents #70, #145, #226, and #110 were submitted late due to human error. On 01/10/2024 at 09:09 AM, the Administrator was interviewed and stated the Minimum Data Set Coordinator was responsible for ensuring assessments were completed and submitted timely. Late completions were the result of human error. There was a change in Minimum Data Set Department staff recently that contributed to late completions and submissions. 10 NYCRR 415.11(a)(1-5)

Based on observation, record review, and interviews conducted during the Recertification survey from 01/03/2024 to 01/10/2024, the facility did not ensure a resident was given the appropriate language and communication services to maintain their ability to carry out activities of daily living. This was evident for 1 (Resident #244) of 5 residents reviewed for activities of daily living out of 38 total sampled residents. Specifically, language interpretation services were not used to communicate effectively with Resident #244. The findings are: The facility policy titled Activities of Daily Living dated 11/2018 documented the facility will provide the necessary care and services based on comprehensive assessment of a resident and consistent with the resident's needs, choices, and preferences, to maintain or improve, the resident's ability to perform activities of daily living. The facility policy titled Communication with Non-English-Speaking Residents dated 1/3/2024 documented the facility shall have a system in place to ensure that residents limited English proficiency is provided with means of communication to enable resident understanding and participation in their care. Resident #244 had diagnoses of low back pain and osteoarthritis. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #244 was moderately cognitively impaired. Resident #244 and their representative did not participate in the assessment. On 01/03/2024 at 12:20 PM, Resident #244 was interviewed and stated they only spoke Fuzhouese, a Chinese dialect, and did not speak or understand English. Staff did not communicate with Resident #244 when providing care and Resident #244 did not understand their medical condition. On 01/03/2024 at 02:24 PM, Resident #244 was observed speaking to Registered Nurse #3 in Chinese and complaining of pain to their knees, shoulders, and hips. Registered Nurse #3 motioned to Resident #244 and stated they did not understand what Resident #244 was saying. Registered Nurse #3 left Resident #244's room, went to the medication cart in the hallway, and continued to administer medication to other residents on the unit. On 01/03/2024 at 02:47 PM, Certified Nursing Assistant #9 was observed weighing Resident #244 in their room and communicated the wight to Resident #244 in English. Resident #244 motioned to Certified Nursing Assistant #9 and stated in their language that they did not understand what Certified Nursing Assistant #9 said to them. Certified Nursing Assistant #9 then left the resident's room. The Admission Record Resident Information documented Resident #244's primary language was Chinese. The comprehensive care plan related to communication created 8/27/2022 and last updated 12/8/2023 documented Resident #244 had a language barrier and interventions included to provide a translator and use a communication book/board, writing pad, gestures, signs, and pictures as needed. On 01/04/2024 at 10:36 AM, Certified Nursing Assistant #9 was interviewed and stated Resident #244 did not speak English and they communicated with Resident #244 by using sign language. Certified Nursing Assistant # 9 did not know Resident #244 wanted to know their weight. They did not use a language communication book and thought Resident #244 could understand them. On 01/04/2024 at 10:25 AM, Registered Nurse #3 was interviewed and stated they used the language communication book to communicate with Chinese speaking residents. They forgot to use a communication book to understand Resident #244 on 1/3/2024 when they were administering medications and did not understand what Resident #244 was trying to tell them at the time. Registered Nurse #3 stated they did not administer as-needed pain medication ordered for Resident #244 on 1/3/2024 because they did not understand that Resident #244 was expressing pain in Chinese. On 01/05/2024 at 03:01 PM, the Director of Nursing was interviewed and stated all staff had training in communicating with non-English speaking residents. The Director of Nursing conducted daily unit rounds to check on patient care, spoke to staff, and spoke to residents regarding their concerns. The Director of Nursing did not know whether they spoke with Resident #244 regarding their language communication concerns and forgot what language Resident #244 spoke. Residents should not be prevented from knowing what care and medications they received because they were not English speaking. 10 NYCRR 415.12(a)(2)

Based on observation, record review, and interviews conducted during the Recertification survey from 01/03/2024 to 01/10/2024, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (Resident #609) resident reviewed for activities out of 38 total sampled residents. Specifically, Resident #609 was not provided with television stations and meaningful activities in their preferred language. The findings are: The facility policy titled Activity Recreation Program and assessment dated ,d+[DATE] documented the facility shall provide for an ongoing program of activities designed to meet the interests and the physical, mental, psychosocial well-being of each resident. The Recreation Therapist will complete a comprehensive assessment to help develop an activity plan that reflects the resident's level of leisure and lifestyle satisfaction. Resident #609 had diagnoses of unspecified dementia and diabetes mellitus. The Minimum Data Set 3.0 dated 12/22/2023 documented Resident #609 was severely cognitively impaired, usually understood others, and found it very important to do their favorite activities such as keeping up with the news and listening to preferred music. On 01/03/2024 at 11:27 AM, Resident #609 was interviewed and stated their primary language is Cantonese and the Recreation Therapist has not asked them about their activity preferences. Resident #609 preferred to watch television in their native language so they could understand the news and programs. On 01/03/2024 at 11:33 AM, Resident #609 was observed in their room turning on their television. All available stations were observed to be in the English or Spanish language. From 01/03/2024 at 11:27 AM to 01/08/2024 at 10:07 AM, there were multiple observations of Resident #609 in their room or in the wheelchair in the hallway with no ongoing activities and the television in their room turned to a station in English. The Comprehensive Care Plan related to activities initiated 12/17/2023 documented Resident #609 speaks Cantonese and Mandarin and expressed interests in music and watching television. The daily activity participation would be based on their therapy schedule and individual preference. The Therapeutic Recreation assessment dated [DATE] documented Resident #609 spoke Chinese and preferred to keep up with the news, listen to music, and do their favorite activities. The facility television channel list documented all provided channels were available in English or Spanish. There was no documented evidence Resident #609's activity preference to watch television in Cantonese and keep up with the news was honored with meaningful therapeutic recreation. On 01/08/2024 at 10:12 AM, Certified Nursing Assistant #5 was interviewed and stated Resident #609 did not speak English and mainly stayed in their room. Certified Nursing Assistant #5 stated they did not see the Recreation Therapist interact with Resident #609, did not see activities provided to Resident #609, and saw the television turned on in Resident #609's room but the resident did not watch the English programs that were available. On 01/08/2024 at 11:40 AM, Activities Aide #1 was interviewed and stated they conducted the recreation assessment for Resident #609. It was very important to Resident #609 that they watch television in Cantonese. The facility offered television channels in English and Spanish. Activities Aide #1 stated they did not know what activities were offered and available to Resident #609. On 01/08/2024 at 01:56 PM, Recreation Therapist #1 was interviewed and stated they provided puzzles to Resident #609 even though they knew Resident #609 did not prefer puzzles as an activity. Recreation Therapist #1 did not know Resident #609's activity interests. The Therapeutic Recreation Department had a tablet for residents to watch programs in their preferred language in the event residents were unable to understand English or Spanish television channels provided by the facility. Recreation Therapist #1 stated they did not provide the tablet to Resident #609 to watch videos in Cantonese and did not involve Resident #609's representative in attempting to accommodate Resident #609's preference for meaningful activities. On 01/08/2024 at 02:23 PM, the Recreation Director was interviewed and stated the facility offered television channels in English and Spanish. The facility should accommodate Resident #609's preference to watch television channel in Cantonese. The Recreation Director was not able to explain why the activity preference for Resident #609 was not provided or accommodated. 10 NYCRR 415.5(f)(1)

Based on observation, record review, and interviews conducted during the Recertification survey from 01/03/2024 to 01/10/2024, the facility did not ensure the Minimum Data Set 3.0 assessment accurately reflected a resident's status. This was evident for 1 (Resident #244) of 38 total sampled residents. Specifically, the Minimum Data Set 3.0 assessment for Resident #244 did not document the resident's pain. The findings are: The facility policy titled Minimum Data Set Assessment Version 3.0 dated 12/2023 documented the Minimum Data Set 3.0 assessment should be accurate with information gathered from multiple sources including interview of resident, communication with and observation of the resident, and communication with the resident's family. Resident #244 had diagnoses of low back pain and osteoarthritis. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #244 was moderately cognitively impaired, received pain medication, rarely had pain, rarely had pain that effected their sleep, and had a pain intensity of 4 out of 10. On 01/03/2024 at 12:20 PM, Resident #244 was interviewed and stated they had pain in their knees, hips, shoulders, and lower back that became worse over the past 3 months. The pain disturbed Resident #244's sleep frequently and Resident #244 complained of pain to the nurse daily. On 01/05/2024 at 02:34 PM, Minimum Data Set Coordinator #2 was interviewed and stated they interviewed residents and staff and reviewed the medical record to gather the information for the Minimum Data Set 3.0 pain assessment. Minimum Data Set Coordinator #2 stated they did not interview Resident #244 about their pain due to a language barrier and was not aware Resident #244's pain became worse over the last 3 months and that the pain frequently disturbed their sleep. Minimum Data Set Coordinator #2 was not confident the pain assessment performed on 11/27/2023 reflected the actual pain level, frequency, and the impact on sleep for Resident #244. 10 NYCRR 415.11(b)

