Every finding on record at East Neck Nursing & Rehabilitation Center

Based on record review and interviews during an Abbreviated Survey (2625704), the facility did not ensure that each resident's clinical condition demonstrated the need for an indwelling urinary catheter in the absence of clinical indications for use and did not document the provision of counseling to assist the resident in understanding the clinical implications and risks associated with the use of a urinary catheter for one (Resident #1) of one resident reviewed for urinary catheter. Specifically, Resident #1 received a urinary catheter insertion after the resident requested a catheter due to urinary incontinence. There was no documented clinical indication for the catheter and there was no documented education regarding clinical implications and risks.The finding is:The facility's policy titled Justification for Use of Indwelling Urinary Catheter dated 10/2021 documented it is the policy of the facility that an indwelling urinary catheter may be inserted after assessment of the resident. Assessment will be based on valid clinical indications consistent with evidence-based guidelines as documented by the physician for the use of the catheter. The following are medical justifications for indwelling catheter use: Urinary retention including obstruction and neurogenic bladder; assistance with healing of perineal and sacral wounds in incontinent patients to avoid further deterioration of wound; resident requires strict immobilization for trauma or surgery; hospice/comfort care or palliative care; and need for accurate hourly output measurements to manage treatment in intensive care units. The facility's policy titled Foley Catheter-Insertion, Removal, Maintenance, dated 09/2021, documented a licensed nursing staff shall perform Foley catheter insertion and removal as per physician's order. All staff will undergo training and education along with an assessment of competency upon hire and as needed. Confirm the order, including catheter and balloon size; use the smallest effective catheter size or the same size as previous catheter if replacing. Document type and size of catheter and balloon Resident #1 was admitted with diagnoses including Dependence on Renal Dialysis, Benign Prostatic Hyperplasia, and Schizophrenia. The 08/12/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident had a urinary catheter.Review of the September 2025 Treatment Administration Record revealed that the urinary catheter was discontinued on 09/04/2025 due to the resident passing a trial void and freely urinating.A Comprehensive Care Plan with a focus of: The Resident has Bladder Incontinence (unable to control leakage of urine), dated 10/24/2025, documented interventions to check and change resident every two to four hours, keep skin clean and dry, monitor resident for non-verbal cues that indicate need for toileting.A Psychiatric Consultation dated 10/22/2025 documented attention seeking behaviors, bed wetting, having Certified Nursing Assistants change the bed constantly when resident is continent (able to control urine); Staff reported that resident has been wetting the bed linens instead of using bedside urinal; Resident states that they are not able to use urinal because the resident is not feeling well. Physician #1's progress note dated 10/24/2025 documented resident wishes for Foley (urinary catheter) to be reinserted as resident has been urinating more frequently. Plan to insert Foley. A Physician's order entered by Registered Nurse #1 on 10/25/2025 at 12:42 AM documented: under direct order of nursing supervisor, placement of a foley catheter and bag was inserted for a diagnosis of STAT (immediate) for urinary incontinency for Resident #1. The size of the catheter was not included in the order.During an interview on 10/30/2025 at 11:18 AM, Registered Nurse #1 stated on the overnight shift the nursing supervisor (Registered Nurse #3) called the unit and spoke to Registered Nurse #2 and gave direction that an indwelling Foley catheter should be inserted in Resident #1 because the resident was having urinary incontinence, and the resident requested the foley catheter. During an interview on 10/30/2025 at 12:00 PM, Registered Nurse #2 stated I they received the call from the nursing supervisor to insert the Foley catheter and they were assisted by Registered Nurse #1 with the insertion as a witness. The resident can use a urinal, but the resident wanted a foley catheter; they do not know why. We tried to convince the resident not to use the catheter, but the resident said they wanted it. Review of the medical record revealed no documented evidence that the staff provided education to the Resident#1 regarding clinical implications and risks of an indwelling foley catheter.During an interview on 10/31/2025 at 9:11 AM, registered nurse #3 (nursing supervisor) stated they directed registered Nurse #2 to insert the catheter as per the physician request; Registered Nurse #3 stated they directed Registered Nurse #2 to enter the order, and the doctor would sign-off in the morning. registered nurse #3 (nursing supervisor) stated they told Registered Nurse #2 to enter the order based on the doctor's note. Registered Nurse #3 (nursing supervisor) didn't write a note because it was based on the doctor's request in his note. There was no documented evidence that Registered Nurse #3 (nursing supervisor) educated resident #1 on the risks of the insertion of the foley catheter.During an interview on 11/04/2025 at 1:50 PM, Physician #1 stated to re-insert the foley was more about the resident's wishes. The resident had a lot of incontinence and was tired of dealing with incontinence, and they wanted to improve their quality of life. They know incontinence is not an indication for a Foley catheter.During an interview on 11/05/2025 at 10:45 AM, the Director of Nursing Services stated The Foley catheter insertion should be for a clinical indication of obstructive uropathy, retention of urine, or to protect a wound from urinary contamination, or quality of life for Hospice. The catheter should not be inserted for convenience. 10 NYCRR 415.12(d)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 09/14/2025 and completed on 09/18/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the initial Kitchen tour and during the Dining Task observation of the lunch meal on 09/14/2025. Specifically, 1) several frozen food items in the walk-in freezer were stored undated and with open packaging; and 2) the facility did not monitor the temperature of cold food items. The findings are: A facility policy and procedure titled Food Storage/Dating Procedures, effective date May 2023, documented that food is stored in compliance with applicable Federal, State, and local regulations regarding sanitary storage conditions. Perishable storage: all food items are dated upon receiving. All food is re-dated once opened with the open date. All food not in the original container is stored in non-absorbent containers, covered, labeled, and dated. A facility policy and procedure titled Storeroom/Food Delivery and Dating Procedures, effective date July 2022, documented the purpose to ensure that all food items delivered are monitored by dietary with proper rotating and dating, and stored in a clean environment. All items received are dated and used first-in and first-out basis. All items needing refrigeration will be dated upon delivery, including but not limited to milk, juice, dairy, frozen, and prepared bulk food items. A facility policy and procedure titled Cold Food Temperature Monitoring of Meal, effective date May 2022, documented that food temperatures are monitored during the food service process and foods are served at acceptable temperatures. The Supervisor will monitor and record the temperature of cold tray items prior to [the food] leaving the kitchen. The Dietary Aide will bring food trucks and food on ice/or a cooler bag up to the assigned unit. Once reaching the dayroom, they will take the temperature of cold food prior to serving to ensure that the food is at the proper serving temperature, less than 41 degrees Fahrenheit. Food will immediately be served after confirmation of proper food temperature. 1) During the initial tour of the Kitchen with the Food Service Supervisor on 09/14/2025 at 08:45 AM, a three (3)-door roll-in refrigerator was observed with three (3) trays of pudding, not dated. A walk-in refrigerator (identified as #1 dairy) was observed with five (5) sandwiches, three (3) cups of cottage cheese, a tray of pudding, and an open bag of shredded mozzarella cheese, not dated. An open bag of shredded cheddar cheese was also observed without a label or a date. A walk-in refrigerator combination (identified as refrigerator #2/freezer #3) freezer section was observed with a box of cheese omelets with the inner plastic bag open, and the product was exposed to the air. During an interview on 09/14/2025 at 09:00 AM, the Food Service Supervisor stated that all food should be labeled and dated, and the food should not be exposed to open air, as it will reduce the food quality. 2) During the Dining Task observation of lunch meal service in Unit one (1) [NAME] day room on 09/14/2025 at 11:55 AM, the cold food items, including milk, juice, yogurt, and desserts, were observed in a container with ice. The individual resident trays were set up on a mobile rack, with a material outer cover. The sandwiches were observed on the individual resident trays without ice or other cooling mechanism. At 12:16 PM, Dietary Aide #1 was observed taking and recording the temperatures of the hot food items. Dietary Aide #1 was immediately interviewed and stated that they only take the temperature of the hot food items and that there was no cold food to be checked. On 09/14/2025 at 12:34 PM, the first lunch tray was being prepared to be served with hot food. A turkey sandwich was observed on the tray. Dietary Aide #1 measured the temperature of the turkey sandwich, which registered 82 degrees Fahrenheit. On 09/14/2025 at 12:35 PM, a chicken salad sandwich from another tray measured 72 degrees Fahrenheit. A review of the Temperature Log, dated 9/14/2025, for Unit one (1) [NAME] and for Unit two (2) [NAME] had no documented/recorded temperature readings for the puree dessert, regular dessert, cold beverage, juice, and sandwiches for breakfast and lunch. During an interview on 09/14/2025 at 12:40 PM, the Food Service Director stated that the sandwich temperatures were not appropriate, as they were outside of the safe serving zone (there is an increased risk for bacterial growth when the food is outside of the safe temperature zone). During an interview on 09/18/2025 at 02:19 PM, the Administrator stated they were aware of the requirement to monitor food temperatures and to label and date items stored in the refrigerator and/or freezer. They further stated that they were not aware that it was not being done and should have been. 10 NYCRR 415.14(h)

