Every finding on record at East Haven Nursing & Rehabilitation Center

Based on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident in 4 of 4 resident units. Specifically, multiple residents reported cockroach and rodent sightings. In addition, the facility's pest control service record documented pest sightings in 4 resident units. The findings include but are not limited to: The facility policy titled Pest Control with a last reviewed date 08/14/2024 documented it is the policy of the facility to maintain a pest free environment as best as possible. A review of Service Tickets documented that the pest management company provided pest management services to the facility on [DATE], 01/07/2025, 01/14/2025-01/15/2025, 01/28/2025-01/29/2025, 02/04/2025-02/05/2025, 02/11/2025, and 02/20/2025. The Service Tickets documented services provided included installing rodent bait stations and gel bait for cockroaches. On 02/20/2025 at 10:52 AM, multiple cockroaches were observed in the hallway on Unit 2, including one that entered room [ROOM NUMBER]. Registered Nurse #1 was notified of the observance and responded to the area, locating and stepping on one of the cockroaches. A review of Unit 1's Pest Control Service Record indicated that the following pest sightings were reported on Unit 1: mice and cockroaches on 11/4/2024, cockroaches on 11/7/2024, cockroaches on 01/02/2025, and pests in the pantry on 01/02/2025. A review of Unit 2's Pest Control Service Record indicated that the following pest sightings were reported on Unit 2: a rat on 08/03/2024, cockroaches on 01/14/2025, cockroaches on 02/03/2025, cockroaches and mice on 02/04/2025, and cockroaches on 02/20/2024. A review of the Unit 3 Pest Control Service Record indicated that the following pest sightings were reported on Unit 3: cockroaches on 06/23/2024, mice on 08/17/2024, mice on 09/05/2024, and mice on 01/27/2025. A review of the Unit 4 Pest Control Service Record indicated that the following pest sightings were reported on Unit 4: a rat on 04/19/2024, mice on 01/13/2025, mice on 01/14/2025, mice on 01/15/2025, cockroaches on 02/13/2025. On 02/21/2025 at 2:00 PM, Resident #172 was interviewed and stated they have observed cockroaches in their room typically at night. On 02/21/2025 at 2:11 PM, Resident #181's next of kin was interviewed and stated they had observed cockroaches in the facility. They reported that they stepped on and killed the cockroaches and did not notify the facility of the sighting. On 02/21/2024 at 2:14 PM, Resident #11 was interviewed and stated they observed mice running around their room at night. They stated the facility placed mice traps in their room but they continue to observe mice in the room at night. On 02/21/2025 at 2:18 PM, Resident #46 was interviewed and stated they observed mice in their room during the night time hours. On 02/20/2025 at 10:56 AM, Registered Nurse #1 was interviewed and stated there were cockroach sightings within the facility and that the facility's maintenance team was aware of the cockroach issue and regularly sprayed pest control substances in the facility. On 02/20/2025 at 11:42 AM, Licensed Practical Nurse #1 was interviewed and stated they had received some complaints from residents related to cockroaches during the evening shift. They stated that residents typically see the cockroaches in the evening if they get up to use the restroom. On 02/24/2025 at 09:33 AM, the Director of Operations was interviewed and stated the facility uses a contracted pest control company that makes weekly visits to provide pest management services. In between the pest control company's visits, the facility also used pest control management tactics including using glue traps, Raid spray, electric rodent traps, and filling gaps in baseboards. The Director of Operations stated pest control is an ongoing job for the facility and that while there are still sightings of pests, they feel that the facility has improved over the past few months. On 02/25/2025 at 11:43 AM, the Administrator was interviewed and stated that they are aware of cockroach and rodent sightings within the facility. They stated that pest control company comes on a weekly basis, and that Environmental Services staff also conducts pest control. They stated they believed the increase in pest sightings was related to construction that was occurring in the area. 10 NYCRR 415. (5) (h)(1)

Based on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that residents had the right to send and promptly receive mail. This was evident in 9 (Residents: #12, #13, #17, #80, #103, #105, #112, #151, #154) out of 39 total sampled residents. Specifically, the facility did not have a procedure in place for residents to send and receive mail on Saturday. The findings are: The facility policy titled Mail/Package Delivery with a last reviewed date of 06/10/2024 documented that it is the policy of the facility to ensure that each resident's rights to personal privacy is respected, including the right to send and promptly receive unopened mail and other letters, packages, and other materials delivered to the facility for the resident. Promptly means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service. On 02/19/2025 at 10:30 AM during the Resident Council Meeting, Residents #12, #13, #17, #80, #103, #105, #112, #151, and #154 stated the facility does not deliver mail to residents on Saturday. They stated this was because the social workers who deliver mail during the week does not work on the weekend. On 02/21/2025 at 2:22 PM, Social Worker #2 was interviewed and stated that mails delivered to the facility on Saturdays are not distributed to the residents until the following Monday. Social Worker #2 stated this delay occurs because mail is delivered to residents by Social Worker #1, Social Worker #2, and the Director of Social Services, and none of them work on the weekend. On 02/21/2025 at 2:33 PM, the Receptionist was interviewed and stated they work every other Saturday. They stated if if a resident receives mail on Saturday, it is left in the Business Office until Monday, when the social workers will then deliver it to residents. On 02/24/2025 at 9:57 AM, the Director of Social Services was interviewed and stated that mails delivered to the facility on the weekend is held until Monday, when it will then be delivered to residents. On 02/25/2025 at 11:50 AM, the Administrator was interviewed and was unable to provide an explanation for why residents had not been receiving mails within 24 hours of its delivery to the facility on the weekends. 10 NYCRR 415.3(e)(2)(i)

Based on observation, record review, and interviews during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that posted menu items were served, that notification was provided when menu items were substituted and that individual food preferences were honored. This was evident in 3 Residents (Resident #96, #129 and #79) of 6 residents observed during dining, out of 35 total sampled residents. Specifically, residents were not served posted menu items, food preferences, or food items that were listed on the meal tray tickets. Additionally, residents were not notified of menu substitutions. The findings are: The undated facility policy titled Menu Planning documented that menus are planned to meet the guidelines as established by current federal and state regulations. Menus are written at least 2 weeks in advance and are distributed to residents and posted in the resident's dining rooms at least three days before service. The individual preferences are considered in meal planning. Appropriate food items are prepared at each of the three daily meals to allow for choices and to accommodate individual preferences. Alternate food items must be prepared to substitute for food residents' dislike. The undated facility policy titled Food Preferences documented that a meal identification ticket will be used to properly identify everyone's needs including food and beverage preferences. Meal tickets will include any therapeutic diet, consistency, preferences and requests. Meal tickets are to be served with the corresponding meal. Meal tickets will be used during meal service to ensure the appropriate diet is being served and food preferences are honored as feasible. The undated facility policy titled Menu Substitution documented that menu substitutions are noted in writing on the posted weekly and daily menus, the reason for the change also must be noted. When making a substitution, consideration is given to residents' likes and dislikes. A menu substitution must be made from the same food group as the removed item. If the item removed is a raw fruit or vegetable, another raw fruit or vegetable should replace the item. This will help ensure adequate intake of vitamins and fiber. 1). Resident #129 was admitted to the facility with diagnoses that include Diabetes Mellitus and Hyperlipidemia. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #129 had intact cognition. On 02/18/2025 at 10:35 AM, Resident #129 was interviewed and stated that the food they receive is not good for them, sometimes they go days without eating and despite speaking with the dietician, nothing changes. During dining observation on 02/18/2025 at 12:35 PM, a meal tray was delivered to Resident #129. The meal ticket documented No Fish, No Pasta, No Meat and send 2x salad with dressing. The meal ticket listed tossed salad 2 cups with dressing and 1 slice of wheat bread as items that were served. No salad and no wheat bread were observed on the meal tray. During dining observation on 02/19/2025 at 9:00 AM, a meal tray was delivered to Resident #129. The meal ticket documented Cold Cereal Only Double Entree, Scrambled Eggs Only. The resident's tray was observed with 1 cup of Hot Oatmeal Cereal. There was no cold cereal observed on the meal tray. During dining observation on 02/21/2025 at 1:03 PM, a meal tray was delivered to Resident #129. The meal ticket documented No Fish, No Pasta, No Meat and send 2x salad with dressing. The meal ticket listed tossed salad 2 cups with dressing and (1) 6 ounce serving of juice as items that were served. There was no salad, and no juice observed on the meal tray. During dining observation on 02/25/2025 at 12:30 PM, a meal tray was delivered to Resident #129. The meal ticket documented No Fish, No Pasta, No Meat and send 2x salad with dressing. The meal ticket listed items served as 2-piece chicken patty, tossed salad 2 cups with dressing and wheat Bread 1 slice. No salad and no bread were observed on the meal tray. Two (2) brown colored meat items were observed on the tray. An undated facility document titled Food Preferences for Resident #129, documented likes: cold cereal, scrambled eggs, cream cheese, salad, ice cream and bread. Dislikes: Fish, buttered noodles. A dietary progress note dated 02/14/2025, documented that Resident #129 had intake that varied and that they complained about the food, food preferences was updated. 2). Resident #96 was admitted to the facility with diagnoses that include Heart Failure and Dementia. The Significant Change Data Set assessment dated [DATE] documented Resident #96 had moderate cognitive impairment. During dining observation on 02/18/2025 at 12:24 PM, a meal tray was delivered to Resident #96. The meal ticket listed items served as rice and beans and chopped zucchini. The menu items posted on Unit 4 to be served on Tuesday, 02/18/2025 were Italian vegetable mix and brown rice. There was no brown rice observed on the meal tray. The vegetable items served were peas and carrots. The meal ticket did not match the items served or the posted menu. There was no menu substitutions posted on Unit 4. During dining observation on 02/19/2025 at 9:30AM, Resident #96 was observed with a meal tray that contained 1 bowl of Hot Oatmeal Cereal. The meal ticket did not list Oatmeal as an item served. During dining observation on 02/21/2025 at 12:30 PM, Resident #96's meal tray was observed containing boiled cabbage. The Resident's meal ticket documented vegetable items served as fresh yams and oriental mixed vegetable. The menu items posted on Unit 4 to be served on Friday, 02/21/2025 were fresh yams and oriental mixed vegetables. There was no menu substitutions posted in Unit 4. Resident #96 tray was not observed to contain fresh Yams or oriental mixed vegetables. On 02/24/2025 at 2:34 PM, the Dietician was interviewed and stated they meet with residents at admission or readmission to ask about their food preferences. The food preferences are entered into meal tracker along with other specific requests and those appear on the meal ticket. The Dietician stated they perform daily rounds but they do not look at the meal ticket. They stated the Certified Nursing Assistants, nursing supervisors, and the kitchen staff are responsible for the accuracy of every meal. On 02/25/2025 at 12:35 PM, Certified Nursing Assistant #2 was interviewed and stated the menu is not always correct and the changes are not always posted. Certified Nursing Assistant #2 stated they inform the nursing supervisor when menu items or tray tickets do not match the food. Certified Nursing Assistant #2 further stated a lot of times Resident #129 does not receive their salad. On 02/25/2025 at 12:45 PM, Registered Nurse #4, who was the nursing supervisor, was interviewed and stated they were en route to the kitchen to retrieve salad and bread that did not arrive on Resident #129's meal tray. Registered Nurse #4 also that Certified Nursing Assistants inform them when the residents do not receive the food items in their meal ticket and the kitchen is called. On 02/20/25 at 12:50 PM, The Director for Dietary Services was interviewed and stated when meal tickets do not match the food items served or menus, it is because the menu is being revamped based on preferences. They stated preferences are placed on the menu, but the food items have not been delivered to the facility yet. The Director stated it may be an ordering or supply issue. They stated that the meal ticket is read in the kitchen and the supervisor ensures it matches the menu and the food items served. The Director for Dietary Services stated they make rounds every other day and sends dietary staff to the units to check if residents are getting food items in their meal ticket according to the menu, but there are still issues with matching items. 45351 Resident #79 was admitted to the facility with diagnoses that include Diabetes Mellitus, Hyperlipidemia, and Hypertension. The Minimum Data Set assessment dated [DATE] documented Resident #79 had intact cognition. During dining observation on 02/18/2025 at 12:48 PM, Resident #79's lunch tray was observed with turkey wings, cabbage, rice and beans, chicken noodle soup, banana and cup of tea with sugar. The Weekly Menu was posted on the wall next to the nursing station which documented Lunch Menu for 2/18/2025 were chicken noodle soup, turkey wings, Italian vegetable mix, brown rice, fresh fruit and coffee/tea. There were no Italian vegetable mix, or brown rice observed on the tray for Resident #79. Resident #79 stated they were not notified of the menu change. During dining observation on 02/20/2025 at 12:38 PM, Resident #79's lunch tray was observed consisting of chicken legs without any sauce/gravy, cabbage mixed with peas, carrots and white rice. The Weekly Menu documented Lunch Menu for 02/20/2025 were stewed chicken, steamed rice, and zucchini. There was no zucchini observed on Resident #79's plate. Resident #79 stated they were not notified of the menu change. On 02/21/2025 at 12:34 PM, Resident #79's lunch tray was observed with breaded fish, yam and mix vegetables. The Weekly Menu documented Lunch Menu for 02/21/2025 were tilapia with dill sauce, fresh yams, and oriental vegetable. There was no dill sauce or any type of sauce for the breaded fish. Resident #79 stated they were not notified of the menu change. On 02/20/2025 at 12:50 PM, the Food Service Director stated they are currently undergoing some food shortage and ordering issue and are not able to prepare the proposed menu items. They stated they were posting menu changes daily on the units next to the weekly menu. On 02/25/2025 at 12:29 PM, the Administrator was interviewed and stated they have not heard of any food related complaints or that there was any food ordering/supply issue until recently. The Administrator stated they do not know why there was any food shortage and supply issue since they order everything from the food vendor. 10 NYCRR 415.14(c)(1-3)

