Every finding on record at Dunkirk Rehabilitation & Nursing Center

Based on observations, interview, and record review conducted during the Standard survey completed on 4/18/25, the facility did not ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents for one (1) (Resident #9) of two (2) residents reviewed for accidents. Specifically, Resident #9's wheelchair left pedal was in disrepair and missing the leg rest, exposing a sharp edge at the hinge point. The sharp edge was noted at times pressing against the residents left lower leg. The finding is: The policy titled Assistive Devices and Equipment dated 2/2025 documented the facility maintained and supervised the use of assistive devices and equipment for residents. Certain devices and equipment that assist with resident mobility, safety, and independence were provided for residents like wheelchairs, walkers, etc. Device condition was addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment, devices and equipment were maintained on schedule and according to manufacturer's instructions. Defective or worn devices were discarded or repaired. If a device or equipment was not functioning or was noted to be in poor repair, the device/equipment must be immediately removed from use. Replacement devices and equipment should be implemented in a timely manner to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individuals clinical condition demonstrated that such a diminution was unavoidable. Resident assistive equipment devices such as wheelchairs (to include cushions, brakes and leg rests) were evaluated quarterly and PRN (as needed). The policy titled Resident Safety and Accident Prevention dated 1/2025 documented the facility would commit to safety by implementation of a system based on assessed risk and need of the resident in order to put individualized interventions into place as well as to minimize any environment hazards for prevention and quality. The facility would ensure that the resident environment remained free of accident hazards as was possible and each resident received adequate supervision and assistant devices to prevent accidents. Resident #9 had diagnoses including diabetes mellitus with diabetic neuropathy (nerve pain) and circulatory complications, complete traumatic amputation of left foot, and vascular dementia. The Minimum Data Set (a resident assessment tool) dated 2/12/25 documented Resident #9 was understood, understands and was cognitively intact. The comprehensive care plan initiated 12/1/21 (identified as current) documented Resident #9 used a standard wheelchair and was independent for transferring, dressing, and bed mobility. Resident #9 required skin inspections every shift for Left AFO (ankle-foot orthosis; device worn to support and stabilize the ankle and foot). Observe for redness, open areas, scratches, cuts, bruises. Educate and encourage resident to use ankle-foot orthosis to provide increased function. Additionally, the comprehensive care plan documented Resident #9 had a history of ulcers. The Visual Bedside/Kardex (a guide for staff to provide care) dated as of 4/17/25 documented Resident #9 preferred to sleep in their wheelchair at times, and staff were to encourage to lay in bed when tired. Review of Wound Weekly Registered Nurse assessment dated [DATE]- 3/18/24 documented Resident #9 had stasis ulcers to their left inner and outer calf that healed. Review of Maintenance Work Order Log dated 3/1/25 to 4/17/25 revealed there was no evidence a work order request was put in for Resident #9's leg rest on their wheelchairs left foot pedal. During intermittent observations on 4/15/25 at 9:17 AM and 3:12 PM, 4/16/25 at 8:06 AM, and 4/17/25 at 8:03 AM, Resident #9 was sitting in their wheelchair in their room wearing sweatpants, the leg rest was missing from their wheelchairs left pedal. The black plastic hinge had sharp edges and was pressing against Resident #9's left calf, they did not have their left ankle-foot orthosis in place. During an observation and interview on 4/17/25 at 1:05 PM, Resident #9 was sitting in their wheelchair with jeans on and their left ankle-foot orthosis on. The leg rest remained missing from their left wheelchair pedal, and the hinge continued to press into their left calf in between the braces Velcro straps. Resident #9 stated they were not sure how long the left leg rest had been missing/in disrepair. During an observation and interview on 4/17/25 at 1:06 PM, Certified Nurse Aide #1 stated Resident #9's left leg rest was broken, and the hinge with sharp edges was exposed. They stated the resident independently transferred and the broken hinge could cause a skin injury if it was not fixed. Additionally, Certified Nurse Aide #1 stated whoever noticed a broken wheelchair piece was responsible for reporting it to therapy if it could be replaced or maintenance if it could be fixed. They stated they did not know how long Resident #9's left leg rest had been broken for and did not know if it had been reported to anyone. During an observation and interview on 4/17/25 at 1:08 PM, the Assistant Director of Nursing stated Resident #9's left leg rest was broken with exposed edges and that could cause a skin issue. Resident #9 transferred independently and slept in their wheelchair often so there was a high potential for skin breakdown or injury if the leg rest was not replaced. During an interview on 4/17/25 at 1:26 PM, Certified Occupational Therapy Assistant #1 the leg rest hinge could be sharp when broken and Resident #9 transferred independently so, anything was possible when it came to potential accidents or skin injuries. Additionally, they stated someone should have been altered, so that the pedal could have been repaired. During an interview on 4/18/25 at 8:12 AM, Nurse Practitioner #1 stated having a broken leg rest on their wheelchair put Resident #9 at risk for skin injury. They stated Resident #9 had edema (swelling) in their legs recently that had improved, and they were diligently working on getting their blood sugars more controlled, these things put Resident #9 at a higher risk. During an interview on 4/18/25 at 8:30 AM, the Director of Maintenance stated there was a clip board at the nurse's station that staff wrote any maintenance work orders on; they reviewed the log daily. They stated they did not recall any work order put in for Resident #9's left wheelchair pedal. During an interview on 4/18/25 at 10:17 AM, the Director of Nursing and Administrator stated Resident #9 had an order to have their skin monitored twice a day so they would have expected staff to notice the broken wheelchair leg rest during one of those inspections. They stated Resident #9 could potentially acquire a skin injury if the leg rest was not fixed. 10 NYCRR 415.12 (h)(1)

Based on observation, record review, and interview conducted during a complaint investigation (Complaint #NY00312696) during the Standard survey completed on 12/1/23, the facility did not ensure residents had the right to be free from physical abuse for one (Resident # 31) of three residents reviewed for abuse. Specifically, the facility did not ensure Resident #31 was free from physical abuse when Resident #12 punched them resulting in a hematoma (collection of blood under the skin) above their eye. The residents had a history of physical altercations. The finding is: The policy and procedure titled Abuse-Investigation, Protection, and Reporting dated 10/24/22, documented resident to resident physical altercations must be reported and include any willful action that results in injury. The document titled Your Rights as a Nursing Home Resident in New York State documented residents have the right to be free from physical abuse. 1. Resident #31 had diagnoses including seizures, cerebral infarction (a stroke), and aphasia (absence or difficulty with speech). The Minimum Data Set (MDS- a resident assessment tool) dated 1/4/23 documented Resident #31 had moderate cognitive impairment, physical behaviors directed toward others, and wandering behaviors. The untitled comprehensive care plan dated 2/24/22 documented Resident #31 had the potential to be physically and verbally aggressive related to poor impulse control and a short temper. Interventions included to monitor the resident for signs of posing a danger to self or others. Another intervention dated 5/30/22 was to encourage distance between the resident and their peer (Resident #12). During an observation and interview on 11/27/23 at 10:17 AM, Resident #31 was lying in bed on top of their blankets. The resident stated they didn't have any problems with anyone at the facility including other residents and that nobody hit them. Resident #12 had diagnoses including vascular dementia, type 2 diabetes mellitus (DM), and hypertension (HTN- high blood pressure). The MDS dated [DATE] documented Resident #12 was understood, understands and cognitively intact. Review of the untitled comprehensive care plan date initiated 5/30/23 documented Resident #12 could be physically aggressive related to anger, and poor impulse control as they had a history of hitting Resident #31 on 5/28/22. Interventions included keeping resident away from Resident #31 and a stop sign placed on their bedroom door. During an interview on 11/27/23 at 1:22 PM, Resident #12 stated Resident #31 came into their room and tried stood over them. The resident stated they kept telling Resident #31 to leave and they wouldn't, and Resident #31 kept coming towards them (#12). That was when I hit Resident #31 with my leg brace. Resident #12 stated they did not get along with Resident #31, they (#31) were always in the way, would not move or made unwanted gestures towards them. The Investigation Summary dated 5/28/22 at 8:00 PM, documented Resident #31 was sitting in front of Resident #12 in the hallway, both residents were yelling, and Resident #12 punched Resident #31 in their left eye. The investigation concluded that physical abuse occurred. Resident care plans were updated, and Resident #12 was educated to not put their hands on anyone and to let staff intervene when needed. The Investigation Summary dated 3/14/23 at 12:45 PM, documented Resident #31 went into Resident #12's room and when they wouldn't leave, Resident #12 struck Resident #31 in the left side of their face above the eyebrow. A Registered Nurse (RN) assessment was done and found a golf ball size hematoma above Resident #31's left eye. The investigation concluded that physical abuse occurred. Review of the Progress Note dated 3/14/23 at 12:59 PM, a Nurse Practitioner (NP) documented Resident #31 sustained a head injury because of an altercation with another resident (#12). The resident (#31) had a small laceration at their left eyebrow with tissue edema (swelling). The plan was for staff to monitor for a concussion and provide safety measures including seizure precautions. During a telephone interview on 11/30/23 at 10:08 AM, Licensed Practical Nurse (LPN) #1 stated they were at the nurse's station when Resident #31 approached the area coming from the direction of their room with an injury above their eye. LPN #1 stated they couldn't remember the last time they saw Resident #31 prior to the incident (3/14/23). LPN #1 stated Resident #12 didn't like it when Resident #31 went into their room and staff would need to redirect Resident #31 to their room. During a telephone interview on 11/30/23 at 10:16 AM, Certified Nurse Aide (CNA) #4 stated Resident #31 didn't always remember where their room was. CNA #4 stated the resident (#31) usually ate lunch in the dining room and left whenever they wanted when they were finished eating. CNA #4 stated they weren't sure of any care plan interventions to keep Resident #12 and #31 away from each other and not sure if they've had previous interactions. During a telephone interview on 11/30/23 at 11:14 AM, CNA #3 (assigned to Resident #31 on 3/14/23) stated they remembered seeing a knot on Resident #31's forehead and it was bleeding. CNA #3 asked what happened and they said another resident punched them. CNA #3 stated they weren't sure the last time they saw the resident prior to this but that they ate in the dining room and lunch was served around 12:00 PM. CNA #3 stated they weren't sure if the resident was care planned to stay away from any other residents prior to this incident but was pretty sure they were afterwards. CNA #3 stated they did not see Resident #31 in Resident #12's room that day or morning. During an interview on 11/30/23 at 11:27 AM, LPN #2 stated they were working with Resident #31 on 3/14/23 and had seen him attempting to go into Resident #12's room that morning and they redirected the resident away a couple times. LPN #2 stated they weren't sure if there was a prior incident between the residents. LPN #2 stated they considered a resident punching another resident abusive and if that happened, the Director of Nursing (DON) and Administrator get notified within two hours. During an interview on 11/30/23 at 3:50 PM, the Director of Social Work (SW) stated after Resident #31 and Resident #12's first altercation they told both residents to stay away from each other and their rooms were moved further apart. The second altercation was when Resident #31 went into Resident #12's room and was punched. The SW stated residents had the right to be free from abuse and that Resident #12 abused Resident #31 when they punched them. During an interview on 12/1/23 at 8:55 AM, the DON stated Resident #31 went into Resident #12's room thinking it was their own room and it probably startled Resident #12 who mostly does their own thing in their room. Resident #12 asked Resident #31 to leave and they wouldn't, so they decided to hit Resident #31 in their forehead resulting in a hematoma. These residents did have a prior incident that happened in the hallway, Resident #31 didn't move out of Resident #12's way quick enough and they struck Resident #31. After the initial incident, there was increased monitoring and they kept the residents separate. The DON stated this was mostly likely considered abuse when there's hitting involved. 10 NYCRR 415.3(d)(1)(vii)

Based on observation, interview, and record review conducted during a Standard survey completed on 12/1/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (Resident #32) of two residents reviewed. Specifically, there was lack of glove changes and hand hygiene after providing bowel incontinence care and applying a clean brief. Additionally, the Certified Nurse Assistant (CNA) touched objects (resident's bed linen, and heel booties) while wearing the same gloves used to provide incontinence care. The finding is: The policy and procedure titled Personal Protective Equipment dated 7/2021 documented gloves should be changed after providing incontinent care and before putting on clean briefs and to wash hands after removing gloves. 1. Resident #32 had diagnoses including dementia, anxiety, and depression. The Minimum Data Set (MDS - a resident assessment tool) dated 8/30/23 documented Resident #32 had severe cognitive impairment and was always incontinent of bowel and bladder. The Kardex (a guide used by staff to provide care) dated 11/30/23 documented Resident #32 required extensive assistance of two staff members for incontinent care. The comprehensive care plan dated 8/7/23 documented Resident #32 required extensive assistance of two staff for incontinent care. During an observation of incontinent care for Resident #32 on 11/30/23 at 1:29 PM, CNA #1 and CNA #2 transferred the resident into their bed. CNA #1 removed the soiled brief and provided urinary incontinence care. The resident was turned onto their right side and CNA #2 assisted by holding the resident on their side. CNA #1 wiped the rectal area; a moderate amount of stool was on the washcloth. CNA used both hands to fold the washcloth to a clean section and cleaned more stool from the resident two more times. Without changing their gloves and washing their hands, CNA #1 applied a clean brief to the resident, removed the resident's heel booties and pants, reapplied the heel booties and covered the resident with a sheet. CNA #1 removed their gloves and used the bed remote to lower the bed. CNA #1 donned new gloves and discarded the basin water into the toilet and placed the basin under the sink. CNA #1 removed one of their gloves and using their gloved hand, gathered up the soiled linen bag and brought it to the soiled utility room, where they disposed of the soiled items and then washed their hands. During an interview on 11/30/23 at 1:49 PM, CNA #1 stated they didn't change their gloves after providing incontinence care because they forgot. During an interview on 11/30/23 at 1:52 PM, CNA #2 stated normally staff were supposed to change their gloves when they were soiled (after incontinence care) to prevent cross contamination. During an interview on 12/1/23 at 9:04 AM, the Director of Nursing (DON) stated they expected staff to change their gloves after providing incontinence care and before touching clean items to prevent contaminating anything because you don't know what's on your gloves. 10 NYCRR 415.12(a)(3)

Based on record review and interviews conducted during an Extended Standard survey started on [DATE] and completed on [DATE], the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident who had Full Code status for one (Resident #86) of three residents reviewed. Specifically, on [DATE] Resident #86 was found unresponsive by Certified Nurse Aide (CNA #1) at approximately 4:30 AM. At that time, CNA #1 notified Licensed Practical Nurse (LPN #1). LPN #1 observed Resident #86, who was unresponsive without a pulse, respirations, or blood pressure and had bubbling excretions from their mouth. LPN #1 failed to initiate a Code Blue (emergency response) to summon additional help, failed to activate the 911 (EMS) system, and failed to provide CPR efforts for a resident who was a full code. LPN #1 instead contacted the Director of Nursing (DON) by telephone, without response. LPN #1 stated during interview it was their professional judgment to not perform CPR. LPN #1 did not provide documented clear evidence to support clinical signs for The American Heart Association (AHA) guidelines of irreversible death at the time the resident was observed unresponsive. This resulted in actual harm to Resident #86's health and safety with the likelihood to affect all residents with full code status in the facility that is Immediate Jeopardy and Substandard Quality of Care. There were 13 full code residents in the facility. The finding is: The facility policy and procedure (P&P) dated ,d+[DATE], titled Cardiopulmonary Resuscitation (CPR) & Emergency Response Team documented CPR will be performed on those residents who are found to be unresponsive, without a Do Not Resuscitate (DNR) order in place that are determined not to be clinically dead. CPR certified nursing staff will perform CPR under these circumstances. If the resident's wishes are to receive CPR, it will commence immediately. Any staff member that discovers an unresponsive resident will immediately overhead page Code Blue and the location 3 times. Retrieve the residents' chart to verify CODE status from the residents MOLST/Advance Directives form(s) and current medical orders. Call 911; unless the Advance Directives indicate no hospitalization . The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised [DATE] documented the American Heart Association (AHA) publishes guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations. The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis (stiffening of the joints and muscles of a body a few hours after death), dependent lividity (reddish-blue discoloration of the skin resulting from the pooling of blood in the blood vessels in the lower lying parts of the body in the position of death), decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. 1. Resident #86 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented Resident #86 had severe cognitive impairments and did not have a DNR order. The undated comprehensive care plan documented Resident #86's Advanced directive wishes will be honored through discharge, and documented interventions the resident had full code status. The facility Order Summary Report documented active orders as of [DATE] that included Resident #86 was a full code. The Progress Note dated [DATE] at 7:15 AM written by Physician #1 documented Resident #86 was pronounced deceased at 7:00 AM. Resident #86 was pulseless with no neurological function. The Progress Note dated [DATE] at 7:30 AM written by LPN #1 documented Resident #86 was found unresponsive on last rounds, cold to the touch and cyanotic (bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood). The same note documented DON notified and MD notified and came in to pronounce dead. There was no documented evidence that Resident #86's vital signs were undetectable and no documented evidence of obvious clinical signs of irreversible death. Additionally, there was no documented evidence LPN #1 initiated code blue response or activated the 911 (EMS) system. The Daily Nurse Staffing Form dated [DATE] documented a resident census of 30. Review of the facility Daily Census document dated [DATE] provided by the facility identified there were 13 full code residents in the facility. Review of the nursing staff schedule dated [DATE] documented that LPN #1 was the sole nurse scheduled for the night shift and CNA #1 was the sole aide scheduled for the night shift. Additional review revealed there was no RN scheduled for any shift (days, evenings, and nights). The schedule did not document who should be contacted when there was no RN on site. During a telephone interview on [DATE] at 6:31 AM, CNA #1 stated when they entered Resident #86's room for last rounds (approximately 4:30 AM) Resident #86 was unresponsive and CNA #1 alerted LPN #1. During a telephone interview on [DATE] at 7:52 AM, LPN #1 stated they had provided a nutritional supplement to Resident #86 between 2:00 AM - 2:30 AM. LPN #1 stated at approximately 4:30 AM, they were alerted by CNA #1 that Resident #86 was unresponsive. LPN #1 stated that they responded the resident's room. Resident #86 was cyanotic, cold to the touch and had bubbling excretions from their mouth. LPN #1 stated Resident #86 had no detectable vital signs, and in their professional opinion there were no signs of revival or survival. Additionally, LPN #1 stated since they were unable to pronounce a resident deceased , they attempted to contact the DON, and notified the on-call physician. During a telephone interview on [DATE] at 8:57 AM, the DON stated they were on sick leave the date of the incident ([DATE]) and had a missed telephone call from the facility. The DON stated they could not recall what time they returned the call to the facility but was informed by LPN #1 that Resident #86 was found unresponsive and no further details were provided. Additionally, the DON stated if a Full Code resident was found unresponsive, CPR should be started immediately, especially in the presence of active bubbling. During a telephone interview on [DATE] at 9:38 AM, Physician #1 stated they received an on-call notification from the facility on [DATE] between 6:00 AM and 7:00 AM to pronounce a resident deceased and there was no further information provided. Physician #1 stated there should be an attempt at resuscitation in all residents that are a Full Code status. During an interview on [DATE] at 10:55 AM, the Regional Administrator stated they expected staff to follow facility P&P regarding CPR. During an interview on [DATE] at 10:58 AM, the Administrator stated they were aware of the lack of RN coverage multiple dates, including [DATE]. Based on the survey team's observations, staff interviews and record review the survey team verified the facility removed the immediacy as of [DATE]. Corrective actions the facility took to remove the immediacy included: -Immediate staff education on Code Blue response to all active LPN and RN staff. -A reporting system was put into place for times when there was not a Registered Nurse on site. -Immediate education to all LPN and RN staff on the notification and reporting process. The reporting system included names and contact information. This is information was posted at the nurses' stations and by the facility time clock. 415.2 (e)(2)(iii)

Based on interview and record review conducted during an Extended Standard survey started on [DATE] and completed on [DATE], the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator did not ensure a Registered Nurse (RN) was scheduled eight consecutive hours per 24-hour period as required and did not designate a full time Director of Nursing (DON) when the DON was off for an extended period. In addition, the Administrator did not ensure there was an effective system in place when there was no RN coverage in the building to respond to an emergency in accordance with facility policy and protocols. The findings are: Refer to: F 678 - Cardio-Pulmonary Resuscitation (CPR) - scope/severity (S/S)= J F 727 - RN 8 hours/ 7 days/ Week, Full Time DON - S/S = F Review of an undated Administrator Job Description provided by the facility documented position purpose was to supervise all clinical and administrative functions within the nursing facility. Essential functions included: develop and implements facility management systems, and ensures compliance with all Federal, State and company policies and regulations. Personnel Functions documented to oversees all department's schedules to assure they meet resident needs and monitors regulatory standards; participates in the recruitment and selection of all department personnel and assures sufficient staff are hired; and assures staff is trained in emergency procedures. a.) Concerns rising to the level of immediate risk to resident health and safety/Substandard Quality of Care (SQC) included the provider's failure to provide basic life support, including CPR to an unresponsive resident who had full code status. This was an isolated incident that resulted in actual harm with the likelihood to affect all residents with a full code status. On [DATE] Licensed Practical Nurse (LPN) #1 was notified by Certified Nurse Aide (CNA) #1 at approximately 4:30 AM that Resident #86 was unresponsive. LPN #1 observed Resident #86, who was unresponsive without a pulse, respirations, or blood pressure and had bubbling excretions from their mouth. LPN #1 failed to initiate a Code Blue (emergency response) to summon additional help, failed to activate the 911 (EMS) system, and failed to provide CPR efforts for a resident who was a full code. LPN #1 instead contacted the Director of Nursing (DON) by telephone, without response. LPN #1 stated during interview it was their professional judgment to not perform CPR. LPN #1 did not provide documented clear evidence to support clinical signs for The American Heart Association (AHA) guidelines of irreversible death at the time the resident was observed unresponsive. During an interview on [DATE] at 10:53 AM, the Administrator stated the DON had been out on leave since [DATE] and they did not designate an RN to act as a full -time interim DON. The Administrator stated there was no direction provided to the nursing staff of who to call in the DON's absence until a note was posted at the nurse's station on [DATE]. In addition, the Administrator stated they were aware the facility did not have an RN scheduled for eight consecutive hours per 24 hours as required. During an interview on [DATE] at 11:00 AM, the Administrator stated they would have expected the LPN to have initiated CPR and follow the Code Blue policy and initiate 911. The Administrator stated LPNs cannot assess and determine the time of death of a resident because it is not within their scope of practice and should have contacted an RN. b.) The facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week and the facility did not have a designated RN to serve as the Director of Nursing (DON) on a full-time basis. Review of facility daily reports titled Punched In and Out dated [DATE] through [DATE] revealed there was no documented evidence that an RN was scheduled for eight consecutive hours on the following dates: [DATE], 19, 25, 26, and 30 2021; [DATE], 9, 10, 15, 16, 18, 22, 23, 29, and 30 2022; February 1, 2, 3, 4, 5, 6, 9, 10, 12, 13, 19, 20, 26, and 27 2022 and [DATE] and 6 2022. During an interview on [DATE] at 10:53 AM, the Administrator stated they did not designate an RN as an interim DON to cover while the DON was out on leave, and did not delegate all the DON's job tasks to other RNs. The Administrator stated the Ownership and Corporate Administrator was aware the DON was out on leave since [DATE] and was not directed by them to appoint an interim DON. The Administrator also stated they were aware the facility did not have an RN scheduled for eight consecutive hours per 24 hours as required and should have notified Corporate/Ownership that the facility was unable to schedule an RN as required. During a telephone interview on [DATE] at 11:59 AM, the Chief Operating Officer (COO) stated they were not aware the facility was unable to schedule an RN for eight consecutive hours per 24 hours as required. The COO stated they should have been notified and would have offered bonuses and provided additional assistance if they were aware. During an interview on [DATE] at 12:18 PM, the Corporate Administrator stated they were not aware the facility was unable to schedule an RN eight consecutive hours per 24 hours as required and would have expected the Administrator to have notified Corporate. 415.26