Based on observations, record reviews, and staff interviews, during the Recertification Survey initiated on 09/14/2025 and completed on 09/18/2025, the facility did not maintain equipment for respiratory care, such as oxygen equipment, in accordance with federal, state, and local laws and regulations. This was identified for two (2) (Resident #200 and Resident#142) of five (5) residents reviewed for Respiratory Care. Specifically, during an observation on 09/14/2025, the oxygen tubing for Resident #142's and Resident #200's oxygen concentrator and nebulizer machines were not changed since 08/25/2025.The findings are:The facility's policy titled Care of Nebulizer Equipment, last reviewed on 09/05/2025, documented to administer treatment via nebulizer as ordered by the physician and to maintain the cleanliness of the equipment. Change the tubing, mouthpiece, and reservoir every seven (7) days, and label.The facility 's policy titled Care of Oxygen Equipment, last reviewed on 09/05/2025, documented that to provide oxygen therapy in accordance with medical orders and aseptic principles. Licensed Nurses are responsible for implementing oxygen delivery orders as prescribed by the physician. Oxygen tubing, nasal cannulas, and masks will be changed weekly and labeled; more frequently if soiled by the 11:00 PM -07:00 AM staff.1) Resident #200 was admitted with diagnoses that include Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. The Quarterly Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status score of 11, indicating the resident had moderately impaired cognition. The Minimum Data Set documented that the resident received oxygen therapy during the assessment lookback period.The physician's orders dated 08/09/2025 documented Oxygen therapy 2 liters per minute via nasal cannula or mask, continuously, every shift for shortness of breath. Change the Oxygen tubing every week during the 11:00 PM -7:00 AM shift on Sundays. Clean the Oxygen filter every week during the 11:00 PM-7:00 AM shift on Sundays. Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083%, inhale orally via nebulizer every 4 hours as needed for shortness of breath or wheezing. There were no physicians' orders for changing the nebulizer tubing per facility policy.The care plan for oxygen dated 08/19/2025 documented the resident received Oxygen Therapy related to Congestive Heart Failure. The interventions documented that the oxygen concentrator required cleaning weekly.The care plan for nebulizer dated 08/19/2025 documented that the resident had Chronic Obstructive Pulmonary Disease related to exposure to industrial pollutants and Respiratory Failure. The care plan documented administering medications as ordered, monitoring for side effects, and assessing effectiveness. During an observation on 09/14/2025 at 10:00 AM, Resident #200 was in bed receiving oxygen therapy. The oxygen tubing was dated 08/25/2025. There was a nebulizer machine on top of the resident's nightstand with the nebulizer tubing with a date of 08/25/2024.A review of the Treatment Administration Record for September 2025 indicated the last Oxygen tubing change was completed on 09/07/2025. There was no documented evidence of routine tubing changes for the nebulizer machine. During an observation on 09/16/2025 at 2:00 PM, Resident #200 was in bed receiving oxygen therapy. The oxygen tubing and nebulizer tubing were dated 09/14/2025.2) Resident #142 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Hypertensive Heart Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of nine (9), which indicated the resident had moderately impaired cognition. The Quarterly Minimum Data Set assessment documented the resident did not receive oxygen therapy during the assessment lookback period.The physician's orders, renewed on 09/05/2025, documented Oxygen Therapy 2-3 liters per minute via nasal cannula or mask every 4 hours as needed. Ipratropium Bromide Solution 0.02 %, 2.5, inhale orally via nebulizer every six (6) hours for Chronic Obstructive Pulmonary Disease.During an observation on 09/14/2025 at 10:30 AM, Resident#142 was observed in their bed watching the television. The resident was not utilizing the oxygen therapy at the time. The oxygen concentrator was behind the resident's wheelchair, and a nebulizer machine was on the nightstand. The oxygen therapy tubing and the nebulizer tubing were both dated 08/25/2025.During an observation on 09/16/2025 at 10:45 AM, Resident #142 was seated in their wheelchair in their room. The nebulizer machine was on the nightstand, and the nebulizer tubing was dated 09/14/2025.A review of the Treatment Administration Records for August and September 2025 indicated no documented evidence of routine tubing changes for the nebulizer machine or the oxygen concentrator for Resident #142.During an interview on 09/18/2925 at 10:20 AM, Licensed Practical Nurse #1 stated the nurses who work during the 11:00 PM to 7:00 AM shift were supposed to replace the oxygen and nebulizer tubing and clean the filters weekly on every Sunday. Licensed Practical Nurse#1 stated they did not realize the oxygen and nebulizer tubing were dated 08/25/2025. Licensed Practical Nurse #1 stated that changing the oxygen and nebulizer tubing prevents the spread of infections.During an interview on 09/18/2025 at 10:38 AM, Registered Nursing Supervisor #3 stated oxygen and nebulizer tubing are supposed to be replaced every Sunday during the 11:00 PM to 7:00 AM shift. Registered Nursing Supervisor #3 stated there should be a physician's order for the oxygen and nebulizer tubing to be changed weekly.During an interview on 09/18/2025 at 10:52 AM, the Director of Nursing Services stated that all physicians' orders for oxygen and nebulizer treatments need to have directions for tubing change every Sunday during the 11:00 PM to 7:00 AM shift. The floor nurses are responsible for changing the oxygen and nebulizer tubing every week to prevent the spread of infection.10 NYCRR 415.12(k)(6)

Based on observation, record review, and interviews during the Recertification Survey initiated on 09/14/2025 and completed on 09/18/2025, the facility did not ensure that nurse staff posting data was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. Specifically, the facility entrance lobby was observed on 09/14/2025 at 09:00 AM with the Daily Staff Posting dated 09/12/2025. There were no Daily Staff Postings for 09/13/2025. The finding is:During an observation on 09/14/2025 at 09:00 AM, a Daily Staff Posting dated 09/12/2025 was observed near the facility reception area. During an interview on 09/14/2025 at 01:29 PM, the Registered Nurse Supervisor #3 stated they were responsible for posting the Daily Staff Posting sheet at the front desk reception area. Registered Nurse # 3 stated that they did not work on 09/13/2025 and stated there was no excuse why the posting for actual staff was not posted for 09/13/2025.During an interview on 09/18/2025 at 02:37 PM, the Director of Nursing stated the Registered Nurse Supervisors were responsible for ensuring the Daily Staff Posting, which included the number of licensed and unlicensed staff, was posted daily. The Director of Nursing Service stated they were unable to explain why the Daily Staff Posting from 09/12/2025 was still posted on 09/14/2025.10 NYCRR415.13

Based on observation, record review, and interviews during the Recertification Survey initiated on 09/14/2025 and completed on 09/18/2025, the facility did not ensure that the attending Physician acted upon a consultant Pharmacist's drug regimen review recommendation regarding the use of a as-needed (PRN) psychotropic medication for one (1) (Resident #12) of five (5) residents reviewed for unnecessary medications. Specifically, the consultant Pharmacist recommended to consider having a stop date for Xanax ([NAME]-anxiety) medication that was ordered as needed (PRN) basis by the resident's Physician. A decision to agree or disagree to the recommendation was not documented by the Physician. The physician orders did not document a stop date on physician orders and continued prescribing Xanax on an as needed basis.The finding is:Resident #12 was admitted with diagnoses including Insomnia (difficulty falling asleep), Chronic Obstructive Pulmonary Disease (COPD), and anxiety disorder. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident had no behaviors and was on anti-anxiety medications.The physician orders reviewed from July 2025 to September 2025 included Xanax Tablet 0.25 MG (Alprazolam)- Give 1 tablet by mouth every 12 hours as needed for Anxiety. The order did not have a stop date. The Pharmacist's review dated 07/07/2025 documented No stop order for Xanax. The Physician did not agree or disagree and documented on the Pharmacist's review sheet psychiatry consult.During an interview on 09/18/2025 at 10:21 AM, the Physician stated they don't want to make Xanax a standing order because the resident has Chronic Obstructive Pulmonary Disease (COPD). The resident requires Xanax on an as-needed basis, and a stop date should have been documented.During an interview on 09/18/2025 at 12:41 PM, the Director of Nursing Services stated that the pharmacy review was given to them to be reviewed by the Physician, and it was the Physician's responsibility to address the Pharmacist's recommendations. During an interview on 09/18/2025 at 01:10 pm Medical Director stated that anytime an as-needed (PRN) antipsychotic or anti-anxiety medication is ordered, a stop date should be documented. The medication should be evaluated after the stop date to assess if the resident continues to need the medication.10 NYCRR 415.18(c)(2)

Based on observations, record review, and interviews during the Recertification Survey on 09/14/2025 and completed on 09/18/2025, the facility did not ensure call bells were within reach for each resident at their bedside. This was identified for one (Resident #201) of one resident reviewed for call systems. Specifically, on multiple occasions, the call bell was not within Resident #201's reach while in bed. The finding is:The facility's policy titled Call Light, last reviewed 09/05/2025, documented every call light shall be attached to the resident's bed within easy reach of the resident.Resident #201 was admitted with diagnoses including Ogilvie syndrome (acute dilatation of the colon in the absence of any mechanical obstruction in severely ill patients), Intellectual Disabilities, and a history of Falls. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set documented that the resident required substantial/maximal assistance for transferring to the chair from the bed, with the helper doing more than half the effort. The Minimum Data Set documented the resident required substantial/maximal assistance for walking 10 feet, with the helper doing more than half the effort.A Care Plan titled Risk for Falls, dated 08/22/2025, documented intervention that included ensuring the resident's call light is within reach and encouraging the resident to use the call bell for assistance as needed. The resident needs a prompt response to all requests for assistance.During an observation on 09/14/2025 at 10:07 AM, Resident #201 was seen sleeping in bed with the call bell rolled up and placed on the night table out of reach of the resident. The resident was sleeping and was not interviewed at this time.During a second observation on 09/15/2025 at 09:07 AM, the call bell was seen rolled up and placed on the night table out of reach of the resident. Resident #201 was seen sitting up in bed, just finishing their breakfast. During an interview on 09/15/2025 at 09:08 AM, Resident #201 stated that the call bell is always on the night table and was not within their reach. They stated they were not sure why the staff put the call bell on the night table. During an observation on 09/15/2025 at 09:21 AM, the call bell was rolled up on the night table. During an interview on 09/15/2025 at 09:27 AM, Certified Nursing Assistant #4 stated they have worked here for one month, and they are a float Certified Nursing Assistant. The call bell should be left in reach of the resident. They stated the call bell was on the resident's bed when they delivered the morning meal tray, and they were not sure who came in and moved the call bell. The call should be within reach of each resident; this resident could not reach the night table on their own. During an interview on 09/18/2025 at 11:45 AM, the Assistant Director of Nursing stated the call bell should be within reach of each resident. They stated they were made aware recently that the call bell was being thrown on the floor by the resident and was out of reach. This is a new behavior they have not noticed before with this resident. The call bell should have been placed within reach of the resident and not curled up on the night table out of reach; they were not sure who rolled the call bell up and placed it on the night table. During an interview on 09/18/2025 at 02:17 PM, the Director of Nursing stated the call bell should be clipped on the bed or within reach of the resident. All staff are responsible for ensuring the call bell is accessible to the resident.10 NYCRR 415.29