Based on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure the Binding Arbitration Agreement provides for the selection of a neutral arbitrator agreed upon by both parties and the agreement provides for the selection of a venue that is convenient to both parties. This was evident in 3 (Resident #77, #109, #163) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Residents #77, #109, and #163 had no documented evidence the agreement addresses the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that is convenient to both parties. The findings are: The facility policy titled Arbitration Agreements with effective date 10/17/2024 and last review date 10/18/2024 documented the agreement shall specifically provide for the selection of a neutral arbitrator agreed upon by both parties. It also documented the agreement shall specifically provide for the selection of a venue that is agreed upon and convenient to both parties. The Schedule 22 of Binding Arbitration Agreement in the admission package was reviewed. The Binding Arbitration Agreement documented all arbitrations shall take place at a mutually agreed upon location in New York County, New York, unless the parties agree otherwise. The Binding Arbitration Agreement also documented the parties agree to appoint a panel of three (3) arbitrators. The Parties will each select a single arbitrator, and these two (2) arbitrators will select a third arbitrator. Scheduled 22 Binding Arbitration Agreement signed by Residents # 109, # 77, and # 163 were reviewed. The Binding Arbitration Agreement documented all arbitrations shall take place at a mutually agreed upon location in New York County, New York, unless the parties agree otherwise. The Binding Arbitration Agreement also documented the parties agree to appoint a panel of three (3) arbitrators. The Parties will each select a single arbitrator, and these two (2) arbitrators will select a third arbitrator. On 02/25/2025 at 10:10 AM, Director of Admissions was interviewed and stated they were responsible to explain the admission package including the attachment of Schedule 22 about Binding Arbitration Agreement to the residents and/or their designated representatives upon their admission to the facility. Director of Admissions also stated the residents and/or their representatives signed the Arbitration Agreement separately from other parts of admission package. Director of Admissions stated they explained to the residents and/or their designated representatives that all arbitrations shall take place in New York County of New York State if both parties were unable to agree on a convenient venue. Director of Admissions also stated it meant the arbitration will be in New York County of New York State if the facility disagree a venue proposed by the residents and/or their representatives. Director of Admissions stated the Binding Arbitration Agreement documented resident and the facility will each select a single arbitrator, and these two arbitrators will select a third arbitrator. Director of Admissions had no explanation how the arbitrator selected by the facility will remain neutral in the arbitration process. On 02/25/2025 at 10:35 AM, the Administrator was interviewed and stated the Binding Arbitration Agreement the facility is using is non-compliant and that they are in th eprocess of revising the agreement. The opportunity to select a neutral arbitrator and a convenient venue will be included in the revised Binding Arbitration Agreement. The Administrator stated the facility would keep on using the current Binding Arbitration Agreement until the revised one was ready. 10 NYCRR 415.30

Based on record review and interview during the Recertification Survey from 02/18/2025 to 02/25/2025, the facility did not ensure the Binding Arbitration Agreement granted the residents and/or their designated representatives the right to rescind the agreement within 30 calendar days of signing it. This was evident in 3 (Resident #77, #109, #163) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Residents #77, #109, and #163 did not grant the residents and/or their designated representatives 30 calendar days to rescind the agreement. The findings are: The facility policy titled Arbitration Agreements with effective date of 10/17/2024 and a last reviewed date of 10/18/2024 documented the arbitration agreement shall explicitly grant resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it. The Schedule 22 of Binding Arbitration Agreement in the admission package was reviewed. The Binding Arbitration Agreement did not document residents and/or their designated representatives had the right to rescind the agreement within 30 calendar days of signing it. The signed Binding Arbitration Agreements for Resident #77, Resident #109, and Resident #163 were reviewed. There was no documented evidence in the agreement that the residents and/or their designated representatives were provided 30 calendar days to rescind the agreements. On 02/25/2025 at 10:10 AM, the Director of Admissions was interviewed and stated they were responsible to explain the admission package including the attachment of Schedule 22 about Binding Arbitration Agreement to the residents and/or their designated representatives upon their admission to the facility.They stated the residents and/or their representatives signed the Arbitration Agreement separately from other parts of admission package. Director of Admissions stated they verbally informed the residents and/or their representatives that they had 30 calendar days to rescind the agreements. Director of Admissions also stated it was not documented in the Binding Arbitration Agreement that residents and/or their designated representative had 30 calendar days to rescind the agreements. On 02/25/2025 at 10:35 AM, the Administrator was interviewed and stated they knew the Binding Arbitration Agreement the facility is using is non-compliant and that they are in the process of revising the agreement.The Administrator further stated the residents' right to rescind the Arbitration Agreement within thirty (30) calendar days of signing was not in the current arbitration agreement and it will be incorporated into the revised Arbitration Agreement. The Administrator stated the facility would keep on using the current Binding Arbitration Agreement until the revised one was ready. 10 NYCRR 415.30

Based on record review and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that the Infection Preventionist was a member of the facility's Quality Assessment and Assurance committee and reported to the committee on the Infection Prevention and Control Program on a regular basis. Specifically, the Infection Preventionist had not participated in any of the Quality Assurance & Performance Improvement meetings held between 02/20/2024 and 01/28/2025. The findings are: The 2024 Quality Assurance and Performance Improvement Plan effective December 2024 documented that the Quality Assurance and Performance Improvement Committee reports to the executive leadership and Governing Body and shall meet, minimally, four times per year to identify, screen, evaluate and key facility functions. It documents that the Quality Assurance and Performance Improvement Committee's members included the Infection Prevention and Control Officer. The document titled Quality Assurance and Performance Improvement dated 02/18/2025 did not list the Infection Preventionist as a member of the committee. A review of the Quality Assurance and Performance Improvement attendance sheets revealed that the Infection Preventionist did not sign the attendance sheets for the following meetings: 02/24/2024, 05/07/2024, 06/18/2024, 07/10/2024, 09/20/2024, 10/22/2024, 11/26/2024, and 01/28/2025. There was no documented evidence that the Infection Preventionist attended the Quality Assurance & Performance Improvement meetings. Multiple attempts were made on 02/24/2025 and 02/25/2025 to reach the Infection Preventionist for interview was unsuccessful. On 02/25/2025 at 11:05 AM, the Director of Nursing Services was interviewed and stated that the Infection Preventionist did not attend Quality Assurance and Performance Improvement meetings. The Director of Nursing stated that the Infection Preventionist was employed at the facility on a part time basis and is not scheduled to work on the days that meetings are held. On 02/25/2025 at 11:45 AM, the Administrator was interviewed and stated that the Infection Preventionist did not attend Quality Assurance and Performance Improvement meetings but should have been attending them. 10 NYCRR 483.80(c)

Based on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure food service equipment are properly cleaned and sanitized. This was evident during the Kitchen Task. The findings are: The undated facility policy titled General Food Preparation and Handling documented that all food service equipment should be cleaned, sanitized, dried and reassembled after each use. The undated facility policy titled Cleaning and Sanitizing of Meat Slicer documented that all removeable parts of the slicer should be put into the pot wash sink and washed, and all stationary parts should be scrubbed with a cellulose pad moistened with detergent, rinsed with water and sanitized. The instruction manual for the Globe Model 3600N Slicer documented that the entire slicer must be both cleaned and sanitized after use to prevent the spread of foodborne illness. The removeable parts should be placed in a dishwasher or a three-compartment sink with warm water and mild detergent, soaked and thoroughly scrubbed, then rinsed with fresh clean water. The other parts of the slicer as well as the slicer table should be cleaned with a clean cloth soaked in mild detergent, wiped down and rinsed. On 02/21/2025 at 1:03 PM, Dietary Aide #1 was observed cleaning the meat slicer. The Dietary Aide disconnected the removable parts of the slicer and sprayed the parts with sanitizer and used a disposable towel to wipe down the slicer. The aide also used the spray sanitizer to clean the blade and the rest of the slicer. The Dietary Aide did not use soap or detergent throughout the procedure. Following the procedure, the Dietary Aide was interviewed and stated they never use water on the slicer because it is electric, and water should not be used on anything electric. On 02/24/2025 at 3:11 PM, the Director for Dietary Services was interviewed and stated that all dietary personnel are instructed to use soap and water on the slicer; the only time they may not do so is when the slicer is actually plugged in. The procedure is to run the removeable parts through the dishwasher. 10 NYCRR 415.14 (h)

Based on observation, record review, and interviews during the Recertification and Complaint (NY00354174) Survey conducted from 02/18/2025 to 02/25/2025, the facility did not provide food and drink that were palatable and at a safe and appetizing temperature. This was evident in 1 (Unit 4) of 1 unit observed during dining. Specifically, food served during lunch had suboptimal temperatures and were not appetizing or palatable. The findings include but are not limited to: The undated facility policy titled Food Temperatures documented the facility maintains system to ensure that food served to the residents is held at safe holding temperatures. Hot foods should be maintained at 140 degrees Fahrenheit or above and cold foods should be at 41 degrees Fahrenheit or below. On 02/18/2025 at 12:24 PM, during dining observation, Resident #96's next of kin was observed waiting by the meal truck for Resident #96's meal tray. They stated they visit daily to get the Resident's meal tray and deliver it to the Resident because the food becomes cold if they wait for the staff to deliver it. During an interview on 02/18/2025 at 10:56 AM, Resident #79 stated the items served for meal are not palatable and not appetizing. During an interview on 2/19/2025 at 10:17 AM, Resident #100 stated food is served cold most of the time. During dining observation on 02/20/2025 from 12:28 PM to 12:50 PM, food trucks were delivered to Unit 4 and the staff delivered the lunch trays to residents in the dining and resident's room. At 12:50 PM, test trays were conducted on Unit 4 and the food temperature were as follows: 1. Puree diet meal consisted of pureed beef at 101 degrees Fahrenheit, pureed cabbage 98 degrees Fahrenheit, mashed potato 115 degrees Fahrenheit, pureed soup 119 degrees Fahrenheit and coffee 128 degrees Fahrenheit 2. Chopped diet meal consisted of chopped chicken at 90 degrees Fahrenheit, mashed potato 98 degrees Fahrenheit, chopped peas and carrot 95 degrees Fahrenheit, soup 118 degrees Fahrenheit, and apple sauce 58 degrees Fahrenheit 3. Regular diet meal consisted of cabbage, peas and carrots at 104 degrees Fahrenheit, stewed chicken at 118 degrees Fahrenheit, white rice at 101 degrees Fahrenheit, soup at 130 degrees Fahrenheit, and canned fruit at 60 degrees Fahrenheit. On 02/20/2025 at 12:50 PM, the Food Service Director was interviewed and stated food should be measured above 150 degrees Fahrenheit during kitchen assembly line and should be served to residents at 135 degrees Fahrenheit or above for hot foods. The Food Service Director stated they are having food supply issue that was why listed menu items are being replaced. They stated today's regular diet meal consists of stew chicken, cabbage mixed with carrot, peas, and white rice and that the stewed chicken appeared tough and dry because the kitchen staff did not pour the sauce over the chicken. On 02/20/2025, the Director for Dietary Services was interviewed right after taking the test tray temperature. They stated the appropriate and optimum food temperature for hot food should be at 135 degrees Fahrenheit and cold food should be below 41 degrees Fahrenheit. They stated that the elevators are extremely cold in the winter and that could be a reason why the food arrives cold. On 02/25/2025 at 12:29 PM, the Administrator was interviewed and stated they were not aware of any food related complaints. 10 NYCRR 415.14(d)(1)(2) 48876