Based on interview and record review conducted during the Standard survey completed on 3/11/22, the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week and the facility did not have a designated RN to serve as the Director of Nursing (DON) on a full-time basis. Specifically, reviewed for staffing revealed an RN was not scheduled for eight consecutive hours per day on multiple dates December 4, 2021 through March 6, 2022, and an RN was not designated as DON from 12/30/21 through 3/7/22. The findings are: Review of a facility policy and procedure (P&P) titled Contingency Staffing Plan dated 3/13/2020 documented; it is the facility's policy to ensure that in the event of a disaster or emergency that a contingency staffing plan is in place so that all residents can be provided the necessary care. In the event of a disaster, whether environmental or health- related, it is crucial to ensure that there are plans in place for contingency staffing in the event additional licensed and /or non-licensed personnel are needed. Review of a facility undated Job Description for DON provided by the Administrator documented; the DON assumes authority, responsibility and accountability for the delivery of nursing services in the facility. In collaboration with facility Administration, allocates department resources in an efficient and economic manner to enable each resident to attain and / or maintain the highest practical physical, mental and psychosocial well-being. Collaborates with other departments, medical professionals, consultants and organizations, including government agencies and advocacy groups, to develop, support and coordinate resident care, related administrative functions and to represent the interests of the facility. Essential Job Functions included; oversees nursing schedules to assure they meet resident needs/ as well as, regulatory and budgetary standards. Review of a facility report, untitled, identified as the facility census report by the Administrator dated 12/1/21 through 3/7/21 revealed the census was between 29 to 40 residents daily. Review of an untitled form, identified as the facility daily shift staffing sheets by the Administrator dated 12/1/21 through 3/6/22 revealed there was no documented evidence that a Registered Nurse (RN) was scheduled for eight consecutive hours on the following dates: December 4, 11, 19, 25, 26, and 30 2021; January 1, 8, 9, 10, 15, 16, 18, 22, 23, 29, and 30 2022; February 1, 2, 3, 4, 5, 6, 9, 10, 12, 13, 19, 20, 26, and 27 2022 and March 3 and 6 2022. Review of the facility Daily Nurse Staffing Forms from 12/1/21 through 3/6/22 revealed there was no documented evidence that an RN was scheduled for eight consecutive hours on the identified dates. Review of facility daily reports titled; Punched In and Out; dated 12/1/21 through 3/6/21 revealed there was no documented evidence that an RN was scheduled for eight consecutive hours on the identified dates. Review of a titled report, Time Cards, dated 12/1/21 through 3/6/22 for the DON, Regional RN Interim DON #1, Regional Director Quality Assurance, and Regional RN #2, revealed there was no documented evidence that an RN was scheduled for eight consecutive hours on the identified dates. Review of a handwritten sign hanging on the nurses station documented; Nurses: The sister facility will be available to take any calls from this facility that require an RN, between 7 PM to 7 AM. They can assist over the home to provide guidance. Day issues can be addressed with RN in the building. From the hours of no RN please call Administrator starting 2/11/22. During an interview on 3/7/22 at 10:41 AM the Administrator stated the DON has not been here for a while related to medical issues, there has not been an RN appointed to be the interim DON and the New York State Department of Health has not been informed of the lack of full time DON coverage. The Administrator stated the facility corporate nurses have been assisting with RN tasks. The Administrator appointed RN Interim DON #2 at this time during the interview. During an interview on 3/7/22 at 11:07 AM RN Interim DON #2 stated they started working for the facility on 2/17/22 as an agency nurse and was appointed as the interim DON this morning during the entrance conference interview. During another interview on 3/9/22 at 6:33 AM RN Interim DON #2 stated prior to 3/7/22 they were aware there was a sign at the nurse's station to contact a sister facility that require an RN guidance between 7 PM - 7 AM dated 2/11/22. During an interview on 3/7/22 at 11:13 AM Regional RN /Interim DON #1 stated they were aware the DON was out on medical leave, they had worked covering some RN duties in the building and had not been appointed to be the interim DON during the DON's absence until today (3-7-22). During an interview on 3/7/22 at 11:18 AM the Regional Administrator stated they were aware the DON had been out on medical leave and Regional RNs have been covering some RN duties. The Regional Administrator stated there should be a full time DON and doesn't know who is covering the DON duties and referred the question to the Administrator. During an interview on 3/8/22 at 12:06 PM the Administrator stated the DON's last day worked was 12/29/21 related to medical issues. During a phone interview on 3/9/22 at 8:57 AM the DON stated the facility's corporation was aware they had been out on medical and unable to work. The DON stated Regional RN Interim DON #1 and Regional Administrator were aware and believes corporate provided some RN coverage for specific RN duties and does not know who is covering DON duties or making DON decisions. The DON stated the facility should have appointed a full time RN to be the acting interim DON while they were out sick. In addition, the DON stated there should be an RN in the facility at least eight consecutive hours ever 24-hour period and was not aware the facility was not meeting this requirement. The DON stated the Scheduling Coordinator is responsible for scheduling and the Daily Nurse Staffing Form should be accurate at all times. During an interview on 3/10/22 at 8:25 AM LPN #2 stated they were aware there is a regulation the facility is to schedule an RN for eight consecutive hours every 24-hour period and the facility has not met that requirement especially on weekends. LPN #2 stated since the DON has been out on medical leave the frequency of a lack of RN coverage has increased. LPN #2 state they had not been informed or educated on a change in DON status until yesterday (3-9-22). During an interview on 3/10/22 at 9:56 AM LPN #5 stated they are aware the facility should have an RN at least 8 hours / 24 hours coverage and stated there is a lack of RN coverage on multiple days especially on the weekends. LPN #5 stated they had not been informed or educated on a change in DON status until yesterday (3-9-22). During a second interview on 3/10/22 at 4:00 PM Regional RN / Interim DON #1 stated they had not returned to work until mid-February 2022 and started working at this facility to cover some RN hours and realized the facility did not have an RN scheduled daily for eight hours as required. Regional RN / Interim DON #1 stated they had hired Agency RN / Interim DON #2 as a full time RN, but there continued to be a lack of RN 8-hour coverage in the building and the Administrator was aware. During an interview on 3/11/22 at 9:43 AM Human Resources Director / Scheduling Coordinator stated they had been in charge of scheduling since November 2021 and is aware there should be an RN scheduled for eight hours / 24 hours per requirement. They stated they were unable to schedule an RN daily and aware there was not eight hours of RN coverage as required for all the dates indicated. The Human Resource Director / Scheduling Coordinator stated the Administrator, and the Regional Director of Quality Assurance (QA) was aware, and they were not provided any further direction how to staff the facility with an RN. During an interview on 3/11/22 at 10:53 AM the Administrator stated they anticipated the DON to return and did not appoint or delegate an RN as an interim DON and did not delegate all the DON's job tasks to other RNs. The Administrator stated the Ownership and Corporate Administrator was aware the DON was not in the building and out on medical leave since 12/29/21 and was not directed to appoint an interim DON. The Administrator stated there was no direction provided to the nursing staff of who to call in the DON's absence until a note was posted at the nurse's station on 2/11/22 for the nurses to call the sister facility for assistance if an RN is required on the off shifts. In addition, the Administrator stated they were aware the facility did not have an RN scheduled for eight consecutive hours per 24 hours as required on multiple dates. The Administrator reviewed the dates identified and agreed the information was correct. The Administrator stated they should have notified Corporate and Ownership that the facility was unable to schedule an RN as required. During a phone interview on 3/11/22 at 11:59 AM the Chief Operating Officer (COO) stated they were not aware the facility was unable to schedule an RN eight consecutive hours per 24 hours as required. The COO stated they should have been notified and would have offered bonuses and provided additional assistance if they were aware. During an interview on 3/11/22 at 12:18 PM the Corporate Administrator stated they were not aware the facility was unable to schedule an RN eight consecutive hours per 24 hours as required and would have expected the Administrator to have notified Corporate. 415.13(b)(1)

Based on observation, interview and record review conducted during an extended standard survey completed on 3/11/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #18) of two residents reviewed. Specifically, Certified Nurse Aide (CNA) #4 requested and accepted money from Resident #18 to provide the resident with sexually explicit photos that was not reported to the New York State Department of Health (NYS DOH) as required within the two-hour time frame. The facility policy and procedure (P&P) titled Abuse, Investigation & Reporting dated 10/1/2019 documented all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations). An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury to the State licensing/certification agency responsible for surveying/licensing the facility. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 11/22/17 documents facility staff are in a position that may be perceived as one of power over a resident. As such, staff may be able to manipulate or unduly influence decisions by the resident. Staff must not accept or ask a resident to borrow personal items or money, nor should they attempt to gain access to a resident's holdings, money, or personal possessions through persuasion, coercion, request for a loan, or solicitation. A resident's apparent consent is not valid if it is obtained from a resident lacking the capacity to consent, or consent id obtained through intimidation, coercion or fear, whether it is expressed by the resident or suspected by staff. Refer to F 602 Freedom from Misappropriation/ Exploitation scope/severity =D 1. Resident #18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 1/25/22 documented Resident #18 understands, was understood, and cognition was not assessed. The 11/17/21 MDS documents Resident #18 was cognitively intact. During intermittent observations 3/7/22 through 3/11/22, Resident #18 was alert, oriented, and cognitively intact. The facility Disciplinary Action Report dated 8/20/21 and signed by CNA #4 documented the following reasons for action: Sexual or other unlawful harassment; Immoral conduct that would be widely regarded as improper or inappropriate in a work group; Soliciting loans/kickbacks from residents, families or vendors; Willful violation of Corporate Compliance Program - Code of Conduct or Ethics Policy; and Other extreme instances of improper conduct not specifically listed. Additionally, the reason for action documented CNA #4 provided resident with sexually explicit photos, and CNA #4 requested and accepted money from the resident. Review of the NYS DOH Automated Complaint Tracking System (ACTS, software that logs and tracks nursing home complaints) 8/1/21 through 8/31/21 revealed the solicitation of Resident #18, by CNA #4 was not reported. During an interview on 3/11/22 at 8:55 AM, the Director of Nursing (DON) stated they had spoken with the Corporate Quality Assurance (QA) Nurse and the Corporate DON who had stated the incident was not reportable to the NYS DOH secondary to the exchange of money for sexually explicit pictures was consensual between CNA #4 and Resident #18. During an interview on 3/11/22 at 9:42 AM, the Administrator stated the incident was not reported to the NYS DOH secondary to Resident #18 and CNA #4 were able to consent to the transaction, and that the photos were not taken inside the building. 415.4(b)(4)

Based on observation, interview and record review conducted during an Extended Standard survey completed on 3/11/22, the facility did not ensure each resident was free from exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion) for one (Resident #18) of two residents reviewed. Specifically, Certified Nurse Aide (CNA) #4 requested and accepted money from Resident #18 to provide the resident with sexually explicit photos. The finding is: The facility policy and procedure (P&P) titled Accident/Incident - Investigation & Reporting dated 6/2021 documented all accidents and incidents occurring within and related to the facility will be investigated. The investigation should rule out or confirm abuse, exploitation or neglect. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 11/22/17 documents facility staff are in a position that may be perceived as one of power over a resident. As such, staff may be able to manipulate or unduly influence decisions by the resident. Staff must not accept or ask a resident to borrow personal items or money, nor should they attempt to gain access to a resident's holdings, money, or personal possessions through persuasion, coercion, request for a loan, or solicitation. A resident's apparent consent is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion or fear, whether it is expressed by the resident or suspected by staff. 1. Resident #18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 1/25/22 documented Resident #18 understands, was understood and cognition was not assessed. The 11/17/21 MDS documented Resident #18 was cognitively intact. During intermittent observations 3/7/22 through 3/11/22, Resident #18 was alert, oriented, and cognitively intact. The facility Disciplinary Action Report dated 8/20/21 and signed by CNA #4 documented the following reasons for action: Sexual or other unlawful harassment; Immoral conduct that would be widely regarded as improper or inappropriate in a work group; Soliciting loans/kickbacks from residents, families or vendors; Willful violation of Corporate Compliance Program - Code of Conduct or Ethics Policy; and Other extreme instances of improper conduct not specifically listed. Additionally, the reason for action documented CNA #4 provided resident with sexually explicit photos, and CNA #4 requested and accepted money from Resident #18. The report also documented the pornographic photos were on file. The Human Resources status update dated 8/20/21 documented on 8/20/21 CNA #4 was asked if they would like union representative present for the disciplinary action report that was being presented to them. CNA #4 was informed that this was regarding the indecent and inappropriate material involving them. CNA #4 verbally refused to have representation and signed off on the disciplinary written report. At that time, CNA #4 stated that things were bad at their home, and they knew their actions were wrong and wanted to leave rather than proceed with any further discussion. Review of an email dated 8/23/21 at 10:23 AM to the Director of Nursing provided by the facility revealed a text message chain from CNA #4 to LPN #5 that documented CNA #4 sent pictures to Resident #18 for cash due to having no money. During an interview on 3/10/22 at 11:16 AM, Resident #18 stated they received sexually explicit photos of CNA #4 on their cell phone, and that they were aware CNA #4 was having domestic and financial problems. During an interview on 3/10/22 at 12:11 PM, the Administrator stated CNA #4 was terminated for the moral/ethical issues of sending sexually explicit photos of themselves to a resident. 415.4(b)

Based on interview and record review conducted during the Standard survey completed on 3/11/22, the facility did not inform the resident's representative of a change in physical status and a transfer to the hospital for one (Resident #34) of one resident reviewed for notification of change. Specifically, the resident's representative was not notified when Resident #34 tested positive for COVID -19 on 12/31/22 and was subsequently transferred to the hospital on 1/6/22. The findings are: Review of the facility policy and procedure (P/P) titled Change in Status Notification dated 9/2021 documented it is the facilities policy that in accordance with State and Federal Regulations; notification to the resident, and the resident's representative(s), consistent with his/her authority, will be made when there is an a significant change in the resident's physical, mental or psychological status in either life threatening conditions or clinical complications; a need to alter treatment significantly or to commence a new form of treatment; or a decision to transfer the resident from the facility. 1. Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-resident assessment tool) dated 1/24/22 documented Resident #34 sometimes understood, understands and was severely cognitively impaired. During an interview on 3/8/22 at 1:49 PM, Resident #34's responsible party stated the resident tested positive for COVID-19 in December of 2021 and was sent to the hospital in January 2022 and they were not notified. Review of the Progress Notes dated 12/31/21 completed by Licensed Practical Nurse (LPN) #2 documented Resident #34 tested positive for COVID, had sinus congestion with rhinorrhea (runny nose), an occasional nonproductive cough (NPC) and general malaise (general feeling of discomfort, illness, or uneasiness). The resident was to be monitored and fluids encouraged. The resident's vital signs were stable. Review of the Progress Notes dated 1/6/22 completed by LPN #3 documented a late entry: resident was having low O2 (oxygen) level and was told by DON (Director of Nursing) to send to ER (emergency room ). Review of the Progress Notes from 12/31/22 and 1/6/22 revealed there was no documented evidence that the responsible party was notified of either event. During an interview on 3/10/22 at 1:03 PM, LPN #2 stated I did not call the family to tell them the resident tested positive for COVID. I was told the Administrator calls everybody when someone tests positive. I did not know at the time it was a 'general' robo call to everyone and not specifically to the residents family. During an interview on 3/10/22 at 1:06 PM, Regional Registered Nurse (RNS) #1, Interim Director of Nursing (DON) stated we should notify a family with any change of status. There should be a family notification when a resident becomes COVID positive and when they are sent to the hospital. Staff should document this in the medical record. I do not see any family notifications for either of these two changes of status. 415.3(e)(2)(ii)(b)(d)

Based on record review and interview conducted during a Complaint Investigation (Complaint #NY 172) completed during the Abbreviated survey on 9/9/21, the facility did not ensure the resident environment remained as free of accident hazards as possible, and that each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed. Specifically, Resident #1 sustained a 42 centimeter (cm) by 7 cm second degree burn (partial thickness) to their left lower leg from an electric baseboard heater located in the resident's room. Resident #1 developed necrotic tissue in the affected area and was subsequently admitted to the hospital burn unit for debridment. This resulted in actual harm that is not immediate jeopardy. The finding is: The Baseboard Heater Commercial/Residential installation instructions dated 3/6/12, provided by the Director of Maintenance, documented high temperatures are present at outlet air openings. Keep electrical cords, drapes and other furnishings or objects clear of these openings. 1. Resident #1 was admitted to the facility with diagnoses including Alzheimer's disease, [CONDITION(S)] heart disease ([CONDITION(S)] - thickening and hardening of the walls of the coronary arteries), and diabetes mellitus (DM). The Minimum Data Set (MDS - a resident assessment tool) dated 1/20/20 documented Resident #1 had severe cognitive impairment. Additionally, the MDS documented a history of falls. The comprehensive care plan (CCP) dated as initiated on 1/15/20 documented Resident #1 had a fall with serious injury/left [CONDITION(S)] related to poor balance, poor communication/comprehension, and unsteady gait. The facility untitled report dated 2/7/20 documented Resident #1 was asleep in their bed at 10:30 PM on 2/6/20 and was found on the floor of their bedroom at 12:00 AM on 2/7/20 with their torso on the bed, and their left lower extremity (LLE) resting on the heat register. The facility wound assessment dated [DATE], completed by the Director of Nursing (DON), documented Resident #1 was found with left leg on the heating unit in their room during rounds. The left lower extremity presented with an area of second-degree burn, with redness and blistering. Physician order obtained for [MEDICATION(S)] (topical antibiotic used in partial thickness and full thickness [CONDITION(S)] to prevent infection) 1% cream to LLE burn every morning, and to apply dressing of gauze wrap over [MEDICATION(S)]. The facility wound assessment dated [DATE], completed by Registered Nurse #1, documented a deep second-degree burn, 42 cm x 7 cm (acquired date 2/7/20), with 80% necrosis (death of cells or tissue) and/or slough (yellow/white material consisting of dead cells in would bed). The Progress Note signed and dated 3/3/20 by the Social Services Director (SSD) documented Resident #1's wound physician directly admitted Resident #1 to the hospital burn unit for LLE wound debridement (removal of dead or infected tissue). During an interview on 9/9/21 at 8:43 AM the Director of Maintenance stated they have previously found linens and a stuffed animal that had been burned from being too close to the electric baseboard heaters. The Director of Maintenance stated the electric baseboard heaters run at 180 to 200 degrees, they don't go less than 180 degrees farenheit or more than 200 degrees farenheit. The Director of Maintenance stated Resident #1's bed was about 12 inches from the electric baseboard heater at the time of the incident. The Director of Maintenance stated since the incident occurred, every room is checked daily to ensure a 24-inch space between the bed and electric baseboard heater. Additionally, the Director of Maintenance stated the external temperatures of the electric baseboard heaters are not routinely monitored. During an interview on 9/9/21 at 10:08 AM, the DON stated they were not aware the baseboard heaters got hot. The DON stated when they arrived at the facility on 2/7/20 the baseboard heater in Resident #1's room was hot to the touch. The DON stated she could not touch the heater for more than a few seconds without pain. The DON stated Resident #1 suffered unintentional harm from the baseboard heater. During an interview on 9/9/21 at 10:47 AM, the Administrator stated at the time of the incident with Resident #1, the electric baseboard heaters were the original heaters from 1963, and that technology in electric heaters isn't anything spectacular, not much can go wrong with them except for a thermostat. Additionally, the Administrator stated the external temperature of the electric baseboard heaters were not routinely monitored; and an external temperature of 180 - 200 degrees farenheit created a potential hazard to the residents. The surveyor made attempts to contact the physician without success. 415.12 (h)(1)

Based on interview and record review conducted during an Infection Control Focus Survey (Complaint #NY 306) completed on 6/10/20 the facility did not ensure that a qualified dietician was employed either full time, part time, or on a consultant basis. Specifically, the facility has not employed a Registered Dietician (RD) since February 2020 and the Dietary Technician (DT) did not receive frequent scheduled consultations from a Registered Dietitian (RD). The finding is: The facility policy regarding titled Weights dated 9/2017 documented the facility will ensure all residents maintain to the extent possible acceptable parameters of nutritional status. The dietician/designee will conduct a calorie count if appropriate, evaluate the food intake and assess the need for evaluation; collaborate with nursing and other disciplines to plan and implement a plan of care; request orders from physician based upon assessment and recommend to the physician appropriate methods of assisting the resident to attain optimum nutritional status; and address nutritional status and interventions in resident's plan of care. During an interview on 6/9/20 at 11:30 AM, DT #1 stated she covered the nutritional care of residents for two different facilities and was the Food Service Director at one of those facilities. The DT stated there was no RD on staff at the facility and she was doing what she could to cover the nutritional aspects in both facilities. During an interview on 6/9/20 at 2:30 PM, the Director of Nursing (DON) stated there has not been a RD on staff since February 2020. The Diet Technician was covering the nutritional status of the facility. During an interview on 6/9/20 at 2:45 PM, the Administrator stated there has not been a RD on staff since February 2020. The Diet Technician has been covering the nutritional status of the facility. He stated he was aware of the need for an RD. 415.14(a)(1),(2)