Based on observation, record review, and interviews during the Recertification and Abbreviated Survey (# 2569298) initiated on 09/14/2025 to 09/18/2025, the facility did not ensure each resident received adequate supervision and assistance devices to prevent Accidents. This was identified for one (1) (Resident #78) of five (5) residents reviewed for Accidents. Specifically, Resident #78 was assessed to require two-person assistance for bath/shower and bed mobility as per their plan of care. Certified Nursing Assistant #6 provided a bed bath to Resident #78 by themselves, without assistance from another staff member.The finding is:The facility policy titled Activities of Daily Living, dated 11/2018 and reviewed 09/05/2025, documented that Individualized care plans are based on an accurate assessment of the resident's self-performance and the amount and type of support being provided to the resident.The facility policy titled Care Planning Process, dated 07/2022, documented that the purpose of the Care Plan is to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho-social well-being.Resident #78 was admitted with diagnoses that included Multiple Sclerosis, Paraplegia (the partial or complete loss of motor and sensory function in the lower half of the body, including both legs), and Acute Respiratory Failure with Hypoxia (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to low levels of oxygen in the blood). The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating Resident #78 was cognitively intact. The Minimum Data Set documented Resident #78 was dependent on two or more staff members for bed mobility, including rolling left and rolling right, where the helper did all the effort for the resident to complete the activity.The Comprehensive Care Plan titled The resident has Activities for Daily Living, Self-Care Performance Deficit related to Multiple Sclerosis, dated 06/09/2025, documented interventions that included the resident was dependent on two (2) staff members for rolling from side to side.The Certified Nursing Assistant documentation report for July 2025, documented Resident #78 received a shower/bath on 07/22/2025 by Certified Nursing Assistant #6. It further documented that Resident #78 was dependent on two (2) Staff members for bathing, including washing, rinsing, and drying self; the assistance of two (2) or more helpers is required for the resident to complete the activity. The resident required two-person assistance for bed mobility for rolling side to side.An Accident/Incident Report dated 07/22/2025 documented that Resident #78 reported to the Recreation Aid that Certified Nursing Assistant #6 was rough with them during a bed bath, causing discomfort while turning. A full body assessment was performed by the Assistant Director of Nursing Services; psychological consult was ordered. Certified Nursing Assistant was suspended pending the investigation.The Summary of the Accident/Incident Report dated 07/22/2025 documented that, based on the investigation, there was insufficient evidence to substantiate the allegation of physical abuse or neglect.A review of the written statement from Certified Nursing Assistant #6 dated 07/22/2025, documented they provided a bed bath to Resident #78 because no one assisted them.During an observation and interview on 09/15/2025 at 09:03 AM, Resident #78 was in bed eating breakfast, and stated that Certified Nursing Assistant #6 came into their room on shower day on 07/22/2025 during the day shift and said they would give them a bed bath and not a shower. Resident #78 stated they refused the bed bath and told Certified Nursing Assistant #6 that they wanted a shower. Certified Nursing Assistant continued to give them a bed bath by themselves, even though they said no and it was not their wish. They stated Certified Nursing Assistant #6 instructed them to turn to their side, and they informed Certified Nursing Assistant #6 that they could not turn on their side. Certified Nursing Assistant #6 roughly turned the resident on their side to wash their back. Resident #7 stated they reported the incident to the Activities Aide #1 later that day, and told the Assistant Director of Nursing Services, they did not want Certified Nursing Assistant #6 to take care of them.During an interview on 09/17/2025 at 08:37 AM, Certified Nursing Assistant #6 stated they were assigned once to Resident #78's unit on 07/22/2025 and only took care of Resident #78 once. Certified Nursing Assistant #6 stated they were not familiar with Resident #78's care. Certified Nursing Assistant #6 stated they asked the unit staff to help them with the resident's shower, but everyone was busy. Certified Nursing Assistant #6 stated Resident #78 refused the bed bath, but they gave the resident a bed bath anyway, because they did not want to get written up. The resident was not happy and said no, as they did not want a bed bath. Certified Nursing Assistant #6 stated they gave Resident #78 a bed bath by themselves; however, they were not rough during care. During an interview on 09/17/2025 at 10:14 AM, Registered Nurse #4 stated Resident #78 preferred showers in the morning. The resident required the assistance of two staff members to complete showers or a bed bath. Registered Nurse #4 stated they could not recall any incident related to Resident #78 on 7/22/2025. Registered Nurse #4 stated they did not know that Certified Nursing Assistant #6 provided a bed bath against the resident's wishes, instead of a shower, and did not seek assistance from other staff members. Registered Nurse #4 stated that if they knew that the resident was refusing the bed bath, they would have spoken to the resident and would have instructed Certified Nursing Assistant #6 to shower the resident. Certified Nursing Assistant #6 should have reviewed the resident's Kardex for instructions related to the assistance needed for showers or bed baths for Resident #78.During an interview on 09/18/2025 at 09:03 AM, Recreation Aide #1 stated they went to Resident #78's room on 7/22/2025 to provide 1:1 recreation therapy, and the resident complained that Certified Nursing Assistant #6 was rough with them and gave them a bed bath when they refused. Recreation Aide #1 reported the incident to their supervisor, who then reported to the Assistant Director of Nursing Services.During an interview on 09/18/2025 with Certified Nursing Assistant #7 at 09:44 AM, Certified Nursing Assistant #8 at 09:53 AM, Certified Nursing Assistant #9 at 10:17 AM, and Certified Nursing Assistant #3 at 11:05 AM, all stated that Certified Nursing Assistant #6 did not request them to assist with Resident #78's bed bath or shower on 7/22/2025.During an interview on 09/18/2025 at 09:53 AM, Certified Nursing Assistant #8 stated that Certified Nursing Assistant #6 requested assistance with Resident #78's shower; however, they could not assist as they (Certified Nursing Assistant #8) were covering the day room at that time and were not allowed to leave the residents in the day room unattended. Certified Nursing Assistant #8 instructed Certified Nursing Assistant #6 to ask other staff for assistance. Resident #78 required a two-person assist for showers and bed mobility.During an interview on 09/18/2025 at 09:59 AM, Social Worker #1 stated they met with Resident #78 in presence of the Assistant Director of Nursing Services on 07/22/2025. Resident #78 stated Certified Nursing Assistant #6 was rough during care, and when they requested a shower, Certified Nursing Assistant #6 gave them a bed bath instead of the shower. The resident complained that, despite their refusal, Certified Nursing Assistant #6 did not listen to them and continued to give a bed bath. Social Worker #1 stated they offered emotional support to the resident and referred the resident for a psychiatric evaluation.During an interview on 09/18/2025 at 11:33 AM, the Assistant Director of Nursing Services stated Resident #78 told them they were provided a bed bath against their wishes by Certified Nursing Assistant #6 instead of a shower. Resident #78 did not want Certified Nursing Assistant #6 to care for them anymore. The resident was very upset and complained that Certified Nursing Assistant #6 did what they wanted to do and not what the resident wanted. The Assistant Director of Nursing Services stated physical assessment was conducted for Resident #78, and there were no injuries. Local law enforcement was notified, and Certified Nursing Assistant #6 was removed from the resident's assignment. The Assistant Director of Nursing Services stated that Resident #78 required the assistance of two staff members for bed mobility, bed bath, and showers. The Assistant Director of Nursing Services stated Certified Nursing Assistant #6 should have asked for assistance from other staff to provide resident care and should have provided a shower instead of the bed bath as per the resident's preferences. During an interview on 09/18/2025 at 01:29 PM, the Director of Nursing Services stated Certified Nursing Assistant #6 did not follow the resident's plan of care and also disregarded the resident's preferences. Resident #78 required two-person assistance with showers, bed baths, and bed mobility.10NYCRR 415.12(h)(2)

Based on observations, interviews, and record review during the Recertification Survey initiated on 09/14/2025 and completed 09/18/2025, the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice. This was identified for one (1) (Resident #225) of two (2) residents reviewed for Skin Conditions. Specifically, Resident #225 was identified with two skin tears to the left forearm on 09/11/2025. Registered Nurse #5 applied the treatment to the skin tears; however, there was no documented evidence of the skin assessment and physician orders for the wound care treatment until 09/16/2025.The finding is:The Facility policy titled Non-Pressure Related Skin Ulcer/Wounds, reviewed on 09/05/2025, documented [the facility will] conduct assessments of wounds and document the clinical basis or underlying conditions contributing to the ulceration. The policy for non-pressure ulcers will emphasize prevention, assessment, treatment, documentation, education, and quality improvement. The [facility will] differentiate the ulcer type, provide appropriate interventions and treatments, and provide high-quality care that promotes the best possible outcomes for residents with non-pressure ulcers.Resident #225 was admitted with diagnoses including Cerebral Infarction, Peripheral Vascular Disease, and Malignant Neoplasm (cancer) of the Colon. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview of Mental Status score of 99, indicating the resident had severely impaired cognition. The Minimum Data Set assessment documented the resident was at risk for pressure ulcers/injuries.The comprehensive care plan for potential for skin breakdown dated 03/18/2025 documented that the resident had thin and fragile skin. Interventions included fragile skin precautions: Gentle handling during care and offloading both heels with pillows when in bed. The care plan was updated on 09/15/2025, including completing skin risk assessment as per facility policy and providing protective/preventative skin care as per protocol.During an observation on 09/14/2025 at 09:53 AM, Resident #225 was in their bed and had two 4-inch by 4-inch border gauzes applied to their left forearm. The gauze was dated 09/11/2025 and was signed by Registered Nurse #5.A review of the resident's medical record indicated no evidence of a physician's order, treatment administration to the left forearm, the nature of the injury, or an assessment of the resident's change in skin condition.A physician's order initiated on 09/16/2025 documented to cleanse the resident's left forearm wound with Dermaklenz (wound cleanser), apply Xeroform (petroleum base dressing) to the wound bed, and cover with dry protective dressing, every day and as needed during the day shift.During an interview on 09/16/2025 at 11:15 AM, Registered Nurse #5 stated they worked on 09/11/2025 from 7:00 AM to 7:00 PM and they were assigned to Resident #225. Registered Nurse #5 stated they observed the resident's left forearm with two open areas. Registered Nurse #5 stated they notified Wound Care Nurse #1 as soon as they saw the resident's arm on 09/11/2025. Wound Care Nurse #1 directed them to apply Xeroform dressing and cover the open areas with the border gauze. Registered Nurse #5 stated they did not notify the Physician and did not enter the physician's order or their assessment in the electronic medical record because they thought Wound Care Nurse #1 would assess the resident.During an interview on 09/18/2025 at 07:40 AM, Wound Care Nurse #1 stated they did not remember that Registered Nurse #5 had notified them of the resident's forearm skin tears on 09/11/2025. Wound Care Nurse #1 stated the resident already had other skin tears on the bilateral legs due to the fragile skin. Wound Care Nurse #1 stated they were notified of Resident #225's left forearm skin tears on 09/14/2025 by Licensed Practical Nurse #1. Wound Care Nurse #1 stated they saw the resident on 09/14/2025. The resident did not have a dressing in place on their forearm, and the area had dried scabbing. Wound Care Nurse #1 stated they did not write a progress note or notify the attending Physician because the scabs looked dry and healed. Wound Care Nurse #1 stated that on 09/16/2025, the dried scab opened again, and that is when they notified the attending Physician. Wound Care Nurse #1 stated Registered Nurse #5 should have called the attending Physician on 09/11/2025 to obtain a physician's order.During an interview on 09/18/2025 at 10:45 AM, Registered Nurse Supervisor #3 stated they worked on 09/11/2025 during the 7:00 AM to 7:00 PM shift. Registered Nurse Supervisor #3 stated they were not notified of the resident's left forearm skin tears. Registered Nurse Supervisor #3 stated that a wound treatment required a physician's order. Registered Nurse Supervisor #3 stated that if nursing staff notice any skin changes, the nurse must do a skin assessment, notify the Supervisor, and the Physician.During an interview on 09/18/2025 at 11:01 AM, the Director of Nursing Services stated that the nurses are not allowed to apply a wound treatment without a physician's order. The Director of Nursing Services stated the nurse should have notified the Nursing Supervisor, the Physician, and the Wound Care Nurse to ensure the resident received the correct treatment.10 NYCRR 415.12