Based on observation, record review, and interview during the Recertification Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure that resident or resident representatives receive their personal funds account statements on a quarterly basis. This was evident in 2 (Resident #79 and Resident #37) of 3 residents reviewed for Personal Funds out of 38 total sampled residents. The findings are: The undated facility policy titled Resident Accounts documented that the facility will assure proper handling of residents' funds and enable each resident to benefit from their funds in a manner which is in their best interest. Upon written authorization from the resident, the facility will hold, safeguard, manage, and account for personal funds of the residents. Residents will be provided with itemized quarterly financial statements by Social Service. 1. Resident #79 was admitted to the facility with diagnoses including Diabetes Mellitus, Hyperlipidemia, Hypertension. The Minimum Data Set, dated dated dated [DATE] documented Resident #79 had intact cognition. On 02/19/2025 at 12:19 PM, Resident #79 stated they have not seen their account balance in a long time and would like to know their balance. The Resident stated the facility will only provide the statement with the balance when requested and not consistently provided every quarter. The Resident Funds Ledgers dated 01/01/2023 to 03/31/2024 and 04/01/2024 to 06/30/2024 documented that Resident #79 was given 1st and 2nd quarter statements on 7/25/2024. It did not contain Resident #79's signature. The Resident Funds Ledgers dated for 07/01/2024 to 09/30/2024 and for 10/01/2024 to 12/31/2024 documented that Resident #79 signed for 3rd quarter statement and for 4th quarter statement. There was no documented date to indicate when Resident #79 received these statements. On 02/24/2025 at 9:53 AM, Social Worker #2 was interviewed and stated the Business Office sends the printed statements to the Social Work Department every quarter. These quarterly statements are distributed to residents who are able, and for those who are not capable, will be given to their representatives. The Social Worker stated they are not sure if they provided statements to residents after every quarter and was not able to explain orverify if Resident #79 was provided the statements every quarter. Social Worker stated they were not aware that Resident #79 had any concerns about their financial statement. On 02/24/2025 at 10:05 AM, the Director of Social Services was interviewed and stated resident's financial statements are provided to residents/representatives at every quarter. The residents who are capable to receive their statement will sign for their statements. The Director stated they do not know why resident's signatures were not always obtained when statements were provided to the residents and stated there are some residents who refuse to sign but are still given their statements. They stated if a resident refused to sign when they receive their statements, it will be documented as such. The Director of Social Services stated they had a delay in distributing statements last year and that the 1st and 2nd quarter statements were distributed together. 50894 Resident #37 was admitted to the facility with diagnoses including Chronic Respiratory Disorder and Cerebellar Stroke Syndrome. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #37 had moderate cognitive impairment. On 02/18/2025 at 09:42 AM, Resident #37 was interviewed and stated they did not consistently receive banking statements from the facility. The Resident Funds Ledgers dated 01/01/2023 to 03/31/2024 and 04/01/2024 to 06/30/2024 documented that Resident #79 was given 1st and 2nd quarter statements on 07/25/2024. The Resident Funds Ledgers dated 07/01/2024 to 09/30/2024 and 10/01/2024 to 12/31/2024 revealed Resident #37 signed for 3rd and 4th quarter statements. There was no documented date to indicate when Resident #37 received these statements. On 02/24/2025 at 11:46 AM, Social Worker #1 was interviewed and stated it is the responsibility of the Director of Social Services to provide residents with their quarterly statements. Social Worker #1 stated they only distribute quarterly statements if the Director of Social Services is on vacation. Social Worker #1 was unable to provide an explanation for why Resident #37 did not consistently receive quarterly banking statements. 10 NYCRR 415.26(h)(5)(i)

Based on observation, record review, and interview during the Recertification and Complaint (NY00354174) Survey conducted from 02/18/2025 to 02/25/2025, the facility did not ensure the residents' right to a safe, clean and comfortable environment was maintained. This was evident in 1 (Unit 1) of 4 units. Specifically, room [ROOM NUMBER]P was observed with chipped wall surfaces, partially detached top dresser, stained ceiling, and peeling non-slip tape on the bathtub. The findings are: The facility's policy titled Homelike Environment with a reviewed date of 06/10/2024 documented residents are provided with a safe, clean, comfortable, and homelike environment. The facility's policy titled Maintenance with a reviewed date of 04/12/2024 documented Maintenance Department shall ensure that the facility is functional, comfortable, and hazard free. Resident #164 was admitted to the facility with diagnoses of Diabetes Mellitus, Hypertension, Hyperlipidemia. The Minimum Data Set, dated dated dated [DATE] documented Resident #164 had intact cognition. During observation on 02/19/2025 at 12:36 PM and on 02/21/2025 at 10:02 AM, Resident #164 stated they are extremely dissatisfied about the condition of their room. room [ROOM NUMBER]P was observed with multiple chipped/broken wall surfaces, partially detached top dresser next to the bed, brown stained tile lowered from the ceiling above the bathtub, and peeling non-slip tape in the bathtub. The Maintenance Issue Log for Unit 1 dated 07/09/2024 to 02/19/2025 documented issues pertaining to the television in room [ROOM NUMBER]P. There was no documentation of any other maintenance work requested for room [ROOM NUMBER]P. On 02/24/2025 at 10:27 AM, the Maintenance Director was interviewed and stated they are aware that the walls behind the headboard are often getting damaged because the bed was hitting against the wall. but was not aware of the chipped wall, broken dresser, stained ceiling tile, and peeling tape in the bathtub in room [ROOM NUMBER]P. On 02/25/2025 at 12:29 PM, the Administrator was interviewed and stated they were recently made aware of the problems in room [ROOM NUMBER]P and stated the issues are being addressed. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews conducted during the Recertification and Complaints survey (NY#00311731) from 02/27/2323 through 03/06/2023, the facility did not ensure that (1) residents' Comprehensive Care Plans (CCP) were reviewed and revised after each assessment, and (2) each resident or resident representative was offered the opportunity to participate in the review of their CCP. This was evident for 5 of 8 residents reviewed for Abuse, 1 of 5 residents reviewed for unnecessary Medication, and 1 of 2 resident review for care planning out 41 residents. (Resident #12, #40, # 173, #181, and #390) Specifically: (1) Care plans for Abuse were not revised quarterly and as needed for Residents # 40, and # 173. (2) Care plan for behavior and abuse was not revised to reflect Resident #181 aggressive behavior. (3) Care plan for behavior and psychotropic drug use was not revised quarterly for Resident # 390. (3) Residents # 12 was not invited to their care plan meetings. The findings include but are not limited to: 1.) Resident # 40 was admitted to the facility with diagnoses that include Parkinson's Disease, Bipolar Disorder, and schizoaffective disorder. The Quarterly Minimum Data Set 3.0 (MDS) assessment completed on 12/02/2022 identified Resident #40 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. The Comprehensive Care Plan (CCP) titled Risk for Abuse, Neglect, Mistreatment was initiated on 05/19/2021 and was last revised on 09/29/2022. There was no documented evidence that the comprehensive care plan for abuse was reviewed and revised after the MDS assessment on 12/02/2022. A Nurse's Progress Note dated 12/05/2022 at 2:19 PM documented that Resident #40 got into a physical altercation with Resident #173 on the unit. There was no documented evidence that the risk-for-abuse care plan was revised after the physical altercation on 12/05/2022. The risk for abuse care plan was updated on 02/27/2023, two months after Resident # 40 had a physical altercation with Resident # 173. 2) Resident # 173 was admitted to the facility with diagnoses that include Psychosis, and Dementia. The quarterly MDS dated [DATE] identified Resident # 173 as cognitively intact with a BIMS score of 13. The Altercation, Victimization, and Abuse CCP initiated on 10/17/2022 documented that Resident # 173 was involved in an altercation with another resident. A Nurse's progress Note dated 12/05/2022 at 2:44 PM documented that Resident # 173 had a physical altercation with another resident on the unit. There was no documented evidence that the abuse CCP was revised after the physical altercation on 12/05/2022. The abuse CCP was updated on 02/27/2023. Two months after, Resident # 173 had a physical altercation with Resident # 40. During an interview on 03/06/2023 at 9:45 AM, the Registered Nurse Supervisor #3 (RNS #3) stated that the nurses are responsible for updating the care plan. Resident # 173 had a physical altercation with Resident #40 on 12/05/2022. The abuse care plan was not updated. The care plan was updated on 02/27/2023. The CCP is updated as needed, quarterly and annually. The supervisors are responsible for ensuring that the CCP is updated. RNS #3 does not know why the CCP was not updated. The abuse care plan should have been updated when the incident occurred. During an interview on 03/06/2023 at 1:34 PM, RNS #2 stated that the incident happened during the day shift, and RNS #2 worked on the evening shift. RNS #2 initiated the incident report but did not update the care plan because the residents were already out of the facility. During an interview on 03/03/2023 at 12:26 PM, the Assistant Director of Nursing (ADNS) stated that the RNs are responsible for initiating and updating the care plan. The RNS on duty should have reviewed and revised the care plan. The care plans are reviewed and revised as needed and quarterly. Resident #40 and Resident #173 had an altercation on 12/05/2022, but their abuse care plan was not updated until 2/27/2023. The care plan should have been revised with new interventions when the incident occurred. During an interview on 03/06/2023 at 11:51 AM, the Director of Nursing (DON) stated that care plan revision and updates are done quarterly and as needed. Resident #40 and Resident #173 had an altercation on 12/05/2022, and their care plans were updated on 02/27/2023. There are no notes that the care plan was updated when the incident occurred on 12/5/2022. The ADNS is responsible for ensuring that the care plans are updated. It should have been updated when the incident occurred. 3) Resident # 12 was admitted to the facility with diagnoses which include Diabetes Mellitus, Anxiety Disorder, and Major Depressive Disorder. The quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that Resident #12 is cognitively intact with a BIMS score of 14 out of 15. On 02/28/2023 at 9:41 AM, an interview was conducted with Resident #12. Resident #12 stated they were not invited to the care plan meeting. A quarterly CCP meeting note dated 11/03/2021 documented that Resident #12 was discussed for review. The resident was alert and oriented and able to make needs and feelings known. The attendance record had no documented evidence that the resident or the designated representative attended the CCP meeting. A quarterly CCP meeting note dated 01/26/2022 documented that Resident #12 was discussed in the CCP meeting. The attendance record has no documented evidence that Resident # 12 or the resident family representative attended the CCP meeting. A quarterly CCP meeting note dated 03/23/2022 documented that Resident # 12 is alert, oriented, and can make needs and feelings known. The resident was assessed and discussed. The attendance record has no documented evidence that Resident # 12 or the family representative attended the CCP meeting. A quarterly CCP meeting note dated 09/14/2022 documented that Resident # 12 was assessed and reviewed. The attendance record has no documented evidence that Resident # 12 or the resident family representative participated in the CCP meeting. A quarterly CCP meeting note dated 12/13/2022 documented that Resident # 12 is alert, oriented, and can make needs and feelings known. The resident was assessed and reviewed. The attendance record has no documented evidence that Resident # 12 or the resident family representative participated in the CCP meeting A review of the social service notes from 11/01/2021 to 12/31/2022 has no documented evidence that Resident #12 or their designated representative were invited to the care plan meeting. During an interview on 03/03/2023 at 3:40 PM, the Social Worker (SW) stated that residents and their families are invited to annual care plan meetings. Resident #12 was invited to the care plan meeting but declined to attend it and asked the SW to invite their designated representative. Resident #12's representative is in a different time zone, so they cannot invite them to the CCP meeting. The SW stated that they are unsure which care plan meeting Resident # 12 was invited to because it is not documented that the resident was invited to any of the care plan meetings. The SW further said it had not been their practice to invite residents to the quarterly CCP meeting. During an interview on 03/06/2023 at 12:11 PM, the Director of Nursing (DON) stated that there should be documentation that Resident #12 was invited to the care plan meeting. The attendance records show no documentation that Resident #12 participated in the CCP meeting. Resident #12 should have been invited to the care plan meeting. During an interview on 03/06/2023 at 12:28 PM, the Director of Social Services (DSS) stated families and residents should be invited to participate in all care plan meetings. Care plan meetings are held upon admission, quarterly, significant change, and annually. The notes do not indicate that Resident # 12 or the family representative was invited to the CCP meeting. There should have been documentation regarding the invitation and attendance at the CCP meeting. The DSS ensures the residents, and their families are invited to the CCP meeting. 415.11(c)(2) (i-iii) 33315 45351

Based on observations, record reviews and interviews conducted during the Recertification survey from 2/27/23 to 3/6/23, the facility did not ensure that medication error rates were not 5 percent or greater. This was evident for 2 of 26 medication observations conducted during the Medication Administration task. Specifically, medications were not administered as ordered by the physician: 1). Fluoxetine 20 mg 1 capsule was administered to resident #43 instead of 3 capsules (60 mg). and 2). Brimonidine/Alphagan P 0.15 % eye drops were omitted for Resident #87, leading to a medication error rate of 7.69%. The findings are: 1.) Resident #43 was admitted to the facility with diagnoses that included Generalized Osteoarthritis and Pressure Ulcers. The Physician order dated 5/31/22, last renewed on 3/1/23 documented the following: Fluoxetine 20 mg capsule give 3 capsules (60 mg) by oral route once daily. The medication was scheduled for 09:00 AM On 03/02/23 at 10:12 AM during a medication administration observation conducted on Unit 2, the Licensed Practical Nurse (LPN) #3 administered Fluoxetine 20 mg 1 capsule to Resident #43 instead of 3 capsules (60 mg). LPN #3 signed the Medication Administration Record confirming 3 capsules of Fluoxetine 20 mg were administered. On 03/02/23 at 10:30 AM, the LPN# 3 was interviewed and stated that they were the regular LPN on the floor and familiar with every resident on the unit. LPN #3 explained medication administration protocols and stated that they follow the 5 rights of medication administrations, which include making sure they have the correct resident, time, dose and route and dates. The LPN #3 could not explain why they missed 2 capsules. They concluded by saying, Maybe I'm nervous, 2)Resident #87 was admitted to the facility with diagnoses which include: Dementia, Schizoaffective disorder, Legal Blindness, Major depressive disorder. The Physician order dated 01/31/2023, last renewed on 3/1/23 documented the following: Brimonidine 0.15 % eye drops, instill 1 drop by Ophthalmic (eye) route in each eye 3 times per day. The medication was scheduled as followed: 10:00AM, 2:00 PM, and 6:00 PM. On 03/03/23 09:45 at AM, during a medication administration observation conducted on Unit 2, the Licensed Practical Nurse (LPN #4) did not administer Brimonidine/Alphagan P 0.15 % eye drops to Resident #87. It was omitted. On 03/03/23 at 10:15 AM, an interview was conducted with LPN #4. They stated they could not find the Brimonidine/Alphagan P 0.15 % eye drops for Resident #87. The LPN #4 stated that the medication was last administered on 3/2/23 and it ran out. The medication was reordered and should arrive later today. LPN #4 also stated that the medication should have been reordered when the nurse noticed the supply was low. They could not explain why it was not ordered. During an interview on 03/03/23 12:53 PM, RN Supervisor (RNS) #3 stated that they provide supervision to the nurses and do a medication pass competency check list at least every year. RNS #3 also stated that the Brimonidine/Alphagan P 0.15 % eye drops were actually in the medication cart, but the LPN# 4 failed to locate it them. Instead, LPN #4 reordered them. RNS #1 further stated that nurses have to check the 5 rights of medication administration before giving medication. RNS #1 stated they completed random observations of staff during medication administration in the past and did not identified any concerns. 415.12(m)(1)