Based on record review and interviews conducted during the Recertification survey from 01/03/2024 to 01/10/2024, the facility did not ensure residents were assessed using the quarterly review instrument specified by the State every 3 months. This was evident in 3 (Residents #62, #70 and #145) of 38 total sampled residents. Specifically, the quarterly Minimum Data Set 3.0 assessments for Residents #62, #70, and #145 were not completed within 14 days of the assessment reference date. The findings are: The facility policy titled Minimum Data Set 3.0 assessment dated ,d+[DATE] documented audit reports will be completed to review for timeliness of completion. Resident #62's quarterly Minimum Data Set 3.0 with assessment reference date of 10/14/2023 documented a completion date of 01/05/2024, more than 14 days after the assessment reference date. Resident #70's quarterly Minimum Data Set 3.0 with assessment reference date of 11/13/2023 documented a completion date of 12/15/2023, more than 14 days after the assessment reference date. Resident #145's quarterly Minimum Data Set 3.0 with assessment reference date of 11/22/2023 documented a completion date of 12/14/2023, more than 14 days after the assessment reference date. There was no documented evidence the Minimum Data Set 3.0 assessments for Residents #62, #70, and #145 were completed within 14 days of their assessment reference dates. On 01/08/2024 at 12:03 PM, an interview was conducted with Minimum Data Set Coordinator #1 who stated the computer system was reviewed daily to ensure assessment were completed and submitted timely. They were unable to provide a reason the resident assessments were completed late. On 01/09/2024 at 11:55 AM, an interview was conducted with the Regional Social Worker who stated Minimum Data Set assessments were completed late because individual staff members were not completing their assigned sections of the assessment timely. On 01/10/2024 at 09:09 AM, the Administrator was interviewed and stated the Minimum Data Set Coordinator was responsible for ensuring assessments were completed and submitted timely. Late completions were the result of human error. There was a change in Minimum Data Set Department staff recently that contributed to late completions and submissions. 10 NYCRR 415.11(a)(4)

Based on record review and interviews conducted during the Recertification survey from 1/3/2024 to 1/10/2024, the facility did not ensure that comprehensive resident assessments were completed within 14 days of the assessment reference date. This is evident for 1 of 38 total sampled residents. Specifically, Resident #226's annual Minimum Data Set assessment was not completed within 14 days. The findings are: The facility policy titled Minimum Data Set Assessment Version 3.0 dated 12/2023 documented the Minimum Data Set Department will complete audit reports to review for quality data and timeliness of Minimum Data Set completion. Resident #226's annual Minimum Data Set assessment reference date was 11/27/2023 and documented a completion date of 12/14/2023, 17 days after the assessment reference date. There was no documented evidence the 11/27/2023 Minimum Data Set assessment was completed within 14 days. On 01/08/2024 at 12:03 PM, an interview was conducted with Minimum Data Set Coordinator #1 who stated the computer system was reviewed daily to ensure assessment were completed and submitted timely. They were unable to provide a reason Resident #226's assessment was completed late. On 01/09/2024 at 11:55 AM, an interview was conducted with the Regional Social Worker who stated Minimum Data Set assessments were completed late because individual staff members were not completing their assigned sections of the assessment timely. On 01/10/2024 at 09:09 AM, the Administrator was interviewed and stated the Minimum Data Set Coordinator was responsible for ensuring assessments were completed and submitted timely. Late completions were the result of human error. There was a change in Minimum Data Set Department staff recently that contributed to late completions and submissions. 10 NYCRR 415.11(a)(3)(i)

Based on observations, record review, and interviews conducted during the Recertification survey from 1/3/2023 to 1/10/2024, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident for 1 (2nd Floor) of 3 dining rooms. Specifically, Certified Nursing Assistant #6 was observed assisting multiple residents with hand hygiene without performing hand hygiene in between residents. The findings are: The facility policy titled Meal Service-Assistance of Residents dated 04/2016 documented Certified Nursing Assistants wash resident hands or offer hand wipes. On 01/03/2024 at 11:44 AM, the 2nd floor dining room was observed during lunch service. Certified Nursing Assistant #6 passed out hand wipes to multiple residents in the dining room with bare hands. Certified Nursing Assistant #6 retrieved a used hand wipe from Resident # 34, went to Resident #116 and assisted the resident with using a hand wipe, went to Resident #68 and assisted the resident with using a hand wipe, and continued assisting Resident #124, Resident #115, and Resident #153 without performing hand hygiene in between each resident. Certified Nursing Assistant #6 then grabbed a paper towel and gathered the used hand wipes from Residents #241, #99, and #85 without performing hand hygiene in between each resident. On 01/03/2024 at 12:06 PM, Certified Nursing Assistant #6 was interviewed and stated they did not clean their hands while assisting residents with hand hygiene in the 2nd floor dining room. Their hand should have been sanitized in between each resident contact to prevent passing germs from one resident to another. On 01/03/2024 at 02:33 PM, Licensed Practical Nurse #1 was interviewed and stated all staff wash their hands before they enter the dining room and when they leave the dining room. On 01/03/2024 at 02:42 PM, Registered Nurse # 5 was interviewed and stated Certified Nursing Assistants should wash their hands before giving hand wipes to residents and should sanitize their hands in between each resident contact. On 01/03/2024 at 02:54 PM, the Assistant Director of Nursing was interviewed and stated they observe dining daily. Staff should wash their hands, give hand wipes to and assist residents with sanitizing their hands, and wash their hands in between dispensing each hand wipe. The Assistant Director of Nursing stated they monitored hand hygiene during dining. 10 NYCRR 415.14(h)

Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that medications were stored in locked compartments and in accordance with professional standards. Specifically, (1) medications were left in a resident's room; and, (2) the narcotics box contained items other than narcotics medication. This was evident for 1 of 36 sampled residents (Resident #108) and 1 of 5 medication rooms on 1 of 5 units observed for Medication storage task (unit 5). The findings are: The facility policy titled Medication Storage dated 4/19 documented that all medications should be kept in safe and locked compartment. Medications and medication rooms should be kept in sanitary condition. 1) Resident #108 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] documented the resident was severely cognitively impaired and required extensive to total assistance with Activities of Daily Living (ADL). On 10/24/21 at 01:12 PM, Resident #108's room was observed. There were 2 boxes of wound care supplies on the resident's windowsill. One of the boxes was labeled Gauze Sponge 50X2 count and contained gauze bandages, scissors, and tape. The box also contained 2 tubes of Santyl [MEDICATION(S)] that were opened, mostly full, and had no tops screwed onto the end so the ointment was visible. The tubes were dated 10/7/21 and 10/18/21 and were labeled with 2 other residents' names. On 10/26/21 at 11:53 AM, Resident #108's room was observed again. A large dark brown bottle with a prescription label was observed on top of the resident's bedside table next to a Ziploc plastic bag with an empty urine sample cup labeled with the resident's name. The pharmacy label documented: [MEDICATION(S)]/[MEDICATION(S)]/[MEDICATION(S)] 742/Es and Refrigerate. The liquid inside the bottle was a total of 425 milliliters. Certified Nursing Assistant (CNA) #11 was in the room attending to Resident #108. CNA #11 stated that she did not know what the bottle was and continued to make the bed of Resident #108. Registered Nurse (RN) #7 came to the resident's room and was interviewed on 10/26/21 at 12:10 PM. A follow up interview with RN #7 was also done on 10/29/21 at 12:05 PM. RN #7 observed the medication bottle and stated the medication should not be out in the resident's room. The medication was a new order and was just delivered to the night charge nurse from 10/25/21. The medicaiton is to be painted onto the resident's wounds during wound care. RN #7 is a regular nurse on the unit and provides the wound care for Resident #108 daily. RN #7 did rounds in the morning upon arriving on the unit and did not see the bottle sitting on the resident's bedside table. The Licensed Practical Nurse (LPN) #3 assigned to the unit last night must have left it out thinking RN #7 would be doing the wound care for Resident #108 early in the morning when RN #7 first arrives at the facility. RN #7 stated this is not standard practice, medications should never be left out in the open for the safety of all the residents on the unit. Resident #7 never uses the wound care supplies of another resident for Resident #108 and did not know the tubes of [MEDICATION(S)] were on the resident's windowsill. This situation has never happened before. RN #7 stated they would check with the pharmacy to ensure the medication was still viable since it was supposed to be refrigerated and must have been left out since 7AM when the night nurse went off shift. RN #7 did not observe the bedside table during the morning rounds. Medications should never be left in a resident's room because it is unsafe if the resident or any other resident on the unit tries to use it. Treatment medications should be locked the same as any any other prescribed medications. There is a locked treatment cart where they are stored and are only taken out when providing the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with RN #2, the Nursing Supervisor for Resident 108s unit, on 10/26/21 at 12:34 PM. RN #2 stated they do rounds every morning and checks every resident's room, but did not see any medications on the bedside table of Residnt #108. RN #2 worked on the previous day and is responsible for receiving medications from the pharmacy, but does not reconcile the medication when it comes in. RN #2 hands it to the charge nurse for the unit and they go through it to make sure refrigerated medications go in the refrigerator and other medications match the list the pharmacy provided. RN #2 checked with the pharmacy during the interview and stated the medication was delivered at midnight and the overnight supervisor was responsible for receiving it. The charge nurses are responsible for securing the medication in the appropriate location. All medications should be put away immediately and kept locked in either the appropriate cart or the medication room. RN #2 is not aware of any residents that are allowed to hold onto their own medication in their room. Resident #108 is cognitively impaired and does not have any plan in place that wound care medications should be in the room. LPN #3 placed the medication for Resident #108 in the fridge but took it out at change of shift to ensure that it warmed up before being applied to the residents skin. LPN #3 was concerned about the resident being uncomfortable with a cold ointment. A telephone interview was conducted with LPN #3 on 10/28/21 at 04:06 PM. LPN #3 stated they were responsible for reconciling and receiving the wound treatment medication for Resident #108. LPN #3 placed the medication in the medication fridge and communicated to RN #2 during change of shift in the morning that the medication had arrived. LPN #3 placed the medication at the resident's bedside with the intention of letting it warm before being applied to the resident's skin. LPN #3 thought RN #2 would be doing the wound care prior to medication pass. This was the first and only time LPN #3 left medication out but knows that is not safe for other residents on the unit and the proper protocol is to leave it locked in the treatment cart until it is ready for use. There should be no resident with medication in their room and LPN #3 is unaware of any other treatments medications or prescription pills in any other resident's room. If LPN #3 observed medications in a resident's room, they would let the supervisor know. An interview was conducted with RN #8, another Nursing Supervisor for Resident #108s, unit, on 10/29/21 at 10:45 AM. RN #8 stated there should never be treatment medications in a resident's room. That is the purpose of a locked treatment cart. The facility does not have an issue with supply of [MEDICATION(S)] and there is no reason that tubes of [MEDICATION(S)] prescribed to other residents should be in the room of Resident #108. RN #8 does not know of any previous reports of medications being left in resident rooms and it has never been reported to them that [MEDICATION(S)] ran out and another resident's prescription needed to be used in its place. 