Based on record review and interviews during the Recertification and Abbreviated Survey (2569298), initiated on 09/14/2025 and completed on 09/18/2025, the facility did not ensure that each resident had the right to make choices about aspects of their life in the facility that are significant to them. This was identified for one (Resident #78) of four Residents reviewed for Abuse. Specifically, Resident #78 wanted a shower on their scheduled shower day; however, Certified Nursing Assistant #6 gave a bed bath against the resident's wishes.The finding is:The facility's policy titled Resident's Rights and Organizational Ethics, dated 11/2016 and last reviewed 09/05/2025, documented that the facility shall ensure that all residents are afforded the right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration, and courtesy in treatment and care of personal needs. All employees shall be in-serviced on Residents' Rights upon hire and annually thereafter. Each resident shall have the right to exercise his or her rights as a Resident of the facility and as a citizen or resident of the United States.The facility's policy titled Bed Bath, dated 08/2020, and reviewed on 09/05/2025, documented that all residents shall receive a bath between scheduled showers or tub/whirlpool bath unless otherwise requested by the resident.The facility's policy tilted Activities of Daily Living dated 11/2018 and reviewed on 09/05/2025, documented the facility will provide the necessary care and services based on the comprehensive assessment of a resident and consistent with the resident's needs, choices, and preferences, to maintain or improve, the resident's ability to perform activities of daily living and to prevent decline unless it's unavoidable.Resident #78 was admitted with diagnoses that included Multiple Sclerosis, Paraplegia (the partial or complete loss of motor and sensory function in the lower half of the body, including both legs), and Acute Respiratory Failure with Hypoxia (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to low levels of oxygen in the blood). The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating Resident #78 was cognitively intact. The Minimum Data Set documented Resident #78 was dependent on two or more staff members for bed mobility, including rolling left and right, where the helper did all the effort for the resident to complete the activity.The Comprehensive Care Plan titled The resident has Activities for Daily Living, Self-Care Performance Deficit related to Multiple Sclerosis, dated 06/09/2025, documented interventions that included the resident required the assistance of two (2) Staff members for rolling from side to side.The Certified Nursing Assistant documentation report for July 2025, documented Resident #78 received a shower/bath on 07/22/2025 by Certified Nursing Assistant #6. It further documented that Resident #78 was dependent on two (2) Staff members for bathing, including washing, rinsing, and drying self; the assistance of two (2) or more helpers is required for the resident to complete the activity. The resident required two-person assistance for bed mobility for rolling side to side.During an observation and interview on 09/15/2025 at 09:03 AM, Resident #78 was in bed eating breakfast, and stated that Certified Nursing Assistant #6 came into their room on shower day on 07/22/2025 during the day shift and said they would give them a bed bath and not a shower. Resident #78 stated they refused the bed bath and told Certified Nursing Assistant #6 that they wanted a shower. Certified Nursing Assistant continued to give them a bed bath by themselves, even though they said no and it was not their wish. They stated Certified Nursing Assistant #6 instructed them to turn to their side, and they informed Certified Nursing Assistant #6 that they could not turn on their side. Certified Nursing Assistant #6 roughly turned the resident on their side to wash their back. Resident #7 stated they reported the incident to the Activities Aide #1 later that day, and told the Assistant Director of Nursing Services, they did not want Certified Nursing Assistant #6 to take care of them.During an interview on 09/17/2025 at 08:37 AM, Certified Nursing Assistant #6 stated they were assigned once to Resident #78's unit on 07/22/2025, and only took care of Resident #78 once. Certified Nursing Assistant #6 stated they were not familiar with Resident #78's care. Certified Nursing Assistant #6 stated they asked the unit staff to help them with the resident's shower, but everyone was busy. Certified Nursing Assistant #6 stated Resident #78 refused the bed bath, but they gave the resident a bed bath anyway, because they did not want to get written up. The resident was not happy and said no, as they did not want a bed bath. Certified Nursing Assistant #6 stated they gave Resident #78 a bed bath by themselves; however, they were not rough during care. During an interview on 09/18/2025 at 09:59 AM, Social Worker #1 stated they met with Resident #78 in the presence of the Assistant Director of Nursing Services on 07/22/2025. Resident #78 stated Certified Nursing Assistant #6 was rough during care, and when they requested a shower, Certified Nursing Assistant #6 gave them a bed bath instead of the shower. The resident complained that, despite their refusal, Certified Nursing Assistant #6 did not listen to them and continued to give a bed bath. Social Worker #1 stated they offered emotional support to the resident and referred the resident for a psychiatric evaluation.During an interview on 09/18/2025 at 11:33 AM, the Assistant Director of Nursing Services stated Resident #78 told them they were provided a bed bath against their wishes by Certified Nursing Assistant #6 instead of a shower. Resident #78 did not want Certified Nursing Assistant #6 to care for them anymore. The resident was very upset and complained that Certified Nursing Assistant #6 did what they wanted to do and not what the resident wanted. The Assistant Director of Nursing Services stated physical assessment was conducted for Resident #78, and there were no injuries. Local law enforcement was notified, and Certified Nursing Assistant #6 was removed from the resident's assignment. The Assistant Director of Nursing Services stated that Resident #78 required the assistance of two staff members for bed mobility, bed bath, and showers. The Assistant Director of Nursing Services stated Certified Nursing Assistant #6 should have asked for assistance from other staff to provide resident care and should have provided a shower instead of the bed bath as per the resident's preferences. During an interview on 09/18/2025 at 01:29 PM, the Director of Nursing Services stated Certified Nursing Assistant #6 did not follow the resident's plan of care and also disregarded the resident's preferences. Resident #78 required two-person assistance with showers, bed baths, and bed mobility.10 NYCRR 415.5(b)(1-3)

Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00333364) initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease of range of motion. This was identified for one (Resident #132) of three residents reviewed for positioning and mobility. Specifically, Resident #132 had a physician's order for right hand Therapy Carrot (a nonsurgical device that helps position contracted hands) to be worn at all times. On 8/1/2024 and 8/2/2024 the resident was observed not wearing the right-hand Therapy Carrot as ordered by the Physician. The finding is: The facility's policy for Application and Management of Splint/Brace/Immobilizer dated 11/2017 documented the nursing staff is responsible for following the wearing schedule for the device and must complete a skin inspection every shift at a minimum unless ordered otherwise. Resident #132 was admitted with diagnoses that included Coronary Artery Disease, Peripheral Vascular Disease, and Non-Alzheimer's Dementia. A Quarterly Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score was 00, which indicated the resident had severely impaired cognition. The resident had no behavioral symptoms, had impairment on both sides of upper and lower extremities, and was totally dependent on staff for all aspects of Activities of Daily Living. A physician's note dated 3/14/2024 documented Splint/Brace: Therapy Carrot to be applied to the right hand at all times by the Certified Nursing Assistant. The nurse is to spot-check for the placement of the Therapy Carrot every shift. A Comprehensive Care Plan for Activities of Daily Living dated 9/13/2023 and revised on 6/7/2024 documented interventions that included right-hand Therapy Carrot at all times to be applied by the Certified Nursing Assistant. Remove every shift for skin checks and hygiene. The Kardex (nursing care instructions for the Certified Nursing Assistants) from 7/1/2024 to 8/10/2024 documented Therapy Carrot to be applied to the right hand at all times by the Certified Nursing Assistant. The nurse is to spot-check for the placement of a Therapy Carrot every shift. Resident #132 was observed out of bed to a Geri-Lounge chair on 8/1/2024 at 3:09 PM. The resident's right hand was observed in a closed-fisted position and the resident was not able to open their right hand on command. The Therapy Carrot was observed not in the resident hand but was resting on top of the resident's torso. A subsequent observation was made on 8/2/2024 at 2:54 PM. The Therapy Carrot was observed on the resident's chest and not appropriately positioned in the resident's right hand. Licensed Practical Nurse #5, who was assigned to Resident #132, was interviewed on 8/2/2024 at 3:04 PM. Licensed Practical Nurse #5 stated that the Therapy Carrot is used for the resident to keep the fingernails from pressing into the resident's palm. Licensed Practical Nurse #5 stated that Certified Nursing Assistant #11 was responsible for ensuring the Therapy Carrot was appropriately placed in the resident's right hand. During an observation on 8/2/2024 at 3:15 PM, with the Wound Care Registered Nurse (acting Nurse Manager) and the Director of Rehabilitation Services, the resident's right hand Therapy Carrot was observed resting on the resident chest. The palm of the resident's right hand was observed with dark crusty flakes and a musty odor was detected from the resident's right hands. The Director of Rehabilitation Services stated that the Therapy Carrot should be appropriately placed in the resident's palm at all times to prevent contractures. The Director of Rehabilitation Services stated if the Certified Nursing Assistants were having difficulty placing the Therapy Carrot in the resident's hand, they should have reported the concern to the charge nurse or them (Director of Rehabilitation Services). The Wound Care Registered Nurse was interviewed on 8/2/2024 at 3:20 PM and stated that they supervised the unit on 8/1/2024 and 8/2/2024. The Wound Care Registered Nurse stated they were not sure how to properly position the Therapy Carrot and would have to follow up with the Director of Rehabilitation Services to learn to properly position the Therapy Carrot in the resident's right hand. The 7:00 AM - 3:00 PM assigned Certified Nursing Assistant #11 was interviewed on 8/5/2024 at 1:51 PM. Certified Nursing Assistant #11 stated they were assigned to Resident #132 on 8/1/2024 and 8/2/2024. Certified Nursing Assistant #11 stated that the resident should use the Therapy Carrot device in the right hand at all times. Certified Nursing Assistant #11 stated that they were having difficulty opening the resident's right hand to insert the Therapy Carrot but did not report it to the charge nurse. The Director of Nursing Services was interviewed on 8/8/2024 at 12:59 PM and stated that after caring for the resident the Certified Nursing Assistant was responsible for ensuring that the Therapy Carrot was appropriately positioned in the resident's right hand at all times and that the nurses should monitor to ensure that the device was in place. 10 NYCRR 415.12(e)(2)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 8/01/2024 and completed on 8/08/2024, the facility did not ensure that each resident's receives adequate supervision and the resident's environment remained as free of accident hazards as possible to prevent accidents. This was identified for one (Resident #28) of seven residents reviewed for accidents. Specifically, Resident #28 was observed on 8/1/2024 with an Albuterol inhaler on their overbed table. There was no staff present in the vicinity. Additionally, Resident #28 did not have a physician's order for the use of the Albuterol inhaler or an order to self-administer medications. The finding is: Resident #28 was admitted to the facility with diagnoses including Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #28 had intact cognition. The Quarterly Minimum Data Set documented that Resident #28 received antibiotic and antidepressant medications. A Comprehensive Care Plan (CCP) dated 2/26/2024 titled Chronic Obstructive Pulmonary Disease (COPD) documented interventions including medications as per physician's order and to monitor signs and symptoms of acute respiratory distress. The physician's order dated 2/2/2024 documented to administer Ipratropium-Albuterol Inhalation Solution 0.5-2.5 Milligrams/3 Milliliters (Ipratropium-Albuterol) 3 Milliliters inhale orally via nebulizer every 6 hours as needed for Chronic Obstructive Pulmonary Disease. During an observation on 8/1/2024 at 9:45 AM, Resident #28 was sitting in their bed with an overbed table in front of them. An Albuterol inhaler (medicine in an inhaler form used to treat Asthma) was observed on the overbed table. The Albuterol inhaler label was faded and hard to read. There was no staff member present in Resident #28's room at the time of the observation. A review of the resident's medical record indicated there was no physician's order for the Albuterol inhaler use prior to 8/1/2024 at 10:24 AM. Resident #28 was interviewed on 8/1/2024 at 10:00 AM and stated they got the Albuterol inhaler from home and have been using the Albuterol inhaler for a long time for their Asthma. Resident #28 stated they had the inhaler since they were admitted to the facility and were using the inhaler at least three times a day. A review of the physician's orders revealed Resident #28 did not have an order to self-administer their medications. A review of the electronic medical record revealed that Resident #28 was not assessed to self-administer their medications. Registered Nurse #12, the medication nurse, was interviewed on 8/1/2024 at 11:26 AM and stated they did not see any inhalers on the resident's over-bed table or the nightstand during the morning medication administration for Resident #28. Registered Nurse #12 stated that Resident #28 should not have medications stored in their room. The Assistant Director of Nursing Services was interviewed on 8/1/2024 at 11:45 AM and stated they did not know why Resident #28 had the Albuterol inhaler in their room. The Assistant Director of Nursing Services stated unless Resident #28 had a physician's order and was assessed by the facility to safely self-administer their medications, they should not have any medications left in their room. The Director of Nursing Services was interviewed on 8/7/2024 at 11:15 AM and stated that medications should not be left unattended in the resident's room. The Director of Nursing Services stated that Resident #28 had hoarding issues and the staff must have overlooked the Albuterol inhaler that Resident #28 was using. 10 NYCRR 415.12(h)(1)

Based on record review and staff interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024 the facility did not ensure that outside professional services were furnished timely. This was identified for one (Resident #222) of one resident reviewed for Dignity and for one (Resident #150) of five residents reviewed for Unnecessary Medications. Specifically, 1) Resident #222 was readmitted from the hospital on 7/13/2024 with a diagnosis of Traumatic Subarachnoid Hematoma (brain bleed). The hospital discharging physician recommended a follow-up with a Neurosurgeon within a week. The recommended consult was not completed as of 8/7/2024 when it was brought to the facility's attention by the Surveyor. 2) Resident #150 was admitted to the facility in November 2023. A physician's order dated 11/14/2023 documented that the resident was to be seen by the Psychiatrist for the Initial Evaluation. The Psychiatry consult/evaluation was not completed until 8/6/2024 when it was brought to the facility's attention by the State Surveyor. The findings are: The facility's policy titled Medical and Dental Consults last revised on 5/2023, documented that the facility will arrange services of qualified professional personnel to render specific medical services. An order for a consultation shall be placed in the electronic medical record (EMR) with the reason for consultation. For new admissions or readmissions, the Registered Nurse Supervisor will reconcile all hospital-scheduled outpatient appointments with the resident's attending physician and log in to the Hospital Consult Reconciliation Form. The attending physician will determine the need for further follow-up (agree, disagree, or use an in-house consultant). The Consult Coordinator will schedule the outpatient consults and arrange for transportation and escort if indicated. 1) Resident #222 was admitted with diagnoses including Traumatic Subarachnoid Hemorrhage (brain bleed), Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #222 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident #222 received anticoagulant (blood thinner) medications. A Comprehensive Care Plan (CCP) titled, Anticoagulant Therapy dated 7/18/2024, documented the resident was at risk for bleeding, The interventions included reinforcing safety measures to prevent injury/bleeding and to administer medications ordered by the Physician. A review of the hospital Discharge Instructions dated 7/13/2024 documented that Resident #222 needed a follow-up consultation with a Neurosurgeon in one week due to a diagnosis of Traumatic Subarachnoid Hematoma (brain bleed). A review of the electronic medical record indicated no physician's order for a Neurosurgery consultation. A review of the electronic medical record revealed Resident #222 did not have a follow-up appointment or consult with the Neurosurgeon as recommended by the hospital. Licensed Practical Nurse #4 was interviewed on 8/5/2024 at 12:02 PM and stated they were one of the nurses who assisted in readmitting Resident #222 on 7/13/2024. Licensed Practical Nurse #4 stated they (Licensed Practical Nurse #4) only reviewed the medication list on the discharge summary from the hospital. Licensed Practical Nurse #4 stated it was Registered Nurse Supervisor #10 who reviewed the consult instructions for Resident #222. The Unit Clerk was interviewed on 8/5/2024 at 2:06 PM and stated they made appointments for any consultations needed for the residents after they received the consultation form from the nurses. The Unit Clerk stated they did not receive a consultation form to schedule a follow-up appointment with the Neurosurgeon for Resident #222. Registered Nurse #10, the nursing supervisor, was interviewed on 8/5/2024 at 2:21 PM and stated they admitted Resident #222 from the hospital on 7/13/2024; however, they did not see any recommendations from the hospital for a follow-up consult with a Neurosurgeon. Registered Nurse #10 stated they must have missed the recommendations documented on the discharge instructions from the hospital. Physician #2 was interviewed on 8/6/2024 at 10:30 AM and stated a Neurosurgery consult should have been completed for Resident #22 as per the hospital's recommendations. Physician #2 stated the facility was responsible for arranging for the consultation. The Director of Nursing Services was interviewed on 8/7/2024 at 11:30 AM and stated the nurses should have thoroughly checked the hospital discharge instructions for Resident #222 and ensured that the consultation form was completed and provided to the Unit Clerk to set up an appointment with the Neurologist as per the hospital discharge summary recommendations. 17732 2) Resident #150 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Hypertension, and Major Depressive Disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognitive skills for daily decision-making. The Minimum Data Set assessment documented that the resident had been receiving an antidepressant medication for the last 7 days. The Physician's Order dated 11/11/2023, obtained by Licensed Practical Nurse #1, documented for the resident to receive Remeron (an antidepressant medication) 7.5 milligrams tablet- give 1 tablet by mouth at bedtime for Major Depressive Disorder. (This order was discontinued on 12/4/2023.) A review of the Psychiatry Consultation Form dated 11/11/2023, initiated by Licensed Practical Nurse #1, revealed that the Consultation Form was never completed by the Psychiatrist. The Physician's Order dated 11/14/2023, obtained by Registered Nurse #1, documented to obtain a Psychiatry Consult Initial Evaluation and follow-up. The Physician's Order dated 12/15/2023 last revised on 3/22/2024 documented to administer Mirtazapine (Remeron) 7.5 milligram - give one tablet by mouth at bedtime for Depression. A review of the Psychiatry Consultation Form dated 7/25/2024, initiated by the Registered Nurse Consultant (Registered Nurse #2), revealed that the Consultation Form was never completed by the Psychiatrist. Registered Nurse #1 was interviewed on 8/6/2024 at 3:05 PM and stated after they (Registered Nurse #1) receive a Physician's Order for a Psychiatric Consultation, they are supposed to initiate a Psychiatry Consultation Form in the resident's Electronic Medical Record, print the resident's face sheet, and place the resident's face sheet in the Psychiatrist's folder which is kept at the reception desk in the lobby of the facility. Registered Nurse #1 stated when the Psychiatrist comes to the facility, they (Psychiatrist) take the face sheets of the residents needing Psychiatric Consultations out of the folder and go see them. Registered Nurse #1 stated that the Psychiatrist comes weekly to the facility, and they (Registered Nurse #1) did not know why Resident #150 was never seen by the Psychiatrist. Registered Nurse #1 stated they may not have opened another Psychiatry Consultation Form after obtaining the Physician's Order on 11/14/2023 because Licensed Practical Nurse #1 had already initiated one on 11/11/2023. Licensed Practical Nurse #1 was interviewed on 8/7/2024 at 9:35 AM and stated that when a resident is admitted to the facility on psychiatric medications, the Physician automatically orders a Psychiatric consultation request. Licensed Practical Nurse #1 stated that Resident #150's Physician must have given a verbal order for the resident to have a Psychiatric Consult, but they (Licensed Practical Nurse #1) must have forgotten to enter the Physician's Order into the computer on 11/11/2023 when the resident was admitted to the facility. The Psychiatrist was interviewed on 8/7/2024 at 10:45 AM and stated they usually do not see a newly admitted resident unless ordered to by the Physician. The Psychiatrist stated that either a Nurse calls them (Psychiatrist) or the resident's face sheet is left at the reception desk for them (Psychiatrist) when a resident needs a Psychiatric Consultation. The Psychiatrist stated that once they see a resident, they (Psychiatrist) will keep track of when the resident needs to be seen for a follow-up. The Psychiatrist stated they would not know when a Psychiatric Consultation Form was initiated unless the resident's face sheet was placed in their folder at the reception desk. The Psychiatrist stated they were never notified to see the resident for their initial Psychiatric Consultation. The Director of Nursing Services was interviewed on 8/7/2024 at 10:50 AM and acknowledged that Resident #15's initial Psychiatric Consultation was never done. The Director of Nursing Services stated that a Psychiatry Consultation should be completed as per the physician's orders. 10 NYCRR 415.26(e)(1)(i-iv)

Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00333364) initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain grooming, personal, and oral hygiene. This was identified for one (Resident #5) of five residents reviewed for pressure ulcers and one (Resident #132) of two residents reviewed for activities of daily living. Specifically, 1) on 8/7/2024, Resident #5's fingernails on both hands were observed to be long and dirty, with a brown substance under the nails and 2) on 8/2/2024, Resident #132's right palm was observed with dark crusty flakes and a musty odor was detected coming from their right hand. The findings are: The facility's policy titled Activities of Daily Living, effective 11/2018, documented the facility will provide the necessary care and services based on the comprehensive assessment of a resident and consistent with the resident's needs, choices, and preferences, to maintain or improve, the resident's ability to perform activities of daily living and to prevent decline unless it is unavoidable. Activities of daily living include hygiene, such as bathing, dressing, grooming, and oral care; individualized care plans are based on an accurate assessment of the resident's self-performance and the amount and type of support being provided. When a resident refuses to comply with activities of daily living, nursing staff shall solicit assistance from other disciplines to determine the cause for refusal, offer options and alternatives, and document refusal in the medical record. 1) Resident #5 was admitted with diagnoses including Schizophrenia, Parkinson's Disease, and Diabetes Mellitus. The 7/10/2024 significant change Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident had mood concerns, including feeling down, depressed, and feeling bad about themselves nearly every day. The resident was dependent on staff for personal hygiene tasks. A comprehensive care plan titled Activities of Daily Living Self-Care Performance Deficit Related to Aggressive Behaviors, Limited Range of Motion, initiated 5/24/2024, documented the resident was dependent on staff for Personal Hygiene needs and will remain clean, neat, dressed appropriately, and free of body odor and that. The Kardex (nursing care instructions for Certified Nursing Assistants), as of 8/7/2024, documented that the resident was dependent on staff for personal hygiene needs and to observe the resident for proper hand hygiene. Under the Personal Hygiene heading, oral care was the only care area listed. Resident #5 was observed in bed on 8/7/2024 at 9:47 AM. The resident's fingernails on both hands were excessively long and dirty, with a brown substance under the nails. The resident stated they would like their nails trimmed. During an observation on 8/7/2024 at 9:53 AM with Certified Nursing Assistant #2 and Registered Nurse #7 (acting unit charge nurse) Resident #5's fingernails were observed to be long and dirty. Certified Nursing Assistant #2, who was the resident's regularly assigned Certified Nursing Assistant, was interviewed on 8/7/2024 at 9:54 AM. Certified Nursing Assistant #2 stated the nurses were supposed to cut Resident #5's fingernails because the resident was Diabetic. Certified Nursing Assistant #2 stated the nurses see the resident every day, which is why they (Certified Nursing Assistant #2) did not report the resident's long fingernails to the nurse. Registered Nurse #7 was interviewed on 8/7/2024 at 9:55 AM and stated the nurses were responsible for cutting Resident #5 nails because the resident was Diabetic and any nurse could have cut the resident's fingernails. Registered Nurse #8, the medication nurse, was interviewed on 8/7/2024 at 10:03 AM and stated they administered the morning medications to Resident #5 and did not notice the resident's fingernails. Registered Nurse #8 then proceeded to check the resident's fingernails and stated the fingernails needed to be trimmed and cleaned. Registered Nurse #8 asked the resident if they wanted their fingernails trimmed and the resident responded yes. Assistant Director of Nursing Services #1, the nurse educator, was interviewed on 8/7/2024 at 11:06 AM and stated the staff members have to ask the resident if they want the fingernails cut; sometimes the resident refuses and gets aggressive. Assistant Director of Nursing Services #1 stated the refusals should be documented in the medical record. Assistant Director of Nursing Services #1 stated the resident's fingernails should be clean and neatly trimmed. A review of nursing progress notes from 8/1/2024 to 8/7/2024 revealed no documentation that Resident #5 refused to have their fingernails trimmed. The Director of Nursing Services was interviewed on 8/7/2024 at 12:54 PM and stated they had never heard that Resident #5 refused care. The Director of Nursing Services stated if the resident was refusing care, there should have been a care plan in place, and the staff should have determined how to maintain the resident's hygiene including nail care. 28670 2) Resident #132 was admitted with diagnoses that included Coronary Artery Disease, Peripheral Vascular Disease, and Non-Alzheimer's Dementia. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 00, which indicated severely impaired cognition. The resident had no behavioral symptoms, had impairment on both sides of upper and lower extremities, and was totally dependent on staff for all aspects of Activities of Daily Living. A Comprehensive Care Plan dated 9/13/2023 and last revised on 6/7/2024 documented the resident had a deficit in Activities of Daily Living, cognitive Impairment, Dementia, limited mobility, and limited range of motion. Interventions included for staff to maintain personal hygiene including combing the resident's hair, shaving, washing, and drying the resident's face and hands. The Kardex (nursing care instructions for the Certified Nursing Assistants), from 8/1/2024 to 8/10/2024 documented to observe the resident for proper hand hygiene. Under the Personal Hygiene heading, oral care was the only care listed. During an observation on 8/1/2024 at 3:09 PM the resident was observed out of bed in their room resting in a Geri chair. The Therapy Carrot was observed on the resident's chest and not appropriately positioned in the resident's right hand. During an observation on 8/2/2024 at 3:15 PM, with the Wound Care Registered Nurse (acting Nurse Manager) and the Director of Rehabilitation Services, the resident's right hand Therapy Carrot was observed resting on the resident chest. The palm of the resident's right hand was observed with dark crusty flakes and a musty odor was detected from the resident's right hands. The Director of Rehabilitation Services stated that the Therapy Carrot should be appropriately placed in the resident's palm at all times to prevent contractures. The Director of Rehabilitation Services stated if the Certified Nursing Assistants were having difficulty placing the Therapy Carrot in the resident's hand, they should have reported the concern to the charge nurse or them (Director of Rehabilitation Services). The 7:00 AM - 3:00 PM assigned Certified Nursing Assistant #11 was interviewed on 8/5/2024 at 1:51 PM and stated they were having difficulty opening the resident's right hand but did not report it to the charge nurse. Certified Nursing Assistant #11 stated they asked another Certified Nursing Assistant (could not recall the name) to assist them with opening the resident's hand and the other Certified Nursing Assistant also could not open the resident's hand. Certified Nursing Assistant #11 stated they washed the outside of the resident's hand but were unable to wash the palm of the resident's right hand. The Director of Nursing Services was interviewed on 8/8/2024 at 12:59 PM and stated that after caring for the resident the Certified Nursing Assistant was responsible for ensuring that the Therapy Carrot was appropriately in the resident's right hand and that the nurses should monitor to ensure that the device was in place. The Director of Nursing Services stated if Certified Nursing Assistant #11 was having difficulty opening the resident's right hand, they (Certified Nursing Assistant #11) should have asked the nurse for assistance. The Director of Nursing Services stated that the resident's right hand should not have been left dirty. 10 NYCRR 415.12(a)(3)