Based on observations, interviews, and record review conducted during a Recertification Survey, the facility did not ensure a resident who is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #114) out of 5 residents reviewed for Unnecessary Medications. Specifically, a Comprehensive Care Plans (CCP) related to Dementia was not developed for Resident #114. The findings are: The facility policy titled Dementia- Clinical Protocol last dated 02/15/23 documented the following: For individual with confirmed dementia, the interdisciplinary Team (IDT) will identify a resident-centered care plan to maximize remaining function and quality of life. Resident #114 had diagnoses which include Dementia, Depression, and Bipolar Disorder. The most recent Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #114's cognition was severely impaired. The MDS also indicated that the resident required extensive assistance with one person when performing Activities of Daily Livings (ADLS). On 03/01/23 at 11:04 AM, Resident #114 was observed participating in an activity titled the memory program Other residents were present during activities. On 03/03/23 at 12:07 PM, Resident #114 was observed participating in group activities at the memory program. The resident log book from 1/2/23 to 3/6/23 documented Resident #114 attended activities 5 times per week. The Physician's Order dated 2/2/23 documented orders for Aripiprazole 5 milligrams (mg) tablet, give 1 tablet (5 mg) by oral route once daily for Psychosis and Benztropine 0.5 mg tablet, give 1 tablet (0.5 mg) by oral route 2 times per day Extrapyramidal and movement disorder. A Physician Progress Note dated 2/10/23 documented that the resident was seen and examined after nursing requested an evaluation for behavioral disturbance. According to nursing, the resident becomes easily agitated, angry, was shouting at staff, and resisting care. Monitor mood and behavior changes. Psychiatry follow up as needed. A Psychiatric Consult dated 2/21/2023 documented that the resident with psychiatric history of Major Depressive Disorder with psychotic symptoms. The consult also documented that the resident expressed relating their depression to current medical/physical condition and being unable to walk or support themselves independently. Resident expressed their wishes to resume Physical Therapy to become more physically active. Staff reported intermittent mood/behavioral symptoms as the resident becomes agitated, angry and yells at staff. Occasionally resisting care. Resident will most likely benefit from psychotherapy to validate emotions and encourage verbalizing feelings and identify positive supports that are in place. Otherwise, support continuation of the current psychotropic regimen as it appears of benefit in addressing psychotic/mood/impulsive symptoms. Gradual Dose Reduction not indicated at this time. The psychiatrist recommended the following plans: Continue Abilify 5 mg daily, Mirtazapine 45 mg every hours of sleep, Wellbutrin 150 mg daily, Benztropine 0.5 mg 2 times a day, and Melatonin 5 mg every hour of sleep. Kindly refer to psychologist for further evaluation and psychotherapy per psychologist's discretion. There were no behavioral notes documented for Resident #114 in the medical record. There was no documented evidence that a person-centered comprehensive care plan for dementia care needs with individualized interventions related to the resident's symptoms and rate of progression was developed. During an interview on 03/03/23 at 11:42 AM, the RN supervisor (RN #3) stated that the RNs are responsible for the development of care plans and care plan updates. RN #3 stated care plans are developed and updated after the admission, quarterly, and significant change assessments by the interdisciplinary team. The RN #3 concluded by saying that they cover several units and could not tell who was responsible for creating and updating the care plan. During an interview on 03/06/23 at 10:47 AM, the assigned Certified Nursing Assistant (CNA #7) stated that the resident sometimes appeared depressed and was not willing to go out of the unit despite encouragement from staff. CNA #7 stated that the resident spends most of their time in the memory program downstairs. During an interview on 03/06/23 at 02:54 PM, the Recreational Director stated that the resident attended the memory program which runs 7 days a week. They stated that the memory program accommodates all residents with dementia and behavioral problems. The Recreation Director also stated that the resident attended the program very often and participated in the program. 415.11(c)(2)

Based on observation, record review and staff interview conducted during the Recertification survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to meet resident's medical, mental and psychosocial needs. This was evident for 1 of 41 sampled residents (Resident #41). Specifically, comprehensive care plans with measurable goals, objectives, and interventions were not developed to address Resident #41's Neurogenic Bladder with foley catheter and newly diagnosed seizure disorder. The finding is: The facility policy on Care Plans, revised on 02/15/2023, documented: A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within 7 days of the completion of the required comprehensive assessment. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Resident #41 was admitted to the facility with diagnoses of Bladder Uropathy, Neurogenic Bladder with Urinary Tract Infection, and Seizure Disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that resident had intact cognition with a Brief Interview for Mental status (BIMS ) score of 15 out of 15. The resident required extensive to total assist of one to two persons for Activities of Daily Living (ADLs). On 03/02/2023 at 3:22 PM, Resident #41 was observed and interviewed in their room. The resident was watching TV, friendly, and conversant. A foley catheter was connected to a drainage bag with yellow colored urine output approximately 300 cubic centimeters (CC). Resident #41 reported no pain or burning sensation. The resident stated they had no seizures since readmission. The Physician's order dated 02/27/2023 documented : Catheter care and monitoring every shift and as per facility protocols. Review of the Comprehensive Care Plans (CCP) reveals no CCP was initiated for the diagnoses of Neurogenic Bladder, Bladder Uropathy and new diagnosis of Seizure. During an interview on 03/032023 at 3:30PM, the Registered Nurse (RN #1) stated care plans for admissions or readmissions are initiated and completed by the Minimum Data Set (MDS) staff. Upon reviewing the CCP of Resident #41, RN #1 acknowledged that she did not see a care plan related to Neurogenic Bladder or Seizure Disorder. RN #1 stated the included the catheter in the Bowel/Bladder elimination care plan. It was overlooked. Resident #41 was sent to the hospital and readmitted . RN #1 stated they did not retrieve the CCP from the previous admission where they addressed the Neurogenic Bladder. 415.11(c)(1)

Based on record review and staff interviews during the Recertification and complaint Survey (NY00311545) initiated on 02/27/2023 and completed on 03/06/2023, the facility did not ensure that a copy of the notice of transfer or discharge was sent to the Office of the State Long-Term Care Ombudsman. This was identified for 1 (Resident #141) of 3 residents reviewed for hospitalization . Specifically, the facility did not notify the Office of the State Long-Term Care Ombudsman of Resident #141's facility-initiated transfer and discharge to the hospital on 2/16/23. The finding is: The facility policy dated titled Admissions, Transfers, Discharges: Transfer/Discharge Notice, revised 1/2023, documented that a resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility. The notice will be given as soon as it is practicable but before the transfer or discharge, which includes an immediate transfer or discharge required by the resident's urgent medical needs; and that a copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. Resident #141 was admitted with diagnoses that included Bipolar Disorder and Diabetes Mellitus. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident's cognition as modified independence, no behaviors, no wandering, no set up help provided for bed mobility, transfers, not set with supervision for eating, extensive assistance with one person's physical assist for toilet use. The discharge MDS dated [DATE] documented that resident was discharged with return anticipated. A nurse's note dated 2/16/23 documented that the resident was being transferred to the hospital for further evaluation. A nurse's note dated 2/23/23 documented that the resident returned to the facility. A Physician's progress note dated 02/19/23 documented the resident was seen for post-admission follow-up and interim review of the current plan of care as resident #141 was recently hospitalized for Diabetic Ketoacidosis, and those medications and treatments were reviewed and to continue with current management and continue to offer current medications. There was no documented evidence that the Office of the State Long-Term Care Ombudsman was given a copy of the notice of transfer when the resident was transferred to the hospital on 02/16/23. During an interview on 03/06/2023 at 3:12 PM, the Social Worker (SW2) was interviewed and stated that they were not aware that they were supposed to notify the Ombudsman's office of a facility-initiated resident transfer or discharge to the hospital. The SW stated that they (SW) do not send any notification or a copy of the notice of transfer or discharge to the Ombudsman's office when a resident is transferred to the hospital, and that this is done only when the resident is discharged out of the facility. During an interview on 03/06/23 03:17 PM, the Director of Nursng (DON) stated that they were not aware the Ombudsman's office must be informed of hospital discharges, but the social workers are responsible for the notification. 415.3(h)(1)(iii) (a-c)

Based on observations, record review and staff interviews during the recertification and complaint survey (NY#00311731) conducted from 2/27/23 to 3/6/23, the facility did not ensure that an alleged violation of abuse, neglect, exploitation, or mistreatment was thoroughly investigated. This was evident for 1 (Resident #394) of 8 residents investigated for Abuse out of a sample 41 residents. Specifically, 1) The facility did not initiate an investigation until five days after an alleged resident to resident incident was reported. 2) There was no documented evidence that the investigation of an alleged resident to resident incident was thoroughly investigated to include witness statements and that interventions were implemented promptly to protect Resident #394. The findings are: The facility policy and procedure titled Abuse Investigation and Reporting revised 2/20/23 documented that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, and mistreatment shall be thoroughly investigated by facility management. Resident #394 was admitted to the facility on [DATE] with diagnoses of left artificial knee joint, morbid obesity, and post operative of total right knee replacement. The social services assessment dated [DATE] documented Resident #394 was alert and oriented times 3. The capacity assessment dated [DATE] documented the resident had intact cognition with a Brief Interview of Mental Status score of 15 out of 15. On 2/28/23, the Complainant reported the alleged violation to the New York State Department of Health (NYSDOH) Hotline. The Aspen Complaint Tracking System intake documented that on 2/25/23, there was an incident of another resident entering Resident #394's room uninvited, and no staff came to Resident #394's room to intervene. During a phone interview on 3/8/23 at 3:24 PM, the complainant stated that their concerns related to the incident were initially reported to the nurse supervisor, and they asked to submit a formal complaint to the facility on [DATE]. However, the complainant stated that the facility did not make prompt efforts to address their concerns, and they were not made aware if a grievance or investigation was initiated. During an interview on 3/3/23 at 10:40 AM, Resident #394 stated that on 2/25/23 between 1:00 PM and 2:00 PM, they heard a loud commotion out in the hallway. A few minutes later, Resident #181 came into their room uninvited, swearing profanity, being verbally aggressive towards Resident #394. Resident #394 stated they are totally bed bound and not ambulatory; therefore, they were not able to move themselves out of the room. Resident #394 called for help using the call bell but no staff came into the room. Resident #394 stated Resident #181 eventually walked out of the room, and there was still no staff member around. This incident was reported to the nurse supervisor on that day, but they were not given any assurance that it will not occur again. Resident #394 stated they do not feel safe in the room. Resident #394 stated they were not aware if a grievance or investigation was initiated for the incident. The Comprehensive Care Plan (CCP) for Potential Resident Abuse initiated 2/23/23, last revised on 2/24/23, was not updated to reflect the verbal resident-to-resident altercation that occurred on 2/25/23. There were no new interventions implemented to ensure safety of Resident #394 following the incident on 2/25/23. The interdisciplinary progress notes from 2/25/23 to 3/3/23 contained no documented evidence the incident occurred or that Resident #394 was evaluated and monitored for any signs and symptoms of emotional distress following the incident. The undated Grievance Reporting and Response Form completed by Director of Nursing (DON), documented that on 2/25/23, the DON received a phone call from Resident #394's church sister, who is also staff member at the facility. The church sister reported Resident #394 informed them that a man entered their room being verbally loud and erratic. It documented that upon investigation, there was no credible evidence that abuse, neglect, exploitation, mistreatment, or misappropriation of property occurred. The form was missing signatures of Resident #394 and the church sister for acknowledgement of the complaint and the final disposition of the complaint. The form was signed by the Administrator on 3/6/23. The Resident to Resident Incident Report completed 3/4/23 by the Assistant Director of Nursing (ADON) documented that the investigation revealed that the incident did not constitute physical abuse, and no physical abuse occurred. The facility's Investigation Form dated 3/3/23 documented that the allegation was refuted by the evidence collected during the investigation; therefore, it was determined no abuse, neglect, or mistreatment occurred. The form was signed by the facility investigator, the ADON, on 3/6/23. There was no documented evidence that an investigation was initiated and completed within 5 days after the allegation was reported on 2/25/23. In addition, there was no documented evidence a thorough investigation, including statements from Resident #394, CNAs, LPNs, RNs, and other staff on the unit at the time of the incident was completed. During an interview on 3/6/23 at 12:06 PM, the Director of Social Worker (DSW) stated they were not informed of the allegation until 3/2/23. On 3/2/23, they visited Resident #394 to discuss the incident that took place on 2/25/23. The DSW stated Resident #394 was very upset that no staff came to the room when they used the call bell during the incident. Resident #394 still feels a little shaky when someone walks past the room. On 3/6/23 at 12:21 PM, the Registered Nurse Supervisor (RNS #4) was interviewed and stated RNS #4 was on duty when the incident occurred. RNS #4 visited Resident #394 multiple times and spoke to the daughter on the phone because Resident #394 was concerned and upset about the occurrence. RNS #4 stated they assured Resident #394 that Resident #181 would not return to thier room, as Resident #181 was not currently in the facility. RNS #4 further stated that there were staff around when Resident #181 went into Resident #394's room, and ackknowledged that staff did not go into the room to redirect/escort Resident #181 out of the room. RNS #4 recalled this day as chaotic and busy as they were checking upon other residents and staff on the unit following the incident. RNS #4 stated that they should have documented the incident in the electronic medical record and completed the incident report, but that was not done. RNS #4 stated they informed the Director of Nursing (DON) about the incident and Resident #394's emotional state/concerns so that someone could follow-up on Resident #394 since RNS #4 was not scheduled to work. During an interview on 3/6/23 at 1:57 PM, the interim Director of Nursing (DON) stated they were informed of the incident by the resident's church sister who is also a staff member at the facility on 2/25/23. The DON instructed the nurse supervisor on duty to check on Resident #394 and find out more information. On the following day, the DON instructed the nurse supervisor to initiate the investigation on 2/26/23. The DON did not know an investigation was not initiated until 3/2/23, after the surveyor asked the investigation. The DON acknowledged that it should have initiated immediately. The DON further stated that staff statements were obtained, but they did not have the actual written statements. The DON stated they were still waiting for the written statements to be sent by the staff via fax. 415.4(b)(3)

Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation, if the allegation involves abuse or results in serious bodily injury, to the state agency. This was evident for 1 (Resident #63) of 2 residents reviewed for accident. Specifically, an incident where Resident #62 was found on the floor, near the exit door, with a hematoma was not reported to New York State Departement of Health (NYS DOH). The finding is: The facility policy on Accident and Incident Reporting, revised 7/13/22 documented: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident #62 was admitted to the facility with diagnoses that included Depression, Non- Alzheimer's Dementia, and Difficulty in Walking. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had intact cognition. Resident #62 required extensive assist of one person with walking, dressing, and using the bathroom. During an interview on 03/02/2023 at 12:16 PM, Resident #62 stated they did not remember having a fall. The resident had a very short attention span during the interaction. The Accident/Incident report documented Resident #62 was found on the floor near the exit door on 01/11/2023 at 6:05 AM, during unit staff regular rounding. Immediate assessment of the resident revealed swelling of the left forehead. The Attending Physician was immediately notified by the Nursing Supervisor, and the resident was transferred to the hospital emergency room . Resident #62 was received a Computer Tomography (CT) scan and was diagnosed with a hematoma to the forehead with no intracranial hemorrhage. Resident #62 was treated conservatively and transferred back to the facility with a diagnosis of syncope. There was no documented evidence this injury of unknown origin was reported to NYS DOH within 2 hours. During an interview on 03/02/2023 at 3:00PM, the Assistant Director of Nursing(ADNS) stated the incident was investigated and statements were taken from staff. The ADNS further stated they were not aware the incident should be reported to the NYS DOH because Resident #62 fell and sustained a hematoma. 415.4(b)(2)

Based on observation, interviews, and record review conducted during an abbreviated survey ( NY00297891 and NY00294958) the facility failed to implement their policy and procedure on reporting an alleged violation involving abuse to law enforcement immediately, but no later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. This was evident in 3 out of 4 residents reviewed (Resident #1, Resident #2, and Resident #3). Specifically, 1) Resident #1 reported to facility staff that Licensed Practical Nurse (LPN) #1 came into their room and hit them (Resident #1 and Resident2) on their face and forehead with the bed remote on 06/22/2022. Resident #1 and Resident #2 were assessed with no visible injuries. The facility did not report the alleged abuse allegation to law enforcement. 3) Resident #3 reported to facility staff that Certified Nursing Assistant (CNA) #1 who worked on the overnight shift pour water on them and hit them on the forehead with a water pitcher on 04/26/2022. Resident #1 was assessed with a skin tear and wet blood on the right side of their forehead. The allegation of physical abuse was not reported to law enforcement. The Findings include: The facility's Policy and Procedure titled Abuse Prevention Program reviewed on 04/28/2022 documented that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: Law enforcement officials. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two hours if alleged violation involves abuse OR has resulted in serious bodily injury; or twenty- four hours if alleged violation does not involve abuse AND has not resulted in serious bodily injury. Resident #1 was admitted to the facility with diagnoses of Cerebellar stroke and Major Depressive Disorder. The Minimum Data Set, (MDS, a resident assessment tool) dated 05/02/2022 documented that Resident #1 had moderately impaired cognition. Resident #2 (Resident #1's roommate) was admitted to the facility with diagnoses including Epilepsy, Aphasia, and Hypertension. The MDS dated [DATE] documented that Resident #2 has short and long-term memory problems with severely impaired cognition. The facility Incident Report dated 06/23/2022 revealed that on 06/22/2022 at about 5:50 PM Resident #1 reported that the charge nurse who was assigned to the unit hit them and their roommate with a bed remote on their face and body. Resident #1 stated that the incident occurred yesterday and did not give a reason why they did not report the incident right away. Resident #1 also said that the incident occurred in the presence of CNA #1 who laughed at them and did nothing. Resident #2 was non-verbal and could not provide a statement of the occurrence. On exam both Residents had no bruising or other visible injury. The MD was informed. The facility investigation concluded that the alleged abuse was unsubstantiated. Resident #3 was admitted to the facility with diagnoses including Dementia and Generalized Anxiety Disorder. The MDS dated [DATE] documented that Resident #3 had moderately impaired cognition. A Nurse's Note dated 04/26/2022 documented that at around 7:10 AM during hourly rounds Resident #3 was observed with a small linear skin tear on the right side of the forehead. Resident #3 alleged that a staff member who was assigned to them last night threw a water pitcher full of milk on their face when Resident #3 asked the staff to do something for them. Resident #3 said that they were not able to reach the call bell as it was stuck under their bed mattress. Resident #3 reported the incident to the staff on the following shift. Upon exam, no active bleeding was observed to the injured area. The injured area was cleaned, and Bacitracin ointment applied. The empty pitcher was observed on the floor under the bed and the floor was clean. The facility Incident Report dated 05/01/2022 revealed that on 04/26/2022 at about 7:00 AM Resident #3 reported that CNA #1 struck them with a water pitcher and poured milk and urine on them. Resident #3 also stated that they kicked CNA #1 on their head while CNA #1 was on the floor trying to clean up the mess. Resident #3's roommate was non-verbal and unable to provide a statement of the occurrence. On exam Resident #3 was noted with a small linear scratch and wet blood on their forehead. There was no swelling or redness to the area. The MD was informed and ordered a STAT X-ray of the skull which came out negative for acute fracture or dislocation. Resident #3 was examined by the psychiatrist and the medications were adjusted. The facility investigation concluded that Resident #2's injuries were inconsistent with what they reported, and abuse did not occur. During an interview on 03/02/2023 at 9:55 PM, the Administrator stated that allegations of abuse must be reported to law enforcement within 24 hours. The Administrator stated that they were not sure why the allegations were not reported to law enforcement. 10 NYC RR 415.4(b)

Based on observations, interview, and record review conducted during the recertification survey, the facility did not ensure that food was prepared and served in a sanitary manner. Specifically, 1) cold sandwiches were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below; and 2) kitchen staff were observed not following proper handwashing guidelines. The findings are: 1) The facility policy and procedure related to Recording-Food Temperatures Prior to Meal Services dated 10/20/19 documented that all food temperatures will be recorded immediately before serving all meals. Cold items should be between 38 and 40 F. On 02/13/20 at 11:14 AM, the Food Service Director (FSD) was observed calibrating a thermometer in the kitchen to test food items that were being served on for the lunch meal. An egg salad sandwich that was sitting on the food prep station, waiting to be transported to the floor for a snack later was tested with the thermometer. The reading was 52 F. A second egg salad sandwich was obtained from inside the kitchen refrigerator and tested with the same thermometer. The reading for the second sandwich was 51 F. A third tuna salad sandwich was obtained from the kitchen refrigerator and was tested with the same thermometer. The reading for the third sandwich was 50 F. The FSD stated that he would try a different thermometer and obtained another thermometer from his pocket. He placed this thermometer in the tuna fish sandwich and the reading was 20 F. He then obtained a third thermometer from the cook and tested the same sandwich. The third thermometer reading was 30 F. All three thermometers had different readings and were inserted into the same tuna sandwich at the same time. On 02/14/20 at 11:27 AM, a bologna sandwich that was sitting on a resident's tray on the food truck was tested with a calibrated thermometer. The reading for the bologna sandwich was 51 F. 2) The policy and procedure related to Infection Control - Hand Washing dated 6/21/18 documented that hands should be washed after removing gloves and between glove changes. On 02/14/20 at 11:27 AM, Cook #1 was observed in the food prep area preparing to make the plates for the residents' lunch trays. He removed his gloves and donned new gloves without washing his hands in between. He then began serving food. At 11:45AM, the FSD was observed washing his hands for approximately 8 seconds. At 11:51 AM, Cook #1 washed his hands for 10 seconds and turned off the water faucet with his bare right hand. At 11:52 AM, Cook #2 was observed at the sink. She washed her hands for approximately 12 seconds and turned off the faucet with her bare right hand. On 02/19/20 at 11:12 AM, an interview was conducted with Cook #1. He stated that he checks the food temperatures of the hot food. He also prepares the cold cereal in the morning and knows that this must be below 40 F. He does not test the sandwiches in the kitchen. He stated that he only checks the temperatures of the refrigerators to ensure that they are holding at the proper temperature. Cook #1 is aware that he must lather up and wash his hands for at least 20 seconds and turn off the water faucet with a dry towel in his hand. He stated that the kitchen has now been equipped with a foot pedal system so that the staff no longer have to turn off the faucets with their hands. An interview was conducted with Cook #2 on 02/19/20 at 11:20 AM. Cook #2 stated that she makes the cold sandwiches in the morning and places them in the freezer. She checks the temperature of the sandwiches while they are in the freezer to ensure that they are at a safe temperature. She does not test the sandwiches prior to serving them. Cook #2 is aware that proper hand washing technique is to use soap and water for at least 20 seconds. The faucet must be turned off with a paper towel in hand. The kitchen no longer has faucets and uses a foot panel. On 02/19/20 at 11:26 AM, the FSD was interviewed. The FSD stated that the chicken, tuna, and egg salad have been placed in the freezer to ensure that they maintain a safe temperature before being served to the residents on the units. The cold cuts, such as the bologna on the bologna sandwich, have not been placed in the freezer to ensure that they maintain a temperature below 41 F prior to serving residents. The kitchen staff are now instructed to place these sandwiches in the freezer as well. The kitchen has not had any issue with testing for food temperatures or with thermometer accuracy prior to survey. The kitchen obtains new thermometers all the time. Once the issue was identified with three different thermometers providing three different readings, the FSD tested the thermometers and threw out the defective ones. The thermometers are tested every day for accuracy. Cold foods, such as sandwiches, should be kept at 40 F or below. In the last month, the kitchen has had 3 in-services on hand washing. One was from an outside consultant, and another was done by the FSD. The FSD performs competencies all the time on the kitchen staff to ensure that they observe proper hand washing protocol and has not had any concerns prior to survey. 415.14(h)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan to meet a resident's medical and nursing needs as identified in the comprehensive assessment was developed for each resident. Specifically, (1) a resident with a [MEDICAL CONDITION] (trach) did not have a comprehensive care plan (CCP) related to [MEDICAL CONDITION] care; (2) a resident's [MEDICAL TREATMENT] CCP had interventions for an av shunt when the resident had a permacath; and (3) a resident's Urinary Incontinence/Indwelling Catheter CCP did not include interventions to address the care needs for a capped Suprapubic catheter and Foley catheter. This was evident for 3 out of 38 sampled residents (Resident #s 82, 434, and 9). The findings are: 1) Resident #82 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, and the resident required oxygen therapy, suctioning, and [MEDICAL CONDITION] care while a resident. The physician's orders [REDACTED].# 0. The orders further documented the [MEDICAL CONDITION] collar should be changed every 3 days, [MEDICAL CONDITION] should be done every shift. The Treatment Administration Record for February 2020 documented that [MEDICAL CONDITION] was being changed every 3 days. There was no Comprehensive Care Plan (CCP) related to [MEDICAL CONDITION] care or respiratory status. On 02/18/20 at 11:55 AM, an interview was conducted with RN #5, the MDS Assessor. RN #5 stated that the other MDS Assessor left the facility 3 weeks prior, and she is the only MDS Assessor in the facility. She completed and signed-off on the resident's MDS dated [DATE]. She is responsible for ensuring that a CCP [MEDICAL CONDITION] is in the medical record after completing the MDS. The Assessor confirmed that there was no respiratory or [MEDICAL CONDITION] CCP in the resident's record. RN #5 stated that it must not have been reactivated when the resident was readmitted from the hospital in December. She stated she will reactivate and update the CCP now. 2) A policy and procedure related to Care of Resident on [MEDICAL TREATMENT] dated 3/2/18 and did not document care planning related to [MEDICAL TREATMENT] treatment. Resident #434 had [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident was cognitively intact and received [MEDICAL TREATMENT] treatment. On 02/19/20 at 10:33 AM, Resident #434 was observed to be sitting in his wheelchair in his room. He had a permacath on the right side of his upper chest. There was no AV shunt observed. The Physician order [REDACTED]. A Nursing Note dated 1/31/20 documented that the resident had a right upper chest permacath for [MEDICAL TREATMENT] treatment. The Comprehensive Care Plan (CCP) related to [MEDICAL TREATMENT]/renal dysfunction, initiated on 2/4/20, inaccurately documented that the resident had an AV shunt for [MEDICAL TREATMENT] access. The interventions addressed care needs for an AV shunt. The CCP did not address the care needs for a permacath. An interview was conducted with Registered Nurse (RN) #4 on 02/19/20 at 10:38 AM. RN #4 was the nurse who filled out the resident's CCPs, including the CCP related to [MEDICAL TREATMENT]. She reviewed the CCP and stated that she can see what the discrepancy is. The resident has a permacath, not an AV shunt. When she documents on the resident's CCP, she looks at the resident's history and picks interventions that are listed in a library in the electronic medical record. RN #4 stated that she reviews the CCPs monthly, but the resident has not had one yet because they are newly admitted . Her documentation was a mistake. 3) Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. The 1/31/20 Admission Minimum Data Set 3.0 (MDS) assessment documented resident #9 was cognitively intact and had an indwelling catheter. physician's orders [REDACTED]. The physician's orders [REDACTED]. The CCP for Urinary Incontinence/Indwelling Catheter dated 1/24/20 documented the resident's suprapubic catheter was capped secondary to blockag, and a new foley catheter was placed. The CCP included the following interventions: assess skin daily, maintain skin integrity x 90 days, and urology consult as needed. The urinary incontinence/indwelling catheter care plan did not include resident-centered interventions for the care of the capped suprapubic catheter and newly placed Foley catheter. On 2/18/20 at 4:57PM, the Registered Nurse Manager (RN # 3) was interviewed. She stated the indwelling catheter care plan did not have interventions for the care of the catheter. She further stated she had recently started working at the facility and would now be responsible for reviewing and revising the care plans. 415.11(c)(1)