2) Observation of the Medication Room on the 5th floor was done with RN #7 on 10/26/21 at 02:31 PM. The narcotics box located affixed to the wall in the medication room had a double lock and was opened by RN #7. The box contained 3 shelves: top shelf contained narcotics medications in labeled blister packs; middle shelf contained blister packs of narcotics mediations; the bottom shelf contained a small plastic bag labeled with 543 A. RN #7 removed the plastic bag and emptied the contents. A set of several keys were observed being removed from the plastic bag. RN #7 stated the keys belonged to a hospitalized resident and RN #7 had placed them there because they looked important and RN #7 did not want them to go missing. On 10/29/21 at 12:16 PM, an interview was conducted with RN #7 who stated the keys should have never been in the narcotics box. Only narcotics medication should be stored in the narcotics box. Placing other items in the box can compromise the medication contained within. RN #7 stated they had placed the keys in the box last week sometime. Every shift of nurses is responsible for checking the medication rooms and narcotics boxes to ensure they are clean and free of any items other than medications and that medications are stored properly. On 10/29/21 at 02:14 PM, an interview was conducted with the Director of Nursing (DNS) who stated only narcotics should be stored in narcotics boxes in the medication rooms. Resident personal items should not be stored in the narcotics box as they can be contaminants. They can be stored safely in the nursing office. The DNS also stated LPN #3 left the treatment medication at the resident's bedside with the intention that wound care treatment was going to be done immediately. RN #7 got caught up in med pass and did not observe that the bottle was there. The DNS stated that they were unaware that [MEDICATION(S)] tubes were found in the room of Resident #108 with labels of other resident's names on them. This is not acceptable and medications should be stored in locked compartments. 415.18(e)(1-4)

Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure a resident's environment remained free of hazards. Specifically, personal medication was found unsecured in a resident's room. This was evident for 1 of 2 residents reviewed in the area of Accidents/Hazards. (Resident #453) The findings are: A facility policy titled Storage of Medications was dated 4/19 and documented medications shall always be kept in a secure storage area. Access to medications is limited to authorized personnel and cannot be removed without a key. Resident #453 was admitted to the facility on [DATE] with diagnosis of [CONDITION(S)], [CONDITION(S)], and diabetes mellitus II. The Minimum Data Set (MDS) dated [DATE] documented the resident had mild cognitive impairment, required extensive assistance of 2 people for trasnfers, did not walk in their room or corridor, and required the total assistance of 1 person for locomotion on and off the unit. Reisdent #453 did not display any adverse behavior during the assessment period. On 10/25/21 at 01:23 PM, Resident #453 was observed lying in the bed closest to the doorway in a 2-bedded room. The resident was alert and oriented X (times) 3, and agreed to be interviewed. During the interview, a large brown paper bag was observed on the floor on the right side of the resident's bed between the bed and the wall. The top of the bag was open and an orange prescription medication bottle was visible from a standing position, approximately 2 feet away. Resident #453 stated the bag contained their medication from the community and gave permission for the contents of the bag to be observed and recorded. The bag contained 10 bottles with varying amounts of pills and 1 ointment tube of the following prescription medications for Resident #453: [MEDICATION(S)] 20mg daily; [MEDICATION(S)] Sulfate 335mg every other day; [MEDICATION(S)] 25mg onset daily; [MEDICATION(S)] 300mg 2 tabs once daily; [MEDICATION(S)] 24/26mg every 12 hours; [MEDICATION(S)] .6mg once daily; [MEDICATION(S)] 80mg twice daily; [MEDICATION(S)] 10mg once daily; [MEDICATION(S)] 50mg once daily; Aspirin 81mg once daily; and [MEDICATION(S)]. Resident #453 stated the bag has been in the room and out in the open since their admission to the facility on [DATE]. Resident #453 brought the medications with them from the hospital. Resident #453 stated facility staff are aware of the bag of medications, including the resident's regularly assigned CNA (CNA #9) and a medication nurse whom Resident #453 could not identify. The nurse advised Resident #453 not to take the medication in the bag because the facility provides medications to the resident. Resident #453 stated the staff never asked to take the bag of medication from the room and never advised the resident to store the medications in a secure and locked location. Facility staff did not educate the resident on the facility policy re: Medication Storage and/or whether the facility allows for self administration of medication. Resident #453 denied taking any of their personal medication since admission to the facility. Resident #453 understood that wandering residents may be at risk for harm if they were to consume any of the medications in the bag. Resident #453 was agreeable to having the bag of medications stored in a locked location for safekeeping, but staff never presented this as an option and did not address the bag of medications after the medication nurse spoke to the resident. There was no documented evidence in the resident's medical record that staff had addressed the bag of medication at the bedside of Resident #453. An interview was conducted with CNA #9 on 10/29/21 at 10:06 AM. CNA #9 has been assigned to care for Resident #453 since the resident was admitted to the facility 2 weeks ago. CNA #9 stated Resident #453 came from the hospital with a bag of medication in their possession. CNA #9 noticed it on the first day that they worked with Resident #453 and informed the charge nurse. CNA #9 could not recall the identity of the charge nurse. CNA #9 stated the resident reported most of the prescription medication bottles were vitamins. CNA #9 did not confirm this information by looking at the medication bottles. After CNA #9 reported the bag of medication to the charge nurse, CNA #9 saw the charge nurse go to the resident's room and educate Resident #453 that they should only be taking medication the facility provides. CNA #9 returned to the room after the charge nurse spoke with Resident #453 and saw the bag of medication was still in the resident's room. CNA #9 and the charge nurse did not discuss the matter any further after the charge nurse spoke with the resident. CNA #9 is not aware of any residents on the unit that are allowed to hold onto their medication and keep it at bedside out in the open. CNA #9 has not looked for the medication since the initial report and does not know if the bag of medication is still at the resident's bedside because they have not provided care to Resident #453 yet today. The roommate of Resident #453 is confused but unable to ambulate and is wheelchair bound. There are other residents on the unit that are confused and can ambulate but CNA #9 could not readily identify them. An interview was conducted with Registered Nurse (RN) #8 on 10/29/21 at 10:20 AM. RN #8 is the supervisor for Resident #453's unit and has been working in the facility for 1 month. RN #8 stated their responsibilities include environmental rounds and room checks to ensure resident safety. RN #8 stated they do not recall seeing a bag of medication in the room of Resident #453 and has not received any reports form nursing staff that Resident #453 had a bag of medication in their room. RN #8 is unfamiliar with the facility policy on medication storage in a resident's room, self-administration of medication, or whether there are any other residents on the unit that hold onto their personal medication. RN #8 does not know if there are confused residents on the unit. In the event RN #8 found a bag of medication in a resident's room, RN #8 would report to the nursing supervisor and the Medical Doctor. The bag of medication would be removed from the resident's room and RN #8 would place the resident on the nursing report to communicate the incident with the next shift. RN #9 would also document this in the resident's progress notes and update the care plan, but RN #8 is still new and learning what types of information the facility documents in the medical record. RN #8 verbally reminds the charge nurses to document occurrences with all residents before they end their shift daily. An interview was conducted with RN #7 on 10/29/21 at 11:41 AM. RN #7 is the charge nurse for Resident's #453's unit and knows that resident requires a hoyer lifter and 2 people to transfer them out of bed. Resident #453 is unable to move on their own without assistance from staff and has been pleasant and cooperative since admission to the facility. The resident is also alert and oriented X3 and cognitively intact. There were only 2 occasions where Resident #453 refused to take medications from the nurse and this was due to resident being on the commode or busy at the time of administration. RN #7 stated they never saw a open bag of medication or any paper bag at all in the resident's room. There are residents that are admitted to the facility and their personal medication comes with them from the hospital. All newly admitted residents arriving from the hospital are screened by security in the lobby before being allowed on the unit. Security searches through the residents' belongings during this process. The nursing supervisor assesses the new admission and creates a property list as part of the resident's admission process. If RN #7 found a bag of medication, they would confiscate the bag from the resident, keep it locked in the medication room, and inform their supervisor. The SW reported to RN #7 that a bag of medication was found in the room of Resident #453 on 10/26/21 and the SW confiscated it. There was also a verbal report of this occurrence in the facility daily morning meeting held with administrative staff and department heads. RN #7 stated they were not provided with any instruction or guidance on documenting the occurrence in the medical record of Resident #453; and, RN #7 has not reviewed or revised the resident's plan of care since the report was given. RN #7 is unaware of any ongoing investigation or the facility's plan to address the found bag of medication. An interview was conducted with the Director of Nursing (DON) on 10/29/21 at 02:19 PM. The DON stated any resident found with personal medication in their possession has 2 options: 1- store the medications in a lockbox in the SW office, or 2- keep the medications locked in the Nursing office until a family member can retrieve them. The SW was doing daily rounds and found a bag of medications in