Based on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #116) of two residents reviewed for Communication. Specifically, Resident #116's comprehensive care plan for Communication documented that the resident was hard of hearing in the left ear. The comprehensive care plan was not updated to indicate the resident used a hearing aid and preferred keeping the hearing aid at the bedside. The finding is: The facility's policy titled Care Planning Process, effective 7/2022 documented the facility shall have a care planning process that is person-centered, which includes integrating assessment findings in care planning, providing services to attain or maintain the resident's highest physical, mental, and psychosocial well-being, and regularly reviewing and revising the care plan. The comprehensive care plan shall include the resident's preferences and is revised by members of the interdisciplinary team based on changing goals, preferences, and needs of the resident and in response to current interventions. Resident #116 was admitted with diagnoses including Morbid Obesity, Bipolar Disorder, and Chronic Obstructive Pulmonary Disease. The 5/1/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident had moderate difficulty with hearing and did not use a hearing aid. A Comprehensive Care Plan, titled Communication Problem Related to Deafness, effective 10/27/2023 and last updated 8/5/2024, documented the resident was was hard of hearing in the left ear and was able to lip read. the interventions included audiology consult as ordered. The care plan did not include use of a hearing aid. Certified Nursing Assistant #1 was interviewed on 8/5/2024 at 10:41 AM and stated they did not know the resident used a hearing aid. Certified Nursing Assistant #1 stated they have to speak loudly with the resident for the resident to understand them. The Kardex (nursing care instructions for Certified Nursing Assistant) dated 8/4/2024 instructed the Certified Nursing Assistant to assist the resident with the hearing aid and keep the hearing aid in the medication cart. Resident #116 was observed on 8/5/2024 at 10:45 AM with Certified Nursing Assistant #1 present. The resident was in bed sleeping and was awakened by Certified Nursing Assistant #1. A message (communication) board was used to help communicate with the resident. The resident stated they use a hearing aid for their left ear and keep the hearing aid in their bag at the bedside. The resident stated they are completely deaf in the right ear. The resident stated they put the hearing aid in themselves and do not need staff assistance. Registered Nurse #5, the medication nurse, was interviewed on 8/5/2024 at 11:07 AM and stated the resident was very hard of hearing; however, they did not know if Resident #116 used a hearing aid. Registered Nurse #6, the Minimum Data Set assessor, was interviewed on 8/5/2024 at 11:41 AM and stated they completed the 5/1/2024 Quarterly Minimum Data Set assessment, for Resident #116 and the resident was able to read lips and was able to understand what was being said to them. Registered Nurse #6 stated they had to speak loudly and clearly. Registered Nurse #6 stated the resident had a hearing aid but did not use the hearing aid during the assessment. Registered Nurse #6 stated any nurse involved with the resident's care, including the Minimum Data Set nurses, can update care plans. Registered Nurse #6 reviewed the resident's communication care plan and the Kardex and stated that the care plan and the Kardex were not consistent with the resident's communication status and preferences. The Director of Nursing Services was interviewed on 8/6/2024 at 12:00 PM and stated the comprehensive care plan and Kardex should reflect the resident's preferences, goals, and needs and everything should be consistent and current. 10 NYCRR 415.11(c)(2)(iii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 8/01/2024, and completed on 8/08/2024 the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for two (Resident #42 and Resident #71) of five residents reviewed for Respiratory Care. Specifically, 1) Resident #42 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen on 8/1/2024 and 8/7/2024. 2) Resident #71 had a physician's order for oxygen to be administered at 2 liters per minute via a nasal cannula. The resident was observed receiving an inaccurate amount of oxygen on 8/1/2024 at 10:30 AM and 2:34 PM. This is a repeat deficiency. The findings are: The facility's policy titled Oxygen Therapy dated 6/2017, documented the physician's order specifies the concentration, type, and duration of the (oxygen) therapy. The nursing staff will set up, check, and supervise all treatments. 1) Resident #42 was admitted with diagnoses including Parkinson's Disease with Dyskinesia (involuntary neurological movements), Osteoporosis, and Type Two Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15, which indicated the resident was cognitively intact. The Minimum Data Set documented Resident #42 used oxygen therapy during the look-back period. The Comprehensive Care Plan for Oxygen Therapy dated 7/11/2024 documented interventions that included administering oxygen therapy as ordered and checking the oxygen tank every shift. The current physician's orders documented to administer oxygen at 2 liters per minute via a nasal cannula continuously for shortness of breath. During an observation on 8/01/2024 at 11:11 AM, Resident #42 was observed in their bed. The resident was receiving 4 liters of oxygen per minute via a nasal cannula from an oxygen concentrator. Resident #42 was interviewed on 8/01/2024 at 11:11 AM and stated they used oxygen therapy daily. Resident #42 stated they did not change the oxygen flow rate setting because they were not able to access the oxygen concentrator. Resident #42 was observed in bed on 8/07/2024 at 10:18 AM. The resident was receiving 3 liters of oxygen a nasal cannula, from an oxygen concentrator. Registered Nurse #13 was interviewed on 8/07/2024 at 10:19 AM and stated Resident #42 should receive oxygen at 2 liters per minute as per their physician's orders. Registered Nurse #13 stated they did not change the resident's oxygen flow rate and did not feel that Resident #42 was able to change the oxygen settings either. Registered Nurse #7, the unit Charge Nurse, was interviewed on 8/07/2024 at 10:35 AM and stated nurses are expected to follow the physician's orders. If a resident needs an increased oxygen flow rate, the Physician should be notified. The Director of Nursing Services was interviewed on 8/07/2024 at 10:47 AM and stated they were unsure why the oxygen flow rate for Resident #42 was set at 3 liters today (8/7/2024) and 4 liters on 8/01/2024. If the resident requires more oxygen, nursing staff should call the Physician and follow the physician's orders. 28670 2) Resident #71 was admitted with diagnoses that included Cirrhosis of the Liver and Ascites (a condition in which fluid collects in spaces within your abdomen). A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14, which indicated the resident had intact cognition. The resident had no behavioral problems and did not reject care. A Comprehensive Care Plan dated 7/31/2024 documented the resident received oxygen therapy related to shortness of breath. Interventions included to administer medications as ordered by the Physician, monitor for signs and symptoms of respiratory distress, and report to the Physician as needed. A physician's order dated 7/31/2024 documented to administer oxygen at 2 liters per minute continuously. During an observation on 8/1/2024 at 10:30 AM, Resident #71 was observed in bed asleep. The resident was receiving oxygen at 3 liters per minute via a nasal cannula from the oxygen concentrator. A subsequent observation was made on 8/1/2024 at 2:34 PM. The resident was in bed asleep and was receiving oxygen at 3 liters per minute via a nasal cannula. Licensed Practical Nurse #1 was interviewed on 8/1/2024 at 2:40 PM and stated they were responsible for checking that the oxygen was delivered to the resident as per the physician's orders. Licensed Practical Nurse #1 stated they should have checked the flow rate at the start of the shift to ensure Resident #71 was receiving the prescribed 2 liters of oxygen. The Director of Nursing Services was interviewed on 8/8/2024 at 1:05 PM and stated that the nurses were responsible for checking the oxygen flow rate to ensure the residents were receiving the correct oxygen flow rate as ordered by the Physician. The Director of Nursing Services stated the nurses should check that all residents are receiving the correct oxygen amount at the beginning of the shift and periodically throughout the shift. 10 NYCRR 415.12(k)(6)

Based on record review and staff interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024 the facility did not provide each resident access to personal and medical records pertaining to themselves, upon an oral or written request, in the form and format requested by the individual. This was identified for one (Resident #222) of one resident reviewed for Dignity. Specifically, Resident #222 was readmitted to the facility from the hospital on 7/13/2024 and requested a copy of their hospital Discharge Summary, which was received by the facility upon the resident's return from the hospital. The facility did not make the requested discharge summary available to Resident #222 within the required timeframe. The finding is: The facility policy titled, Medical Record Request Policy last revised on 3/2023 documented that if an individual should request a release of medical records from the facility, the individual shall be referred to the Social Worker who shall provide the Health Insurance Portability and Accountability Act (HIPAA) authorization form. The Social Worker will review the request to determine the individual's capacity and the validity of the request. The Social Worker will forward the request with any supporting documentation to the Medical Record Clerk. The Medical Record Clerk will send the medical record request and all supporting documents to the Legal Department for final review and approval. A resident or qualified person/personal representative has the right to request access to patient information. The facility shall allow access to inspect medical records to individuals and their legal representatives within 24 hours or provide copies of medical records within 48 hours after receipt of a valid request for medical records. Resident #222 was admitted with diagnoses including Traumatic Subarachnoid Hemorrhage (brain bleed), Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #222 had intact cognition. Resident #222 was interviewed on 8/5/2024 at 3:00 PM and stated they had requested a copy of the hospital discharge summary and hospital recommendations after they were readmitted from the hospital to the facility in July 2024. Resident #222 stated they needed the discharge summary recommendation information to schedule their follow-up appointments with the specialists from the hospital. Resident #222 stated they requested the discharge summary from Social Worker #3 and were told that they (Resident #222) could request the documents directly from the hospital. A review of the hospital Discharge Instructions dated 7/13/2024 documented that Resident #222 needed a follow-up consultation with a Neurosurgeon in one week due to a diagnosis of Traumatic Subarachnoid Hematoma (brain bleed). Social Worker #3 was interviewed on 8/6/2024 at 11:04 AM and stated that Resident #222 had requested a copy of their hospital discharge summary for the July 2024 hospital stay. Social Worker #3 stated they gave Resident #222 a copy of the Health Insurance Portability and Accountability Act (HIPAA) authorization form and told Resident #222 that they could also obtain the requested records directly from the hospital. Social Worker #3 stated they did not follow up with Resident #222 to ascertain if the resident received the requested records. A review of Resident #222's electronic medical record revealed there was no documented evidence of the Health Insurance Portability and Accountability Act (HIPAA) authorization form present in the resident's medical record. The Medical Record Clerk was interviewed on 8/6/2024 at 12:03 PM and stated they did not receive the Health Insurance Portability and Accountability Act (HIPAA) authorization form from Resident #222. The Medical Record Clerk stated Social Worker #3 did not follow up with their department regarding Resident #222's medical record request. Resident #222 was re-interviewed on 8/7/2024 at 10:54 AM and stated they did not receive the Health Insurance Portability and Accountability Act (HIPAA) authorization form from the facility. Resident #222 stated they asked the facility staff for the hospital discharge summary for the July 2024 hospital stay numerous times and were told to request the record from the hospital. The Director of Nursing Services was interviewed on 8/7/2024 at 11:30 AM and stated that Resident #222 should not have difficulties obtaining their medical record. The Director of Nursing Services stated that Social Worker #3 should have assisted Resident #222 in obtaining the medical records. The Administrator was interviewed on 8/7/2024 at 2:39 PM and stated that Resident #222 should have been assisted by Social Worker #3 in obtaining the requested medical records. The Administrator stated that Resident #222 did not have to request their (Resident #222) medical record from the hospital. 10 NYCRR 415.3(c)(1)(iv)