Based on observation, record reviews, and staff interviews during a Recertification and complaint survey it was determined that the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, the facility staff failed to develop and implement policies and procedures to identify, provide supervision and prevent the elopement of those residents who were identified as high risk for such behaviors. This was evidenced by the following: 1) The Nursing staff did not provide monitoring of a resident identified as high risk for elopement. 2) The facility failed to inform the Housekeeping/Porter staff of the residents who were identified as high risk for elopement. 3) The facility staff failed to ensure that all exit doors were monitored. 4) The Registered Nursing Supervisor Nursing (RNS) failed to ensure that the beeper linked to the wanderguard alarm system were in her possession at all times. 5) The facility staff failed to respond immediately to an alarm triggered when a resident identified as high risk for elopement exited from an exit door located in the basement. As a result the resident was able to elope from the facility and was not found until 6 days later, after admission into a local hospital. This practice has affected one of three residents reviewed for elopment risk (Res# 426) and had the potential to affect 31 residents who have been identified by the facility as being at risk to elope from the facility. This resulted in no actual harm with the potential for more than minimal harm that was immediate jeopardy and substandard quality of care. Complaint #: NY 751 The findings are: Resident #426 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3-11 shift RNS (Registered Nurse Supervisor ) new admission nurse's note dated 10/21/14 at 7:45 PM, documented that the resident was A/O x 1 (alert and oriented times one), able to ambulate on the unit and able to make his needs known. The Medical Admission Note dated 10/21/14 documented the resident was alert and oriented, with dementia present. The resident /family educational assessment form dated 10/21/14 documented that the resident is receptive with fair capacity to learn. The NA (New Admission) Elopement Risk assessment dated [DATE] documented a total risk score of 3, indicating the resident was NR (No Risk) for elopement. The Resident /Family Education assessment dated [DATE] documented the resident's vision was poor, his existing knowledge of disease was limited and his capacity to learn was fair. The CCP (Comprehensive Care Plan) dated 10/21/14 documented "No elopement attempts made at this time." in the evaluation section. The 11-7 shift LPN (Licensed Practical Nurse) nurses note dated 10/21/14 at 11:05 PM, documented that "upon arrival to the unit writer heard exit alarm at the lower side, immediately check(ed) the exit door and found resident almost at the door at the roof top. Resident was reoriented to place and time. Resident stated don't touch me. Will continue to monitor resident." There was no documented evidence that the resident was identified as at risk for elopement on 10/21/14 after he was found at the door to the roof at 11:05 PM. The nursing 24 hour report documented that on 10/21/14 at 11:05 PM the resident was found by Licensed Practical Nurse (LPN) at exit door leading to the roof. On 10/22/14 during the day shift it was reported that the resident was an elopement risk, needs wanderguard and during the evening wandering behavior was observed. A Comprehensive Care Plan (CCP) to address the resident's wandering behavior was developed on 10/22/14. The CCP identified that the resident was at risk for wandering as evidenced by walking off the unit and pacing related to cognitive impairment. There is an evaluation note documenting that the resident was observed verbalizing the need to leave facility and inquiring of public transportation around the area. The intervention put in place was to monitor behavior and record on monitoring maintenance log. There is no documented evidence of this behavior monitoring form being initiated in the resident's medical record. A Brief Interview of Mental Status was conducted by the facility's Social Worker. The resident was assessed with [REDACTED]. The Social Worker new admission assessment dated [DATE] documented the resident as alert, verbal and able to express his basic needs. The note further documented that the resident displays periodic confusion. The Care Area Assessment (CAA) dated 10/27/14 documented that the resident displays problem of periodic confusion and further documents that there is supporting documentation of this from the progress notes. There is no documented evidence of the periodic confusion episodes in the nursing progress notes dated 10/21/14 thru 10/28/14. On 10/30/14 at 10:00 AM the administrator reported to the survey team that during the evening on 10/29/14 Resident #426 had eloped from the facility and had not been found until 11/3/14 at a local area hospital. He was admitted to the hospital for symptoms related to alcohol abuse. On 10/30/14 at 6:00 PM a member of the Survey team along with the Administrator reviewed the facility's video surveillance footage from the previous day and evening. The video system had no audio. The video revealed the following order of events: At 10:35 PM the receptionist was viewed at the front desk, which is located in the lobby level at the front of the main entrance door. The receptionist was observed labeling clothing at desk area. However, while performing this task she was not standing directly in front of the video monitoring system and was not watching video screen. The video also showed the porter cleaning chairs in the basement. At 10:39 PM the resident exited out of the elevator in the basement wearing his hat and coat. The resident was pacing back and forth in the dining room which is located in the basement. At 10:40 PM the receptionist was observed leaving the front desk unattended. She returned at 10:42 PM and continued to label clothes and answer telephone. At 10:43 PM the resident was observed still in basement. The resident sat in a chair across from an elevator (identified as elevator A). At 10:44 PM the resident got up and walked toward the corridor where wheel chairs were stacked. At this time there was a Porter in that area, the resident looked at the Porter and walked back to dining area. At 10:45 PM the video of the basement reveals resident pacing in dining room. The video of the front desk reveals the receptionist being approached by a staff member. At 10:46 PM the video of the front desk revealed that the receptionist left the front desk unattended for approximately 5 seconds. Upon her return to the desk, she was approached by RN (Nursing Supervisor). At 10:47 PM the video of the basement revealed that the resident left the dining room and proceeded to the corridor. The resident went to the exit door, which has a sign posted over the door that reads "15 second delay" and pushed it open. there was no delay to the door opening. Simultaneous to this time, the video of the front desk reveals the receptionist talking on the telephone while standing at the desk. The video monitors were below her scope of view. The resident was able to reach the outside ramp by 10:48 PM with no intervention. At 10:49 PM the receptionist went over to the alarm panel located at the desk. The surveyor was unable to determine what action the receptionist took at this time. At 11:03 PM CNA# 1 starting to exit the facility, but remained in the lobby talking. At 11:06 PM the receptionist was puting on her coat and was approached by the RNS. The RNS stayed at the desk until 11:08 PM. At 11:09 PM the the porter, RNS and security guard were all in the lobby at the front desk. At 11:10 PM the receptionist reset the alarm. According to the sequence of events recorded on video there was a lapse of 23 minutes between the resident leaving the facility and the receptionist resetting the alarm. The receptionist was not monitoring the video surveillance monitor and did not see the resident exit from the basement door. The receptionist did not respond to the alarm when the resident with the wanderguard exited the building and did not alert staff when the alarm sounded. On 10/30/14 at 6:30 PM the evening shift RNS who was on duty on 10/29/14 was interviewed and stated, at approximately 11:00 PM she was notified by the security/ receptionist staff and a CNA that the resident was missing. A search was done and resident was not found and code green was called. Which is when an alarm is sent throughout the facility informing staff that a resident has attempted to elope through an exit door. During the interview, she took a beeper out of her pocket and stated that the beeper is linked to the resident's wanderguard bracelet, and beeps and displays the resident's name and location if a resident elopes. She stated that she did not have the beeper on her at all times on the evening of 10/29/14. She was unable to demonstrate how the beeper works or how to retrieve the stored information. She further stated that she did not check the beeper for the resident's name at the time that she was made aware that the resident was missing. On 10/31/14 at 10:00 AM the Security/Receptionist staff was interviewed. She stated that her duties included checking the camera monitors at all times. However, she said that she could not do this because she was assigned other duties as well. Her other duties include making photo copies, labeling clothing, signing visitors in and out of the facility. She stated that when making copies and labeling clothes the monitors are behind her and not within her sight. She has stated that she has spoken to her supervisor who is the Director of Operations (DOO) as well as the Administrator about her various duties and her ability to perform them. She stated that on 10/29/14 due to a power outage the facility was on generator power. She stated that the Box Alarm Panels located behind the front desk and near the front door were not working. When asked what did she mean by not working, she said she meant that the alarms were making noise every thirty seconds. She further stated that to temporarily stop the noise she used a paper clip many times to push in the Alarm Box. She said that she called the administrator on the telephone to report the noise, but she had difficulty hearing him during the call. She was informed by the porter via phone that a Resident was in the basement and she notified the RNS. The receptionist stated that there were times that she did view the monitor, but did not see any Resident in the basement. She said she did not see when the resident went through the exit. The receptionist stated that she was not aware of the resident's elopement until a Certified Nurse Assistant (CNA) informed her that they conducted a head count and the resident was missing. The receptionist stated that she has been educated on the facility's elopement/wandering policy. She stated that she was supposed to call a "code green" which means "missing resident" when a resident exits the facility and the alarm sounds. She is also supposed to immediately reset the alarm. She has the access code to reset the alarm at the location from where the alarm is ringing. However, she did not do this on 10/29/14 because she thought that the resident was somewhere in the facility. She stated that she reset the alarm, but was unable to recall the timeframe between the time the alarm sounded and the time it took her to reset it. The personnel file of the security/receptionist lists the job description and duties, it is dated 2/13/14. The duties are to follow the elopement policy and procedures, assure that no resident wanders outside the facility. It also lists to immediately respond to all fires, disasters and emergencies. Her personnel file included documentation that she received a warning on 8/1/14 for failing to respond immediately to a fire alarm that was activated on Unit 3. She was also given a warning for not using the alarm code reference in the same incident. There is no documented evidence that the security/receptionist received supervised monitoring after the incident of 8/14. The facility developed a list of residents who require a wanderguard. There were 32 residents identified on the wanderguard list as high risk for elopement. There were 25 residents listed as wearing wanderguards and 7 who refused the wanderguard. The policy and procedure on wireless resident monitoring system dated 5/30/14. documented that residents identified as high risk for elopement will be monitored via wireless monitoring system to detect any signs of elopement as quickly as possible. It also documented that the list of residents who are identified as high risk for wandering/elopement would be updated and distributed to all departments. The facility's attendance sheet dated 5/15/14 regarding the facility's policy and procedure on wandering resident/ elopement documented that the security/receptionist staff had received inservice on this topic. On 11/1/14 at approximately 9:00PM the Porter who was identified in the video was interviewed and stated that he did not know that the resident was identified as at high risk for elopement. He stated that he was never provided with a list of residents identified as high risk for elopement. The resident was in the basement dining room after dining hours. He called the security/receptionist desk to report the resident being in the dining room. He did not observe the resident leave the exit door. On 11/04/14 at 09:52 AM the DON (Director of Nursing) was interviewed. She stated that she was informed about the resident going through the stairwell on 10/21/14. She stated that an investigation should have been initiated after that incident. When the resident eloped on 10/29/14 an investigation was initiated for the elopement and the incident was reported to the NYS Department of Health. She further stated that the supervisors are required to carry the beepers on them at all times. However, at the time of the elopement there was no written policy regarding the use of the beeper system. On 11/04/14 at 2:00 PM the Director of Operations (DOO) was interviewed. He stated that he supervises the Housekeeping / Porters, Maintenance and Security /Receptionist Staff. He stated that the Security/Receptionist staff perform many duties which include, following the elopement policy and procedures; answers the telephone; assures that no residents wanders outside the facility; responds to all emergencies immediately. He further stated that he was fully aware that the receptionist has additional duties that include: labeling clothing, distributing check stubs, and making photo copies. He stated that the security/ receptionist was doing too much and could not monitor the cameras at all times. He further stated that the security receptionist staff had one (1) prior infraction in August 1, 2014 regarding a delay in responding to a fire alarm. She was given a warning. He stated that no monitoring was done of this security / receptionist staff after the August 1, 2014 incident. The DOO stated that he was provided with a list of high risk for elopement residents, but did not forward or provide this list to his porters / maintenance / housekeeping staff. The DOO stated that he completes the Door Alarm Audit Log Sheets on a weekly basis. This audit includes the basement exit doors. The door alarm audit log sheet dated 10/28/14 lacked documented evidence that the hallway door in the basement next to the electrical room was checked for alarm sound. The policy and procedure for wandering resident/elopement dated 2/7/14 documented: "Residents will be maintained in a safe and secure manner. Every effort possible will be made to identify residents who wander and ensure immediate implementation of resident search procedures upon discovery of a missing resident. The purpose is to safeguard the health and welfare of any resident who leaves the facility without notification of staff. If a resident has been identified for risk of elopement the facility staff will ensure that all exit door alarms are responded to immediately. Security staff will assure that all exterior doors are armed/monitored at all times. Recreation/social service/ nursing will issue a written notification to all departments with the names of the residents who are identified as at risk for elopement and/or wandering. If the receptionist leaves the front desk for any reason or any period of time, regardless of how short, a trained replacement employee must be stationed at the front desk. When the alarms go off, an announcement and follow up call should be made by the receptionist. The receptionist also monitors the exit doors via a TV monitor. It is the responsibility of all staff to report any resident verbalizing the desire to leave the facility to the nursing supervisor immediately. At the time of the elopement there was no documented evidence of a policy and procedure, or in-service for the usage of the beeper system which is directly linked to the wanderguard / wireless bracelet that the residents wear. The Immediate Jeopardy was removed prior to exit. The facility employed corrective measures prior to the completion of the survey that removed the IJ. Investigation for 10/21/14 incident of going through stairwell has been initiated. The facility called the alarm company and was onsite during survey. All exit alarms were checked and properly functioning . The Policy and Procedures for the Wireless Resident Monitoring System were revised. The revision includes the instruction that all Professional Registered Nursing staff who are assigned a beeper have must wear the beeper at all times while on duty. The Policy and Procedures for Resident access to the basement via elevator has been revised. The The Residents access to the basement via the elevator after dining hours has been restricted. The Policy and Procedures for Wandering and Resident Elopement were revised to include notifying all staff of residents identified as at risk for wandering and/or elopement. All staff in all departments are to receive a list of residents identified as high risk for elopement and wandering. The Job Description of the Receptionist was revised to reflect that the duties are solely to monitor the front exit door and video surveillance system. The receptionist will have no other assigned duties. Facility Staff were educated on the aforementioned revised policies and procedures. ? Social services, Psychiatric consultants, administration, Admissions, Rehabilation, Maintenance, Recreation staff 100% completed ? Medical records staff 1 of 3 completed ? Porters staff 12 of 14 completed ? Dietary staff 26 of 28 completed Nursing staff inclusive of RN, LPN, CNA 118 of 129 = 90% 415.12(h)