Based on observation, interview, and record review conducted during a Focus Infection Control Survey (Complaint #NY 306) completed on 6/10/20 the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for two (Residents #1 and #4) of four residents reviewed. Specifically, residents (Residents #1 and #4) were not assessed by a Registered Dietician (RD) and there were no nutritional interventions initiated for significant weight loss. The findings are: The facility policy regarding titled Weights dated 9/2017 documented the facility will ensure all residents maintain to the extent possible acceptable parameters of nutritional status. The dietician/designee will conduct a calorie count if appropriate, evaluate the food intake and assess the need for evaluation; collaborate with nursing and other disciplines to plan and implement a plan of care; request orders from physician based upon assessment and recommend to the physician appropriate methods of assisting the resident to attain optimum nutritional status; and address nutritional status and interventions in resident's plan of care. 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 3/5/20 documented the resident had severe cognitive impairment. Review of the Comprehensive Care Plan initiated 3/9/20 documented Resident #4 had a nutritional problem or was at risk for nutritional problems related to dementia, gastro-[MEDICAL CONDITION] reflux disease (GERD), limited physical mobility, impaired skin integrity and weight loss. Interventions include, RD to evaluate and make diet changes and recommendations as needed. Review of the Initial Nutritional Comprehensive Assessment completed by the Diet Technician (DT) dated 3/9/20 documented the resident was 72 inches tall with the most recent weight 198.8 pounds, usual body weight at 198 pounds and Ideal Body Weight (IBW) at 178 pounds. The assessment also documented, Resident #4 was admitted with a Stage II pressure injury present on the coccyx. The average meal intake documented at 50-100% (percent). Review of the Monthly Weight Report documented weights as followed: February = 198.8 pounds (lbs) March = 195.6 pounds April = 185.6 pounds May = 171.6 pounds (Weight loss of 13.6% in three months) June = 168.5 pounds (Weight loss of 15% in four months) Review of the Nutritional Progress Notes and Nutritional Assessments from 2/6/20 until 6/10/20 revealed there were no further nutritional assessments or documented evidence that the resident was assessed and monitored by the DT or an RD regarding the resident's weight loss and nutritional status. Review of a physician note dated 5/22/20 documented resident #4's weight was at 171.6 pounds, weight prior 185.6 pounds, Ideal Body Weight 178 pounds. Appears to be stable in weight. During an interview on 6/9/20 at 11:30 AM, Diet Technician (DT) #1 stated she was covering the residents' nutritional care for two facilities and was also the Food Service Director at one of those facilities. She said, Resident #4 was on her radar to look at due to their weight loss but she had not completed any further assessments. During an interview on 6/9/20 at 2:30 PM, the Director of Nursing (DON) stated there has not been a RD on staff since February 2020, but the Diet Technician was covering the nutritional aspect for the facility. During an interview on 6/9/20 at 11:15 AM, the Administrator stated the RD that was working there left sometime earlier this year. He was aware that a RD was required to work at the facility. 2. Resident #1 had [DIAGNOSES REDACTED]. Resident #1 receives [MEDICAL TREATMENT] every Monday, Wednesday and Friday. The MDS dated [DATE] documented the resident had moderate cognitive impairments. Review of the Nutritional Comprehensive Assessment completed by DT #1 dated 2/27/20 revealed Resident #1 was admitted to the facility after a fall. The resident's most recent weight on 2/18/20 was 110 lbs. The resident's food intake was fair to poor with refusals noted. Review of the CCP initiated on 3/2/20 and revised on 6/8/20 revealed the resident #1 was at nutritional risk related to [MEDICAL CONDITION], DM, adult failure to thrive, refusals of meals and medications. The goal was to maintain weight within 3 pounds of [MEDICAL TREATMENT] recommendations, no signs/symptoms of malnutrition, and consuming at least 50% of at least two meals daily. Interventions included that the Registered Dietician was to evaluate and make diet change recommendations as needed. Review of the Monthly Weight Report documented weights as followed: February = 110.0 pounds March = 107.2 pounds April = 91.4 pounds (Weight loss of 16.9% in two months) May = 84.8 pounds (Weight loss of 22.9% in three months) June = 85.1 pounds (Weight loss of 22.6% in four months) Review of the Nutritional Progress Notes and Nutritional Assessments from 2/27/20 until 6/10/20 revealed there were no further nutritional assessments or documented evidence that the Resident #1 was assessed and monitored by the DT or an RD regarding the resident's weight loss and nutritional status. Additionally, there was no documented evidence of weight recommendations made by the [MEDICAL TREATMENT] staff. Review of a physician note dated 4/20/20 documented the patient lost over 20 lbs in the past 8 weeks, since the time of their admission to the facility. The note documented abnormal weight loss due to not liking food and GI (gastro-intestinal) side effects of Calcium Acetate (supplement). Review of meal intake sheets from 5/1/20 - 6/10/20 for breakfast, lunch and dinner revealed the resident often refused the meals. Many times, the intake was documented as 0-25% or 25-50%. Resident #1 had occasional times when 50-75% or 75-100% was consumed. During an interview on 6/9/20 at 11:30 AM, Diet Technician #1 stated she was aware of Resident #1's weight loss. The resident was refusing to eat. The family had been bringing in food but now there was no visitation allowed. During an observation on 6/9/20 at 12:00 PM the Resident #1 appeared thin and frail. During an interview on 6/9/20 at 3:00 PM, the Director of Nursing (DON) stated the resident had not been evaluated by a Registered Dietician since admission to the facility. The facility had not had a registered dietician on staff at the facility since February 2020. The initial nutritional assessment on 2/27/20 was completed by the diet technician. The DON stated Resident #1 should have been evaluated by an RD and was not because the facility did not have one. 415.12 (i)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 8/23/19, it was determined that the facility did not ensure that the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Specifically, one of one resident (Resident #30) reviewed for reasonable accommodations, had issues with a resident who was non-weight bearing on one leg did not have a commode with a bucket for toileting for several days. The finding is: A review of a policy and procedure (P&P) titled Activities of Daily Living dated 8/2019 revealed that a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence. 1. Resident #30 was admitted on [DATE] for rehabilitation related to knee surgery and a knee infection. The Minimum Data Set (MDS, a resident assessment tool) dated 7/25/19 documented the resident was cognitively intact. The MDS documented the resident required extensive assist for transferring between surfaces. Review of the resident's chronological medical record revealed the following: - Current Comprehensive Care Plan (CCP) dated 7/19/19 documentred the resident had limited physical mobility related to a right knee infection; had a limited assist of one staff with use of bariatric front wheeled walker to do stand pivot sit, non-weight bearing on right lower extremity; and required extensive assist of one staff with bedside commode. - Current Certified Nurse Aide (CNA) Kardex (guide used by staff to provide care) dated 8/22/2019 documented the resident required limited assist of one staff with use of bariatric front wheeled walker to do stand pivot sit non-weight bearing on right lower extremity; and that resident required extensive assist of one staff with bedside commode. - Physical Therapy Treatment Encounter Notes from 7/22/19 to 8/21/19, revealed the resident was on non-weight bearing precautions on his right lower leg; the resident was completing strength training for transfer using a four wheeled walker with stand by assistance from his bed to the bedside commode using a stand pivot sit motion without loss of balance. - Occupational Therapy Progress Report from 7/19/19 to 8/18/19, revealed the resident progressed from maximum assist while toileting to stand by assist while toileting. During intermittent observations on 8/19/19 at 9:01 AM and on 8/20/19 at 10:59 AM revealed the resident's commode was in the resident's bathroom and that the commode bucket was missing. During an interview on 8/20/19 at 10:59 AM, the resident stated the commode should be in his room next to his bed for him to have bowel movements. He hasn't had the commode next to his bed for several days. The aides took the bucket and he hasn't seen it all weekend. He had tried to walk to his bathroom but he almost fell . The aide caught him; and his catheter tubing (tube inserted into the bladder to drain urine) came out of his leg strap and was leaking urine. He further stated he was very upset and embarrassed about it because his clothes were soaked and there was urine all over the floor. During an interview on 8/21/19 at 10:55 AM, certified nurse aide (CNA #1) revealed that she last saw the bucket for the commode the Thursday (8/15) or Friday (8/16)before the weekend. She thought the bucket might have been taken to another resident's room. During this same interview, the Physical Therapist (PT) stated that she saw that the resident didn't have a bedside commode and bucket and brought one to him in the afternoon on 8/20/19. The PT further stated the resident should have a bedside commode. During an interview on 8/21/19 at 11:00 AM, the Director of Rehabilitation stated the resident was issued a commode with a bucket and he did not understand why the resident did not have one. The resident should have a commode with a bucket in his room next to his bed. If there was a shortage of buckets, someone should have told him, and he would have ordered more. During an interview on 8/21/19 at 12:04 PM, the Director of Nursing (DON) stated mmode buckets should not be shared between residents and said that she just ordered more buckets for the commodes. Additionally, the resident should have had a bedside commode. 415.5(e)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 8/23/19, it was determined that the facility did not ensure that a resident who displays or is diagnosed with [REDACTED]. Specifically, one (Resident #16) of two residents reviewed for dementia care had issues with lack of individualized, person centered interventions to address behaviors and identification of the possible triggers for the resident's behaviors. This resident also received [MEDICAL CONDITION] medications. The finding is: Review of the facility policy titled [MEDICAL CONDITION] Medication Use/Non-Pharmacological Interventions dated 8/22/19 revealed non pharmacological interventions will be considered and used when indicated, instead of, or in addition to, medication. 1. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 6/28/19 documented the resident had severely impaired cognition, no physical or verbal behavioral symptoms, received antidepressant and antipsychotic medications on a routine basis, and no GDR had been attempted. Review of the Progress Notes revealed the following: 2/1/19 through 2/28/19 there was no documentation of agitation, yelling or combative behaviors 3/1/19 through 3/31/19: - 3/13/19 at 8:48 PM had periodic agitation and restlessness with attempts to self-transfer/ambulate, repeated 1:1 by staff to redirect, effective for short periods 4/1/19 through 4/30/19: - 4/4/19 at 2:24 PM resistive to care at times, continually repeats herself over and over, 1:1 ineffective, MD aware, sometimes resident will nap and then is better once she has rested, takes entire staff to care for her when she is anxious - 4/5/19 5:20 PM has been nonstop yelling at staff and being nasty to everyone. Makes no logical sense at this time, and when staff approach is even more nasty. Put down for a nap but she only stayed in bed for a few minutes then was up again. Making no sense at all, took entire staff the last two hours to take care of her and is still being nasty - 4/10/19 1:36 PM continues to argue with others, yelling and screaming at others and staff. 1:1 is ineffective she becomes more resistive. - 4/19/19 3:49 PM resident continues with disruptive behaviors. Yells at staff, calling other residents names and telling them to shut up. MD updated new orders received today to increase [MEDICATION NAME] (antidepressant) to 75 milligrams (mg) daily and Trazadone (antidepressant) 50 mg twice daily. 5/1/19 through 5/31/19 there was no documentation of agitation, yelling, or combative behaviors 6/1/19 through 6/30/19 there was no documentation of agitation, yelling, or combative behaviors 7/1/19 through 7/31/19 there was no documentation of agitation, yelling, or combative behaviors 8/1/19 through 8/18/19 no documentation of agitation, yelling, or combative behaviors Review of the care plan, identified as current by Registered Nurse (RN) Unit Manager #1, documented a behavior problem, the resident becomes agitated and strikes out at caregivers and was initiated on 12/27/18. Non-pharmacological interventions initiated 12/27/18 included to adjust tone of voice, anticipate and meet resident's needs, attempt to determine triggers that caused behavior, provide opportunity for positive interaction, attention. Stop and talk with her as passing by, engage in activities as needed (PRN), move to a less stimulating environment, offer a snack/food PRN, offer toileting PRN, reapproach PRN. The focus area impaired cognitive function and thought process related to Alzheimer's with [MEDICAL CONDITION] and dementia was initiated 10/18/18. Interventions initiated on 9/21/18 include ask yes/no questions in order to determine resident's needs, communicate with family regarding resident's capabilities and needs, cue, reorient and supervise as needed (PRN), discuss concerns about confusion, disease process, and NH (nursing home) placement with family, identify yourself at each interaction, face the resident when speaking and make eye contact, reduce any distractions, the resident understands simple, consistent, directive sentences, provide the resident with necessary cues-stop and return if agitated. Additional focus areas include use of antipsychotic medication for [MEDICAL CONDITION] initiated on 1/25/19 and use of antidepressant medications for [DIAGNOSES REDACTED]. There were no different or revised non pharmacological interventions documented prior to antidepressant medication dose increases. The interventions were not specific to this resident and did not address triggers to behaviors. During an intermittent observation on 8/20/19 through 8/22/19 between 10:56 AM and 3:15 PM the resident displayed no behaviors and was cooperative with care during a transfer from wheelchair to her bed. During an interview on 8/21/19 at 3:31 PM, Certified Nurse Aide (CNA) #3 stated the resident's behaviors are up and down, the resident needs a nap and has to wake up in a good mood, then she's good for the rest of the night. She uses laughter with the resident when she wakes her up from her nap. The CNA further stated the resident likes to be in control, and the staff have to kind of give her that control, like having her roll in bed the way she wants to. The resident has never been combative with her, sometimes she gets agitated if she doesn't want to be touched or do anything, but mostly she's good. During an interview on 8/22/19 at 7:48 AM, RN #1 stated lately the resident's behavior has been fairly good, you can redirect her and calm her down just by sitting with her and talking with her. She used to be horrible, she would scream and scream, I think it was more her dementia than anything else and she wasn't sleeping either. [MEDICATION NAME] was given for behaviors and stated she doesn't think the resident had a psychiatric diagnosis. The RN stated the resident has unspecified [MEDICAL CONDITION] on her [DIAGNOSES REDACTED]. Non pharmacological interventions they have tried moving her to different areas, taking her to activities, and as a last resort would call her husband. The Trazadone and [MEDICATION NAME] were increased in April, the resident was having behaviors yelling, disruptive, calling other residents names and telling them to shut up. They should have documented non pharmacological interventions tried at that time and they don't have a set routine for when she acts up or gets in and out of her chair, they toilet her and give her a nap. A lot of the interventions on the care plan were done in (MONTH) and that she will add something today. They could do moving to a less stimulating environment, food, reapproach-sometimes if you just leave her alone, she's better. The RN stated she thinks her triggers are noise/congestion around the desk can irritate her. During an interview on 8/22/19 at 10:51 AM, the Director of Social Services (DSS) stated the resident has been pretty good lately. The resident has been a little combative with care, constantly yelling, trying to get up all the time and had several falls because of that. The DSS stated trying to get up is not a behavior that needs medications. The DSS also stated non pharmacologic things they've done for her include folding issues, take her to activities, one on one (1:1) sometimes wasn't effective, it depended on the day, and if there was too much activity in front of her they would move her. During interview on 8/23/19 at 11:01 AM, the Director of Nursing (DON) stated all the interventions the staff mentioned should be on the resident's dementia care plan including any identified triggers that can cause her behaviors. During further interview on 8/23/19 at 11:56 AM, the DON stated the staff are doing non-pharmacological interventions, but they are not documenting them like naps, she needs in the afternoon, I'm having RN #1 update the care plan and individualize it a little more. The DON stated unless someone is in danger of hurting themselves, they shouldn't use antipsychotics. 415.12

Based on interview and record review conducted during a Standard survey completed on 8/23/19, it was determined that the facility did not ensure that a resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident; and the residents have a right to interact with members of the community and participate in community activities both inside and outside the facility. Specifically, three of three residents (Residents #8, 22, 30) reviewed for choices had issues. Specifically, Resident #30 did not receive showers twice a week as per his preference. Additionally, Residents #8 and #22 were not offered outside activities in the community since the end of (YEAR). The findings are: 1. Resident #30 was admitted on [DATE] with rehabilitation for knee surgery and infection. The Minimum Data Set (MDS, a resident assessment tool) dated 7/25/19 revealed that the resident was cognitively intact, was understood and understands. A facility policy and procedure titled Activities of Daily Living (ADL) dated 8/2019 documented an assessment of the resident is consistent with the resident's needs and choices, care and services will be provided to maintain their current ADL status. Review of the current Comprehensive Care Plan (CCP) dated 7/19/19 documented the resident was an extensive assist of one person for lower body washing. Additionally, the resident was to receive showers on Tuesday and Friday each week. Review of the current Certified Nurse Aide (CNA) Kardex (guide used by staff to provide care) dated 8/22/19 documented the resident was to get showers two times a week on Tuesday and Friday evenings. The Shower List/ Weekly Skin Check sheet documented the resident was to receive two showers a week on Tuesdays and Fridays. Review of the Daily Unit Management Sheet from 7/18/19 to 8/20/19 revealed the resident showers were not signed off for 8/2/19, 8/9/19, and 8/16/19. Review of the 24 Hour Nurse Services Report from 7/19/19 to 8/22/19 revealed there were no notations the resident refused care including showers. Review of Nursing Progress Notes from 7/18/19 to 8/22/19 revealed there were no notations of the resident refusing showers. Review of an Occupational Therapy Treatment encounter notes from 7/19/19 to 8/21/19 revealed the resident was observed by the Certified Occupational Therapist Aide (COTA) during a shower activity on 8/5/19 and 8/20/19. During an interview on 8/19/19 at 9:01 AM, the resident stated he was supposed to get two showers a week and he has only been getting one shower a week. He asked the surveyor, Oh my God, do I stink? Please tell me I don't stink. He stated he can wash his upper body however because of of his knee, he can't wash his lower body. He stated he wants to get two showers a week. During an interview on 8/22/19 at 11:39 AM, CNA #3 stated the resident can wash himself at their sink with a set up and the resident has never asked her for a shower. She said that she believes the COTA has given him showers and to ask her. During an interview on 8/22/19 at 12:29 PM, the COTA stated she gave the resident a shower on 8/5/19 and 8/20/19. She wanted to see how he was progressing and that he was able to perform 25% (percent) of the shower activity by himself. He needs help with his lower body because he is non weight bearing on his right leg and wasn't stable standing or getting on the shower chair. She further stated that she volunteered to give him a shower on those days because she knew that the CNA's were busy. During an interview on 8/22/19 at 12:44 PM, Registered Nurse Resident Care Coordinator (RN RCC) #1 revealed the CNA's are supposed to let the nurses know when a resident did not receive a shower. If the CNA assignment sheets aren't initialed and there aren't any nurses' notes, then staff cannot tell if the shower was done or not. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact, understands and was understood. The MDS documented preferred activities were very important to the resident which included doing things with groups of people, to go outside to get fresh air when the weather was good, and to do their favorite activities. Review of an undated comprehensive care plan identified as current revealed the resident was able to make his own decisions about activity involvement and had strong family support. Preferences were listed which included socials/ outings. During an interview on 8/20/19 at 1:04 PM, the resident stated he has not gone out on a community outing since last year. He said he wanted to go shopping and get out of the building for a while. He said, I'm sick at looking at the same four walls. Review of the Resident Council Meeting minutes from 2/21/19 to 7/25/19 revealed that the residents asked about doing trips to the store, going to the county fair, and more outings during the summer months as there had been no outings to the community. Review of the Activities calendars from (MONTH) 2019 to (MONTH) 2019 revealed no community outings noted on the calendars. During an interview on 8/20/19 at 1:12 PM, the Activity Aide stated the residents have not been on an outing since before Christmas. She started working at the facility (MONTH) (YEAR) and there had only been one outing during the time she has been employed and the outing was before Christmas. There was a casino outing planned however, because the residents needed photo identification in case a resident won a prize, they couldn't go. She had volunteered to take residents to Bingo at the local church but never received permission from the facility. During an interview on 8/21/19 at 10:50 AM, the Activities Director stated there was no transportation for the residents because the facility van was at a sister facility and the driver of the van was on leave. She was aware of other transportation options but was not sure how it would be financed. She did not know how much was in the Resident Council fund as she had started her employment last week at the facility. During an interview on 8/22/19 at 9:18 AM, the Director of Social Services stated there was no Activities Director from (MONTH) 2019 to last week. They had a van and a driver, but they were not available to the residents. There are transportation companies, but the residents would have to pay extra to go anywhere. She didn't know how much was in the Resident Council fund as she was only covering while they looked for an Activities Director. In addition, she stated the residents should be able to go on outings in the community. 3. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] documented the resident was cognitively intact, understands, and was understood. The MDS also documented preferred activities that were very important to the resident included doing things with groups of people, going outside to get fresh air when the weather is good, and to do their favorite activities. Review of a current Comprehensive Care Plan (CCP) for the resident revealed that the resident is independent with choosing his activities and will continue to choose activity programs of interest. Further review of the CCP revealed that staff was to invite or remind the resident of programs that the resident may enjoy. During an interview on 8/20/19 at 1:05 PM, the resident stated he has not gone out on an outing in the community since last Christmas. He stated they could not go shopping nor the county fair and other residents were upset about it as well. During an interview on 8/21/19 at 11:17 AM, the Activities Director she stated that any outings had to be financed by corporate before the residents could go anywhere. She said going forward she will look into different programs to help the residents get out into the community. 415.5(b)(1)(d)(1)(f)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 8/23/19, the facility did not store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys. One of one medication storage room observed for safe medication storage was not secure. Specifically, the keys to unlock the medication room door were left in the door on two separate occasions and one key on the set of keys was able to unlock the outside door of the high side narcotic storage cabinet. The finding is: Review of the facility policy titled Storage and Maintenance of Medications effective 8/2019 revealed only authorized licensed personnel are to have access to the keys and the medications and controlled substance medications must be kept in a double locked cabinet attached to a permanently affixed wall. During an observation on 8/19/19 at 8:37 AM the medication storage room had a set of keys in the door lock. There was no staff behind the desk or in the Director of Nursing (DON) office (located next to the medication storage room). The surveyor opened the door to the medication room and observed several blister packs of prescription medication located on top of the automated medication dispensing system and some stock medications located on the shelves. Further observation at 11:14 AM revealed the keys were no longer in the door. During an observation on 8/22/19 at 6:59 AM the medication storage room had a set of keys in the door lock (same set of keys as 8/19/19 observation). There was no staff behind the desk at this time, there were two Licensed Practical Nurses (LPN) at their medication carts with their backs turned to the nurses' desk and medication storage room. Two staff members went behind the nurse's station to get their belongings. At 7:10 AM the Registered Nurse (RN) Unit Manager #1 was behind the desk. At 8:48 AM the keys remained in the in the door lock. At 8:49 AM LPN #2 was seen leaving the medication storage room with her keys and the other set of keys remained in the door. During an interview on 8/22/19 at 8:51 AM, RN Unit Manager #1 stated the keys belong on the desk, they are everybody's keys, they open the oxygen room, the med room key is on there, but everything is locked up except for the stock meds. The RN also stated they are usually kept on the hook at the nurse's station. During an observation and interview on 8/22/19 at 8:58 AM revealed one key on the keyring was not labeled. The DON stated the keys are the supervisor's keys, the medication room key is on there, the narcotic keys are not. The DON stated she will find out what the unlabeled key was for. At 9:08 AM the DON stated the key was for the old sharps container (plastic bin that holds discarded needles/syringes) holder on the medication carts. Further observation of the medication storage room with the DON present at 9:08 AM revealed the unlabeled key was able to open the outside lock of high end narcotic cupboard, it did not open the inside lock. The DON stated the outside lock was loose and she would have maintenance fix it, and she would discard the unlabeled key. The medication blister packs located on top of the automated medication dispensing system were from a discharged resident and included atorvastatin (cholesterol lowering medication), [MEDICATION NAME] (heart medication), [MEDICATION NAME] (steroid), sodium [MEDICATION NAME] (antacid), [MEDICATION NAME] (treats digestive disorders), [MEDICATION NAME] (heart medication), folic acid (supplement), and [MEDICATION NAME] ([MEDICATION NAME]). During further interview on 8/23/19 at 11:21 AM, the DON stated when the nurse leaves the desk, we try not to leave the keys unattended, they are never supposed to be kept in the doorknob to the medication room. The night shift supervisor works until 6:00 AM, the LPNs are here at 6:00 AM, if there is a gap between the night supervisor and the day shift person coming in, the LPNs are responsible for the keys. 415.18(e)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/23/19, the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs for one (Resident #16) of five residents reviewed for unnecessary medications. Specifically, issues involved the lack of a gradual dose reduction (GDR) attempt for a resident on [MEDICATION NAME] (antipsychotic medication), Trazadone and [MEDICATION NAME] (antidepressant medications), lack of documented behaviors to support the continued use of the medications, lack of revised non pharmacological interventions prior to increasing doses of two antidepressant medications. The finding is: Review of the facility policy titled [MEDICAL CONDITION] Medication Use/Non-Pharmacological Interventions dated 8/22/19 revealed non pharmacological interventions will be considered and used when indicated, instead of, or in addition to, medication. For antipsychotic medications (AP) and psycho-pharmacological medications (other than AP and sedative/hypnotics) a GDR is to be attempted twice a year in two separate quarters with at least one month in between the attempts. 1. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a resident assessment tool) dated 6/28/19 documented the resident had severely impaired cognition, no physical or verbal behavioral symptoms, received antidepressant and antipsychotic medications on a routine basis, and no GDR had been attempted. Review of the Order Summary Report revealed the following medication orders [REDACTED] - 9/21/18 [MEDICATION NAME] 25 mg (milligrams) at bedtime (HS) - 10/12/18 [MEDICATION NAME] 25 mg at 12:00 PM daily (time changed from HS) - 11/8/18 Trazadone 25 mg twice daily - 12/10/18 [MEDICATION NAME] 25 mg twice daily - 12/20/18 [MEDICATION NAME] 50 mg in the morning and 25 mg at HS - 1/14/19 [MEDICATION NAME] 25 mg daily for 7 days, then 50mg daily - 4/19/19 [MEDICATION NAME] 75mg daily - 8/19/19 [MEDICATION NAME] 25 mg twice daily There were no GDRs attempted of the antidepressant medications. Review of the care plan, identified as current by Registered Nurse (RN) Unit Manager #1, documented the resident had a behavior problem and becomes agitated and strikes out at caregivers that was initiated 12/27/18. Non-pharmacological interventions initiated 12/27/18 included to adjust tone of voice, anticipate and meet resident's needs, attempt to determine triggers that caused behavior, provide opportunity for positive interaction, attention. Stop and talk with her as passing by, engage in activities as needed (PRN), move to a less stimulating environment, offer a snack/food PRN, offer toileting PRN, reapproach PRN. Additionally, the use of antipsychotic medications for [MEDICAL CONDITION] was initiated on 1/25/19 and included interventions to consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly and to administer medications as ordered by a physician. The use of antidepressant medications for [DIAGNOSES REDACTED]. Interventions initiated on 1/9/19 included to monitor/document/report PRN adverse reactions to medications and to administer the medication as ordered by a physician. There were no different, revised non pharmacological interventions documented prior to antidepressant medication dose increases. Review of a Pharmacy Consultant Review dated 10/15/18 revealed [MEDICATION NAME] 25 mg at HS on admission 8/10/18 started in hospital for [MEDICAL CONDITION]. The MD declined discontinuation of [MEDICATION NAME]. Review of the Note to Attending Physician/Prescriber revealed the following: - 3/29/19 there were no agitated behaviors documented in the progress notes for the past month. A recommendation to decrease Trazadone to 25 mg at HS to determine the lowest effective dose was made. The physician documented there was no indication of a GDR after speaking to nursing, continues to have disruptive behavior but relatively more redirectable. - 4/28/19 the resident's [MEDICATION NAME] and Trazadone were increased due to an increase in behaviors but is lacking documentation of care planned, non-pharmacological interventions prior to the increase in dose and increasing both medications at the same time prevents assessments of effectiveness of either dose adjustment. The physician disagreed with the recommendation on 5/9/19 and documented see my notes. - 5/31/19 recommended a GDR in accordance with regulations or if contraindicated to update documentation to support. Also, to document resident centered nonpharmacologic interventions care planned for the use of this medication as a substitute for the reduction in medication. The physician disagreed and documented resident has disruptive behaviors on 6/10/19. - 6/17/19 recommended to assess the need for two antidepressant medications and to consider discontinuing or tapering one of the medications. If continued need for both is indicated clearly document in the chart. The physician wrote documented on 6/24/19. - 8/8/19 recommended [MEDICATION NAME] 25 mg twice daily (GDR), the physician agreed on 8/19/19. Review of the physician notes revealed the following: - 11/5/18 the resident current medications included [MEDICATION NAME] 25 mg at bedtime for [MEDICAL CONDITION]. The medication was started at the hospital and will continue with it due to acute issues, having increased agitation and aggressive behaviors, non-cooperative with care. Redirection has been attempted but continues to have behavior issues. Will consider Trazadone (antidepressant medication). - 4/18/19 staff says behaviors have been aggressive lately, she will yell and argue with multiple staff members and other residents, redirection attempted but she becomes more resistant, one on one is ineffective too. Having increased agitation and aggressive behaviors, non-cooperative with care, redirection has been attempted and failed, she is now on [MEDICATION NAME], Trazadone and [MEDICATION NAME]. Will increase dose of [MEDICATION NAME] and Trazadone today. - 6/6/19 chronic issues with aggressive behaviors, yelling, arguing with staff and other residents. On medications and redirection. Having increased agitation and aggressive behaviors, non-cooperative with care. Redirection has been attempted and failed. She is now on [MEDICATION NAME], Trazadone, and [MEDICATION NAME]. Doses increased 4/2019 with stable behaviors. She continues to have episodes of aggression and yelling. No indication of a GDR at this time. Review of the Progress Notes revealed the following: 2/1/19 through 2/28/19 there was no documentation of agitation, yelling or combative behaviors 3/1/19 through 3/31/19: - 3/13/19 at 8:48 PM had periodic agitation and restlessness with attempts to self-transfer/ambulate, repeated 1:1 by staff to redirect, effective for short periods 4/1/19 through 4/30/19: - 4/4/19 at 2:24 PM resistive to care at times, continually repeats herself over and over, 1:1 ineffective, MD aware, sometimes resident will nap and then is better once she has rested, takes entire staff to care for her when she is anxious - 4/5/19 at 5:20 PM has been nonstop yelling at staff and being nasty to everyone. Makes no logical sense at this time, and when staff approach is even more nasty. Put down for a nap but she only stayed in bed for a few minutes then was up again. Making no sense at all, took entire staff the last two hours to take care of her and is still being nasty - 4/10/19 at 1:36 PM continues to argue with others, yelling and screaming at others and staff. 1:1 is ineffective she becomes more resistive. - 4/19/19 at 3:49 PM resident continues with disruptive behaviors. Yells at staff, calling other residents names and telling them to shut up. MD updated new orders received today to increase [MEDICATION NAME] to 75 mg daily and Trazadone 50 mg twice daily. - 5/1/19 through 5/31/19 there was no documentation of agitation, yelling, or combative behaviors - 6/1/19 through 6/30/19 there was no documentation of agitation, yelling, or combative behaviors - 7/1/19 through 7/31/19 there was no documentation of agitation, yelling, or combative behaviors - 8/1/19 through 8/18/19 there was no documentation of agitation, yelling, or combative behaviors During an observation on 8/21/19 at 3:15 PM, Certified Nurse Aide (CNA) #3 transferred resident from her wheelchair into her bed to lie down before dinner. The resident was pleasant and cooperative. During an interview on 8/21/19 at 3:31 PM, CNA #3 stated the resident's behaviors are up and down, the resident needs a nap and has to wake up in a good mood, then she's good for the rest of the night. She uses laughter with the resident when she wakes her up from her nap. The CNA further stated the resident likes to be in control, and the staff have to kind of give her that control, like having her roll in bed the way she wants to. The resident has never been combative with her, sometimes she gets agitated if she doesn't want to be touched or do anything, but mostly she's good. During an interview on 8/22/19 at 7:44 AM, Licensed Practical Nurse (LPN) #1 stated the resident's behaviors include getting agitated, her body goes rigid, can be argumentative, sarcastic, and would hit you if you tried to do anything with her. The LPN stated they would try to talk to her, give her magazines, towels/ washcloths to fold. The resident's behavior was more mellow now and they are decreasing her antipsychotic medication. During an interview on 8/22/19 at 7:48 AM, RN Unit Manager #1 stated lately the resident's behavior has been fairly good, you can redirect her and calm her down just by sitting with her and talking with her. She used to be horrible, she would scream and scream, I think it was more her dementia than anything else and she wasn't sleeping either. The [MEDICATION NAME] was given for behaviors and doesn't think the resident has a psychiatric diagnosis. The RN stated the resident has unspecified [MEDICAL CONDITION] on her [DIAGNOSES REDACTED]. She did not know the last time she had a GDR. The pharmacist recommends them, the doctor has to approve it and the social worker keeps track. The RN stated she would hesitate to take anything away from her at this point because she's stable and she has been for a little bit. Non pharmacological interventions they have tried moving her to different areas, taking her to activities, and as a last resort would call her husband. When the Trazadone and [MEDICATION NAME] were increased in April, the resident was having behaviors yelling, disruptive, calling other residents names and telling them to shut up. The RN stated they should have documented non pharmacological interventions tried at that time and they don't have a set routine for when she acts up or gets in and out of her chair, they toilet her and give her a nap. A lot of the interventions on the care plan were done in (MONTH) and that she will add something today. They could do moving to a less stimulating environment, food, reapproach-sometimes if you just leave her alone, she's better. The RN stated she thinks her triggers are noise/ congestion around the desk can irritate her. During an interview on 8/22/19 at 8:39 AM, the Physician stated the resident's behaviors were difficult to control, she would be very agitated, yelling, disruptive to other residents, going in other resident's rooms. She's more redirectable now, she still has some episodes, but much calmer and they are doing a GDR now. They are using the medication for dementia with behaviors and depression diagnoses, those are the indications for use. When her symptoms were not controlled, they added the 2nd and 3rd agents. The physician bases her decisions on report from nursing staff and what she observes when she visits. The physician stated they didn't do GDRs because of the resident's behaviors and had to keep adding medications. During an interview on 8/22/19 at 10:51 AM, the Director of Social Services (DSS) stated the resident has been pretty good lately. The resident has been a little combative with care, constantly yelling, trying to get up all the time and had several falls because of that. The DSS stated trying to get up is not a behavior that needs medications. The DSS also stated non pharmacologic things they've done for her include folding tissue, take her to activities, one on one (1:1) sometimes wasn't effective, it depended on the day, and if there was too much activity in front of her they would move her. During further interview on 8/23/19 at 1:16 PM the DSS stated the resident has not had a psychological consult, they use tele psych and feel the resident wouldn't benefit from it. During an interview on 8/22/19 at 2:28 PM, the Pharmacy Consultant stated they make recommendations to reduce [MEDICAL CONDITION] medications even if it's not indicated, but it prompts the providers to update their progress notes and to justify why on the doses. They also encourage them to monitor resident's target behaviors and make sure they are care planned and should be documenting the frequency and presentation of targeted behaviors. During an interview on 8/23/19 at 11:56 AM, the Director of Nursing (DON) stated they do have behavior meetings monthly, but when the Director of Social Services was out on leave the note didn't get done, they should have had someone from nursing pick it up. The DON stated the staff are doing non-pharmacological interventions, but they are not documenting them like naps, she needs in the afternoon, I'm having (RN Unit Manager) update the care plan and individualize it a little more. The DON stated unless someone is in danger of hurting themselves, they shouldn't use antipsychotics. 415.12(l)(2)(ii)