the room of Resident #453 on 10/26/21 but cannot recall the time of day. Resident #453 reported to the SW that they did not take any of the medication and was compliant with giving the medication to the SW for safekeeping. Nursing supervisors and SW did not report seeing the bag of medication previously. DON does not know of any staff member that observed this bag of medication prior to 10/26/21. RN #8 completed the admission assessment for Resident #453 and does not recall seeing the bag of medication upon admission. The DON has not had an opportunity to interview any CNAs or other staff who have interacted with Resident #453. The investigation of the incident is ongoing. The facility does not have a property list for Resident #453 from admission. All staff members are required to report if a resident is found with medication in their room. There is no documentation in the medical record that Resident #453 was found with medication on 10/26/21 because the SW was aware, Resident #453 is alert and oriented, and Resident #453 reported they did not take any of the medication in the bag. There are times that situations would be documented in a grievance form instead of the resident's medical record. There is good communication between the Nursing and SW staff. This is sufficient and every incident may not be documented in the resident's medical record. An interview was conducted with the Director of SW (DSW) on 10/29/21 at 03:11 PM. The DSW stated they were doing rounds on 10/26/21 prior to lunch, but cannot recall the exact time. DSW was having a conversation with Resident #453 when the resident reported that there was a bag of medication at their bedside. DSW observed a brown paper bag on the resident's chair at bedside. The bag was not sealed but the top was slightly folded over so the DSW could not readily see the medication bottles prior to unfolding the top. DSW educated Resident #453 that medications could not be kept at their bedside and took the medication to the SW office for safekeeping. DSW stated this incident does not need to be documented in the resident's chart because Resident #453 was counseled. 415.12(h)(1)

Based on observations, interviews, and record reviews during the Recertification survey, the facility did not ensure that a resident was provided with appropriate treatment and services to maintain or improve their ability to ambulate. Specifically, Resident #162 was not provided with the Unit Ambulation Program (UAP) in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: The facility's policy titled Activities of Daily Living was dated 11/2018 and documented the facility will provide the necessary care and services based on the comprehensive assessment of a resident and consistent with the resident's needs, choices, and preferences, to maintain or improve the resident's ability to perform ADLs and to prevent decline. Resident #162 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set (MDS) dated [DATE], documented that Resident #162 was severely cognitively impaired, did not display any adverse behaviors, and required extensive assistance from staff to ambulate. On 10/24/21 at 11:20 AM, 10/26/21 at 9:00 AM, 10/28/21 at 2:54 PM, and 10/29/21 at 9:03 AM Resident #162 was observed to be alert and in bed. On 10/27/21 at 11:30 AM and 10/29/21 at 10:32 AM Resident #162 was observed sitting in their wheelchair in the dining room. There were no observations of Resident #162 being provided with assistance to ambulate with a wheelchair to follow. The Comprehensive Care Plan (CCP) related to limited physical mobility was initiated 9/16/21 and documented Resident #162 had impaired balance and fatigue. Interventions included UAP: Ambulation 40 feet using a FWW with extensive assist and wheelchair follow, daily. A Physical Therapy Discharge Summary completed on 9/11/21, documented that, at their baseline on 8/26/21, Resident #162 required substantial/maximal assistance to ambulate 5 feet. Upon discharge from physical therapy on 9/10/21, Resident #162 was able to ambulate 50 feet with partial/moderate assistance. The comments section of the discharge summary documented the resident was able to ambulate using a Forward Wheel Walker (FWW) and wheelchair follow with minimal assistance on the unit incorporated with ADLs throughout the day. The discharge recommendations documented Functional Maintenance Program (FMP) Established/Trained = Range of Motion Program. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Note titled Rehab Intervention dated 9/14/21 documented Resident #162 was discharged from physical therapy and occupational restorative therapy. Resident can transfer safely with extensive assistance of one and resident ambulates with rolling walker (RW) up to 40 feet and will resume FMP with nursing staff on the unit. The Certified Nursing Assistant Accountability Record (CNAAR) dated September 2021 documented Resident #162 should receive UAP: Ambulation 40 feet using a FWW with extensive assist and wheelchair follow, daily. The CNAAR documented 40 opportunities to enter the UAP done on the 7-3 and 3-11 shifts from 9/11/21 to 9/30/21, a 20-day period. Out of 40 opportunities, there were 3 refusals, 19 entries of Not Applicable, and 19 entries documenting ambulation was completed with distances ranging from 2 to 100 feet (ft). CNA #3 completed 8 of the 19 completed ambulation entries. No ambulation was documented for 5 out of 20 days. The CNAAR dated October 2021 documented 54 opportunities to enter the UAP done on the 7-3 and 3-11 shifts from 10/1/21 to 10/27/21, a 27-day period. Out of 54 opportunities, there were 3 refusals, 29 entries of Not Applicable, and 22 entries for ambulation completed with distances ranging from 2 to 1000ft. CNA #3 completed 9 of the 22 completed ambulation entries and 7 of 29 Not Applicable entries. No ambulation was documented for 8 out of 27 days. CNA #3, the regularly assigned CNA for Resident #162, was interviewed on 10/27/21 at 9:28 AM. CNA #3 stated they were unaware Resident #162 was ordered to receive UAP with a FWW. No attempt has been made to use the FWW to ambulate with the resident on the unit. The resident does not display any behaviors and has never refused care. The CNA documented Not Applicable on the report because the UAP does not apply to the resident's current condition. Resident #162 uses a wheelchair and requires extensive assistance of 1 person to transfer out of bed. On the days CNA #3 signed that Resident #162 recieved UAP, CNA #3 stated they thought they were supposed to document the amount of feet the CNA walked when pushing the resident's wheelchair from their bedroom to the dining room. The CNA stated they have received general inservice and training related to UAP but has not been provided with specific instruction on how to provide UAP to Resident #162. CNA #3 did not communicate with the charge nurse or the rehabilitation department to clarify the UAP order and ensure the correct services were provided. Per the interview with CNA #3, the entries CNA #3 entered for ambulation were not distance walked but distance pushed in the wheelchair. On 10/27/21 at 2:41 PM, Registered Nurse (RN) #3, the charge nurse for Resident#162's unit, was interviewed. RN #3 stated they were unaware that Resident #162 had orders for UAP with FWW. RN #3 was not the nurse who reconciled the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no system in place to monitor whether the CNAs were providing the UAP according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/29/21 at 9:35 AM, the Director of Rehabilitation (DOR) was interviewed and stated the physical therapist who made the recommendation for UAP with FWW for Resident #162 was unavailable for an interview. The CNAs on the unit had been provided with general inservice related to UAP. The rehabilitation department does not communicate with the CNAs about UAP services for each individual resident. There was no training or inservice provided to the unit staff re: how to provide UAP with FWW for Resident #162. There was no follow up from the rehabilitation department to ensure the services were provided. Everything the CNAs and nurses need to know is in the physical therapy discharge instructions. The nurse reads the instructions and is responsible for obtaining a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/29/21 at 11:48 AM, Director of Nursing Services (DNS) was interviewed and stated the CNA is responsible for documenting in the resident's medical record when UAP is provided. If a resident refuses or is unable to complete the task, the CNA should communicate this to the charge nurse. The CNA documentation is continuously monitored by the charge nurses to ensure residents are receiving care in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 415.12(a)(2)

Based on record reviews, and staff interviews during the recertification survey, the facility did not ensure that a resident's Comprehensive Care Plan (CCP)was person-centered and individualized. Specifically, there was no documented evidence the facility invited residents and/or their designated representative to attend interdisciplinary (IDT) CCP meetings to review and revise. This was evident for 2 of 4 residents reviewed for Care Planning. (Residents #170 and #207) The findings are: The facility's undated policy titled Care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Person Centered Care - IDT will focus on the resident as the focus of control and supporting the resident in making their own choices and having control over their own daily lives. Care plans are developed by the IDT and the facility will facilitate the inclusion of the resident/representative in the process. The facility policy & procedure titled Care Planning Summary revised 7/2019 documented if resident is unable to attend or sign the summary and the representative is not in attendance, the social worker will mail a copy of the summary to the representative and document same in the EMR. The policy and procedure titled Care Planning Process revised 7/2018 documented resident and/or designated representative will be informed by providing the scheduled Comprehensive Care Plan meetings reflecting the date and time by the Social Service Department. Social worker will document a plan of care note in the progress note section indicating that the letter was sent or additional communication with the family occurred regarding the invite to the care plan meeting. 1) Resident #170 was diagnosed with Diabetes Mellitus (Type 2) and major depressive disorder (MDD). The most recent Minimum Data Set (MDS) 3.0 dated 09/07/2021 documented Resident #170 was cognitively intact. An interview was conducted with Resident #170 on 10/26/2021 at 02:23 PM. Resident #170 stated they were only aware of an IDT meeting once a year. The resident was not aware of nor was invited to CCP meetings held by the IDT on 07/23/2020, 10/23/2020 and 01/15/2021. The Comprehensive Care Plan Meeting Attendance Record documented CCP meetings held on 07/23/2020, 10/23/2020 and 01/15/2021. The attendance record did not document a signature from Resident #170 on these dates. There was no documented evidence in the resident's medical record that Resident #170 was invited to the CCP meetings held on 07/23/2020, 10/23/2020 and 01/15/2021. On 10/28/2021 at 09:52 AM, an interview was conducted with the Director of Social Work (SW #9) who is responsible for inviting residents and/or designated representatives to CCP meetings. SW #9 stated Resident #170 was not invited to and did not attend the quarterly CCP meetings held on 07/23/2020, 10/23/2020 and 01/15/2021. Residents and their designated representatives are only invited to admission, annual, and significant change CCP meetings. 