Based on observation, record review and staff interviews, the facility failed to provide a Quality Assessment and Assurance (QA&A) program that identified, developed and implemented appropriate plans of action to correct identified quality deficiencies related to the supervision of residents at risk for elopement. Specifically: 1) The committee failed to identify the immediate and potential risk to residents health and safety from unsafe wandering and elopement; 2) The committee failed to evaluate the existing system and implement revised plans of action to prevent a resident from eloping after the resident was initially found on a stairwell near the roof exit; 3) The committee failed to provide monitoring and education to the staff on the QAA process. This practice has affected one of three residents reviewed for elopment risk (Res# 426) and had the potential to affect 31 residents who have been identified by the facility as being at risk to elope from the facility. This resulted in no actual harm with the potential for more than minimal harm that was immediate jeopardy. COMPLAINT # NY 751 (See F 226, F323, F490 F520) The findings are: On 10/31/14 at 3:45 PM the Administrator was interviewed and she stated that she is responsible for the overall administration of the facility and is part of the QA&A committee. She stated that the facility has an active list of 32 residents identified as high risk for elopement and the QA&A Committee had not identified elopement / unsafe wandering as a QA issue. She further stated that the topics for the scheduled meetings are pre-planned and distributed to the QA team, and that the CNA's (Certified Nurse Assistants, porters and dietary aides are not involved in the QA meetings. On 11/04/14 at 09:52 AM the DON (Director of Nursing) was interviewed and stated that although there are 32 residents identified as high risk for elopement, this issue had not been an identified QA concern. On 11/04/14 at 2:00 PM the Director of Operations (DOO) in charge of the Housekeeping / Porters / Maintenance, Security / Receptionist staff was interviewed and stated that he is part of the Q A team and that elopement / wanderering, alarm systems, and security responsibilities had not been an identified concern. On 11/06/14 at 12:00 PM the Assistant Administrator was interviewed and stated that he is part of the QA committee and that the nurses and department heads are responsible for gathering information in the facility regarding any incidents. On 11/06/14 12:50 PM the day shift RN Supervisor was interviewed and stated that no feed back is given to direct care staff about the QA meetings unless a concern is being addressed that requires inservice. On 11/06/14 at 3:30 PM an attending Physician was interviewed about QA and was unsure about what the process of QA entailed. On 11/06/14 six (6) CNA's (Certified Nurse Assistant's) were interviewed and all of the CNA's stated that they had no knowledge about the QA meetings or about the overall process of QA. An interview with the Medical Director was conducted on 11/06/14 at 4:00 PM. The Director stated that he receives e-mails alerting him to the scheduled QA meetings, and does not always attend. A review of the "Continuous Quality Assessment & Improvement Program Policy and Procedure" dated 02/24/11 documented: "Goals: to provide a means whereby negative outcomes related to care could be identified and resolved through an interdisciplinary approach and positive outcomes can be reinforced through education and monitoring. Identify negative and positive outcomes on direct or indirect resident care." The Immediate Jeopardy was removed prior to exit. The facility employed corrective measures prior to the completion of the survey that removed the IJ. Investigation for 10/21/14 incident of going through stairwell has been initiated. The facility called the alarm company and was onsite during survey. All exit alarms were checked and properly functioning . The Policy and Procedures for the Wireless Resident Monitoring System were revised. The revision includes the instruction that all Professional Registered Nursing staff who are assigned a beeper have must wear the beeper at all times while on duty. The Policy and Procedures for Resident access to the basement via elevator has been revised. The The Residents access to the basement via the elevator after dining hours has been restricted. The Policy and Procedures for Wandering and Resident Elopement were revised to include notifying all staff of residents identified as at risk for wandering and/or elopement. All staff in all departments are to receive a list of residents identified as high risk for elopement and wandering. The Job Description of the Receptionist was revised to reflect that the duties are solely to monitor the front exit door and video surveillance system. The receptionist will have no other assigned duties. Facility Staff were educated on the aforementioned revised policies and procedures. ? Social services, Psychiatric consultants, administration, Admissions, Rehabilation, Maintenance, Recreation staff 100% completed ? Medical records staff 1 of 3 completed ? Porters staff 12 of 14 completed ? Dietary staff 26 of 28 completed Nursing staff inclusive of RN, LPN, CNA 118 of 129 = 90% 415.27

Based on observations, records reviews and interviews the facility failed to administer the facility in a manner that maintained each resident's highest practible level of physical, mental and psychosocial well being, as evidenced by: 1.) Failed to ensure a High Risk for Elopement Resident was appropriately monitored to prevent an actual incident of elopement. (Res #426) 2) Failure to ensure that security surveillance cameras were being properly and adequately monitored. 3) Failure to ensure that an investigation was conducted for a Resident with a known history of exiting the unit floor and who actually eloped on 10/29/14. (Res #426) 4) Failure to ensure that the facility's policies and procedures were enforced to prevent an actual elopement incident. (Res #426) 5) Failure to ensure that all Departments were included in indentifying High Risk for Elopement Residents. This practice has affected one of three residents reviewed for elopment risk (Res# 426) and had the potential to affect 31 residents who have been identified by the facility as being at risk to elope from the facility. This resulted in no actual harm with the potential for more than minimal harm that was immediate jeopardy. COMPLAINT # NY 751 (See F323, F490 F520) The findings are: On 10/31/14 at 3:45 PM the Administrator was interviewed and she stated that she is responsible for the overall functioning of the facility. She was aware and at times assigned the security / receptionist staff of other duties beyond her regular duties, which could have contributed to lack of monitoring of the surveillance cameras. Since the elopement the security part of the receptionist job description has been deleted. The Administrator attended morning meetings and was aware of the resident's first attempt of going through the stairwell. She acknowledged that the policy and protocols governing accidents and incidentst should have been followed and an investigation should have been initiated, and was not done. The policy for elopement was reviewed and found that the housekeeping /porter / maintenance were not included in the protocols. The elopement policy has now been revised to include providing the staff of those departments of the list of residents identified for high risk of elopement / wanderers. On 11/04/14 at 2:00 PM the Director of Operations (DOO) in charge of Housekeeping / Porters / Maintenance, Security / Receptionist Staff was interviewed. He stated that the Security / Receptionist staff performed many duties which included the following: follows the elopement policy and procedures; answers telephone; assures that no residents wanders outside the facility; responds to all emergencies immediately. He further stated that he was fully aware that she had additional duties that included: labeling clothing, distributing check stubs, and making photo copies. He stated that the security/ receptionist was doing too much and could not monitor the cameras at all times. He further stated that he was aware that the security / receptionist staff had one (1) prior infraction in August 1, 2014 regarding a delay in responding to a fire alarm. A warning was given. He stated that no monitoring was done of this security / receptionist staff after the August 1, 2014 incident. He stated that he was provided with a list of high risk for elopement residents, but did not forward or provide this list to his porters / maintenance / housekeeping staff. He completes the Door Alarm Audit Log Sheets on a weekly basis. This was not checked for the basement exit for the date of 10/28/14. On 11/04/14 at 09:52 AM the DON (Director of Nursing) was interviewed and stated that she was informed about the resident going through the stairwell on 10/21/14. Is aware that an investigation should have been initiated as per the A/I (Accident/Incident) policy. She further stated regarding the beepers that are linked to the wanderguard system, the supervisors are responsible to carry the beepers on them at all times. There is no policy for the beeper system, and one will be developed and all staff responsible will be inservice regarding the usage of the beepers. On 11/06/14 at 12:00 PM the Assistant Administrator was interviewed and he stated that the nurses and department heads are responsible to gather information in the facility regarding any incidents that occur. He does not attend morning meetings, and at times attends Quality Assurance meetings. He stated he is more of a go between person such as talking to the vendors and helping out with projects. He further stated he receives the list of high risk for elopement residents once in a while and does not know if the list has been updated. The Immediate Jeopardy was removed prior to exit. The facility employed corrective measures prior to the completion of the survey that removed the IJ. Investigation for 10/21/14 incident of going through stairwell has been initiated. The facility called the alarm company and was onsite during survey. All exit alarms were checked and properly functioning . The Policy and Procedures for the Wireless Resident Monitoring System were revised. The revision includes the instruction that all Professional Registered Nursing staff who are assigned a beeper have must wear the beeper at all times while on duty. The Policy and Procedures for Resident access to the basement via elevator has been revised. The The Residents access to the basement via the elevator after dining hours has been restricted. The Policy and Procedures for Wandering and Resident Elopement were revised to include notifying all staff of residents identified as at risk for wandering and/or elopement. All staff in all departments are to receive a list of residents identified as high risk for elopement and wandering. The Job Description of the Receptionist was revised to reflect that the duties are solely to monitor the front exit door and video surveillance system. The receptionist will have no other assigned duties. Facility Staff were educated on the aforementioned revised policies and procedures. ? Social services, Psychiatric consultants, administration, Admissions, Rehabilation, Maintenance, Recreation staff 100% completed ? Medical records staff 1 of 3 completed ? Porters staff 12 of 14 completed ? Dietary staff 26 of 28 completed Nursing staff inclusive of RN, LPN, CNA 118 of 129 = 90% 415.26