Based on observation, interview, and record review during the Standard Survey completed on 6/14/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, two (Residents #19 and 30) of two residents observed for infection control practices during blood glucose monitoring had issues when nursing staff did not disinfect the shared blood glucose meter with a germicidal (a substance that destroys germs) cleaning agent between resident use. Additionally, the facility did not review and update their Legionella water management plan and environmental assessment annually. This affected the entire building, including one of one resident unit. The findings are: 1. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Clinical Physician order [REDACTED]. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Review Report revealed a physician's orders [REDACTED]. A continuous observation on 6/14/18 at 10:42 AM revealed Licensed Practical Nurse (LPN) #1 was observed to go into Resident #19's room. LPN #1 placed a glucose meter next to the sink (without placing a barrier underneath), donned (put on) gloves and used a lancet (needle used to puncture skin for blood sample) to pierce the resident's left middle finger, picked up the glucose meter and touched the testing strip to the drop of blood on resident's finger. LPN #1 obtained the reading, removed the testing strip from glucose meter, removed her gloves and threw them away. The LPN washed her hands for 20 seconds and walked down to her medication cart. The LPN placed the glucose meter on top of the medication cart, unlocked the cart, obtained an alcohol pad and wiped the glucose meter with the alcohol pad, and placed the glucose meter back on top of medication cart. The LPN went back to Resident #19's room to give a dose of insulin and left the glucose meter on top of the medication cart. At 10:46 AM, LPN #1 returned to the medication cart, washed her hands using hand sanitizer, gathered the glucose meter, testing strip, and lancet and went into Resident #30's room. The LPN placed the glucose meter on the sink, donned gloves, placed glucose meter on resident's overbed table (without placing barrier underneath), used a lancet to pierce the resident's right ring finger, picked up the glucose meter and touched the testing strip to the drop of blood on resident's finger. The LPN obtained the reading, removed the testing strip from the glucose meter, removed gloves, and threw them away. The LPN washed her hands for 20 seconds and walked down to medication cart, placed glucose meter on top, and used an alcohol pad to wipe down the glucose meter. During an interview on 6/14/18 at 10:50 AM, LPN #1 stated that's how she always cleans the glucose meters. The LPN stated she did not know what the facility policy was, but someone told her a long time ago to do it that way. During an interview on 6/14/18 at 11:02 AM, the Director of Nursing (DON) stated, the nurses usually use an alcohol pad to clean it. When asked if she knew the facility policy or the manufacturer recommendations the DON stated, I have to review the policy and we recently switched suppliers so I have to see which glucometer we are using. The DON retrieved the glucose meter insert and said, it does say we can use Micro-Kill with alcohol but it doesn't say anything about using an alcohol pad. The DON reviewed the facility policy and stated, it says to cleanse/disinfect the glucose meter with 70% alcohol swab before using and after each use. When asked what the staff should be doing to clean the glucose meter, the DON stated, we are going to use the Clorox wipes now so everyone is on the same page and staff will be in serviced today. During an interview on 6/14/18 at 11:10 AM, LPN #2 stated she uses bleach wipes to clean the glucose meter between residents. She wipes it down and lets it air dry. Review of the EvenCare g3 (glucose monitoring system) user guide revealed the glucose meter should be cleaned and disinfected between each patient. 2. To assess the most recent revision, a review of the document called Risk Management Plan for Legionella Control revealed that written on the cover page of the document was see revision dated 1/22/17. During an interview on 6/13/18 at 1:54 PM, the Administrator stated, the plan was created prior to (YEAR), and was reviewed and updated by himself on 1/22/17. Continued interview revealed the document has not been reviewed since 1/22/17, but there have been no changes since then. Review of the form DOH-5222, Environmental Assessment of Water Systems in Healthcare Settings, revealed it was signed and dated on 8/22/16 by the Maintenance Director. During an interview on 6/13/18 at 3:30 PM the Maintenance Director stated he thought the Environmental Assessment was to be completed every other year, then annually after the second year. Per New York Codes, Rules and Regulation, Part 4- Protection Against Legionella, subpart 4-2, Health Care Facilities: Environmental assessments shall be updated annually and under the following conditions: in the event that one or more cases of [DIAGNOSES REDACTED] are, or may be, associated with the facility; upon completion of any construction, modification, or repair activities that may affect the potable water system; or any other conditions specified by the department. The facility shall retain copies of the completed environmental assessment form in accordance with section 4-2.6 of this Subpart. 415.19(a)(1)(b)(2) Subpart 4-2.3(b), 4-2.4(c)

Based on interview and record review conducted during the Standard survey completed on 6/14/18, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries. Specifically, for two (Resident #16 and 21) of three residents reviewed for beneficiary protection notification, the facility did not provide residents with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) or denial letter at the termination of Medicare Part A benefits. The findings are: Review of the policy entitled Notification of Medicare A Non-Coverage dated 4/1/18 revealed the SNF denial letter will be issued to the beneficiary or authorized representative upon admission or when Part A services are ending, but the resident remains in the SNF for custodial care. 1. Resident #16 was admitted to the facility on [DATE] under Medicare part A services. The Notice of Medicare Non- Coverage (NOMNC), signed on 1/24/18, included that the resident's Part A services were to end on 1/26/18. There was no evidence that the SNF ABN or denial letter was given to the resident or their representative informing them of their potential liability for payment when the resident remained in the facility for custodial care. Review of the SNF Beneficiary Protection Notification Review form revealed Medicare Part A services started 12/31/17 and ended on 1/26/18. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The form included that the SNF ABN, CMS (Centers for Medicare & Medicaid Services)- was provided to the resident. 2. Resident #21 was admitted to the facility on [DATE] under Medicare Part A services. The Notice of Medicare Non- Coverage, signed on 3/20/18, included that the resident's Part A services were to end on 3/22/18. There was no evidence that the SNF ABN or denial letter was given to the resident or their representative informing them of their potential liability for payment when the resident remained in the facility for custodial care. Review of the SNF Beneficiary Protection Notification Review form revealed Medicare Part A services started 1/30/18 and ended on 3/22/18. The facility initiated the discharge from Medicare part A services when benefit days were not exhausted. The form included that the SNF ABN, CMS- was provided to the resident. During an interview on 6/13/18 at approximately 10:30 AM, the per diem Administrative Assistant stated, I don't think they (the residents) were given the ABN forms, maybe I filled the form out wrong, it's my first-time filling that out. (Referring to the SNF Beneficiary Protection Notification Review form). During an interview on 6/13/18 at 10:35 AM, the Human Resource (HR) Director stated she does give the forms but nobody knows if a resident is going long term unless therapy tells us and that I give a cut letter form but I didn't know about the second form. During further interview on 6/13/18 at 11:13 AM, the per diem Administrative Assistant stated I didn't train the new person (HR Director) regarding the ABN because I used it for Part B only and I retired in December. She further stated she used the chart to know which letters to give a resident and she provided a copy of the chart. The per diem Administrative Assistant also stated she got another form from another facility that has instructions for the ABN that started in (YEAR). Review of the undated SNF Notice Chart indicated a resident that no longer required skilled nursing services on Part A (cut), but is remaining in the SNF at custodial level of care should be provided the NOMNC CMS form # and 2 page cut letter. The chart does not include that the SNF ABN is to be given when Part A services are ending. 415.3(g)(2)(i)

Based on interview and record review conducted during the Standard Survey completed on 6/14/18, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility did not implement an antibiotic stewardship program until (MONTH) 1, (YEAR). The finding is: Review of the facility policy entitled, Antibiotic Stewardship Program, dated 5/2018 revealed the facility would optimize the treatment of [REDACTED]. The Antibiotic Stewardship Program's main goal is to optimize the treatment of [REDACTED]. In order to achieve this goal, the Centers for Disease Control and Prevention (CDC) have published guidelines that outline the seven core elements required for the successful implementation and maintenance of an effective antibiotic stewardship program. The seven core elements include leadership commitment, accountability, drug expertise, action plans, tracking, reporting and education. Record review of the facility's Antibiotic Usage Report revealed the report was initiated (MONTH) (YEAR). There was no record of a tracking report prior to (MONTH) (YEAR). During an interview on 6/13/18 at 10:36 AM, the Director of Nursing (DON) stated, the Antibiotic Stewardship Program included tracking the facility's antibiotic use, and verifying the culture results to ensure the antibiotic was appropriate was initiated 4/1/18. The DON further stated she was unaware of any previous antibiotic usage tracking information prior to 4/1/18. During an interview on 6/14/18 at 9:40 AM, the Administrator stated, the previous DON should have been tracking the antibiotic usage and he was unaware if it was being completed prior to (MONTH) (YEAR). At 2:10 PM the Administrator further verified there was no record for tracking the antibiotic use prior to (MONTH) (YEAR). 415.19(a) (1,3)

Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint #NY 500) completed on [DATE], it was determined that the facility did not honor a resident's Advance Directives. Specifically, One (Resident #1) of fifteen residents reviewed for advanced directives had a physician's orders [REDACTED]. when it was determined that he was unresponsive with no heartbeat or respirations. In addition, the facility failed to have an effective system in place to identify and ensure current CPR certification of staff. This resulted in a pattern of IMMEDIATE JEOPARDY WITH ACTUAL HARM TO RESIDENT HEALTH AND SAFETY. The Immediate jeopardy was removed on [DATE], prior to the completion of the survey. The findings are: 1. Resident #1 was admitted to the facility for rehabilitation on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sheet ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment, usually understands, and was usually understood. Review of the medical record Face Sheet revealed the resident was identified as having a Full Code status. Review of an Advance Directive Checklist for Resident #1 revealed the resident had a Health Care Proxy and a Power of Attorney. Review of physician's orders [REDACTED]. a.) Review of a facility investigation, of an incident that occurred on [DATE], revealed an "Investigation Statement" written by RN #1 dated [DATE] at 3:20 PM. The written statement documented that on [DATE] at approximately 6:25 PM, Resident #1 was "wheeled (transported in a wheelchair) out" of the dining room into the hall. At 6:30 PM, RN #1 came out of the dining room to take the resident's vital signs (temperature, blood pressure, pulse, respiratory rate) because a Licensed Practical Nurse (LPN #2) was having difficulty obtaining a blood pressure (BP) reading and thought the resident wasn't doing well. RN #1 documented that the resident's temperature was 95.2 (normal 98.6), pulse was "54" (average 80), and respirations were 24 (normal 12 to 20). The RN's statement documented "there was no BP in the right or left arm"; the SP O2 (oxygen saturation level - amount of oxygen in the blood) was 95 % (percent) (normal 90 to 100 %) on 2 liters of oxygen; lung sounds were diminished; there was [MEDICAL CONDITION] (swelling) of the lower extremities; and the resident had no response to a sternal rub (the application of painful stimulus by vigorously rubbing the sternum with the knuckles of a closed fist to assess consciousness). RN #1 stated that she told the two LPNs that were present that she was going to send the resident "out." RN #1 documented that "she thought she could buy ,[DATE] minutes of time" because the resident's status hadn't changed from when she first saw him at 3:15 PM. RN #1 documented that she went back into the dining room. Additional review of RN #1's written statement revealed the following: - On [DATE] at 6:40 PM - The resident's daughter called and LPN #3 told her that "we would be sending (the resident) to the hospital because he was not doing well and not responding to any verbal or tactile stimulation". - 6:45 PM - Certified nurse aide (CNA) #1 came into the dining room and told RN #1 that the resident's fingers were turning blue. RN #1 documented that she immediately went to the desk to start the transfer process, while CNA #1 wheeled the resident to his room. - 6:50 PM - RN #1 notified the on-call Physician of the resident's status, relayed to the Physician her assessment and the vital signs. The Physician gave a verbal order to transfer the resident to the hospital. - 6:55 PM - The resident's daughter was notified that the resident was being transferred to the emergency room . RN #1 documented that she extracted the necessary forms from the resident's chart and gave them to LPN #3 to copy. At 6:55 PM, RN #1 documented that she started filling out the transfer forms. - 7:05 PM - RN #1 documented that she began to call the ambulance company when CNA #1 came out to the desk to tell her that the resident was dead. At 7:05 PM, RN #1 entered the resident's room and found that the resident was not breathing, with no heart rate and no blood pressure. RN #1 went back to the desk and attempted to call the resident's daughter. There was no answer. - 7:15 PM - RN #1 contacted the Coroner. RN #1 called the resident's daughter again and informed her that the resident had passed away. RN #1 went back to the resident's room to attempt to transfer him back to bed (from the wheelchair), but was unsuccessful so she draped a flat sheet over the resident's body. - 8:00 PM - The Coroner arrived and pronounced the resident's death at 8:16 PM. Review of the Director of Nursing's (DON) summary of her interview with RN #1 (dated [DATE]) revealed that the DON asked RN #1 what the resident's code status was. RN #1 stated that he was a "Full Code" and then stated "Oh, maybe not." After the DON checked the resident's chart, the DON informed RN #1 that Resident #1 was a Full Code. The DON asked RN #1 why she did not start the code and RN #1 stated that there was so much going on and she did not look at the resident's code status. During a telephone interview on [DATE] at approximately 12:00 PM, LPN #2 stated that she worked the 6:00 PM to 6:00 AM shift on [DATE]. LPN #2 stated that she was told on report by the supervisor that Resident #1 was lethargic probably due to [MEDICATION NAME] (antipsychotic medication). LPN #2 stated that after counting narcotics at the beginning of her shift, she went to the Main Dining Room to check on the residents. LPN #2 stated she found Resident #1 sitting (in his wheelchair), with his chin to his chest, his arms to his side, and he was not responsive. LPN #2 stated that she did a sternal rub with no response. LPN #2 stated she moved the resident out of the Dining Room into the hallway and she could not obtain a blood pressure on the resident but got an oxygen saturation of 95 %. LPN #2 stated that they notified RN #1 who was in the Main Dining Room. RN #1 came out of the Dining Room and assessed the resident. RN #1 could not get a blood pressure but obtained an oxygen saturation of 95% and a pulse of "44" (not 54 as reported by RN#1). LPN #2 stated that RN #1 told the LPNs that they should compare these vital signs to the day shift vitals. LPN #3 could not find the day shift vital signs at the desk so RN #1 said "we're going to send him out". LPN #2 stated that RN #1 then went back into the dining room to feed the other residents. LPN #2 stated that at that time, she disconnected the resident's oxygen tank (which was not quite empty) and "filled it partially". LPN #2 stated that the tank was only off the resident for three to five minutes. LPN #2 stated that the resident remained in the wheelchair in the hallway and approximately ,[DATE] minutes later, she noticed that the resident's fingers were turning blue. CNA #1 was walking past. LPN #2 stated that she told CNA #1 to tell RN #1 about the resident's fingers being blue. She stated that RN #1 came out of the dining room to send the resident to the hospital. LPN #2 stated that the resident was taken to his room by another staff member. LPN #2 stated that she let RN #1 and LPN #3 handle the situation from that point on. LPN #2 stated that a short time later she found out from RN #1 that the resident had expired. LPN #2 stated that she was not aware of the resident's code status, she did not check to see what it was, and she did not know if the resident had a code status ID (identification) band on. LPN #2 stated that she considered calling "911" herself since RN #1 was slow to respond to the situation, but she did not. LPN #2 stated that she did not consider initiating CPR on Resident #1. The LPN stated that "the RN is in charge and should be making the decisions". During a telephone Interview with LPN #3 on [DATE] at approximately 3:00 PM, the LPN stated that she worked the 6:00 PM to 6:00 AM shift on [DATE] . She stated that she was told by the day shift nurse (LPN) that Resident #1 was lethargic due to his [MEDICATION NAME]. LPN #3 stated that at approximately 6:30 PM, LPN #2 brought the resident out of the Dining Room into the hallway and asked her to check the resident. LPN #3 stated that she did a sternal rub and there was no response from the resident so they informed RN #1 who was in the dining room with the other residents. LPN #3 stated that RN #1 came out and assessed the resident's vital signs. RN #1 obtained a pulse of "44", an oxygen saturation of 95 %, and no BP. RN #1 instructed LPN #3 to check the resident's vital signs from the day shift. LPN #3 stated that she could not find the day shift vital signs at the desk so RN #1 stated "we are going to send him to the hospital". LPN #3 was at the nurse's desk at approximately 6:40 PM when the resident's daughter called and LPN #3 informed her that they were going to send him to the hospital. LPN #3 stated that after the phone call, she went back to the resident in the hallway. LPN #2 was still with the resident and RN #1 was in the dining room feeding the other residents. At this time, LPN #2 showed her the resident's fingers which were purple. LPN #3 stated that she instructed CNA #1 to tell RN #1 that the resident's fingers were blue. During the telephone interview, LPN #3 stated that she took the resident to his room and went to the copy machine to make copies of the resident's medication records for the hospital transfer. LPN #3 stated that she thought that CNA #1 was with the resident in his room. LPN #3 stated that while making copies, CNA #1 came down the hall and stated that the resident was dead. LPN #3 stated that she was not aware of the resident's code status; she did not check the resident's code status; and she did not know if he had a code status ID band on. LPN #3 stated that she did not consider initiating CPR on the resident because the resident was breathing when she was with him. She stated that she did not consider calling "911" because she knew the resident was being sent to the hospital. LPN #3 stated that "the RN Supervisor is supposed to take the lead in these situations". LPN #3 stated that she completed her CPR certification online on [DATE] and she was not CPR certified on [DATE] (the day that Resident #1 died ). During a telephone interview on [DATE] at approximately 12:30 PM, RN #1 stated that she was the full time RN Supervisor in the facility on the 3:00 PM to 11:00 PM shift. RN #1 stated that on [DATE], she arrived at the facility at approximately 3:15 PM. She stated that she observed Resident #1 sitting at the nurse's desk in a wheelchair with his eyes closed and the resident appeared to be sleeping. She stated that that the day shift LPN (LPN #1) had informed her that the resident's vital signs were stable and that maybe he was lethargic due to the [MEDICATION NAME]. RN #1 stated that she did not assess the resident at that time. RN #1 stated that at approximately 6:30 PM, she was feeding residents in the Dining Room when LPN #2 informed her that the resident did not have a blood pressure. RN #1 stated that she came out of the dining room to where Resident #1 was sitting in the hallway, to check his vital signs. She stated that she could not get a blood pressure but that the resident's oxygen saturation level was 95%, his temperature was 95.2 degrees, pulse was 54 and respirations were 24. The RN Supervisor (RN #1) stated that she did not check the resident's code status. RN #1 stated that she went back in the Dining Room to continue feeding residents with the plan to send the resident to the hospital. She stated that it did not occur to her that the resident's condition was declining, since he seemed the same as he did when she saw him at 3:15 PM. RN #1 stated a few minutes later, CNA #1 told her that the resident was getting cyanotic (bluish discoloration of the skin due to decreased oxygen in the blood). RN #1 stated that she immediately went to the desk to call the Physician and begin the process of sending the resident to the hospital. RN #1 stated that during this time, CNA#1 took the resident to his room. RN #1 stated that at approximately 7:05 PM, CNA #1 came out of the resident's room and told her that the resident was dead. RN #1 stated that she went to the room to check the resident and "found him not breathing with no pulse". RN #1 stated that she "knew he was gone". RN #1 stated that she attempted to get him into bed (from the wheelchair) but could not, so she draped a flat sheet over his body and went to call the resident's daughter. RN #1 stated that she was not aware of the resident's code status and she did not check to see what it was. RN #1 stated that she "did not even know if the resident had an ID band on". RN #1 stated that she is totally responsible for her actions and she should have done something sooner to address the resident's condition. She stated that she should have gotten an ambu bag (a hand held device used to provide artificial ventilation to an individual who is not breathing) and she should have started CPR. RN #1 stated in retrospect, she should have sent the resident to the hospital at 3:15 PM. Interview with CNA #1 on [DATE] at 3:00 PM revealed that CNA #1 worked the 2:00 PM - 10:00 PM shift on [DATE]. CNA #1 stated that she was in the Dining Room at approximately 6:00 PM and she observed that Resident #1 couldn't keep his head up, he was not responding, and he was drooling. She stated that the resident "didn't look good and would not wake up". CNA #1 stated that she told RN #1 at approximately 6:00 PM that the resident was not responding. CNA #1 stated that RN #1 came over to look at the resident and stated "he's fine, he's had a medication change", and walked away. CNA #1 stated that "awhile later", LPN #2 and LPN #3 were in the hallway with the resident. The LPNs told her that the resident's hands were blue and to go tell RN #1 about it. CNA #1 stated that she went into the dining room to tell RN #1 that the resident's hands were blue and that she needed to do something. CNA #1 stated that RN #1 said that she "had to finish her intakes first". CNA #1 said she told RN #1 that she would finish the intakes for her. CNA #1 stated that one of the LPNs took Resident #1 to his room. CNA #1 stated that she went to the resident's room and sat with him for a few minutes then left to care for two other residents. CNA #1 stated that when she returned to the resident's room about 15 minutes later, he was not breathing and she "knew he was dead". CNA #1 stated that she went out to the nurse's station to tell RN #1 that the resident was gone. The Physician stated during a telephone interview on [DATE] at approximately 2:00 PM that when the nurses found the resident unresponsive and without vital signs, they should have initiated CPR, called 911, and then called her in that order. b.) Review of a facility policy and procedure entitled Cardio-Pulmonary Resuscitation (CPR) dated ,[DATE] revealed that CPR will be performed by licensed nurses and CPR certified staff that are trained in and able to perform CPR. All licensed nurses certified in CPR will know which residents requested Full Code status and will be aware of the facility policy, the location of the Full Code list, and the identifying blue band. If a resident appears to have an arrest (the abrupt loss of heart and respiratory function), the licensed nurse will determine if there is a heart rate and respirations present. Review of the personnel files for the two LPNs (LPNs #2 and 3) on duty the evening of [DATE] revealed that their CPR certifications had lapsed in October, 2014. Review of CPR certifications for the remaining nursing staff in the facility revealed that five licensed nurses (three RNS, two LPNS) including the Director of Nursing (DON) had CPR certifications that lapsed. One agency staff LPN, who had been working at the facility through [DATE], had an unacceptable online CPR certification. Review of the facility staffing sheets from [DATE] through [DATE] revealed there were multiple shifts without CPR certified staff on duty. The following days and shifts were identified to have nursing staff with lapsed CPR certification or unacceptable online certification: - [DATE] - night shift - [DATE] and [DATE]- night shift - [DATE] - both the day shift and the night shift - [DATE] - night shift - [DATE] - day shift - [DATE] night shift - [DATE] and [DATE] - night shift - [DATE] and [DATE] - day shift and night shift - [DATE] - night shift - [DATE] - day shift and night shift - [DATE] - evening shift - [DATE] through [DATE] - day shift and evening shift - [DATE] - day shift and evening shift - [DATE] - day shift and night shift Interview with the Administrator on [DATE] at 1:15 PM revealed he did not know that the nursing staff CPR certifications had expired. The Administrator stated that he was made aware of the expired certifications after the facility's investigation of this incident. The Administrator stated that he was unaware that online certification was no longer an acceptable means of recertification for CPR. He stated that the Business Office Manager was responsible for tracking CPR certifications and that the expiration of staff certification was missed. Interview with the Business Office Manager on [DATE] at 2:00 PM revealed she does keep a copy of staff CPR certification in a book in her office but she was not watching the dates of expiration. She stated since this incident her procedure would be changing. Interview with the DON on [DATE] at 2:00 PM revealed she was not aware that there were nursing staff who were not currently certified in CPR and she was not aware that there were shifts without CPR certified staff on duty. The DON stated she also was not aware that online certification was not a valid recertification method for CPR. She reported that agency staff are used for staffing needs and that the same agency staff members were used for consistency. The DON stated that agency staff are required to be CPR certified before they can work at the facility. The DON stated she believed that all agency staff being used at the facility at this time were currently certified. 2. During an interview on [DATE] at 4:00 PM, the Administrator stated that actions were taken to remove the Immediate Jeopardy situation in the facility. a.) Review of a letter to the New York State Department of Health, signed by the Administrator dated [DATE] revealed an Immediate Jeopardy Abatement Plan was submitted included the following: - "A 100% audit of Advanced Directives was completed and colored bands verified to reflect the code status of each resident. Care Guides and Care Plans were reviewed for accuracy". - "After record review, additional audits were completed for Hospital Discharge/ Change of Condition". - "All Care Plans and Care Guides were updated with any corrections for code status". - All active Medical Records were reviewed back to [DATE] for physician and family notification and change of condition". - All licensed nurses, full and part time, were re-inserviced on "Change of condition" and "Physician and family notification of change in condition". - A 100% audit of all residents and their code status was completed including: a. Paperwork, HCP (health care proxy), and gold sheets DNR (do not resuscitate - to with hold emergency resuscitation measures if an individual stops breathing or heart stops) consent b. "Care Plans and Care Guides updated" c. "Master list of Full Codes redeveloped and posted at the nurses station, crash cart and MARS (medication administration records)". - "All licensed staff were re-inserviced for CPR Certification. CPR training classes were scheduled". - "The staffing schedule was revised to plan for two certified staff per shift". - "All FT (full time)/PT (part time) staff were inserviced to assure accurate identification of DNR, CPR (bands)". - "The Social Worker was inserviced for Advanced Directives". b.) Observations and interviews on [DATE] revealed the following: - Observations on [DATE] at approximatley 3:00 PM, of the following residents currently residing in the facility, revealed that the residents had correct resuscitation status name bands on in accordance with their Advance Directive documentation and physician's orders [REDACTED]. Residents #11, 12, 13, and 14 were identified as DNR. Resident #15 was identified as a Full Code. - Interviews with RN #2, LPNs #4, 5, and 6 and CNA #1 on [DATE] between 2:00 PM and 3:00 PM revealed the staff were inserviced on Advance Directives including accurate identification of DNR/ CPR bands, resident change of condition, and physician notification of change of condition. 415.3(e)(1)(i,ii)

Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint #NY 500) completed on [DATE], the facility failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of five residents reviewed for quality of care. Specifically, there was a lack of a registered professional nurse assessment when the resident had multiple changes in condition, there was a lack of ongoing monitoring of the resident's condition, and nursing staff failed to provide cardiopulmonary resuscitation (CPR - cardiopulmonary resuscitation - emergency resuscitation measures, including artificial ventilation and chest compressions) on an unresponsive resident with a Full Code Status (the provision of emergency measures in an attempt to resuscitate an individual). One Registered Nurse (RN) and two Licensed Practical Nurses (LPN) failed to initiate CPR on Resident #1, resulting in his death. This resulted in a pattern of IMMEDIATE JEOPARDY WITH ACTUAL HARM AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The immediate jeopardy was removed on [DATE], prior to the completion of the survey. The findings are: 1. a.) LACK OF ONGOING MONITORING OF THE RESIDENT'S CONDITION: Resident #1 has [DIAGNOSES REDACTED]. Review of an "Interdisciplinary Progress Note", written by the Registered Nurse (RN) Resident Care Coordinator (RCC) ( RN #2) dated [DATE] at 1:15 PM revealed that the resident was noted to have "three to four plus (+) [MEDICAL CONDITION]" (swelling in the tissue under the skin, resulting from fluid accumulation, that is measured by the depth of indentation made by finger pressure.) of the bilateral lower extremities (BLEs). RN #2 documented that the resident's legs were weepy, intact and ruptured blisters were noted on the BLEs. The Physician was notified and ordered [MEDICATION NAME] (medication to promote the excretion of urine) 40 milligrams (mg) daily and instructed to wrap the BLEs with ace wraps. Review of a Physician's Telephone Order dated [DATE] at 3:00 PM revealed an order for [REDACTED]. Review of "Interdisciplinary Progress Notes" and "24-Hour Nursing Services Reports", both dated [DATE] to [DATE], revealed no documented evidence that an RN assessed Resident #1's vital signs (temperature, blood pressure, pulse respiratory rate), respiratory status or BLEs related to the initiation of [MEDICATION NAME] therapy regarding the [MEDICAL CONDITION] of the BLEs. Interview with RN #2 on [DATE] at approximately 10:15 AM revealed that on [DATE] she observed "three to four + [MEDICAL CONDITION]" of the resident's BLEs while doing treatments. RN #2 stated that she notified the Physician who ordered [MEDICATION NAME] 40 mg daily and to wrap the resident's BLEs with ace wraps. RN #2 stated that she did not obtain vital signs on the resident on [DATE]. RN #2 stated that she was "off" for the next several days. Licensed Practical Nurse (LPN) #1 stated during a telephone interview on [DATE] at approximately 11:00 AM that on [DATE] and [DATE] she applied the ace wraps to the resident's BLEs. LPN #1 stated that the [MEDICAL CONDITION] was decreased and appeared to be about "one to two + [MEDICAL CONDITION]". She stated that she did not assess the resident's vital signs on [DATE] but assessed vital signs on [DATE] at approximately 1:00 PM. LPN #1 stated that the resident's vital signs were stable on [DATE]. LPN #1 stated that she did not document the resident's condition in the nurse's notes (Interdisciplinary Progress Notes) for ,[DATE] or [DATE]. She stated that she did not report her observations of the resident's legs to an RN on [DATE] or [DATE]. During a telephone interview on [DATE] at 2:00 PM, the Physician stated that the RN notified her of the resident's BLE [MEDICAL CONDITION] for which she ordered [MEDICATION NAME] and ace wraps to the legs. The Physician stated that she would then expect nursing staff to monitor, assess, and chart the resident's vital signs, the condition of the BLEs, and whether the resident had shortness of breath or open wounds. The Physician stated that she would expect to be notified of any change in the resident's condition. b.) LACK OF RN ASSESSMENT OF A SIGNIFICANT CHANGE IN THE RESIDENT'S CONDITION. Review of admission "physician's orders [REDACTED]. Review of an "Interdisciplinary Progress Note", written by RN #2, dated [DATE] at 8:30 AM revealed the resident was noted to have increased behaviors; was combative with care; and was striking out at staff. The RN documented that the Physician ordered to increase [MEDICATION NAME] to 10 mg daily. Review of a Physician's Telephone Order dated [DATE] revealed an order to increase [MEDICATION NAME] to 10 mg by mouth daily for behaviors. Review of an "Investigation Statement", dated [DATE], written by LPN #1, revealed that the resident consumed 50% of his breakfast on [DATE]. After breakfast, the resident was placed in a reclining wheelchair and was seated by the nurses' station. LPN #1 documented on the investigation form that the resident had an oxygen saturation (amount of oxygen in the blood) of 95% (percent) (normal 90 to 100%) on room air, a blood pressure of ,[DATE] (normal) and the respiratory rate was 20 (normal 12 to 20) and non-labored. LPN #1 documented that the resident had no shortness of breath or respiratory distress. Additional review of of the Investigation Statement revealed that the resident did not eat lunch on [DATE]. LPN #1 further documented that she reported to RN #1 (evening shift RN Supervisor) that the resident slept all afternoon and his vital signs were stable. LPN #1 told RN #1 that the resident may have been up all night "or maybe the [MEDICATION NAME]." During a telephone interview on [DATE] at approximately 12:00 PM, LPN #1 stated that on [DATE] she worked the 6:00 AM to 2:00 PM shift. The LPN stated that Resident #1 ate 50% of his breakfast and then was placed in the reclining wheelchair. LPN #1 stated that at lunchtime the resident stated "leave me alone" and did not consume any of his lunch. She stated that she obtained vital signs at approximately 1:00 PM and they were stable. LPN #1 stated that the resident slept the rest of the afternoon in the reclining wheelchair but was arousable and responsive. LPN #1 stated that at approximately 3:00 PM, she reported to RN #1 that the resident was very sleepy but arousable and advised her to keep an eye on him due to the [MEDICATION NAME]. LPN #1 stated that she did not notify the Physician of the resident's condition during her shift. Telephone interview with RN #1 on [DATE] at 12:30 PM revealed that she worked the 3:00 PM to 11:00 PM shift on [DATE]. RN #1 stated she arrived at approximately 3:15 PM and observed Resident #1 sitting at the nurses' desk with his eyes closed and he appeared to be sleeping. She stated that the day shift LPN (LPN #1) informed her that the resident's vital signs were stable and that the resident's lethargy was possibly due to the [MEDICATION NAME]. RN #1 stated that she did not assess the resident at the time nor did she contact the Physician about the resident's lethargy. During an interview on [DATE] at 3:00 PM, the certified nurse aide (CNA #1) stated that she worked the 2:00 PM to 10:00 PM shift on [DATE]. CNA #1 stated that at approximately 6:00 PM while in the dining room she observed that Resident #1 couldn't keep his head up, he was not responding, and he was drooling. She stated that the resident "didn't look good and would not wake up". CNA #1 stated that she told RN #1 at approximately 6:00 PM that the resident was not responding. CNA #1 stated that RN #1 came over to look at the resident and stated "he's fine, he's had a medication change" and walked away. During a telephone interview on [DATE] at approximately 2:00 PM, the Physician stated that she tells staff that when residents are on [MEDICAL CONDITION] medications, if there is any change in the resident's condition including increased lethargy or decreased intake that they should call her and she will instruct them to hold the medication and then she will re-evaluate. The Physician stated that staff should have called her during the day when the resident was getting worse. c.) LACK OF ONGOING MONITORING AND RN ASSESSMENT OF SIGNIFICANT CHANGES IN THE RESIDENT'S CONDITION AND FAILURE OF OF NURSING STAFF TO PROVIDE CPR. Review of the facility investigation of the incident that occurred on [DATE] revealed an "Investigation Statement" written by RN #1 dated [DATE] at 3:20 PM. The written statement documented that on [DATE] at approximately 6:25 PM, Resident #1 was "wheeled (transported in a wheelchair) out" of the dining room into the hall. At 6:30 PM, RN #1 came out of the dining room to take the resident's vital signs (temperature, blood pressure, pulse, respiratory rate) because a Licensed Practical Nurse (LPN #2) was having difficulty obtaining a blood pressure (BP) reading and thought the resident wasn't doing well. RN #1 documented that the resident's temperature was 95.2 (normal 98.6), pulse was "54" (average 80), and respirations were 24 (normal 12 to 20). The RN's statement documented "there was no BP in the right or left arm"; the SP O2 (oxygen saturation level - amount of oxygen in the blood) was 95 % (percent) (normal 90 to 100 %) on 2 liters of oxygen; lung sounds were diminished; there was [MEDICAL CONDITION] (swelling) of the lower extremities; and the resident had no response to a sternal rub (the application of painful stimulus by vigorously rubbing the sternum with the knuckles of a closed fist to assess consciousness). RN #1 stated that she told the two LPNs that were present that she was going to send the resident "out." RN #1 documented that "she thought she could buy ,[DATE] minutes of time" because the resident's status hadn't changed from when she first saw him at 3:15 PM. RN #1 documented that she went back into the dining room. Additional review of RN #1's written statement revealed the following: - On [DATE] at 6:40 PM - The resident's daughter called and LPN #3 told her that "we would be sending (the resident) to the hospital because he was not doing well and not responding to any verbal or tactile stimulation". - 6:45 PM - CNA #1 came into the dining room and told RN #1 that the resident's fingers were turning blue. RN #1 documented that she immediately went to the desk to start the transfer process, while CNA #1 wheeled the resident to his room. - 6:50 PM - RN #1 notified the on-call Physician of the resident's status, relayed to the Physician her assessment and the vital signs. The Physician gave a verbal order to transfer the resident to the hospital. - 6:55 PM - The resident's daughter was notified that the resident was being transferred to the emergency room . RN #1 documented that she extracted the necessary forms from the resident's chart and gave them to LPN #3 to copy. At 6:55 PM, RN #1 documented that she started filling out the transfer forms. - 7:05 PM - RN #1 documented that she began to call the ambulance company when CNA #1 came out to the desk to tell her that the resident was dead. At 7:05 PM, RN #1 entered the resident's room and found that the resident was not breathing, with no heart rate and no blood pressure. RN #1 went back to the desk and attempted to call the resident's daughter. There was no answer. - 7:15 PM - RN #1 contacted the Coroner. RN #1 called the resident's daughter again and informed her that the resident had passed away. RN #1 went back to the resident's room to attempt to transfer him back to bed (from the wheelchair), but was unsuccessful so she draped a flat sheet over the resident's body. - 8:00 PM - The Coroner arrived and pronounced the resident's death at 8:16 PM. Review of the Director of Nursing's (DON) summary of her interview with RN #1 (dated [DATE]) revealed that the DON asked RN #1 what the resident's code status was. RN #1 stated that he was a "Full Code" and then stated "Oh, maybe not." After the DON checked the resident's chart, the DON informed RN #1 that Resident #1 was a Full Code. The DON asked RN #1 why she did not start the code and RN #1 stated that there was so much going on and she did not look at the resident's code status. During a telephone interview on [DATE] at approximately 12:00 PM, LPN #2 stated that she worked the 6:00 PM to 6:00 AM shift on [DATE]. LPN #2 stated that she was told on report by the supervisor that Resident #1 was lethargic probably due to [MEDICATION NAME] (antipsychotic medication). LPN #2 stated that she found Resident #1 sitting (in his wheelchair) in the Main Dining Room, with his chin to his chest, his arms to his side, and he was not responsive. LPN #2 stated that she did a sternal rub with no response. LPN #2 stated she moved the resident out of the Dining Room into the hallway and she could not obtain a blood pressure on the resident but got an oxygen saturation of 95 %. LPN # 2 stated that she told LPN #3 who also could not get a response from the resident. LPN #2 stated that they notified RN #1 who was in the Main Dining Room. RN #1 came out of the Dining Room and assessed the resident. RN #1 could not get a blood pressure but obtained an oxygen saturation of 95% and a pulse of "44". LPN #2 stated that RN #1 told the LPNs that they should compare these vital signs to the day shift vitals. LPN #3 could not find the day shift vital signs at the desk so RN #1 said "we're going to send him out". LPN #2 stated that RN #1 then went back into the dining room to feed the other residents. LPN #2 stated that at that time, she disconnected the resident's oxygen tank (which was not quite empty) and filled it partially. LPN #2 stated that the tank was only off the resident for three to five minutes. LPN #2 stated that the resident remained in the wheelchair in the hallway and approximately ,[DATE] minutes later, she noticed that the resident's fingers were turning blue. CNA #1 was walking past. LPN #2 stated that she told CNA #1 to tell RN #1 about the resident's fingers being blue. She stated that RN #1 came out of the dining room to send the resident to the hospital. LPN #2 stated that the resident was taken to his room by another staff member. LPN #2 stated that she let RN #1 and LPN #3 handle the situation from that point on. LPN #2 stated that a short time later she found out from RN #1 that the resident had expired. LPN #2 stated that she was not aware of the resident's code status, she did not check to see what it was, and she did not know if the resident had a code status ID (identification) band on. LPN #2 stated that she considered calling "911" herself since RN #1 was slow to respond to the situation, but she did not. LPN #2 stated that she did not consider initiating CPR on Resident #1. The LPN stated that "the RN is in charge and should be making the decisions". During a telephone Interview with LPN #3 on [DATE] at approximately 3:00 PM, the LPN stated that she worked the 6:00 PM to 6:00 AM shift on [DATE] . She stated that she was told by the day shift nurse (LPN) that Resident #1 was lethargic due to his [MEDICATION NAME]. LPN #3 stated that at approximately 6:30 PM, LPN #2 brought the resident out of the Dining Room into the hallway and asked her to check the resident. LPN #3 stated that she did a sternal rub and there was no response from the resident so they informed RN #1 who was in the dining room with the other residents. LPN #3 stated that RN #1 came out and assessed the resident's vital signs. The RN obtained a pulse of "44" (not 54 as reported by RN #1), an oxygen saturation of 95 %, and no BP. RN #1 instructed LPN #3 to check the resident's vital signs from the day shift. LPN #3 stated that she could not find the day shift vital signs at the desk so RN #1 stated "we are going to send him to the hospital". LPN #3 was at the nurse's desk at approximately 6:40 PM when the resident's daughter called and LPN #3 informed her that they were going to send him to the hospital. LPN #3 stated that after the phone call, she went back to the resident in the hallway. LPN #2 was still with the resident and RN #1 was in the dining room feeding the other residents. At this time, LPN #2 showed her the resident's fingers which were purple. LPN #3 stated that she instructed CNA #1 to tell RN #1 that the resident's fingers were blue. During the telephone interview, LPN #3 stated that she took the resident to his room and went to the copy machine to make copies of the resident's medication records for the hospital transfer. LPN #3 stated that she thought that CNA #1 was with the resident in his room. LPN #3 stated that while making copies, CNA #1 came down the hall and stated that the resident was dead. LPN #3 stated that she was not aware of the resident's code status; she did not check the resident's code status; and she did not know if he had a code status ID band on. LPN #3 stated that she did not consider initiating CPR on the resident because the resident was breathing when she was with him. She stated that she did not consider calling "911" because she knew the resident was being sent to the hospital. LPN #3 stated that "the RN Supervisor is supposed to take the lead in these situations". LPN #3 stated that she completed her CPR certification online on [DATE] and she was not CPR certified on [DATE] (the day that Resident #1 died ). During a telephone interview on [DATE] at approximately 12:30 PM, RN #1 stated that she was the full time RN Supervisor in the facility on the 3:00 PM to 11:00 PM shift. RN #1 stated that on [DATE], she arrived at the facility at approximately 3:15 PM. She stated that she observed Resident #1 sitting at the nurse's desk in a wheelchair with his eyes closed and the resident appeared to be sleeping. She stated that that the day shift LPN (LPN #1) had informed her that the resident's vital signs were stable and that maybe he was lethargic due to the [MEDICATION NAME]. RN #1 stated that she did not assess the resident at that time. RN #1 stated that at approximately 6:30 PM, she was feeding residents in the Dining Room when LPN #2 informed her that the resident did not have a blood pressure. RN #1 stated that she came out of the dining room to where Resident #1 was sitting in the hallway, to check his vital signs. She stated that she could not get a blood pressure but that the resident's oxygen saturation level was 95%, his temperature was 95.2 degrees, pulse was "54" and respirations were 24. The RN Supervisor (RN #1) stated that she did not check the resident's code status. RN #1 stated that she went back in the Dining Room to continue feeding residents with the plan to send the resident to the hospital. She stated that it did not occur to her that the resident's condition was declining, since he seemed the same as he did when she saw him at 3:15 PM. RN #1 stated a few minutes later, CNA #1 told her that the resident was getting cyanotic (bluish discoloration of the skin due to decreased oxygen in the blood). RN #1 stated that she immediately went to the desk to call the Physician and begin the process of sending the resident to the hospital. RN #1 stated that during this time, CNA#1 took the resident to his room. RN #1 stated that at approximately 7:05 PM, CNA #1 came out of the resident's room and told her that the resident was dead. RN #1 stated that she went to the room to check the resident and "found him not breathing with no pulse". RN #1 stated that she "knew he was gone". RN #1 stated that she attempted to get him into bed (from the wheelchair) but could not, so she draped a flat sheet over his body and went to call the resident's daughter. RN #1 stated that she was not aware of the resident's code status and she did not check to see what it was. RN #1 stated that she "did not even know if the resident had an ID band on". RN #1 stated that she is totally responsible for her actions and she should have done something sooner to address the resident's condition. She stated that she should have gotten an ambu bag (a hand held device used to provide artificial ventilation to an individual who is not breathing) and she should have started CPR. RN #1 stated in retrospect, she should have sent the resident to the hospital at 3:15 PM. Interview with CNA #1 on [DATE] at 3:00 PM revealed that CNA #1 worked the 2:00 PM - 10:00 PM shift on [DATE]. The CNA stated that she was in the Dining Room at approximately 6:00 PM and she observed that Resident #1 couldn't keep his head up, he was not responding, and he was drooling. She stated that the resident "didn't look good and would not wake up". CNA #1 stated that she told RN #1 at approximately 6:00 PM that the resident was not responding. CNA #1 stated that RN #1 came over to look at the resident and stated "he's fine, he's had a medication change", and walked away. CNA #1 stated that "awhile later", LPN #2 and LPN #3 were in the hallway with the resident. The LPNs told her that the resident's hands were blue and to go tell RN #1 about it. CNA #1 stated that she went into the dining room to tell RN #1 that the resident's hands were blue and that she needed to do something. CNA #1 stated that RN #1 said that she "had to finish her intakes first". CNA #1 said she told RN #1 that she would finish the intakes for her. CNA #1 stated that one of the LPNs took Resident #1 to his room. CNA #1 stated that she went to the resident's room and sat with him for a few minutes then left to care for two other resident's. CNA #1 stated that when she returned to the resident's room about 15 minutes later, he was not breathing and she "knew he was dead". CNA #1 stated that she went out to the nurse's station to tell RN #1 that the resident was gone. The Physician stated during a telephone interview on [DATE] at approximately 2:00 PM that when the nurses found the resident unresponsive and without vital signs, they should have initiated CPR, called 911, and then called her in that order. 2. During an interview on [DATE] at 4:00 PM, the Administrator stated that actions were taken to remove the Immediate Jeopardy situation in the facility. a.) Review of a letter to the New York State Department of Health, signed by the Administrator dated [DATE] revealed an Immediate Jeopardy Abatement Plan was submitted included the following: - "A 100% audit of Advanced Directives was completed and colored bands verified to reflect the code status of each resident. Care Guides and Care Plans were reviewed for accuracy". - "After record review, additional audits were completed for Hospital Discharge/ Change of Condition". - "All Care Plans and Care Guides were updated with any corrections for code status". - All active Medical Records were reviewed back to [DATE] for physician and family notification and change of condition". - All licensed nurses, full and part time, were re-inserviced on "Change of condition" and "Physician and family notification of change in condition". - A 100% audit of all residents and their code status was completed including: a. Paperwork, HCP (health care proxy), and gold sheets DNR (do not resuscitate - to with hold emergency resuscitation measures if an individual stops breathing or heart stops) consent b. "Care Plans and Care Guides updated" c. "Master list of Full Codes redeveloped and posted at the nurses station, crash cart and MARS (medication administration records)". - "All licensed staff were re-inserviced for CPR Certification. CPR training classes were scheduled". - "The staffing schedule was revised to plan for two certified staff per shift". - "All FT (full time)/PT (part time) staff were inserviced to assure accurate identification of DNR, CPR (bands)". - "The Social Worker was inserviced for Advanced Directives". b.) Observations and interviews on [DATE] revealed the following: - Observations on [DATE] at approximately 3:00 PM, of the following residents currently residing in the facility, revealed that the residents had correct resuscitation status name bands on in accordance with their Advance Directive documentation and physician's orders [REDACTED]. Residents #11, 12, 13, and 14 were identified as DNR. Resident #15 was identified as a Full Code. - Interviews with RN #2, LPNs #4, 5, and 6 and CNA #1 on [DATE] between 2:00 PM and 3:00 PM revealed the staff were inserviced on Advance Directives including accurate identification of DNR/ CPR bands, resident change of condition, and physician notification of change of condition. 415.12

Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint # NY 500) completed on [DATE], the facility was not 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. Specifically, the facility administration failed to ensure that adequately trained and certified CPR (cardiopulmonary resuscitation - emergency resuscitation measures, including artificial ventilation and chest compressions) staff were available on all shifts. There were multiple shifts from [DATE] to [DATE] when adequately trained staff were not available. One (Resident #1) of five residents reviewed for quality of care had issues involving the failure of nursing staff to provide CPR to an unresponsive resident with a Full Code status (the provision of emergency measures in attempt to resuscitate an individual, in the event that breathing or heartbeat stops), resulting in his death. This resulted in a pattern of IMMEDIATE JEOPARDY WITH ACTUAL HARM TO RESIDENT HEALTH AND SAFETY. The immediate jeopardy was removed on [DATE], prior to the completion of the survey. The findings are: REFER TO: F155 - Right to Refuse; Formulate Advance Directives S/S=K F157 - Notify of Changes (injury/decline/room, etc) S/S=J F224 - Prohibit Mistreatment/ Neglect/ Misappropriation S/S=J F309 - Provide Care/Services for Highest Well-Being S/S=K 1. Resident #1 was admitted to the facility for rehabilitation on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sheet ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment, usually understands, and was usually understood. Review of the medical record Face Sheet revealed the resident was identified as having a Full Code status. Review of an Advance Directive Checklist for Resident #1 revealed the resident had a Health Care Proxy and a Power of Attorney. Review of physician's orders [REDACTED]. a.) Review of a facility investigation of an incident that occurred on [DATE] revealed an "Investigation Statement" written by RN #1 dated [DATE] at 3:20 PM. The written statement documented that on [DATE] at approximately 6:25 PM, Resident #1 was "wheeled (transported in a wheelchair) out" of the dining room into the hall. At 6:30 PM, RN #1 came out of the dining room to take the resident's vital signs (temperature, blood pressure, pulse, respiratory rate) because a Licensed Practical Nurse (LPN #2) was having difficulty obtaining a blood pressure (BP) reading and thought the resident wasn't doing well. RN #1 documented that the resident's temperature was 95.2 (normal 98.6), pulse was "54" (average 80), and respirations were 24 (normal 12 to 20). The RN's statement documented "there was no BP in the right or left arm"; the SP O2 (oxygen saturation level - amount of oxygen in the blood) was 95 % (percent) (normal 90 to 100 %) on 2 liters of oxygen; lung sounds were diminished; there was [MEDICAL CONDITION] (swelling) of the lower extremities; and the resident had no response to a sternal rub (the application of painful stimulus by vigorously rubbing the sternum with the knuckles of a closed fist to assess consciousness). RN #1 stated that she told the two LPNs that were present that she was going to send the resident "out." RN #1 documented that "she thought she could buy ,[DATE] minutes of time" because the resident's status hadn't changed from when she first saw him at 3:15 PM. RN #1 documented that she went back into the dining room. Additional review of RN #1's written statement revealed the following: - On [DATE] at 6:45 PM - CNA #1 came into the dining room and told RN #1 that the resident's fingers were turning blue. RN #1 documented that she immediately went to the desk to start the transfer process, while CNA #1 wheeled the resident to his room. - 6:50 PM - RN #1 notified the on-call Physician of the resident's status, relayed to the Physician her assessment and the vital signs. The Physician gave a verbal order to transfer the resident to the hospital. - 7:05 PM - RN #1 documented that she began to call the ambulance company when CNA #1 came out to the desk to tell her that the resident was dead. At 7:05 PM, RN #1 entered the resident's room and found that the resident was not breathing, with no heart rate and no blood pressure. RN #1 went back to the desk and attempted to call the resident's daughter. There was no answer. b.) During a telephone interview on [DATE] at approximately 12:00 PM, LPN #2 stated Resident #1 remained in the wheelchair in the hallway and approximately ,[DATE] minutes later, she noticed that the resident's fingers were turning blue. LPN #2 stated that she told CNA #1 to tell RN #1 about the resident's fingers being blue. She stated that RN #1 came out of the dining room to send the resident to the hospital. LPN #2 stated that the resident was taken to his room by another staff member. LPN #2 stated that she let RN #1 and LPN #3 handle the situation from that point on. LPN #2 stated that she was not aware of the resident's code status, she did not check to see what it was, and she did not know if the resident had a code status ID (identification) band on. LPN #2 stated that she considered calling "911" herself since RN #1 was slow to respond to the situation, but she did not. LPN #2 stated that she did not consider initiating CPR on Resident #1. The LPN stated that "the RN is in charge and should be making the decisions". During a telephone interview on [DATE] at approximately 12:30 PM, RN #1 stated that she was the full time RN Supervisor in the facility on the 3:00 PM to 11:00 PM shift. RN #1 stated that on [DATE], she arrived at the facility at approximately 3:15 PM. She stated that she observed Resident #1 sitting at the nurse's desk in a wheelchair with his eyes closed and the resident appeared to be sleeping. She stated that that the day shift LPN (LPN #1) had informed her that the resident's vital signs were stable and that maybe he was lethargic due to the [MEDICATION NAME]. RN #1 stated that she did not assess the resident at that time. RN #1 stated that at approximately 6:30 PM, she was feeding residents in the Dining Room when LPN #2 informed her that the resident did not have a blood pressure. RN #1 stated that she came out of the dining room to where Resident #1 was sitting in the hallway, to check his vital signs. She stated that she could not get a blood pressure but that the resident's oxygen saturation level was 95%, his temperature was 95.2 degrees (normal 98.6), pulse was "54" and respirations were 24 (normal 12 to 20). The RN Supervisor (RN #1) stated that she did not check the resident's code status. RN #1 stated that she went back in the Dining Room to continue feeding residents with the plan to send the resident to the hospital. She stated that it did not occur to her that the resident's condition was declining, since he seemed the same as he did when she saw him at 3:15 PM. RN #1 stated a few minutes later, CNA #1 told her that the resident was getting cyanotic (bluish discoloration of the skin due to decreased oxygen in the blood). RN #1 stated that she immediately went to the desk to call the Physician and begin the process of sending the resident to the hospital. RN #1 stated that during this time, CNA#1 took the resident to his room. RN #1 stated that at approximately 7:05 PM, CNA #1 came out of the resident's room and told her that the resident was dead. RN #1 stated that she went to the room to check the resident and "found him not breathing with no pulse". The RN stated that she "knew he was gone". RN #1 stated that she attempted to get him into bed (from the wheelchair) but could not, so she draped a flat sheet over his body and went to call the resident's daughter. RN #1 stated that she was not aware of the resident's code status and she did not check to see what it was. The RN stated that she "did not even know if the resident had an ID band on". RN #1 stated that she is totally responsible for her actions and she should have done something sooner to address the resident's condition. She stated that she should have gotten an ambu bag (a hand held device used to provide artificial ventilation to an individual who is not breathing) and she should have started CPR. RN #1 stated in retrospect, she should have sent the resident to the hospital at 3:15 PM. Interview with the Administrator on [DATE] at approximately 1:00 PM revealed that the facility initially identified that RN #1 was responsible for not providing CPR to Resident #1. During a follow-up interview on [DATE] at approximately 2:30 PM, the Administrator stated that LPNs #2 and 3 were also responsible to take actions to address the resident's medical condition. The Physician stated during a telephone interview on [DATE] at approximately 2:00 PM that when the nurses found the resident unresponsive and without vital signs, they should have initiated CPR, called 911, and then called her in that order. c.) Review of a facility policy and procedure entitled Cardio-Pulmonary Resuscitation (CPR) dated ,[DATE] revealed that CPR will be performed by licensed nurses and CPR certified staff that are trained in and able to perform CPR. All licensed nurses certified in CPR will know which residents requested Full Code status and will be aware of the facility policy, the location of the Full Code list, and the identifying blue band. If a resident appears to have an arrest (the abrupt loss of heart and respiratory function), the licensed nurse will determine if there is a heart rate and respirations present. Review of the personnel files for the two LPNs (LPNs #2 and 3) on duty the evening of [DATE] revealed that their CPR certifications had lapsed in October, 2014. Review of CPR certifications for the remaining nursing staff in the facility revealed that five licensed nurses (three RNS, two LPNS) including the Director of Nursing (DON) had CPR certifications that lapsed. One agency staff LPN, who had been working at the facility through [DATE], had an unacceptable online CPR certification. Review of the facility staffing sheets from [DATE] through [DATE] revealed there were multiple shifts without CPR certified staff on duty. The following days and shifts were identified to have nursing staff with lapsed CPR certification or unacceptable online certification: - [DATE] - night shift - [DATE] and [DATE]- night shift - [DATE] - both the day shift and the night shift - [DATE] - night shift - [DATE] - day shift - [DATE] night shift - [DATE] and [DATE] - night shift - [DATE] and [DATE] - day shift and night shift - [DATE] - night shift - [DATE] - day shift and night shift - [DATE] - evening shift - [DATE] through [DATE] - day shift and evening shift - [DATE] - day shift and evening shift - [DATE] - day shift and night shift Interview with the Administrator on [DATE] at 1:15 PM revealed he did not know that the nursing staff CPR certifications had expired. The Administrator stated that he was made aware of the expired certifications after the facility's investigation of this incident. The Administrator stated that he was unaware that online certification was no longer an acceptable means of recertification for CPR. He stated that the Business Office Manager was responsible for tracking CPR certifications and that the expiration of staff certification was missed. Interview with the Business Office Manager on [DATE] at 2:00 PM revealed she does keep a copy of staff CPR certification in a book in her office but she was not watching the dates of expiration. She stated since this incident her procedure would be changing. Interview with the DON on [DATE] at 2:00 PM revealed she was not aware that there were nursing staff who were not currently certified in CPR and she was not aware that there were shifts without CPR certified staff on duty. The DON stated she also was not aware that online certification was not a valid recertification method for CPR. She reported that agency staff are used for staffing needs and that the same agency staff members were used for consistency. The DON stated that agency staff are required to be CPR certified before they can work at the facility. The DON stated she believed that all agency staff being used at the facility at this time were currently certified. 2. During an interview on [DATE] at 4:00 PM, the Administrator stated that actions were taken to remove the Immediate Jeopardy situation in the facility. a.) Review of a letter to the New York State Department of Health, signed by the Administrator dated [DATE] revealed an Immediate Jeopardy Abatement Plan was submitted included the following: - "A 100% audit of Advanced Directives was completed and colored bands verified to reflect the code status of each resident. Care Guides and Care Plans were reviewed for accuracy". - "After record review, additional audits were completed for Hospital Discharge/ Change of Condition". - "All Care Plans and Care Guides were updated with any corrections for code status". - All active Medical Records were reviewed back to [DATE] for physician and family notification and change of condition". - All licensed nurses, full and part time, were re-inserviced on "Change of condition" and "Physician and family notification of change in condition". - A 100% audit of all residents and their code status was completed including: a. Paperwork, HCP (health care proxy), and gold sheets DNR (do not resuscitate - to with hold emergency resuscitation measures if an individual stops breathing or heart stops) consent b. "Care Plans and Care Guides updated" c. "Master list of Full Codes redeveloped and posted at the nurses station, crash cart and MARS (medication administration records)". - "All licensed staff were re-inserviced for CPR Certification. CPR training classes were scheduled". - "The staffing schedule was revised to plan for two certified staff per shift". - "All FT (full time)/PT (part time) staff were inserviced to assure accurate identification of DNR, CPR (bands)". - "The Social Worker was inserviced for Advanced Directives". b.) Observations and interviews on [DATE] revealed the following: - Observations on [DATE] at approximately 3:00 PM, of the following residents currently residing in the facility, revealed that the residents had correct resuscitation status name bands on in accordance with their Advance Directive documentation and physician's orders [REDACTED]. Residents #11, 12, 13, and 14 were identified as DNR. Resident #15 was identified as a Full Code. - Interviews with RN #2, LPNs #4, 5, and 6 and CNA #1 on [DATE] between 2:00 PM and 3:00 PM revealed the staff were inserviced on Advance Directives including accurate identification of DNR/ CPR bands, resident change of condition, and physician notification of change of condition. 415.26

Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint # NY 500) completed on [DATE], the facility did not consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. One (Resident #1) of five residents reviewed for physician notification had issues involving the lack of timely physician notification when the resident experienced multiple significant changes in condition. Nursing staff did not notify the physician when the resident was initially noted to be lethargic during the day shift on [DATE]; when the resident was unresponsive and without a blood pressure during the supper meal; and when the resident's fingers became cyanotic (bluish discoloration of the skin due to decreased oxygen in the blood). This resulted in IMMEDIATE JEOPARDY WITH ACTUAL HARM AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate jeopardy was removed on [DATE], prior to the completion of the survey. The findings are: 1. Resident #1 was admitted to the facility for rehabilitation on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sheet ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment, usually understands, and was usually understood. Review of the medical record Face Sheet revealed the resident was identified as having a Full Code status (the provision of emergency measures in attempt to resuscitate an individual in the event that breathing or heartbeat stops). Review of admission "physician's orders [REDACTED]. Review of an Interdisciplinary Progress Note, written by a registered nurse (RN #2), dated [DATE] at 8:30 AM revealed that the resident was noted to have increased behaviors, was combative with care, and striking out at staff. The RN documented that the physician ordered to increase [MEDICATION NAME] to 10 mg daily. Review of a Physician's Telephone Order dated [DATE] revealed an order to increase [MEDICATION NAME] to 10 mg daily by mouth for behaviors. a. LACK OF PHYSICIAN NOTIFICATION OF A CHANGE IN THE RESIDENT'S CONDITION DURING THE DAY SHIFT Review of a facility "Investigation Statement", written by a licensed practical nurse (LPN #1) dated [DATE] revealed that Resident #1 consumed 50 percent (%) of his breakfast on [DATE]. After breakfast, the resident was placed in a reclining wheelchair and was seated by the nurses' station. LPN #1 documented that the resident had an oxygen saturation (amount of oxygen in the blood) of 95% (percent) (normal 90 to 100 %) on room air; a blood pressure of ,[DATE] (normal) and a respiratory rate of 20 (normal 12 to 20) that was non-labored. The LPN documented that the resident had no shortness of breath or respiratory distress. In addition, LPN #1 documented that the resident did not eat lunch. The LPN documented that she reported to RN #1 (evening shift RN Supervisor) that the resident slept all afternoon and his vital signs were stable. LPN #1 told RN #1 that the resident may have been up all night "or maybe the [MEDICATION NAME]." During a telephone interview on [DATE] at approximately 12:00 PM, LPN #1 stated that she worked the 6:00 AM to 2:00 PM shift on [DATE]. LPN #1 stated that Resident #1 ate 50% of his breakfast and was then placed in a reclining wheelchair. LPN #1 stated that at lunchtime, the resident stated "leave me alone" and he did not consume any of his lunch. The LPN stated that she obtained vital signs (blood pressure, pulse, temperature, respiratory rate) at approximately 1:00 PM and they were stable. LPN #1 stated that the resident slept the rest of the afternoon in the reclining wheelchair, but was arousable and responsive. LPN #1 stated that at approximately 3:00 PM, she reported to RN #1 that the resident was very sleepy but arousable and advised her to keep an eye on him due to the [MEDICATION NAME]. LPN #1 stated that she did not notify the Physician of the resident's condition. Review of Nursing Interdisciplinary Progress Notes and 24-Hour Nursing Services Reports dated [DATE] revealed no documented evidence that the physician was notified that Resident #1 was lethargic during the day shift on [DATE]. Telephone interview with RN #1 on [DATE] at 12:30 PM revealed that she worked the 3:00 PM to 11:00 PM shift on [DATE] . RN #1 stated that she arrived at approximately 3:15 PM and observed the resident sitting at the nurses' desk with his eyes closed and he appeared to be sleeping. The RN stated that the day shift LPN (LPN # 1) informed her that the resident's vital signs were stable and that the resident's lethargy was possibly due to the [MEDICATION NAME]. RN #1 stated that she did not assess the resident at the time nor did she contact the Physician about the resident's lethargy. During a telephone interview on [DATE] at approximately 2:00 PM, the Physician stated that she tells staff that when residents are on [MEDICAL CONDITION] medications, if there is any change in the resident's condition including increased lethargy or decreased intake, they should call her and she will instruct them to hold the medication and she will re-evaluate. The Physician stated that staff should have called her "during the day when the resident was getting worse". Interview with a certified nurse aide (CNA #1) on [DATE] at 3:00 PM revealed that she worked the 2:00 PM to 10:00 PM shift on [DATE]. CNA #1 stated that at approximately 6:00 PM while in the dining room, she observed that Resident #1 couldn't keep his head up; he was not responding; and he was drooling. She stated that the resident didn't look good and would not wake up. CNA #1 stated that she told RN #1 at approximately 6:00 PM that the resident was not responding. CNA #1 stated that RN #1 came over to look at the resident and stated "he's fine, he's had a medication change", and walked away. b.) LACK OF PHYSICIAN NOTIFICATION OF A SIGNIFICANT CHANGE IN CONDITION Review of the facility's investigation of the events involving Resident #1 on [DATE] revealed an "Investigation Statement" written by RN #1 dated [DATE] at 3:20 PM. The written statement documented that on [DATE] at approximately 6:25 PM, Resident #1 was "wheeled (transported in a wheelchair) out" of the dining room into the hall. At 6:30 PM, RN #1 came out of the dining room to take the resident's vital signs (temperature, blood pressure, pulse, respiratory rate) because a Licensed Practical Nurse (LPN #2) was having difficulty obtaining a blood pressure (BP) reading and thought the resident wasn't doing well. RN #1 documented that the resident's temperature was 95.2 (normal 98.6), pulse was "54" (average 80), and respirations were 24 (normal 12 to 20). The RN's statement documented "there was no BP in the right or left arm"; the SP O2 (oxygen saturation level - amount of oxygen in the blood) was 95 % (percent) (normal 90 to 100 %) on 2 liters of oxygen; lung sounds were diminished; there was [MEDICAL CONDITION] (swelling) of the lower extremities; and the resident had no response to a sternal rub (the application of painful stimulus by vigorously rubbing the sternum with the knuckles of a closed fist to assess consciousness). RN #1 stated that she told the two LPNs that were present that she was going to send the resident "out." RN #1 documented that "she thought she could buy ,[DATE] minutes of time" because the resident's status hadn't changed from when she first saw him at 3:15 PM. RN #1 documented that she went back into the dining room. RN #1 failed to notify the Physician at that time of the significant change in the resident's condition. Additional review of RN #1's written statement revealed the following: - 6:45 PM - CNA #1 came into the dining room and told RN #1 that the resident's fingers were turning blue. RN #1 documented that she immediately went to the desk to start the transfer process, while CNA #1 wheeled the resident to his room. - 6:50 PM - RN #1 notified the on-call Physician of the resident's status, relayed to the Physician her assessment and the vital signs. The Physician gave a verbal order to transfer the resident to the hospital. - 7:05 PM - RN #1 documented that she began to call the ambulance company when CNA #1 came out to the desk to tell her that the resident was dead. At 7:05 PM, RN #1 entered the resident's room and found that the resident was not breathing, with no heart rate and no blood pressure. During a telephone interview on [DATE] at approximately 12:00 PM, LPN #2 stated that she worked the 6:00 PM to 6:00 AM shift on [DATE]. LPN #2 stated that she was told on report by the supervisor that Resident #1 was lethargic probably due to [MEDICATION NAME] (antipsychotic medication). LPN #2 stated that at approximately 6:30 PM, she went to the Main Dining Room to check on the residents. LPN #2 stated she found Resident #1 sitting (in his wheelchair), with his chin to his chest, his arms to his side, and he was not responsive. The LPN stated that she did a sternal rub with no response. LPN #2 stated moved the resident out of the Dining Room into the hallway and she could not obtain a blood pressure on the resident but got an oxygen saturation of 95 %. LPN # 2 stated that she told LPN #3 who also could not get a response from the resident. LPN #2 stated that they notified RN #1 who was in the Main Dining Room. RN #1 came out of the Dining Room and assessed the resident. RN #1 could not get a blood pressure but obtained an oxygen saturation of 95% and a pulse of "44" (not 54 as reported by RN #1). LPN #2 stated that RN #1 told the LPNs that they should compare these vital signs to the day shift vitals. LPN #3 could not find the day shift vital signs at the desk, so RN #1 said "we're going to send him out". LPN #2 stated that RN #1 then went back into the dining room to feed the other residents. LPN #2 stated that at that time, she disconnected the resident's oxygen tank (which was not quite empty) and filled it partially. LPN #2 stated that the tank was only off the resident for three to five minutes. LPN #2 stated that the resident remained in the wheelchair in the hallway and approximately ,[DATE] minutes later, she noticed that the resident's fingers were turning blue. CNA #1 was walking past. LPN #2 stated that she told CNA #1 to tell RN #1 about the resident's fingers being blue. She stated that RN #1 came out of the dining room to send the resident to the hospital. During a telephone Interview with LPN #3 on [DATE] at approximately 3:00 PM, the LPN stated that she worked the 6:00 PM to 6:00 AM shift on [DATE] . She stated that she was told by the day shift nurse (LPN) that Resident #1 was lethargic due to his [MEDICATION NAME]. LPN #3 stated that at approximately 6:30 PM, LPN #2 brought the resident out of the Dining Room into the hallway and asked her to check the resident. LPN #3 stated that she did a sternal rub and there was no response from the resident so they informed RN #1 who was in the dining room with the other residents. LPN #3 stated that RN #1 came out and assessed the resident's vital signs. The RN obtained a pulse of "44", an oxygen saturation of 95 %, and no BP. RN #1 instructed LPN #3 to check the resident's vital signs from the day shift. LPN #3 stated that she could not find the day shift vital signs at the desk so RN #1 stated "we are going to send him to the hospital". LPN #3 was at the nurses' desk at approximately 6:40 PM when the resident's daughter called and LPN #3 informed her that they were going to send him to the hospital. LPN #3 stated that after the phone call, she went back to the resident in the hallway. LPN #2 was still with the resident and RN #1 was in the dining room feeding the other residents. At this time, LPN #2 showed her the resident's fingers which were purple. LPN #3 stated that she instructed CNA #1 to tell RN #1 that the resident's fingers were blue. During the telephone interview, LPN #3 stated that she took the resident to his room and went to the copy machine to make copies of the resident's medication records for the hospital transfer. During a telephone interview on [DATE] at approximately 12:30 PM, RN #1 stated that she was the full time RN Supervisor in the facility on the 3:00 PM to 11:00 PM shift. RN #1 stated that on [DATE], she arrived at the facility at approximately 3:15 PM. She stated that she observed Resident #1 sitting at the nurse's desk in a wheelchair with his eyes closed and the resident appeared to be sleeping. She stated that that the day shift LPN (LPN #1) had informed her that the resident's vital signs were stable and that maybe he was lethargic due to the [MEDICATION NAME]. RN #1 stated that she did not assess the resident at that time. RN #1 stated that at approximately 6:30 PM, she was feeding residents in the Dining Room when LPN #2 informed her that the resident did not have a blood pressure. RN #1 stated that she came out of the dining room to where Resident #1 was sitting in the hallway, to check his vital signs. She stated that she could not get a blood pressure but that the resident's oxygen saturation level was 95%, his temperature was 95.2 degrees, pulse was 54 and respirations were 24. RN #1 stated that she went back in the Dining Room to continue feeding residents with the plan to send the resident to the hospital. She stated that it did not occur to her that the resident's condition was declining, since he seemed the same as he did when she saw him at 3:15 PM. RN #1 stated a few minutes later, CNA #1 told her that the resident was getting cyanotic (bluish discoloration of the skin due to decreased oxygen in the blood). RN #1 stated that she immediately went to the desk to call the Physician and begin the process of sending the resident to the hospital. RN #1 stated that during this time, CNA#1 took the resident to his room. RN #1 stated that at approximately 7:05 PM, CNA #1 came out of the resident's room and told her that the resident was dead. RN #1 stated that she went to the room to check the resident and "found him not breathing with no pulse". The RN stated that she "knew he was gone". Interview with CNA #1 on [DATE] at 3:00 PM revealed that CNA #1 worked the 2:00 PM - 10:00 PM shift on [DATE]. The CNA stated that she was in the Dining Room at approximately 6:00 PM and she observed that Resident #1 couldn't keep his head up, he was not responding, and he was drooling. She stated that the resident "didn't look good and would not wake up". CNA #1 stated that she told RN #1 at approximately 6:00 PM that the resident was not responding. CNA #1 stated that RN #1 came over to look at the resident and stated "he's fine, he's had a medication change", and walked away. CNA #1 stated that "awhile later", LPN #2 and LPN #3 were in the hallway with the resident. The LPNs told her that the resident's hands were blue and to go tell RN #1 about it. CNA #1 stated that she went into the dining room to tell RN #1 that the resident's hands were blue and that she needed to do something. CNA #1 stated that RN #1 said that she "had to finish her intakes first". CNA #1 said she told RN #1 that she would finish the intakes for her. CNA #1 stated that one of the LPNs took Resident #1 to his room. CNA #1 stated that she went to the resident's room and sat with him for a few minutes then left to care for two other resident's. The CNA stated that when she returned to the resident's room about 15 minutes later, he was not breathing and she "knew he was dead". CNA #1 stated that she went out to the nurse's station to tell RN #1 that the resident was gone. The Physician stated during a telephone interview on [DATE] at approximately 2:00 PM that when the nurses found the resident unresponsive and without vital signs, they should have initiated CPR, called 911, and then called her in that order In summary, the nursing staff including RN #1, LPN #2 and LPN #3 failed to contact the Physician in a timely manner on [DATE] at approximately 6:30 PM when the resident was unresponsive, had no blood pressure, and no response to a sternal rub. 2. During an interview on [DATE] at 4:00 PM, the Administrator stated that actions were taken to remove the Immediate Jeopardy situation in the facility. a.) Review of a letter to the New York State Department of Health, signed by the Administrator dated [DATE] revealed an Immediate Jeopardy Abatement Plan was submitted included the following: - "A 100% audit of Advanced Directives was completed and colored bands verified to reflect the code status of each resident. Care Guides and Care Plans were reviewed for accuracy". - "After record review, additional audits were completed for Hospital Discharge/ Change of Condition". - "All Care Plans and Care Guides were updated with any corrections for code status". - All active Medical Records were reviewed back to [DATE] for physician and family notification and change of condition". - All licensed nurses, full and part time, were re-inserviced on "Change of condition" and "Physician and family notification of change in condition". - A 100% audit of all residents and their code status was completed including: a. Paperwork, HCP (health care proxy), and gold sheets DNR (do not resuscitate - to with hold emergency resuscitation measures if an individual stops breathing or heart stops) consent b. "Care Plans and Care Guides updated" c. "Master list of Full Codes redeveloped and posted at the nurses station, crash cart and MARS (medication administration records)". - "All licensed staff were re-inserviced for CPR Certification. CPR training classes were scheduled". - "The staffing schedule was revised to plan for two certified staff per shift". - "All FT (full time)/PT (part time) staff were inserviced to assure accurate identification of DNR, CPR (bands)". - "The Social Worker was inserviced for Advanced Directives". b.) Observations and interviews on [DATE] revealed the following: - Observations on [DATE] at approximately 3:00 PM, of the following residents currently residing in the facility, revealed that the residents had correct resuscitation status name bands on in accordance with their Advance Directive documentation and physician's orders [REDACTED]. Residents #11, 12, 13, and 14 were identified as DNR. Resident #15 was identified as a Full Code. - Interviews with RN #2, LPNs #4, 5, and 6 and CNA #1 on [DATE] between 2:00 PM and 3:00 PM revealed the staff were inserviced on Advance Directives including accurate identification of DNR/ CPR bands, resident change of condition, and physician notification of change of condition. 415.3(e)(2)(ii)(b)

Based on observation, interview, and record review conducted during a Partial Extended survey (Complaint # NY 500) completed on [DATE], the facility failed to implement written policies and procedures that prohibit neglect of residents. One (Resident #1) of five residents reviewed for neglect had issues including the provider's failure to assess a change in condition of the resident, failure to notify the Physician of a change in the resident's condition, and failure of staff to initiated cardiopulmonary resuscitation (CPR- emergency resuscitation measures, including artificial ventilation and chest compressions) on an unresponsive resident with a Full Code Status (the provision of emergency measures in attempt to resuscitate an individual, in the event that breathing or heartbeat stops). One Registered Nurse (RN) and two Licensed Practical Nurse (LPNs) failed to provide CPR to the resident with a Full Code Status resulting in his death. This resulted in actual harm that is IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The immediate jeopardy was removed on [DATE], prior to the completion of the survey. The findings are: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Sheet ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment, usually understands, and was usually understood. Review of the medical record Face Sheet revealed the resident was identified as having a Full Code status. a.) LACK OF RN ASSESSMENT OF A SIGNIFICANT CHANGE IN THE RESIDENT'S CONDITION. Review of admission "physician's orders [REDACTED]. Review of an "Interdisciplinary Progress Note", written by a registered nurse (RN #2), dated [DATE] at 8:30 AM revealed the resident was noted to have increased behaviors; was combative with care; and was striking out at staff. RN #2 documented that the Physician ordered to increase [MEDICATION NAME] to 10 mg daily. Review of a Physician's Telephone Order dated [DATE] revealed an order to increase [MEDICATION NAME] to 10 mg by mouth daily for behaviors. Review of an "Investigation Statement", written by a licensed practical nurse (LPN #1), dated [DATE]revealed that the resident consumed 50% of his breakfast on [DATE]. After breakfast, the resident was placed in a reclining wheelchair and was seated by the nurses' station. LPN #1 documented on the investigation form that the resident had an oxygen saturation (amount of oxygen in the blood) of 95% (percent) (normal 90 to 100%) on room air, a blood pressure of ,[DATE] (normal) and the respiratory rate was 20 (normal 12 to 20) and non-labored. LPN #1 documented that the resident had no shortness of breath or respiratory distress. Additional review of the Investigation Statement revealed that the resident did not eat lunch on [DATE]. The LPN further documented that she reported to RN #1 (evening shift RN Supervisor) that the resident slept all afternoon and his vital signs were stable. LPN #1 told RN #1 that the resident may have been up all night "or maybe the [MEDICATION NAME]." During a telephone interview on [DATE] at approximately 12:00 PM, LPN #1 stated that on [DATE] she worked the 6:00 AM to 2:00 PM shift. The LPN stated that Resident #1 ate 50% of his breakfast and then was placed in the reclining wheelchair. LPN #1 stated that at lunchtime the resident stated "leave me alone" and did not consume any of his lunch. She stated that she obtained vital signs at approximately 1:00 PM and they were stable. LPN #1 stated that the resident slept the rest of the afternoon in the reclining wheelchair but was arousable and responsive. LPN #1 stated that at approximately 3:00 PM, she reported to RN #1 that the resident was very sleepy but arousable and advised her to keep an eye on him due to the [MEDICATION NAME]. LPN #1 stated that she did not notify the Physician of the resident's condition. Telephone interview with RN #1 on [DATE] at 12:30 PM revealed that she worked the 3:00 PM to 11:00 PM shift on [DATE]. The RN stated she arrived at approximately 3:15 PM and observed Resident #1 sitting at the nurses' desk with his eyes closed and he appeared to be sleeping. She stated that the day shift LPN (LPN #1) informed her that the resident's vital signs were stable and that the resident's lethargy was possibly due to the [MEDICATION NAME]. RN #1 stated that she did not assess the resident at the time nor did she contact the Physician about the resident's lethargy. During an interview on [DATE] at 3:00 PM, the certified nurse aide (CNA #1) stated that she worked the 2:00 PM to 10:00 PM shift on [DATE]. CNA #1 stated that at approximately 6:00 PM while in the dining room she observed that Resident #1 couldn't keep his head up, he was not responding, and he was drooling. She stated that the resident "didn't look good and would not wake up". CNA #1 stated that she told RN #1 at approximately 6:00 PM that the resident was not responding. CNA #1 stated that RN #1 came over to look at the resident and stated "he's fine, he's had a medication change" and walked away. During a telephone interview on [DATE] at approximately 2:00 PM, the Physician stated that she tells staff that when residents are on [MEDICAL CONDITION] medications, if there is any change in the resident's condition including increased lethargy or decreased intake that they should call her and she will instruct them to hold the medication and then she will re-evaluate. The Physician stated that staff should have called her during the day when the resident was getting worse. b.) LACK OF ONGOING MONITORING AND RN ASSESSMENT OF SIGNIFICANT CHANGES IN THE RESIDENT'S CONDITION AND FAILURE OF NURSING STAFF TO PROVIDE CPR. Review of the facility investigation of the incident that ocurred on [DATE] revealed an "Investigation Statement" written by RN #1 dated [DATE] at 3:20 PM. The written statement documented that on [DATE] at approximately 6:25 PM, Resident #1 was "wheeled (transported in a wheelchair) out" of the dining room into the hall. At 6:30 PM, RN #1 came out of the dining room to take the resident's vital signs (temperature, blood pressure, pulse, respiratory rate) because a Licensed Practical Nurse (LPN #2) was having difficulty obtaining a blood pressure (BP) reading and thought the resident wasn't doing well. RN #1 documented that the resident's temperature was 95.2 (normal 98.6), pulse was "54" (average 80), and respirations were 24 (normal 12 to 20). The RN's statement documented "there was no BP in the right or left arm"; the SP O2 (oxygen saturation level - amount of oxygen in the blood) was 95 % (percent) (normal 90 to 100 %) on 2 liters of oxygen; lung sounds were diminished; there was [MEDICAL CONDITION] (swelling) of the lower extremities; and the resident had no response to a sternal rub (the application of painful stimulus by vigorously rubbing the sternum with the knuckles of a closed fist to assess consciousness). RN #1 stated that she told the two LPNs that were present that she was going to send the resident "out." RN #1 documented that "she thought she could buy ,[DATE] minutes of time" because the resident's status hadn't changed from when she first saw him at 3:15 PM. RN #1 documented that she went back into the dining room. Additional review of RN #1's written statement revealed the following: - On [DATE] at 6:40 PM - The resident's daughter called and LPN #3 told her that "we would be sending (the resident) to the hospital because he was not doing well and not responding to any verbal or tactile stimulation". - 6:45 PM - CNA #1 came into the dining room and told RN #1 that the resident's fingers were turning blue. RN #1 documented that she immediately went to the desk to start the transfer process, while CNA #1 wheeled the resident to his room. - 6:50 PM - RN #1 notified the on-call Physician of the resident's status, relayed to the Physician her assessment and the vital signs. The Physician gave a verbal order to transfer the resident to the hospital. - 6:55 PM - The resident's daughter was notified that the resident was being transferred to the emergency room . RN #1 documented that she extracted the necessary forms from the resident's chart and gave them to LPN #3 to copy. At 6:55 PM, RN #1 documented that she started filling out the transfer forms. - 7:05 PM - RN #1 documented that she began to call the ambulance company when CNA #1 came out to the desk to tell her that the resident was dead. At 7:05 PM, RN #1 entered the resident's room and found that the resident was not breathing, with no heart rate and no blood pressure. RN #1 went back to the desk and attempted to call the resident's daughter. There was no answer. - 7:15 PM - RN #1 contacted the Coroner. RN #1 called the resident's daughter again and informed her that the resident had passed away. RN #1 went back to the resident's room to attempt to transfer him back to bed (from the wheelchair), but was unsuccessful so she draped a flat sheet over the resident's body. - 8:00 PM - The Coroner arrived and pronounced the resident's death at 8:16 PM. Review of the Director of Nursing's (DON) summary of her interview with RN #1 (dated [DATE]) revealed that the DON asked RN #1 what the resident's code status was. RN #1 stated that he was a "Full Code" and then stated "Oh, maybe not." After the DON checked the resident's chart, the DON informed RN #1 that Resident #1 was a Full Code. The DON asked RN #1 why she did not start the code and RN #1 stated that there was so much going on and she did not look at the resident's code status. During a telephone interview on [DATE] at approximately 12:00 PM, LPN #2 stated that she worked the 6:00 PM to 6:00 AM shift on [DATE]. LPN #2 stated that she was told on report by the supervisor that Resident #1 was lethargic probably due to [MEDICATION NAME] (antipsychotic medication). LPN #2 stated that after counting narcotics at the beginning of her shift, she went to the Main Dining Room to check on the residents. LPN #2 stated she found Resident #1 sitting (in his wheelchair), with his chin to his chest, his arms to his side, and he was not responsive. The LPN stated that she did a sternal rub with no response. LPN #2 stated moved the resident out of the Dining Room into the hallway and she could not obtain a blood pressure on the resident but got an oxygen saturation of 95 %. LPN # 2 stated that she told LPN #3 who also could not get a response from the resident. LPN #2 stated that they notified RN #1 who was in the Main Dining Room. RN #1 came out of the Dining Room and assessed the resident. RN #1 could not get a blood pressure but obtained an oxygen saturation of 95% and a pulse of 44. LPN #2 stated that RN #1 told the LPNs that they should compare these vital signs to the day shift vitals. LPN #3 could not find the day shift vital signs at the desk so RN #1 said "we're going to send him out". LPN #2 stated that RN #1 then went back into the dining room to feed the other residents. LPN #2 stated that at that time, she disconnected the resident's oxygen tank (which was not quite empty) and filled it partially. LPN #2 stated that the tank was only off the resident for three to five minutes. LPN #2 stated that the resident remained in the wheelchair in the hallway and approximately ,[DATE] minutes later, she noticed that the resident's fingers were turning blue. CNA #1 was walking past. LPN #2 stated that she told CNA #1 to tell RN #1 about the resident's fingers being blue. She stated that RN #1 came out of the dining room to send the resident to the hospital. LPN #2 stated that the resident was taken to his room by another staff member. LPN #2 stated that she let RN #1 and LPN #3 handle the situation from that point on. LPN #2 stated that a short time later she found out from RN #1 that the resident had expired. LPN #2 stated that she was not aware of the resident's code status, she did not check to see what it was, and she did not know if the resident had a code status ID (identification) band on. LPN #2 stated that she considered calling "911" herself since RN #1 was slow to respond to the situation, but she did not. LPN #2 stated that she did not consider initiating CPR on Resident #1. LPN #2 stated that "the RN is in charge and should be making the decisions". During a telephone interview on [DATE] at approximately 3:00 PM, LPN #3 stated that she worked the 6:00 PM to 6:00 AM shift on [DATE] . She stated that she was told by the day shift nurse (LPN) that Resident #1 was lethargic due to his [MEDICATION NAME]. LPN #3 stated that at approximately 6:30 PM, LPN #2 brought the resident out of the Dining Room into the hallway and asked her to check the resident. LPN #3 stated that she did a sternal rub and there was no response from the resident so they informed RN #1 who was in the dining room with the other residents. LPN #3 stated that RN #1 came out and assessed the resident's vital signs. The RN obtained a pulse of "44", an oxygen saturation of 95 %, and no BP. RN #1 instructed LPN #3 to check the resident's vital signs from the day shift. LPN #3 stated that she could not find the day shift vital signs at the desk so RN #1 stated "we are going to send him to the hospital". LPN #3 was at the nurse's desk at approximately 6:40 PM when the resident's daughter called and LPN #3 informed her that they were going to send him to the hospital. LPN #3 stated that after the phone call, she went back to the resident in the hallway. LPN #2 was still with the resident and RN #1 was in the dining room feeding the other residents. At this time, LPN #2 showed her the resident's fingers which were purple. LPN #3 stated that she instructed CNA #1 to tell RN #1 that the resident's fingers were blue. During the telephone interview, LPN #3 stated that she took the resident to his room and went to the copy machine to make copies of the resident's medication records for the hospital transfer. LPN #3 stated that she thought that CNA #1 was with the resident in his room. LPN #3 stated that while making copies, CNA #1 came down the hall and stated that the resident was dead. LPN #3 stated that she was not aware of the resident's code status; she did not check the resident's code status; and she did not know if he had a code status ID band on. LPN #3 stated that she did not consider initiating CPR on the resident because the resident was breathing when she was with him. She stated that she did not consider calling "911" because she knew the resident was being sent to the hospital. LPN #3 stated that "the RN Supervisor is supposed to take the lead in these situations". LPN #3 stated that she completed her CPR certification online on [DATE] and she was not CPR certified on [DATE] (the day that Resident #1 died ). During a telephone interview on [DATE] at approximately 12:30 PM, RN #1 stated that she was the full time RN Supervisor in the facility on the 3:00 PM to 11:00 PM shift. RN #1 stated that on [DATE], she arrived at the facility at approximately 3:15 PM. She stated that she observed Resident #1 sitting at the nurse's desk in a wheelchair with his eyes closed and the resident appeared to be sleeping. She stated that that the day shift LPN (LPN #1) had informed her that the resident's vital signs were stable and that maybe he was lethargic due to the [MEDICATION NAME]. RN #1 stated that she did not assess the resident at that time. RN #1 stated that at approximately 6:30 PM, she was feeding residents in the Dining Room when LPN #2 informed her that the resident did not have a blood pressure. RN #1 stated that she came out of the dining room to where Resident #1 was sitting in the hallway, to check his vital signs. She stated that she could not get a blood pressure but that the resident's oxygen saturation level was 95%, his temperature was 95.2 degrees, pulse was "54" and respirations were 24. The RN Supervisor (RN #1) stated that she did not check the resident's code status. RN #1 stated that she went back in the Dining Room to continue feeding residents with the plan to send the resident to the hospital. She stated that it did not occur to her that the resident's condition was declining, since he seemed the same as he did when she saw him at 3:15 PM. RN #1 stated a few minutes later, CNA #1 told her that the resident was getting cyanotic (bluish discoloration of the skin due to decreased oxygen in the blood). RN #1 stated that she immediately went to the desk to call the Physician and begin the process of sending the resident to the hospital. RN #1 stated that during this time, CNA#1 took the resident to his room. RN #1 stated that at approximately 7:05 PM, CNA #1 came out of the resident's room and told her that the resident was dead. RN #1 stated that she went to the room to check the resident and "found him not breathing with no pulse". The RN stated that she "knew he was gone". RN #1 stated that she attempted to get him into bed (from the wheelchair) but could not, so she draped a flat sheet over his body and went to call the resident's daughter. RN #1 stated that she was not aware of the resident's code status and she did not check to see what it was. RN #1 stated that she "did not even know if the resident had an ID band on". RN #1 stated that she is totally responsible for her actions and she should have done something sooner to address the resident's condition. She stated that she should have gotten an ambu bag (a hand held device used to provide artificial ventilation to an individual who is not breathing) and she should have started CPR. RN #1 stated in retrospect, she should have sent the resident to the hospital at 3:15 PM. Interview with CNA #1 on [DATE] at 3:00 PM revealed that CNA #1 worked the 2:00 PM - 10:00 PM shift on [DATE]. The CNA stated that she was in the Dining Room at approximately 6:00 PM and she observed that Resident #1 couldn't keep his head up, he was not responding, and he was drooling. She stated that the resident "didn't look good and would not wake up". CNA #1 stated that she told RN #1 at approximately 6:00 PM that the resident was not responding. CNA #1 stated that RN #1 came over to look at the resident and stated "he's fine, he's had a medication change", and walked away. CNA #1 stated that "awhile later", LPN #2 and LPN #3 were in the hallway with the resident. The LPNs told her that the resident's hands were blue and to go tell RN #1 about it. CNA #1 stated that she went into the dining room to tell RN #1 that the resident's hands were blue and that she needed to do something. CNA #1 stated that RN #1 said that she "had to finish her intakes first". CNA #1 said she told RN #1 that she would finish the intakes for her. CNA #1 stated that one of the LPNs took Resident #1 to his room. CNA #1 stated that she went to the resident's room and sat with him for a few minutes then left to care for two other resident's. CNA #1 stated that when she returned to the resident's room about 15 minutes later, he was not breathing and she "knew he was dead". CNA #1 stated that she went out to the nurse's station to tell RN #1 that the resident was gone. The Physician stated during a telephone interview on [DATE] at approximately 2:00 PM that when the nurses found the resident unresponsive and without vital signs, they should have initiated CPR, called 911, and then called her in that order. 2. During an interview on [DATE] at 4:00 PM, the Administrator stated that actions were taken to remove the Immediate Jeopardy situation in the facility. a.) Review of a letter to the New York State Department of Health, signed by the Administrator dated [DATE] revealed an Immediate Jeopardy Abatement Plan was submitted included the following: - "A 100% audit of Advanced Directives was completed and colored bands verified to reflect the code status of each resident. Care Guides and Care Plans were reviewed for accuracy". - "After record review, additional audits were completed for Hospital Discharge/ Change of Condition". - "All Care Plans and Care Guides were updated with any corrections for code status". - All active Medical Records were reviewed back to [DATE] for physician and family notification and change of condition". - All licensed nurses, full and part time, were re-inserviced on "Change of condition" and "Physician and family notification of change in condition". - A 100% audit of all residents and their code status was completed including: a. Paperwork, HCP (health care proxy), and gold sheets DNR (do not resuscitate - to with hold emergency resuscitation measures if an individual stops breathing or heart stops) consent b. "Care Plans and Care Guides updated" c. "Master list of Full Codes redeveloped and posted at the nurses station, crash cart and MARS (medication administration records)". - "All licensed staff were re-inserviced for CPR Certification. CPR training classes were scheduled". - "The staffing schedule was revised to plan for two certified staff per shift". - "All FT (full time)/PT (part time) staff were inserviced to assure accurate identification of DNR, CPR (bands)". - "The Social Worker was inserviced for Advanced Directives". b.) Observations and interviews on [DATE] revealed the following: - Observations on [DATE] at approximately 3:00 PM, of the following residents currently residing in the facility, revealed that the residents had correct resuscitation status name bands on in accordance with their Advance Directive documentation and physician's orders [REDACTED]. Residents #11, 12, 13, and 14 were identified as DNR. Resident #15 was identified as a Full Code. - Interviews with RN #2, LPNs #4, 5, and 6 and CNA #1 on [DATE] between 2:00 PM and 3:00 PM revealed the staff were inserviced on Advance Directives including accurate identification of DNR/ CPR bands, resident change of condition, and physician notification of change of condition. 415.4(b)