2) Resident #207 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #207 was interviewed on 10/24/21 at 12:28 PM. Resident #207 stated they were invited to their admission CCP meeting but has not been invited to attend any CCP meetings since then. The most recent MDS dated [DATE], documented that Resident #207 had intact cognition, participated in the assessment, and had no guardian or legally authorized representative. The Comprehensive Care Plan Meeting Attendance Record dated 9/23/21 did not document a signature from Resident #207 that they attended the quarterly CCP meeting held by the IDT. There was no documented evidence in the medical record that Resident #207 was invited to the quarterly CCP meeting held on 9/23/21. On 10/29/21 at 11:45 AM, an interview was conducted with Director of Nursing Service (DNS) who stated residents and/or representatives are invited to attend the admission, annual, and significant change IDT CCP meetings. Resident and/or their designated representatives are not invited to quarterly IDT CCP meetings to review and revise their plan of care. 415.11(c)(2) (i-iii)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure that a resident was free from physical restraints. Specifically, a concave mattress was observed being used to restrict a resident with no prior history of falls from the bed. This was evident for 1 of 1 resident reviewed for Physical Restraints. (Resident #57) The findings are: The facility policy titled Restraints Devices and Siderails dated 11/17 documented physical restraints will only be utilized after less restrictive alternatives have been attempted and considered as a last resort to treat the resident's medical symptoms. The clinical team will consider various alternatives prior to the use of the restraints, monitor the use of and assess for the possibility of reducing restraints. At no time will a restraint be utilized for staff convenience or resident discipline. Resident # 57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set 3.0 assessment (MDS) dated [DATE] documented Resident # 57 displayed moderate cognitive impairments and required 1 person to assist with bed mobility, 2 people to assist with transfers, and did not walk in their room or corridor. The resident did not display any adverse behaviors within the assessment period and had no falls since their most recent admission to the facility. The MDS also documented physical restraints were not used with Resident #57. On 10/24/21 at 09:33 AM, 10/25/21 at 09:12 AM, 10/26/21 at 08:59 AM, 10/27/21 at 09:14 AM, and 10/29/21 at 9:16 AM, Resident # 57 was observed in bed with a concave mattress and bilateral upper side rails fully raised. The bed was not at the lowest position and there was no floor mat. Resident # 57 was calm and quiet. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Fall precautions were ordered for the resident on 3/9/20. The comprehensive care plan (CCP) related to risk for falls was initiated 1/16/19 and last revised 8/10/2021. The CCP documented the resident's risk was related to new environment and age-related debility. Interventions to prevent falls included placing a yellow charm on resident's identification bracelet, having call light within reach, and anticipating the resident's needs. The CCP related to siderails was initiated 1/17/19 and last revised on 8/10/21. The CCP documented Resident #57 uses 2 siderails that are not restraints because control panels are located on the rails providing the resident and caregiver with easy access to bed controls and personal care. Resident was to be observed for entrapment/injury and to ensure they maintain autonomy in changing positions. There was no documented evidence in the medical record that Resident #57 was assessed for a concave mattress or that a concave mattress was ordered. There was no documented evidence in the medical record Resident #57 was assessed for restraints or that restraints were an intervention to address the resident's medical and physical condition. There was no documented evidence that Resident #57 had a fall from bed. On 10/26/21 at 09:04 AM, an interview was conducted with Certified Nursing Assistant (CNA) # 1 who stated Resident # 57 was confused, responsive, and totally dependent for most Activities of Daily Living (ADLs). Resident # 57 previously attempted to try to get out of the bed without assistance, but CNA #1 was not aware of the resident having any falls. The resident required a Hoyer lifter and 2 people to transfer from bed to wheelchair. CNA #1 noticed the concave mattress was placed in the resident's room a few months ago. This type of mattress is used to prevent Resident #57 from getting out of bed without assistance. Resident #57 has not attempted to get out of the bed since the concave mattress was put in place because the concave mattress prevents Resident #57 from moving their legs. CNA #1 stated the resident does not have any other fall interventions in place such as floor mats. On 10/26/21 at 03:26 PM, an interview was conducted with Licensed Practical Nurse (LPN) # 1 who has been working as the charge nurse in the evening for approximately 1 year. Resident # 57 has had the concave mattress in place since LPN #1 began working on the unit. LPN #1 was unsure when Resident # 57 was first provided the concave mattress. Resident # 57 was responsive but confused and was unable to follow instructions. The concave mattress was used to keep the resident in bed and prevent falls because Resident #57 moves around in bed a lot. Resident #57 has not had any falls, has not other fall precautions in place, and is unable to get out of the bed because of the concave mattress. On 10/26/21 at 09:22 AM, an interview was conducted with Registered Nurse (RN) # 1 who identified themselves as a floating nurse first assigned to the resident's unit 3-4 weeks ago. RN #1 observed Resident # 57 in bed and stated the resident was alert but confused and required extensive assistance with ADLs, including transferring in and out of bed. RN #1 did not know who determined Resident #57 was a candidate for using a concave mattress or when it was put in place. The concave mattress is used for positioning and as a barrier in the event Resident #57 attempts to get out of bed. RN #1 stated they were not aware of Resident #57 having any fall incidents or any other fall interventions in place, i.e., floor mats or having the bed in the lowest position. On 10/26/21 at 09:45 AM, an interview was conducted was RN #2, a supervisor who has been working at the facility for 2 months and covers 2 units. RN #2 observed Resident # 57 in bed with concave mattress in place and stated they were not familiar with the resident's care or condition. RN #2 was unaware Resident #57 had a concave mattress in place. The concave mattress restricts a resident's position while in bed, thereby preventing falls. Resident #57 was not currently receiving any other fall interventions, i.e., floor mats or having the bed in the lowest position. After observing the resident and reviewing their medical record, RN #2 stated Resident #57 would not be able to get out of the bed with the concave mattress in place due to the resident's functional status. On 10/26/21 at 10:22 AM, an interview was conducted with the Occupational Therapist (OT) who most recently worked with Resident #57 in August 2021. The resident had been referred to OT for a decline in ADL status. Upon discharge from OT, Resident #57 required extensive to total assistance with their ADLs, was confused, and was unable to follow commands. Resident #57 is not physically capable of getting out of bed with a concave mattress in place. OT stated they were unaware of any Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interdisciplinary (IDT) team meeting had not taken place to discuss the need for fall prevention interventions, including a concave mattress. If it was determined that Resident #57 was at risk for falls, the IDT team would meet and determine the necessary interventions to prevent falls. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents were placed in concave mattresses for positioning and to prevent falls by keeping them in bed. On 10/26/21 at 12:10 PM, an interview was conducted with Director of Nursing (DON) who began working at the facility approximately 2 weeks ago. The DON stated they were not familiar with Resident #57. The concave mattress currently in place is used by the resident for positioning and is not used to restrict the resident ability to get out of bed. On 10/26/21 at 03:20 PM, a telephone interview was conducted with primary Physician (PMD) for Resident #57. The PMD stated they did not order the concave mattress for Resident # 57. Concave mattresses are used to promote positioning and comfort, not to restrict the resident in bed. Due to the functional status of Resident #57, a concave mattress may prevent Resident # 57 from getting out of bed. On 10/28/21 at 11:46 AM, an interview was conducted with Medical Director (MD) who stated the concave mattress was used to prevent a resident from rolling and falling out of bed. Concave mattresses do not restrict the movement of residents with higher functional capabilities. Residents who require extensive to total assistance with ADLs would be restricted to the bed if a concave mattress were in place. A concave mattress would create a barrier for Resident # 57 due to their functional status, and Resident #57 would be prevented from getting out of bed. 415.4 (a)(2-7)

Based on record review and interview conducted during the recertification survey, the facility did not ensure that residents received quarterly statements of their personal funds account. Specifically, the family member of a cognitively impaired resident was not provided with quarterly financial statements. This was evident for 1 of 1 resident reviewed for Personal Funds. (Resident #30) The finding is: The facility policy titled Establishment of Residents' Personal Incidental Allowance Fund dated 11/2017 documented financial statements of deposits or withdrawal of funds shall be issued quarterly. When a designated family member is responsible, the quarterly statements shall be mailed to them. The Social Worker (SW) shall be available to assist and direct the resident and/or family member to the Business Office when questions arise. Resident #30 was diagnosed with Acute Kidney Disease and Major Depressive Disorder. The most recent Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition. On 10/24/21 at 11:56 AM, a telephone interview was conducted with the next of kin (NOK) listed on the facesheet of Resident #30. The NOK stated they had not been receiving quarterly financial statements from the facility. The resident's income goes to the facility, but the NOK has not been updated re: the status of the resident's account. An interview was conducted with SW #1 on 10/27/2021 at 2:45 PM. SW #1 stated residents who are cognitively intact receive their financial statements on a quarterly basis. Statements are only mailed to the legally appointed Power of Attorney (POA) of a cognitively impaired resident. The NOK of Resident #30 is not the resident's POA. On 10/27/2021 at 3:00 PM, an interview was conducted with the Business Coordinator (BC) who stated the SW assists the business office with delivering the quarterly financial statements to cognitively intact residents in the facility who can receive and sign for their statements. Resident #30 is cognitively impaired and does not have POA appointed to manage their finances. The BC is unaware of any requests for quarterly financial statements from the NOK of Resident #30. On 10/29/2021 at 10:57 AM, the Administrator was interviewed and stated financial statements cannot be issued to anyone other than a cognitively intact resident or the financial POA of the resident. If the resident does not have a POA in place, the statements are kept in the facility for review and safekeeping. 415.26 (h)(5)(I)

Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that infection control practices were maintained for a resident receiving respiratory care. Specifically, oxygen tubing was observed on the floor on multiple occasions. This was evident for 1 of 1 residents reviewed for Respiratory Care (Resident #108). The findings are: Facility policy titled Oxygen Therapy dated 6/17 documented oxygen tubing should be changed once weekly and as needed if the cleanliness of the tubing is compromised. Resident #108 was diagnosed with dementia and [CONDITION(S)]. The Minimum Date Set (MDS) dated [DATE] documented Resident #108 was severely cognitively impaired and required extensive to total assistance with activities of daily living. On 10/25/21 at 01:04 PM, Resident #108 was observed in bed, alert with continuous oxygen via nasal canula in use. The tubing was running from resident nose down the right side of the bed to the concentrator. The oxygen tubing was on the floor. On 10/26/21 at 11:53 AM, Resident #108 was observed in a gerichair next to their bed. The resident was partially behind the privacy curtain and 2 Certified Nursing Assistants (CNA) were in the room. CNA #10 pushed the hoyer lifter out of the room while CNA #11 made the resident's bed with new sheets. CNA #10 and #11 both pushed the resident's gerichair away from bed so Resident #108 was in front of the foot of their bed. Resident #108 had a nasal canula in their nose and the attached oxygen tubing was observed on the floor. Both CNAs continued to move the resident by pushing the gerichair and concentrator closer to the wall. CNA #10 backed up and stepped on the oxygen tubing with the right foot during the maneuver. CNA #10 left the room and CNA #11 continued to finish making the resident's bed. As CNA #11 was making the bed, RN #7 entered the room, observed the resident in the gerichair and then left the room without addressing the oxygen tubing on the floor. CNA #11 left the room to get another sheet for the bed and returned and finished making the bed. CNA #11 then left the room. The Comprehensive Care Plan (CCP) related to alteration in respiratory status initiated 8/14/21 documented the staff were to monitor respiratory status during care and administer respiratory medications according to physician order. The CCP related to oxygen therapy was initiated 9/8/21 and documented staff were to monitor the oxygen tank every shift. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with CNA #11 on 10/26/21 at 12:18 PM. CNA #11 stated that they had completed their morning care routine for Resident #108 and had moved on to the next assignment. CNA #11 did not notice the oxygen tubing on the floor and stated it was not on the floor during transferring the resident. The resident is transferred via hoyer lifter and the CNA removes the nasal canula during transfer to make sure the tubing does not get tangled. If oxygen tubing is on the floor, it should be picked up and sanitized and then placed back on the resident. CNA #11 observed that the oxygen tubing was on the floor during the interview. An interview was conducted with RN #7 on 10/29/21 at 12:05 PM. RN #7 stated they noticed the tubing on the floor while being interviewed in the resident's room on 10/26/21. RN #7 stated they picked the tubing up off the floor and placed it in a plastic bag after the SA left the room. There was inservice done immediately afterwards with staff on the unit to ensure they were aware of how to properly care for oxygen tubing. RN #7 stated they personally change the entire tubing instead of sanitizing it, but it is acceptable to sanitize the tubing. This should be done immediately upon finding the tubing on the floor. 415.19(a)(1-3)

Based on record review and interviews conducted during the recertification survey and complaint investigation (NY 9748), the facility did not ensure that a resident's medical record contained adequate documentation of scheduled clinic appointments. Specifically, the facility did not provide documentation for several scheduled and missed clinic appointments in the medical record of Resident #449. (1 of 34 residents in sample). The findings are: The facility policy titled Medical and Dental Consults was dated 11/17 and documented the Consult Coordinator (CC) will enter the consult appointment into a log book and document the nurse who transcribed the order. The log book will document resident refusal to go and/or if a consult was rescheduled. The CC is responsible for informing the nursing supervisor of any unresolved issues related to consults. Resident #449 was diagnosed with fracture of the right femur and malignant neoplasm of the lung. Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was rarely understood, was nonverbal, and had intact short term and long term memory with some difficulty in new situations. A telephone interview was conducted with the Complainant on 10/27/21 at 11:31 AM who stated Resident #449 did not keep appointments with the oncology clinic on 12/29/20, 12/30/20, and 12/31/20. The Complainant received a referral because the resident had missed multiple appointments for [CONDITION(S)], [CONDITION(S)], and follow up with the Oncologist re: lung cancer diagnosis. The Complainant had documented their conversations with multiple staff members at the facility in an attempt to resolve any issues related to Resident #449 keeping their appointments. The staff members the complainant spoke to included the Social Worker (no longer at the facility), the Assistant Director of Nursing (ADNS)(no longer at the facility), and the CC. The Complainant confirmed with the CC that the facility was aware of appointments scheduled on 1/4/21 and 1/6/21 and was told Resident #449 would be able to go without any concern. The complainant was informed Resident #449 again missed appointment for 1/6/21 and spoke with the ADNS. The appointment was rescheduled for 1/7/21. The resident's son was at the Oncology clinic on 1/7/21 in anticipation of meeting the resident there once Resident #449 was transported from the facility to their appointment. The resident again did not show up to the appointment at the scheduled time and the facility was contacted at 3:45PM. The clinic was assured the resident was in the ambulette and was en route to the oncology clinic. A Certified Nursing Assistant (CNA) from the facility showed up at the oncology clinic shortly before 5PM and escorted a resident from the facility into the waiting room. The resident's son and the Oncology clinic staff observed that the resident who accompanied the CNA was not Resident #449. The complainant did not have a name of the resident who arrived of or the CNA that accompanied them. At this point, a supervisor at the Oncology Clinic became involved and spoke directly with the ADNS. There were no further concerns with the resident keeping appointments after 1/8/21. The facility never followed up with the Oncology Clinic to explain why a different resident showed up to the appointment for Resident #449 and never provided any outcome of an investigation into the multiple missed appointments. A Patient Review Instrument dated 12/24/20 documented under the Treatments section that Resident #449 had a final [CONDITION(S)] therapy appointment scheduled for 12/29/20. A hospital After Care Summary dated 12/24/20 documented Resident #449 had [CONDITION(S)] and [CONDITION(S)] appointments at the oncology clinic scheduled for 12/29/20 and 12/30/20 respectively. The facility provided an untitled, computer generated template that documented appointment dates of Resident #449 as 12/28/20, 01/04/21, 01/05/21, 01/06/21, 01/07/21, and 01/08/21. Nursing Notes dated 12/28/20 and 12/29/20 documented Resident #449 returned from [CONDITION(S)] clinic appointment. Nursing Notes dated 12/30/20 and 12/31/20 did not document that Resident #449 left or returned to the facility for a clinic appointment. Nursing Note dated 1/4/21 documented the resident went and returned to oncology clinic appointment. Nursing Notes dated 1/5/21, 1/6/21, and 1/7/21 did not document the resident left or returned to the facility for any appointments. Nursing Note dated 1/8/21 documented the resident went to a clinic appointment. There was no documented evidence in the resident's medical record re: missed clinic appointments and no investigation into another resident being transported to an appointment instead of Resident #449. The facility did not provide documentation of any communication with the Oncology Clinic re: resident's missed appointments. An interview was conducted with the CC on 10/28/21 at 11:58 AM. The CC stated they do not recall speaking with the oncology clinic but can recall that Resident #449 made most of his appointments to the oncology clinic. The ADNS would be responsible for documenting any conversations with the oncology clinic and the CC was unable to provide any log book entries documenting whether Resident #449 missed any appointments and the reason. An interview was conducted with the Director of Nursing (DNS) on 10/29/21 at 02:47 PM. The DNS stated they were unaware of any concerns with Resident #449 keeping their appointments. If the resident did not keep an appointment, the nurse on the unit is required to document the reason and if the resident was rescheduled. The DNS and ADNS employed by the facility at the time did not make any corporate entity aware there was a concern with Resident #449. If corporate was aware, there would have been an investigation. The nurse did not document missed appointments and if it is not documented, then it did not occur. 415.22(a)(1-4)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 931) on 06/09/2021, the facility failed to provide adequate supervision to prevent elopement. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 was assessed as being at high risk for elopement and a wander guard was placed on Resident #1's left ankle on 02/23/2021. Resident #1 eloped from the facility on 05/29/2021 at 5:00 PM using the 5th floor unit stairwell exit door and through the cafeteria exit door (located on the 1st floor) undetected by facility staff. Facility staff became aware at 5:55 PM that Resident #1 was missing. Resident #1 was located on 05/29/2021 at 8:00 PM in a restaurant, 1.3 miles from the facility. The findings are: Review of the facility's policy and procedure entitled Elopement Prevention effective in 07/2018, documented: It is the policy of the facility to electronically monitor residents who may tend to wander from the safety of the building, without sacrificing their freedom of mobility or their quality of life. The purpose is to prevent elopement and protect the safety of residents who become disoriented and tend to wander. Waterproof bracelet, which contains the transmitter on the wrist or ankle (at times, may be placed on assistive device). The bracelet is worn twenty-four (24) hours a day. If the resident wanders through a monitored exit, an alarm is triggered at that exit and the main control panel. Other preventative measures used in the facility for residents identified as high risk for Elopement and unsafe wandering includes magnetic door lock with delayed egress, surveillance cameras, security/receptionist, photos and list of applicable residents, alarmed door, wander guard alert system and an annual elopement drill conducted, and findings reviewed at Safety Committee meeting. Resident #1 was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease and Chronic Kidney Disease. The Minimum Data Set (MDS, a resident assessment tool) dated 02/25/2021 identified Resident #1 with a Brief Interview for Mental Status (BIMS) score of 06/15, associated with severely impaired cognition. The MDS documented that Resident #1 required extensive assistance of 2 persons with walking in room and walking in corridor of unit was documented as activity did not occur. A Hospital Discharge Summary dated 02/18/2021 documented that Resident #1 was brought to the emergency room by Emergency Medical Service after being found wandering on the streets. A Nursing Progress Note dated 02/23/2021 at 11:14 PM, documented that Resident #1 was