Based on observation, record reviews and staff interviews, the facility failed to implement written policies and procedures that prohibit the neglect of a resident. Specifically, 1) the facility staff did not initiate an investigation on 10/21/14 after Resident #426 was found attempting to exit through door leading to the roof. 2) The facility did not have written policies and procedures for the use of the wireless beeper that is linked to its wanderguard system. As a result the Nursing Staff assigned to the beeper did not have the beeper in use when Resident #426 who eloped from the facility on 10/29/14 through an exit door located in the basement. This practice has affected one of three residents reviewed for allegations of neglect/abuse or mistreatment. (Res# 426) This resulted in no actual harm with the potential for more than minimal harm that was immediate jeopardy and substandard quality of care. COMPLAINT # NY 751 (See F323, F490 F520) The finding is: Resident # 426 was admitted to the facility on [DATE] from an acute care hospital, with [DIAGNOSES REDACTED]. The Medical Admission Note dated 10/21/14 documented resident alert and oriented, with dementia present. The 3-11 shift RNS (Registered Nurse Supervisor ) new admission nurse's note dated 10/21/14 at 7:45 PM, documented that the resident was A/O x 1 (alert and oriented times one), able to ambulate on the unit and able to make his needs known. The NA (New Admission) Elopement Risk assessment dated [DATE] documented a total risk score of 3, indicating the resident was NR (No Risk) for elopement. The Resident /Family Education assessment dated [DATE] documented the resident's vision was poor, his existing knowledge of disease was limited and his capacity to learn was fair. The CCP (Comprehensive Care Plan) dated 10/21/14 documented "No elopement attempts made at this time." in the evaluation section. The 11-7 shift LPN (Licensed Practical Nurse) nurses note dated 10/21/14 at 11:05 PM, documented that "upon arrival to the unit writer heard exit alarm at the lower side, immediately check(ed) the exit door and found resident almost at the door at the roof top. Resident was reoriented to place and time. Resident stated don't touch me. Will continue to monitor resident." There was no documented evidence that the resident was identified as at risk for elopement on 10/21/14 after he was found at the door to the roof at 11:05 PM. There was also no documented evidence that an investigation was initiated after the incident on 10/21/14 by the LPN, evening or night shift Supervisors. The 7-3 shift nurses note dated 10/22/14 at 3:00 PM documented the resident asked the staff whether there was a train or a bus that was around the facility. The resident further expressed that he wanted to take the # 4 train and did not state his destination or why he wanted to leave the facility. The note further documents that the security guard stated that the resident "always wanders around the exit door." Elopement risk assessment done and indicated he was an elopement risk. Wander guard put on and on hourly monitoring, shoes also requested from social service." The Elopement Risk assessment dated [DATE] documented a total risk score of 17, indicating the resident was High Risk for elopement. The elopement risk re-assessment was not conducted until 16 hours after the resident's initial attempt at elopement on 10/21/14 at 11:05 PM. The CCP (Comprehensive Care Plan) dated 10/22/14 documented " Resident verbalized desire to leave facility. Tried to breach exit door. Wanderguard placed on hand." in the evaluation section. A (BIMS) Brief Interview of Mental Status was conducted by the facility's Social Worker on 10/25/14. The resident was assessed with [REDACTED]. The Social Worker new admission assessment dated [DATE] documented the resident as alert, verbal and able to express his basic needs. The note further documented that the resident displays periodic confusion. The RN Investigation Report dated 11/3/14 (initiated after the surveyor inquired about the facility's investigation into the resident's elopement from the facility) documented: "Type of Abuse: other: Egress from unit to stairway. Incident occurred at lower side 3rd floor stairway. On 10/21/14 at 11:05 pm, the LPN stated that she reported for duty and immediately responded to the lower side stairway door alarm. Resident (resident's initials) as per nurses note was observed at the top of the stairs near the roof exit. RNS (Supervisor) was notified. No incident report was completed for possible egress. The Licensed Practical Nurse (LPN) on duty on 10/21/14 was unavailable for interview. On 11/4/14 at 11:00 am the Assistant Director of Nursing (ADN) was interviewed and stated that she is responsible for initiating investigations. She stated that she did not attend the morning meeting on 10/22/14 and was made aware of the incident on 10/30/14 and had not initiated an investigation. She further stated that the RN Supervisor on duty should have initiated an investigation immediately. On 11/05/14 at 9:35 am, the 7-3 RN Supervisor (on duty on 10/22/14) was interviewed. The RNS stated that the 11-7 shift LPN informed her that she heard the exit door alarm sound at the lower side of the unit and found the resident almost at the door to the roof top. She stated that an investigation was not initiated for this incident. The RNS stated that she should have initiated the investigation once the LPN reported the incident. She further stated that she attended "morning meeting" on 10/22/14 and informed the team members which included the unit charge nurses, the DON (Director of Nursing) and the Administrator about the incident which occurred on 10/21/14. On 11/06/14 at 8:30 am, the 11-7 RNS ( on duty on 10/22/14) was interviewed and stated that no investigation related to the resident's attempted elopement on 10/21/14 had been initiated. There was no documented evidence that the Director of Nursing (DON) or Administrator implemented the facility's policies and procedures related to the identification and protection of residents at risk for elopement or an investigation of an attempted elopement of a resident on 10/21/14. The facility's policy and procedure for Accident/Incident (A/I) dated 11/7/12 documented that the goal of the safety management program is to achieve a safe environment. Incident is defined as an unexpected, unintended event. The A/I form will be completed in its entirety. The Registered Nurse (RNS) supervisor will obtain statements and investigate all incidents immediately utilizing the investigative report form. Statements will be obtained from staff involved. All reports will be generated to the Director of Nursing (DNS) / Designee and Administrator within 5 days of occurrence. The facility's policy and procedure for "Resident Abuse" dated 9/13/12 documented identification and investigation of incidents. The facility's policy and procedure for "Resident Abuse Committee" dated 9/13/12 documented: Procedure: Administrator, Director of Nursing will assure that all staff employed by the facility is informed of Resident Abuse Policy. The Director of Nursing will complete a report and submit the final report to the Administrator. 2) The policy and procedure on wireless resident monitoring system dated 5/30/14. documented that residents identified as high risk for elopement will be monitored via wireless monitoring system to detect any signs of elopement as quickly as possible. It also documented that the list of residents who are identified as high risk for wandering/elopement would be updated and distributed to all departments. On 10/30/14 at 6:30 PM the evening shift RNS who was on duty on 10/29/14 was interviewed and stated, at approximately 11:00 PM she was notified by the security/ receptionist staff and a CNA that the resident was missing. A search was done and resident was not found and code green was called. During the interview, she took a beeper out of her pocket and stated that the beeper is linked to the resident's wanderguard bracelet, and beeps and displays the resident's name and location if a resident elopes. She stated that she did not have the beeper on her at all times on the evening of 10/29/14. She was unable to demonstrate how the beeper works or how to retrieve the stored information. She further stated that she did not check the beeper for the resident's name at the time that she was made aware that the resident was missing. At the time of the elopement there was no documented evidence of a policy and procedure, or in-service for the usage of the beeper system which is directly linked to the wanderguard / wireless bracelet that the residents wear. The Immediate Jeopardy was removed prior to exit. The facility employed corrective measures prior to the completion of the survey that removed the IJ. Investigation for 10/21/14 incident of going through stairwell has been initiated. The facility called the alarm company and was onsite during survey. All exit alarms were checked and properly functioning . The Policy and Procedures for the Wireless Resident Monitoring System were revised. The revision includes the instruction that all Professional Registered Nursing staff who are assigned a beeper have must wear the beeper at all times while on duty. The Policy and Procedures for Resident access to the basement via elevator has been revised. The The Residents access to the basement via the elevator after dining hours has been restricted. The Policy and Procedures for Wandering and Resident Elopement were revised to include notifying all staff of residents identified as at risk for wandering and/or elopement. All staff in all departments are to receive a list of residents identified as high risk for elopement and wandering. The Job Description of the Receptionist was revised to reflect that the duties are solely to monitor the front exit door and video surveillance system. The receptionist will have no other assigned duties. Facility Staff were educated on the aforementioned revised policies and procedures. ? Social services, Psychiatric consultants, administration, Admissions, Rehabilation, Maintenance, Recreation staff 100% completed ? Medical records staff 1 of 3 completed ? Porters staff 12 of 14 completed ? Dietary staff 26 of 28 completed Nursing staff inclusive of RN, LPN, CNA 118 of 129 = 90% 415.4(b)

Based on observation, record reviews and staff interviews the facility did not ensure that a resident received adequate supervision during ambulation to prevent falls. Specifically on two separate occasions the resident was not supervised while ambulating off of the unit and fell resulting in a fracture. This was evident for 1 out of 29 sampled residents. (Resident #2). This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #2 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Comprehensive Assessment as documented on the The Minimal Data Set 3.0 (MDS) and dated 6/15/12 documented that the resident has a BIMS (Brief Interview for Mental status) score of 12. This score indicates that the resident is cognitively intact, but requires cueing to recall some information. It further documented that the resident requires supervision during locomotion on the unit. During locomotion off of the unit the resident was assessed as requiring supervision with set up. The MDS defines supervision as providing oversight, encouragement or cueing. The rehabilitation assessment dated [DATE] assessed the resident's ROM (Range of Motion) and Balance status. It documented a recommendation to continue ambulation on and off unit without an assistive device, but the resident requires supervision The CCP (Comprehensive Care Plan) for Falls/injuries dated 6/26/12 documented that the resident may ambulate with assist of supervision because of history of falls. The resident's quarterly assessment as documented on the MDS 3.0 dated 7/20/12 documented the resident as having a BIMS score of 6 which indicates that the resident is cognitively impaired. The Comprehensive Care Plan for Falls/injuries implemented on 6/27/12 identified the resident as at risk for falls and injuries related to history of falls, confusion, poor judgment and syncope/dizziness. The CCP documented that the resident used assistive devices and requires assist of supervision during ambulation. The interventions noted in the CCP were to assist with ambulation in room/corridor as needed, monitor for use of handrails; assist as needed. The Physician orders [REDACTED]. The physician ordered that the resident may ambulate on and off of the unit without assistive device. The CNA Accountability record dated 8/12/12 documented that the resident required supervision/setup for ambulation. Upon further review the form documented that the resident received supervision during all three shifts. The Resident Accident and Incident Report dated 8/12/12 documented that on 8/12/12 at 10:40 AM the resident was found lying in the elevator. The resident stated that he felt dizzy and fell . The resident was assessed with [REDACTED]. The MD ordered the resident transferred to the hospital. The Accident and Incident report documented the following question and answer: "Was anyone with the resident at the time of fall? No..........". The Nurses Notes dated 8/16/12 documented that the Resident was readmitted from hospital s/p (status [REDACTED]. The Comprehensive Care Plan for Falls/Injuries was reviewed and revised on 8/26/12. It documented that the resident requires assist of supervision during ambulation. It further documented that on 8/26/12 the resident was found lying on the floor of the elevator on L (left) side C (with) cast and was sent for x-ray. New interventions implemented were that staff were to acknowledge resident's unpredictable involuntary movements secondary to poor cognition. The Accident and Incident (A&I) Report dated 8/26/12 and time stamped at 10:55 AM documented a statement provided by the CNA who was assigned to the care of the resident. It documented: "I was the assigned CNA I saw resident lying on the floor. The Resident complained of headache and dizziness after fall. He reported he felt dizzy and fell ." The A&I report further documented: 'the resident was found with hypotension BP(blood pressure) 94/51, and the resident had a history of [REDACTED]. It further documented that he was found on the elevator with the left arm in a cast from previous fracture that happened on 8/12/12 as a result from a fall. He was transferred to hospital for an evaluation. There is no documented evidence of a staff being with the resident at the time of the fall in the elevator. The Stat Radiology Report dated 8/30/12 documented: 'R/O (rule out) FX (fracture).......Acute moderately displaced transverse fracture of mid shaft of humerus.....'. On 9/21/12 at 1:38 PM the resident was observed slowly ambulating independently through the hallway corridor of the main floor and entered the men's bathroom. At 1:45 PM the resident was observed walking slowly out of the bathroom to the elevator with no staff supervision. On 9/21/12 at 3 PM, the Physical therapist was interviewed and stated: "I assessed the resident on 6/5/12. I did a screen and we recommended to nursing in writing that the resident can continue to ambulate on and off unit without assistive device, but with supervision". The Physical Therapist explained that supervision means he has to have somebody with him when he is walking at all times everywhere he goes throughout the facility. On 9/21/12 at 3:25 PM, the Director of nursing (DNS) was interviewed. She stated that supervision means visual and verbal cueing and staff has to see the resident. She further stated that the CNA accountability record documented that on 8/12/12 on the 7A-3P shift supervision for locomotion was done. The DNS stated that on 8/26/12 the 7A-3P shift CNAs documented that the resident received extensive assist of one person for locomotion. She then stated that on 8/12/12 and 8/26/12 during the 7A-3P shift the resident was found by staff in the elevator alone and unsupervised. He had fallen on both occasions. The assigned CNAs are no longer employed by the facility and were not available for interview. 415.12 (h) (2)