THIS IS A REPEAT DEFICIENCY FROM THE ABBREVIATED SURVEY COMPLETED ON [DATE]. Based on interview and record review conducted during the Standard survey completed on [DATE], the facility did not immediately consult with the resident's physician or notify the resident's legal representative or an interested family member when there was a significant change in the resident's physical condition. Specifically, one (Resident #1) of one resident reviewed for notification of change lacked timely notification of the Physician and Health Care Agent, regarding significant changes in the resident's oral intake of food and fluids and physical condition. The resident had a marked decrease in oral consumption as well as refusal of meals and fluids during the period of [DATE] through [DATE]. The Physician evaluated the resident on [DATE] and transferred the resident to the hospital with dehydration and respiratory distress. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated [DATE] revealed the resident had severe cognitive impairment with long and short term memory problems, was rarely understood, and rarely understands. Additional review of the MDS revealed the resident was completely dependent for transfers, bed mobility, personal hygiene, oral care and was non-ambulatory. The resident required the limited assistance of one to eat meals. Review of a Health Care Proxy signed by the resident on [DATE] revealed the resident named a Health Care Agent and an alternate Agent to make health care decisions for the resident if she was unable to make her own health care decisions. Review of a Nutritional Screening assessment dated [DATE] revealed the resident's appetite was poor and she required staff encouragement and assistance for meals. The Assessment documented approaches to monitor weights, laboratory results, and oral intakes. Review of a Physician Admission assessment dated [DATE] revealed the resident was admitted to the facility after being transferred from a nearby nursing home. The resident was admitted to the prior nursing home on [DATE] following hospitalization for pneumonia and pleural effusion (excess fluid build up around the lungs). The Assessment documented that the resident had significant dementia and [MEDICAL CONDITION]. A Mini Mental State Examination (MMSE - a test to determine cognitive ability) completed on [DATE] revealed the resident had a score of "0" which indicated severe cognitive impairment. Review of an undated comprehensive Care Plan revealed the resident had poor intakes with a goal for adequate nutrition and hydration. The Care Plan documented an approach to offer 240 cubic centimeters (cc) of fluid three times a day for additional hydration in addition to whole milk at meals and for cereal for additional calories and protein. Review of a Weight Change History Sheet revealed the resident had the following weights: - [DATE] - 153.80 pounds (#) - [DATE] - 157.70# - [DATE] - 151.80# - [DATE] - 144.80# Review of a Dehydration Risk assessment dated [DATE] revealed the resident was identified at risk for dehydration with a score of 8. Review of a Quarterly Nutritional Progress Note dated [DATE] revealed that the Registered Dietitian (RD) estimated that the resident's daily nutritional needs included 2088 calories and 1650 cc of fluid. The RD noted that the resident had a seven pound weight loss in 30 days; a nine pound weight loss in 90 days; and documented that an Intake Study was initiated on [DATE]. Review of a "3 Day Food Intake Study" completed [DATE] to [DATE] revealed the resident's intake was "Below Estimated Needs". The Registered Dietitian documented a plan to change four ounces (oz) of whole milk to eight oz of a fortified shake for additional calories and protein. The RD documented that the resident "Exceeded Estimated Needs" for fluids. Review of Nutrition/ Hydration Monitoring Committee Records dated [DATE] to [DATE] revealed the resident was evaluated due to a Stage 2 area on the sacrum (area above the tailbone on the right and left buttocks). On [DATE] the committee reviewed the resident and suggested starting an Intake Study. On [DATE], the committee noted that the resident's intake was poor at meals. The committee changed the meal plan and started weekly weights for four weeks. The Exceptional Care Plan dated [DATE] documented that the resident had an impaired nutritional status due to poor intakes, weight loss, and a Stage 3 decubitus (pressure sore) on the right ischium (lower, back part of the hip bone). The Exceptional Care Plan documented that the resident was to receive 240 cc three times a day for Hydration Protocol along with eight ounces of fortified shake at breakfast, 16 ounces of fortified shake at lunch and 8 ounces of fortified shake at dinner. A physician progress notes [REDACTED]. The Physician documented that the resident had "an isolated bout of emesis this morning", a swallowing evaluation had been done, and the resident was allowed to have pureed solids. Review of Meal/ Fluid Intake Logs dated [DATE] through [DATE] revealed the resident consumed "0%" or "bites" at 12 of 19 meals and 25% at six of the 19 meals. Intake Logs documented that the resident's average consumption of fluids for the 19 meals was equal to 64 cc's (approximately two ounces of fluid). Review of the Medication Administration Record [REDACTED]. Additional review of the ,[DATE] MAR indicated [REDACTED] - [DATE] - 210 cc - [DATE] - 360 cc - [DATE] - 120 cc - [DATE] - 360 cc - [DATE] - 120 cc - [DATE] - 240 cc - [DATE] - 120 cc Additional review of the Meal/ Fluid Intake Logs and the ,[DATE] MAR indicated [REDACTED]. Complete review of Nursing Interdisciplinary Progress Notes and the "24-Hour Nursing Services Report" sheets dated [DATE] through [DATE] revealed no documented evidence that the physician was notified regarding the resident's significant change/ refusal in oral intake. Interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) and the Director of Nursing (DON) on [DATE] at approximately 4:20 PM revealed the resident's Physician was notified (of the resident's condition) on the morning of [DATE] and he made an acute visit on [DATE]. Review of an untimed "Transfer Form", completed by the RN DON, dated [DATE] and a Nursing Interdisciplinary Progress Note dated [DATE] at 11:00 AM revealed the resident had labored breathing; decreased level of awareness (LOA) decreased verbal response, and decreased oral (po) intake the past four days with no intake the last two days. The DON documented that the resident was hypothermic (low body temperature) with rapid shallow respirations. Vital signs included a blood pressure of ,[DATE] (low blood pressure); a heart rate of 104 (average pulse 80); respirations of 22 (normal 12 to 20); and a temperature of 94.1 degrees (normal 98.6). Review of a Physician Acute Visit Note dated [DATE] revealed the Physician evaluated the resident as an acute visit for respiratory difficulty, lethargy, and decreased appetite. The Physician documented that the resident had a blood pressure of ,[DATE], an pulse of 104 and was found dehydrated, tachypneic (high heart rate) and with possible pneumonia. The Physician documented that the resident was being transferred to the emergency department (ED) for further work up and the family was notified. Interview with the Registered Dietitian (RD) on [DATE] at approximately 1:55 PM revealed that upon admission an initial assessment is completed and residents are set up for a monthly weight unless otherwise indicated. The RD stated that she visits the facility weekly for assessments, and is available by phone on the days that she is not at the facility. The RD stated that Resident #1's initial evaluation showed that her appetite was poor and that staff had to feed her. Fluid assessment showed that her estimated daily fluid need was 1750 cc, but she was consuming 750 cc daily. The RD stated that the evaluation was not shared with the MD. The RD stated she developed a Care Plan upon admission on [DATE] which noted a poor appetite with a goal for adequate food and oral fluid intake. The RD initiated an intake study on [DATE]. When shown the intake sheets for ,[DATE], the RD stated if a resident is eating poorly for three to four days, the nurses need to call the RD. "I can be reached by phone when I am not in the building." Interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) on [DATE] at approximately 2:41 PM revealed the RN reviews the appetite sheets daily. The RN stated that when she reviews the sheets, she is looking for poor appetite which would be indicated by 25% or less or non-acceptance. The RN RCC stated "We add 240 cc fluids three times a day. If the pattern continues, then an evaluation of the resident is done. This evaluation would include vital signs, checking of skin turgor, and oral assessment for signs of dehydration and a lung assessment. If the resident is not able to independently make decisions, then we would call that family." Interview with the DON on [DATE] at approximately 2:31 PM revealed facility staff record the intake of each resident at meals. The DON stated if changes in intake are seen, then substitutions are offered. If it happens for three meals in a row, "then we would probably call the doctor and do laboratory work to evaluate the resident". The facility usually calls the family to notify them that a resident is not eating and "catches it as early as possible". Interview with the RN Quality Assurance (QA) Nurse on [DATE] at approximately 4:13 PM revealed that when a Health Care Proxy (HCP) is activated, it is placed on the Care Plan. The RN QA Nurse stated that the resident's MMSE was "0" so it (HCP) should have been activated. Interview with the DON on [DATE] at approximately 4:13 PM revealed that the resident's Health Care Agent was an active participant in the resident's plan of care and attended all conferences via telephone conference calls. The DON stated that with a Mini Mental of "0", the resident was not able to make decisions. The DON stated that on the morning of [DATE] she did call the Health Care Agent, who directed the facility to do whatever needed to be done for the resident. The DON stated the HCP was not charted as activated nor care planned. An interview was completed with the Medical Director on [DATE] at approximately 10:35 AM. The Medical Director stated that he reviewed the medical record and saw several things that were of concern to him. The Medical Director stated he reviewed the notes for several days prior to the resident's transfer: the transfer out, dietary notes and volume and weekly intakes. The Medical Director reviewed the Acute Visit Note from the attending Physician as well as the 30 and 60 day notes. The Medical Director stated he noted a significant change in the resident with a weight loss on about [DATE]. The RD began an intake study that revealed the caloric and fluid needs were increased due her decubitus. The Medical Director stated that the resident had a dramatic change in intake the last four days prior to her transfer, specifically poor intake for two days and "essentially nothing for two days. An RN should have reviewed the data for this resident whether through direct observation or collecting data such a vital signs". The Medical Director stated that the resident's "family should have been informed within a couple of days and the Health Care Agent should have been contacted to make decisions regarding the resident's care." The Medical Director stated he reviews all discharges, admissions, and transfers to the hospital but had not been asked to review this chart prior to contact by the survey team. Interview with the RN who worked on [DATE] on [DATE] at approximately 2:44 PM revealed she was not aware that there had been a change in the resident including a decreased level of awareness with poorly consumed foods and fluids. The RN stated that if she was aware she would have performed an assessment that including vital signs, bowel and lung sounds. The RN did not call the family as she was not aware there was a change in condition of the resident. Interview with the RN who worked on [DATE] and [DATE] on [DATE] at approximately 11:50 AM revealed she was neither informed nor aware that Resident #1 was less aware and had a significant change or refusal of food and fluids. The RN stated that if she had been informed, she would have completed an assessment including vital signs, auscultating lung sounds and looking at the entire resident. The RN stated "If a resident does not eat for two or three days, then the family should have been called." Review of Emergency Department Primary Notes dated [DATE] revealed the resident was admitted through the emergency room at 11:25 AM and was lethargic/ responsive to verbal stimuli at 12:05 PM. physician's orders [REDACTED]. Patient Notes dated [DATE] documented that the resident was unresponsive with no blood pressure or peripheral pulses at 7:40 PM and expired on [DATE] at 10:46 PM. Resident #1 had a marked decline in oral consumption of food and fluids for approximately seven days. The facility did not notify the family (Health Care Agent) or the Physician until day four when she was less responsive and in respiratory distress. When the facility contacted the Health Care Agent regarding the change in status, the Agent did want life sustaining measures. The resident was transferred to the hospital on [DATE] where she expired later that evening. 415.3(e)(2)(ii)(b)(c)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON [DATE]. Based on interview and record review conducted during the Standard survey completed on [DATE], the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being for one (Resident #1) of one resident reviewed for quality of care related to hospitalization . Specifically, the resident was not assessed by a qualified licensed professional (Registered Nurse (RN)/ Physician) for a four day period when the resident had a change in mental status with poor intake and refusal of food and fluids. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated [DATE] revealed the resident had severe cognitive impairment with long and short term memory problems, was rarely understood, and rarely understands. Additional review of the MDS revealed the resident was completely dependent for transfers, bed mobility, personal hygiene, oral care and was non-ambulatory. The resident required the limited assistance of one to eat meals. Review of a Health Care Proxy signed by the resident on [DATE] revealed the resident named a Health Care Agent and an alternate Agent to make health care decisions for the resident if she was unable to make her own health care decisions. A Mini Mental State Examination (MMSE - a test to determine cognitive ability) completed on [DATE] revealed the resident had a score of "0" which indicated severe cognitive impairment. Review of a Weight Change History Sheet revealed the resident had the following weights: - [DATE] - 153.80 pounds (#) - [DATE] - 157.70# - [DATE] - 151.80# - [DATE] - 144.80# Review of the Dehydration Risk assessment dated [DATE] revealed the resident was identified with a score of 8. Interview with the Registered Dietitian on [DATE] at approximately 1:55 PM revealed a score of "8" indicates that the resident was at high risk for dehydration. Review of a Quarterly Nutritional Progress Note dated [DATE] revealed that the Registered Dietitian (RD) estimated that the resident's daily nutritional needs included 2088 calories and 1650 cc of fluid. The RD noted that the resident had a seven pound weight loss in 30 days; a nine pound weight loss in 90 days; and documented that an Intake Study was initiated on [DATE]. Review of Nutrition/ Hydration Monitoring Committee Records dated [DATE] to [DATE] revealed the resident was evaluated due to a Stage 2 area on the sacrum (area above the tailbone on the right and left buttocks). On [DATE] the committee reviewed the resident and suggested starting an Intake Study. On [DATE], the committee noted that the resident's intake was poor at meals. The committee changed the meal plan and started weekly weights for four weeks. The Exceptional Care Plan dated [DATE] documented that the resident had an impaired nutritional status due to poor intakes, weight loss, and a Stage 3 decubitus (pressure sore) on the right ischium (lower, back part of the hip bone). The Exceptional Care Plan documented that the resident was to receive 240 cc three times a day for Hydration Protocol along with eight ounces of fortified shake at breakfast, 16 ounces of fortified shake at lunch and 8 ounces of fortified shake at dinner. A physician progress notes [REDACTED]. The Physician documented that the resident had "an isolated bout of emesis this morning", a swallowing evaluation had been done, and the resident was allowed to have pureed solids. Review of Meal/ Fluid Intake Logs dated [DATE] through [DATE] revealed the resident consumed "0%" or "bites" at 12 of 19 meals and 25% at six of the 19 meals. Intake Logs documented that the resident's average consumption of fluids for the 19 meals was equal to 64 cc's (approximately two ounces of fluid). Review of the Medication Administration Record [REDACTED]. Additional review of the ,[DATE] MAR indicated [REDACTED] - [DATE] - 210 cc - [DATE] - 360 cc - [DATE] - 120 cc - [DATE] - 360 cc - [DATE] - 120 cc - [DATE] - 240 cc - [DATE] - 120 cc Additional review of the Meal/ Fluid Intake Logs and the ,[DATE] MAR indicated [REDACTED]. Review of the Medication Administration Record [REDACTED]. There are no entries of a blood pressure or pulse entered for either [DATE] or [DATE]. Review of the "Weekly Record of Vital Signs" sheet dated 2014 revealed blood pressure, temperature, pulse and respirations were not documented on [DATE] and [DATE]. Review of Nursing Interdisciplinary Progress Notes for ,[DATE] revealed the following: - [DATE] at 3:30 AM - Blood to be drawn by the lab (laboratory) in the AM - [DATE] at 8:00 PM - "Medication Refusal" - Several attempts were made to give 8:00 PM medications. The resident stated "I feel horrible tonight". - [DATE] at 2:00 AM - Blood to be drawn by the lab in the AM. - [DATE] at 11:00 AM - Decline in condition There was no documentation regarding the resident's physical condition from [DATE] to [DATE] and no evidence of an assessment by a Professional RN until [DATE] at 11:00 AM. Review of a Nursing Interdisciplinary Progress Note, written by an RN, dated [DATE] at 11:00 AM revealed the resident had labored breathing, decreased LOA (level of awareness), decreased verbal response, and decreased po (oral) intake for the past four days with "0" intake for the past two days. The RN documented that the resident was hypothermic (low body temperature) with a temperature of 94.1 (normal 98.6), rapid shallow respirations of 22 (normal 12 to 20), a blood pressure of ,[DATE] (low), and a heart rate of 104 (average 80). The RN documented that the physician evaluated the resident and ordered for her to be transported to the emergency room (ER) for evaluation. Review of Daily Unit Management Sheets, used to assign resident care and monitoring to CNA staff, dated [DATE] through [DATE] revealed none of the fifteen shifts for this period identified that Resident #1 required vital signs (temperature, pulse, blood pressure), weight, intake and output or any other specific monitoring. Review of "24-Hour Nursing Services Reports" dated [DATE] through [DATE] revealed the resident was added to the Report with a notation to "push fluid". There was no documentation of an RN assessment of the resident including vital signs. The "24-Hour Nursing Services Report" dated [DATE] documented that on the day shift, Resident #1 was admitted to the hospital. The night shift documented "expired". Review of five of five 24-Hour Nursing Services Reports dated [DATE] to [DATE], revealed there was no documentation regarding meals and fluids or of the resident's decreased intake. Review of a Physician Acute Visit Note dated [DATE] revealed the Physician evaluated the resident as an acute visit for respiratory difficulty, lethargy, and decreased appetite. The Physician documented that the resident had a blood pressure of ,[DATE], an pulse of 104 and was found dehydrated, tachypneic (high heart rate) and with possible pneumonia. The Physician documented that the resident was being transferred to the emergency department (ED) for further work up and the family was notified. Interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) on [DATE] at approximately 2:41 PM revealed the RN reviews the appetite sheets daily. The RN stated that when she reviews the sheets, she is looking for poor appetite which would be indicated by 25% or less or non-acceptance. The RN RCC stated "We add 240 cc fluids three times a day. If the pattern continues, then an evaluation of the resident is done. This evaluation would include vital signs, checking of skin turgor, and oral assessment for signs of dehydration and a lung assessment. If the resident is not able to independently make decisions, then we would call that family." Interview with the DON on [DATE] at approximately 2:31 PM revealed facility staff record the intake of each resident at meals. The DON stated if changes in intake are seen, then substitutions are offered. If it happens for three meals in a row, "then we would probably call the doctor and do laboratory work to evaluate the resident". The facility usually calls the family to notify them that a resident is not eating and "catches it as early as possible". Interview with the RN Quality Assurance (QA) Nurse on [DATE] at approximately 4:13 PM revealed that when a Health Care Proxy (HCP) is activated, it is placed on the Care Plan. The RN QA Nurse stated that the resident's MMSE was "0" so it (HCP) should have been activated. Interview with the DON on [DATE] at approximately 4:13 PM revealed that the resident's Health Care Agent was an active participant in the resident's plan of care and attended all conferences via telephone conference calls. The DON stated that with a Mini Mental of "0", the resident was not able to make decisions. The DON stated that on the morning of [DATE] she did call the Health Care Agent, who directed the facility to do whatever needed to be done for the resident. The DON stated the HCP was not charted as activated nor care planned. An interview was completed with the Medical Director on [DATE] at approximately 10:35 AM. The Medical Director stated that he reviewed the medical record and saw several things that were of concern to him. The Medical Director stated he reviewed the notes for several days prior to the resident's transfer: dietary notes, the transfer out, dietary notes and volume and weekly intakes. The Medical Director reviewed the Acute Visit Note from the attending Physician as well as the 30 and 60 day notes. The Medical Director stated he noted a significant change in the resident with a weight loss on about [DATE]. The RD began an intake study that revealed the caloric and fluid needs were increased due her decubitus. The Medical Director stated that the resident had a dramatic change in intake the last four days prior to her transfer, specifically poor intake for two days and "essentially nothing for two days. An RN should have reviewed the data for this resident whether through direct observation or collecting data such as vital signs". The Medical Director stated that the resident's "family should have been informed within a couple of days and the Health Care Agent should have been contacted to make decisions regarding the resident's care." The Medical Director stated he reviews all discharges, admissions, and transfers to the hospital but had not been asked to review this chart prior to contact by the survey team. Interview with the RN who worked on [DATE] on [DATE] at approximately 2:44 PM revealed she was not aware that there had been a change in the resident including a decreased level of awareness with poorly consumed foods and fluids. The RN stated that if she was aware she would have performed an assessment that including vital signs, bowel and lung sounds. The RN did not call the family as she was not aware there was a change in condition of the resident. Interview with the RN who worked on [DATE] and [DATE] on [DATE] at approximately 11:50 AM revealed she was neither informed nor aware that Resident #1 was less aware and had a significant change or refusal of food and fluids. The RN stated that if she had been informed, she would have completed an assessment including vital signs, auscultating lung sounds and looking at the entire resident. The RN stated "If a resident does not eat for two or three days, then the family should have been called." Review of a hospital Initial Physical assessment dated [DATE] revealed the resident was admitted through the emergency room at 11:25 AM and was lethargic/ responsive to verbal stimuli. physician's orders [REDACTED]. Patient Notes dated [DATE] documented that the resident was unresponsive with no blood pressure or peripheral pulses at 7:40 PM and expired on [DATE] at 10:46 PM. Resident #1 had a marked decline in oral consumption of food and fluids for approximately seven days. The facility did not notify the family (Health Care Agent) or the Physician until day four when she was less responsive and in respiratory distress. When the facility contacted the Health Care Agent regarding the change in status, the Agent did want life sustaining measures. The resident was transferred to the hospital on [DATE] where she expired later that evening. 415.12