observed trying to enter the elevator several times during the tour. Resident #1's behavior was discouraged, and Resident #1 was educated on safety. Resident #1 was redirected and assisted to room. Call bell and safety precautions were in place and the bed was kept at lowest level. The Supervisor and Physician were informed. An order was given for wander guard to be placed on Resident #1's left ankle. Resident #1's Next of kin was made aware and verbalized understanding. An Elopement Risk/Wanderer as evidenced by Alzheimer's Disease Care Plan was initiated on 02/23/2021. The interventions included applying a wander guard device to Resident #1's left ankle. Check for functioning of the wander guard daily and hourly checks for unsafe wandering/elopement. A photo of Resident #1 will be maintained at the front desk and on the unit. An Elopement/ Unsafe Wandering Screen dated 02/23/2021 documented that Resident #1 was at Risk for Elopement and scored 16. A Physician's Order Audit Report dated 02/23/2021 at 11:12 PM, revealed an order for Resident #1 to have a wander guard to the left ankle. The wander guard to be checked every night for placement and functionality. A Nursing Progress Note dated 03/01/2021 at 8:35 AM documented that Resident #1 was alert, oriented to person and was able to make needs known. Resident #1 was a wanderer, wandered at nights and slept intermittently at nights. Negative behavior redirected. A Stairway Door Alarm Check Log from 05/17/2021 to 05/29/2021, revealed that the stairway door Alarms were checked twice weekly. The Stairway Door Alarm Check Log reflected that the 5th floor stairway door alarm was last checked on 05/27/2021 prior to the elopement on 05/29/2021. A CNA Documentation Survey Report v2 dated 05/29/2021 at 3:00 PM-11:00 PM shift, revealed that Resident #1 was wearing a wander guard on the left ankle. A Daily Resident Room Check document dated 05/29/2021, revealed that Resident #1 was being monitored hourly. The form documented that Resident #1 was last monitored by staff at 4:30PM on 05/29/2021. The documented code at 4:30 PM identified Resident #1 as being awake in the hallway. A Nursing Progress Note dated 05/29/2021 at 11:02 PM documented that staff was made aware that Resident #1 was not in the room on the unit. Elopement Code was activated, and all units/floors were checked. Staff went outside to surrounding neighborhood. Resident #1's emergency contact was made aware and assisted with the search. NYPD was called and assisted in the search. At around 8:00PM, the facility received a call from a nearby restaurant stating that Resident #1 had been sitting inside the restaurant. Resident #1 was brought back to the facility and assessed by the Physician. Resident #1 was noted in no distress with stable vital signs. Resident #1 was transferred to the 3rd floor; room change was performed for close monitoring. Wander guard in place on left ankle and functioning properly. Continue to monitor for safety. Review of the Facility's Investigation dated 05/29/2021, revealed that at approximately 5:00 PM, Resident #1 left the facility undetected by staff. Resident #1 was found safe at a nearby restaurant and was returned to the facility on [DATE] at 8:00PM. At 5:05 PM, the Security Guard observed a flashing light of the wander guard alarm at the main desk. At 5:05 PM-5:11PM, the Security Guard located the kitchen supervisor and asked the kitchen supervisor to check the activated door. At 5:12 PM, the kitchen supervisor checked the door and returned with information to the Security Guard. At 5:15 PM, the Security Guard checked the alarm door. At 5:17 PM, the Security Guard informed the Nursing Supervisor of the activated wander guard alarm. At 5:18 PM, head count of the whole building initiated. At 5:55PM, head count completed, and Resident #1 was identified as a missing person. At 6:00PM, the Director of Nursing Services (DNS) and Administrator were informed. At 6:20 PM, Resident #1's family was notified. At 6:30PM, New York Police Department (NYPD) informed, and 2 officers responded. At 7:50PM, the facility received a call from a restaurant that they identified Resident #1. At 8:00PM, Resident #1 was found and returned to the facility. The elopement was unavoidable due to the door panel damaged driver board, which did not properly activate the alarm on the unit when Resident #1 was leaving due to a short circuit. The facility's camera (#1) surveillance recording, of the 5th floor, dated 05/29/2021, revealed that on 05/29/2021 at 4:25 PM, Resident #1 was observed walking in the lobby going towards the North side unit (Resident #1 resided on the East side of the unit). At 4:27 PM, Resident #1 was escorted back to the unit by a Certified Nursing Assistant (CNA). At 4:47 PM, Resident #1 was observed standing by the lobby area near the elevator (elevator equipped with a wander guard alarm system) between the East and the North side of the units. Resident #1 had a handbag over Resident #1's shoulder. Resident #1 then pressed the elevator button. At 4:56 PM, Resident #1 was observed standing in front of the elevator. At 4:57 PM, Resident #1 was taken out of the elevator by a CNA. At 5:00 PM, Resident #1 pushed open the stairwell exit door on the 5th floor and exited the unit. Resident #1 was no longer in camera #1's view. No staff members were in camera view on the unit. Resident #1 was next seen on camera #2 surveillance recording, walking by the back-parking lot towards Park Place (the camera recording time stamped 4:57PM. As per the Assistant Administrator, each video had its own time and that the video time also fluctuated. During observation on 06/09/2021, Resident #1 was observed on the 3rd floor sitting at the nursing station. Resident #1 had a wander guard to the left ankle. The resident was clean and well-groomed. Observation of the security desk revealed that a wander guard alarm panel was located behind the security desk. When an exit door is pushed open without entering a code on the keypads, the wander guard alarm is activated. Once the alarm is activated, a flashing light showed on the alarm panel. The security desk had a monitor that captured all the exits and surveillance of the facility. One Security Guard was covering the front desk. Observation of the 5th floor East stairwell exit was conducted on 06/09/2021 between 11:00 AM and 11:30 AM. The 5th floor had three stairwells with exit doors. All stairwells exit doors were equipped with wander guard sensors. Keyboard boxes/devices were on the walls next to the exit doors. Staff are required to punch in a code to deactivate the exit door alarm before entering the stairwell. The Assistant Administrator stated that when an exit door is opened, the antenna sends a signal to the driver board which activates the speaker sound alarm. Resident #1's former room on the 5th floor was approximately 11 feet from the East side stairwell exit door. The 5th floor stairwell exit door led directly to the 1st floor cafeteria exit door which leads into the parking. The cafeteria exit door had a wander guard alarm system. During an interview on 06/09/2021 at 12:05 PM, the Assistant Administrator (AA) stated that the facility had a wander guard security system in place prior to the elopement. A wander guard security system was installed at all exits, in elevators and at the stairwell exit doors. The AA stated that the driver panel at the 5th floor stairwell exit door, where Resident #1 exited the unit, was broken. Therefore, the alarm did not go off when Resident #1 opened the exit door and left the unit. The AA stated that the facility had three exit doors at each stairwell on each floor. The stairwell exit door alarms were checked twice a week for functionality. The stairwell exit doors are equipped with a keyboard to deactivate the alarm before entering the stairwells. The AA stated that when an exit door is opened, the antenna sends a signal to the driver board which activates the speaker sound alarm. The driver board then sends a signal to the front desk alarm panel which flashes a light on the alarm panel and the alarm sounds. The Maintenance Director checks the wander guard security system twice weekly. The AA stated that when Resident #1 exited the unit via the 5th floor stairwell, the alarm was not activated. The AA stated that all the exit doors were checked 2 days before Resident #1 exited through the 5th floor stairwell exit door. The AA added that the kitchen (cafeteria) exit door had a wander guard protection with push bar at the time of Resident #1's elopement. The AA stated that one Security Guard monitors the main lobby per shift. The AA stated that the Security Guards are familiar with the residents who are at risk for elopement and that a list with pictures of the residents who are at risk for elopement is at the front desk. During interviews on 06/09/2021 at 1:05PM and 08/17/2021 at 12:20 PM, the Dietary Aide stated that on 05/29/2021 at around 5:00 PM, Security Guard #1 asked the Dietary Aide to check the cafeteria area to see if anyone had exited through the back (cafeteria) exit door. The Dietary Aide stated that the Dietary Aide went out of the cafeteria exit door and checked the yard and did not see anyone. During an interview on 06/09/2021 at 1:15PM, Registered Nurse Supervisor #2 (RNS #2) stated that RNS #2 oversaw Resident #1. RNS #2 stated that Resident #1 wandered around the unit, into other residents' rooms and the elevators. RNS #2 stated that the elevator has a wander guard alarm system. RNS #2 stated that Resident #1 had a wander guard on the left ankle, so the elevator did not move when Resident #1 entered. RNS #2 stated that the 5th floor stairwell exit door did not alarm when Resident #1 exited the unit. RNS #2 said that none of the staff members reported that the stairwell door alarm was broken prior to Resident #1's elopement. RNS #2 stated that Resident #1's wander guard was in place to the left ankle when the resident returned to the facility. Resident #1 was assessed with no visible injury. During an interview on 06/09/2021 at 1:32 PM, Security Guard #1 (SG #1) stated that SG #1 was on duty when Resident #1 eloped from the facility. SG #1 stated that on 05/29/2021 at around 5:05 PM, the alarm panel at the front desk sounded and indicated that someone with a wander guard exited from the cafeteria exit area. SG #1 stated that SG #1 was not able to see the cafeteria exit door area on the monitor when the alarm panel sounded at 5:05 PM. SG #1 said that SG #1 called the cafeteria as soon as the alarm sounded and asked the kitchen staff to check to see if anyone exited the area. The kitchen staff informed SG #1 that the door was open, but no one was there. SG #1 stated that SG #1 informed RNS #1 that the cafeteria exit door alarm was activated. SG #1 stated between 5:10 and 5:15 PM, SG #1 and RNS #1 went out the back door and checked around the building, then a head count of residents was done. Resident #1 was discovered missing during the head count. SG #1 said that SG #1 did not see Resident #1 on the monitor at security desk when Resident #1 exited the cafeteria exit door. During an interview on 06/09/2021 at 2:25 PM, the Maintenance Supervisor (MS) stated that the stairwell alarms are checked twice weekly. The MS stated that the stairwell alarms, including the 5th floor stairwell alarms, were last checked on 05/27/2021 and there was no malfunction. The checks included all stairwell exits and exit gates. The MS said that the facility staff conducted the checks, if a problem is identified then the facility will contact an outside company. The MS further stated that on 05/29/2021, there was a problem with the driver panel of the 5th floor stairwell exit alarm and the alarm did not sound when Resident #1 exited the door. The MS added that the 5th floor stairwell exit door was fixed by a contracting company. During a follow up interview on 08/17/2021 at 11:28 AM, the Maintenance Supervisor (MS) stated that the facility continues to check the stairwell exit door alarms for functioning twice weekly (Mondays and Thursdays). The MS stated that the MS checks the door alarms to see if the alarms sound when the exit doors are opened. The MS added that the problem with the 5th floor exit door could have been detected during the stairwell door checks. During an interview on 06/09/2021 at 3:05 PM and on 08/03/2021 at 12:23 PM, RNS #1 stated that RNS #1 was the Nursing Supervisor on duty when Resident #1 eloped from the facility. RNS #1 stated that SG #1 went to the office on 05/29/2021 around 5:15 PM and informed RNS #1 that SG #1 noted a flashing light on the alarm monitor at the front desk. RNS #1 said that RNS #1 went downstairs with SG #1 and saw one of the exit doors, from the cafeteria to the bottom of the stairwell was opened. RNS #1 stated that they immediately told SG #1 to make an overhead announcement. Staff started searching all the rooms and around the building. RNS #1 verbalized that RNS #1 went to the train station (couldn't recall the time) but Resident #1 was not found. RNS #1 said that RNS #1 went back to the facility around 6:00 PM and notified the Director of Nursing (DON), Administrator, Resident #1's family and New York City Police Department (NYPD). RNS #1 stated that RNS #1 was not informed that Resident #1 attempted to leave by the elevator several times on the evening of the elopement. RNS #1 also stated that RNS #1 did not use the 5th floor East stairwell during the shift. During an interview on 06/09/2021 at 4:55 PM, the Registered Nurse (RN) stated that RN was the nurse on duty when Resident #1 eloped. The RN stated that Resident #1 was a wanderer and an elopement risk. Resident #1 was on hourly monitoring and staff redirected and distracted Resident #1 as needed. The RN stated that RN last saw Resident #1 at around 4:00 PM when RN was administering medications. The RN said that RNS #1 called between 5:20 PM and 5:30 PM and instructed them to perform a head count of residents. The unit staff started searching and discovered that Resident #1 was missing. During an interview on 06/09/2021 at 5:20 PM, CNA #2 stated that CNA #2 was on duty when Resident #1 eloped from the facility. CNA #2 was not assigned to Resident #1 but was familiar with Resident #1's care. CNA #2 stated that Resident #1 had a wander guard because Resident #1 was at risk for elopement. Resident #1 was confused, wandered around and often tried to go on the elevator. CNA #2 said that CNA #2 last saw Resident #1 walking in the hallway around 4:30PM. CNA #2 said that they did not hear the stairwell alarm go off when Resident #1 exited through the stairwell. During an interview on 07/21/2021 at 9:58 AM, CNA #1 stated that CNA #1 was assigned to Resident #1 on the evening Resident #1 eloped from the facility on 05/29/2021. CNA #1 stated that Resident #1 usually wandered around the unit. CNA #1 said that CNA #1 saw Resident #1 wandering in the hallway at the beginning of the shift (3:00PM). CNA #1 said that Resident #1 was on hourly monitoring and was last seeing wandering in the hallway around 4:25 PM on the evening of the elopement. CNA #1 stated that CNA #1 checked Resident #1's ankle for wander guard placement during the shift and the wander guard was in place. CNA #1 verbalized that CNA #1 did not see Resident #1 exited the unit and did not hear the alarm sound when Resident #1 opened the stairwell exit door. CNA #1 added that CNA #1 assisted with searching the neighborhood for Resident #1. CNA #1 stated that CNA #1 was not aware that the stairwell exit door alarm was not working. During an interview on 07/21/2021 at 12:10 PM, CNA #4 stated that the stairwell alarm did not sound when Resident #1 opened the stairwell exit door. CNA #4 added that Resident #1 was quiet some evenings and other evenings Resident #1 would pack Resident #1's belongings and verbalized wanting to go home. During an interview on 07/26/2021 at 2:25 PM, the Director of Nursing (DON) stated that Resident #1 was not identified as at risk for elopement on the admission assessment because Resident #1 was not ambulatory, and Resident #1 did not express the desire to leave. The DON stated that elopement precautions were implemented on 02/23/2021 when Resident #1 attempted to leave the facility. A wander guard was placed on Resident #1's ankle and Resident #1 was placed on hourly monitoring. The DON also verbalized that Resident #1 was transferred to the 4th floor Dementia unit away from any exit door. Resident #1 continues to wander in the hallway and staff continue to monitor Resident #1 hourly. The DON added that SG #1 responded appropriately to the elopement. During an interview on 08/03/2021 at 2:38 PM, the Administrator stated that whenever a stairwell exit door is opened, an alarm sounds and the signal is relayed to the security panel at the front desk. It tells the location of the opened door and is seen on the security monitor. The Administrator stated that when Resident #1 exited on 05/29/2021, the 5th floor unit stairwell door alarm did not sound. The Administrator verbalized that the company identified, there was a problem with circuit board that needed to be repaired. The Administrator also said that the facility still checks the stairwell exit doors alarms twice weekly and said the checks frequency is appropriate. The Administrator stated that staff would alert management if the exit door alarms are not working on the days when the stairwells exit doors alarms checks are not done. The Administrator said that when a wander guard alarm is activated at the security desk, the Security Guard should notify the Nursing Supervisor. The Administrator added that the Security Guard responded appropriately to the activated alarm at the front desk. 415.12(h)(2)

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that a physician was immediately notified of a change in a resident medical condition. This was evidenced by 1 of 3 residents sampled for Quality of Care/Treatment (Resident #1). Specifically, Resident #1 reported that she vomited and was not feeling well. The RN did not assess Resident #1 and the RN did not notify Resident #1's physician. Subsequently, Resident #1 was observed unresponsive in the room. Cardiopulmonary Resuscitation (CPR) initiated, but was unsuccessful. The Emergency Medical Service pronounced Resident #1 on [DATE] at 1:19PM. Complaint # 4 The findings include: Resident #1 was an 88-year female initially admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified the resident with long/short-term memory impairments. A Licensed Practical Nurse (LPN) note dated [DATE] at 3:23PM documented that the Certified Nursing Assistant (CNA) called her to the resident room stating that the resident vomited. The resident verbalized to this writer that she vomited. I took her vital signs (VS) ,[DATE], 98.1, 72, 18. I asked the resident did she have any pain she stated no I just feel nauseous. I gave the resident a ginger ale and an emesis basin. I spoke with the resident for 20 minutes. The resident stated she felt better and I left the room. Daughter came to call director (RN) to the room and I followed her. We found the resident lying in bed unresponsive. CPR was started 911 was called. 911 reached facility at 1:10PM. Resident was pronounced at 1:19PM. CNA provided care and family remains at bedside. An RN note dated [DATE] at 3:34PM documented that Resident #1 expired at 1:20PM today. The doctor made aware and her daughter is present on the unit. Family still at bedside post mortem care to be provided and Resident #1's body to remove to holding. A review of Resident #1's medical record, revealed that the RN did not perform an assessment and the RN did not notify the doctor regarding Resident #1's complaints of not feeling well, vomiting, and nausea. On [DATE] at 2:18PM, the complainant was interviewed. She stated that she arrived at the facility at approximately 12:30PM and went to Resident #1's room. She observed Resident #1 lying in bed with her head facing the foot of the bed. She stated that as she was talking to Resident #1, she realized that Resident #1 was not responding. She also stated that she called Resident #1's name and Resident #1 did not respond or move. She stated that she ran to the dining room, grabbed the RN and they went back to Resident #1's room. She stated that the RN checked Resident #1's pulse stating that the pulse was weak. In addition, the complainant stated that a nurse verbalized to her that earlier in the day Resident #1 complained of not feeling good and that she threw up. She further stated that no one assessed Resident #1 after she complained of not feeling good. On [DATE] at 11:23AM, the CNA was interviewed. She stated that Resident #1 called her to the room stating that she vomited and that she did not feel good. She also stated Resident #1 stated that she flushed the vomitus down the toilet. She affirmed that she informed the LPN who was sitting at the nursing station. She also stated the LPN went in to see Resident #1. The CNA was asked approximately what time did Resident #1 complained of not feeling well and she stated, approximately 11:00AM before lunch. She added that the lunch was not on the unit when Resident #1 complained and when she informed the LPN. The CNA was asked about the time lunch arrived on the unit, and she stated, about 12:00PM or a little after 12:00PM. On [DATE] at 11:10AM, the LPN was interviewed. She stated, at approximately 12:00PM, the CNA came into the dining room and informed her that Resident #1 stated that she was not feeling well and that she had vomited. The LPN stated that she went to Resident #1's room took vital signs, and gave Resident #1 the emesis basin and a ginger ale as Resident #1 stated that she was nauseous. She also stated that she spoke with Resident #1 for approximately 20 minutes before leaving the room. She affirmed that she went to the nursing station where the RN was sitting and informed the RN that Resident #1 complained of not feeling well and that Resident #1 had vomited. She also informed the RN that she gave Resident #1 a ginger ale for the nausea. The LPN was asked about the RN's response, and she stated the RN replied, Ok. The LPN was asked what time did Resident #1's daughter come to the dining room to get the RN, and she stated, I am not sure; I believe it was about 15 minutes or more after I left the resident room. The LPN was asked if the doctor was informed and she stated that she notified the RN. She also stated that when they arrived in Resident #1's room, Resident #1 was unresponsive. She stated that she initiated CPR and that the RN called 911. She stated Resident #1 expired in the facility. On [DATE] at 11:00AM, the RN was interviewed. She stated that she was in the dining room, between 12:00PM and 12:30PM, when Resident #1's daughter came into the dining room on the unit, grabbed her by the hand stating, Come with me. She stated that the LPN was also in the dining room and followed them to Resident #1's room where Resident #1 was lying in bed unresponsive. The RN was asked if she had conducted an assessment of Resident #1 when the LPN informed her that Resident #1 was not feeling well and she stated, No, I did not assess Resident #1, the LPN told me after Resident #1 was observed unresponsive. She further stated the LPN initiated CPR and that she called 911 and Code Blue. She affirmed that EMS pronounced Resident #1 at 1:20PM. On [DATE] at 11:32AM, the Director of Nursing Service (DNS) was interviewed. She stated that she was informed of the code and she went to Resident #1's room where she observed CPR in progress. She further stated that she did not suspect anything was wrong until she was being interviewed. She affirmed that she was not aware that the RN did not assess Resident #1 and that the doctor was not informed when Resident #1 first complained of not feeling well. 483.10(b)(11)