Based on record review, and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure medical records for each resident were complete and accurately documented. This was identified for one (Resident #90) of three residents reviewed for Choices. Specifically, Resident #90 had a physician's order for a finger stick blood glucose monitoring every morning. The Medication Administration Record did not include the finger stick blood glucose level results and the Vital Signs record had inconsistent documentation of the finger stick blood glucose level results. The finding is: The policy titled Blood Glucose Monitoring dated 7/2013 documented findings (of finger stick blood glucose levels) shall be documented in the medical chart. Resident #90 was admitted with diagnoses including Spinal Stenosis, Dementia, and Type two Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 12, which indicated the resident had moderately impaired cognition. The Comprehensive Care Plan for Diabetes Mellitus dated 5/20/2021 and last revised on 5/17/2024 documented interventions including monitoring finger stick blood glucose as ordered by the Physician. A physician's order dated 7/14/2024 documented to obtain finger stick blood glucose level every morning one time a day. The Vital Sign documentation record for July and August 2024 was reviewed. The Vital Sign record lacked documented evidence of finger stick blood glucose results on 7/15/2024, 7/19/2024, 7/20/2024, 7/21/2024, 7/23/2024, 7/24/2024, 7/25/2024, 7/26/2024, 7/27/2024, 7/28/2024, 7/30/2024, 7/31/2024, 8/01/2024, and 8/02/2024. The Medication Administration Record for July 2024 and August 2024 did not document morning finger stick glucose levels. The Assistant Director of Nursing Services #1, the Nurse Educator, was interviewed on 8/05/2024 at 10:43 AM and stated there should be a section on the Medication Administration Record to document the morning finger stick glucose levels. The Assistant Director of Nursing Services #1 stated Resident #90's Medication Administration Record did not include a space to document the finger stick blood glucose level and should have. The Director of Nursing Services was interviewed on 8/07/2024 at 10:49 AM and stated that the nurses are responsible for the resident's care and for documenting the finger stick blood glucose level in the Medication Administration Record to monitor the blood glucose level trends. 10 NYCRR 415.22(a)(1-4)

Based on observations, record review, and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for three (Resident #5, Resident #94, and Resident #201) of five residents reviewed for Pressure Ulcers. Specifically, 1) Resident #5 had a Stage 4 pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle) at the sacrum (triangular bone in between the two hips). A comprehensive care plan intervention required that the resident be turned and positioned every two hours to offload (relieve pressure) from the sacra; ulcer. The resident was observed on multiple occasions on 8/6/2024 from 7:50 AM to 11:21 AM, lying flat on their back. The certified nursing assistant assigned to the resident stated the resident did not like to be on their side. The medical record lacked documented evidence that Resident #5 refused to turn and position or that the clinicians were notified of the resident's behavior to determine new interventions to offload the sacral region. 2) Residents #94 and Resident #201 had a physician's order for a low air loss alternating air mattress. During multiple observations, the adjustable weight setting for the air mattresses, which is meant to correspond to the resident's weight, was not set accurately. The finding is: The facility's policy titled Pressure Injury/Pressure Ulcer Assessment, Prevention, and Management, effective 3/24/2023 documented the facility shall provide care and services consistent with professional standards of practice to promote the healing of existing pressure injury/ulcer. Develop a positioning schedule and avoid positioning residents on existing pressure injuries; notify the wound care coordinator of any skin conditions or injuries. The Certified Nursing Assistant should report any changes or areas of concern to a nurse; redistribute pressure when in bed and position at least every two hours, and as needed. 1) Resident #5 was admitted with diagnoses including Schizophrenia, Parkinson's Disease, and Diabetes Mellitus. The 7/10/2024 Significant Change Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident had one unhealed Stage 4 pressure ulcer and was dependent on staff for moving from side to side in bed. The nursing admission assessment dated [DATE] documented the resident had an unstageable (the wound is covered with dead tissue and the depth cannot be determined) pressure ulcer to the sacrum. The resident's Braden Scale (a scale used to predict pressure ulcer risk) score was documented as 16, which indicated the resident was at mild risk for developing pressure ulcers. A Comprehensive Care Plan titled Pressure Ulcer Related to Impaired Mobility, Stage 4 to Sacrum (post debridement), initiated on 5/27/2024, had an intervention to turn and position the resident every two hours and when needed. The Kardex (nursing care instructions for Certified Nursing Assistants) documented the resident has a pressure ulcer to the sacrum and to turn and position the resident every two hours and when needed. A wound physician consultation dated 5/29/2024 documented the resident had a sacrum Stage 4 pressure ulcer measuring 10.5 centimeters in length, 12.5 centimeters in width, and 4 centimeters in depth. The bone was palpable. Negative pressure wound therapy (wound vacuum) was started. A physician's order dated 6/28/2024 documented to cleanse the sacral ulcer with normal saline, pat dry, and then apply the wound vacuum at 125 millimeters of mercury, every Tuesday, Thursday, and Saturday. A wound physician consult dated 7/16/2024 documented that offloading the sacral area was difficult due to Parkinson's Disease. The resident was always on their back when the wound physician saw the resident. The Physician documented that the sacrum pressure ulcer was a Stage 4 ulcer, measuring 10 centimeters in length, 8 centimeters in width, and 2.5 centimeters in depth. During an observation on 8/6/2024 at 7:50 AM, Resident #5 was observed in bed on their back. During an observation on 8/6/2024 at 9:27 AM Resident #5 was observed in bed on their back. During an observation on 8/6/2024 at 10:45 AM Resident #5 was observed in bed on their back. During an observation on 8/6/2024 at 11:21 AM Resident #5 was observed in bed on their back. A review of the Certified Nursing Assistant Accountability for 8/6/2024 for the 7:00 AM- 3:00 PM shift revealed that Certified Nursing Assistant #2 documented they had turned and positioned the resident every 2 hours. There was no documentation in the accountability record indicating which side the resident was turned. Certified Nursing Assistant #2, the assigned Certified Nursing Assistant for Resident #5, was interviewed on 8/6/2024 at 11:29 AM. Certified Nursing Assistant #2 stated Resident #5 did not like to turn on their side. Certified Nursing Assistant #2 lifted the resident's sheet to show two pillows, one on the resident's left side torso and one on the resident's right side torso, and stated these pillows provided offloading. Upon observation, these pillows were keeping the resident positioned on their back and the resident's sacrum was directly placed on the bed, not offloaded. Wound Care Registered Nurse #1 was interviewed on 8/6/2024 at 11:46 AM and stated the resident was on a turning and positioning schedule and should be re-positioned every two hours on their left side, right side, and back. Wound Care Registered Nurse #1 stated there are times when the resident will be on their back but should not be on their back all the time. On 8/7/2024 at 9:03 AM Resident #5 was observed in bed. The resident was positioned on their left side with the sacrum completely offloaded from the mattress. Wound Care Registered Nurse #1 was re-interviewed on 8/7/2024 at 9:07 AM and stated they spoke to Certified Nursing Assistant #2 and educated them about turning and positioning. Wound Care Registered Nurse #1 stated the resident needs to spend time off their back for optimal wound healing. Wound Care Registered Nurse #1 stated if the resident does not want to be on their side, or is uncomfortable, we have to keep encouraging and turning and positioning while keeping them as comfortable as possible, so the resident is not flat on their back. On 8/7/2024 at 9:47 AM Resident #5 was interviewed. Resident #5 stated they do not mind being on their side and staying on their back sometimes bothers them. The Director of Nursing Services was interviewed on 8/7/2024 at 3:11 PM and stated the staff must offload the affected areas using pillows to help the wound heal and determine how to make the residents comfortable if they are expressing discomfort. The Director of Nursing Services stated certified nursing assistants needed to be re-educated. 49245 2) The facility's policy and procedure titled, Air Mattress last revised in 10/2023 documented that the selection of the air mattress will be based on the individual's specific needs, including mobility levels, weight, and any pre-existing medical condition. The Wound Care Coordinator will conduct a monthly audit of the resident's weight and assessment of the staff's knowledge of operating the equipment. The operation manual for the low air loss alternating pressure relief air mattress documented instructions that included determining the patient's weight and setting the control knob to that weight setting on the control unit. -Resident #94 was admitted with diagnoses including End Stage Renal Disease, Acute Respiratory Failure, and Type 2 Diabetes. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #94 had moderately impaired cognition. Resident #94 had one Stage 4 (defined as full-thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum and an Unstageable (defined as full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by an eschar [tan, brown or black] in the wound bed) wound on the right heel. A Comprehensive Care Plan (CCP) dated 6/15/2024 documented that Resident #94 had pressure ulcers on the sacrum and right heel related to immobility. Interventions included the use of an air mattress, offloading both heels with pillows when in bed, monitoring nutritional status, and administering medications as ordered. A physician's order dated 6/17/2024 documented the use of a Low Air Loss Alternating Pressure Mattress. A physician's order dated 6/17/2024 and renewed on 7/26/2024 documented cleaning the sacrum wound with DermaKlenz (a wound cleanser) and applying DermaBlue Foam (an anti-microbial, absorbent wound dressing) every Tuesday, Thursday, and Saturday and as needed everyday shift and cleaning the right heel with DermaKlenz (a wound cleanser) and applying Sting-Free Skin-Prep (a barrier between skin and adhesive) to the area everyday shift. A review of the electronic medical record indicated that Resident # 94's most recent weight dated 7/26/2024 was 134 pounds. On 8/1/2024 at 12:10 AM, Resident #94 was observed in bed. The air mattress control knob was set at 300 pounds. On 8/2/2024 at 7:16 AM, Resident #94 was observed in bed. The air mattress control knob was set at 300 pounds. On 8/5/2024 at 11:00 AM, Resident #94 was observed in bed. The air mattress control knob was set at 300 pounds. -Resident #201 was admitted to the facility with Diagnoses including Hypertension, Muscle Weakness, and Alcohol Dependence with Intoxication. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #201 had intact cognition. The Admission Minimum Data Set (MDS) assessment documented that Resident #201 had one Unstageable (defined as full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by an eschar (tan, brown, or black) in the wound bed) wound on the right hip. A Comprehensive Care Plan (CCP) dated 7/16/2024 documented that Resident #201 had a right hip pressure ulcer related to immobility and had interventions that included an air mattress, turning and positioning every two hours, and monitoring for changes in skin condition every shift. A physician's order dated 7/18/2024 documented cleaning the right hip with normal saline and applying Santyl Collagenase (an enzymatic debriding agent) ointment, then covered with bordered gauze daily. A physician's order dated 7/28/2024 documented an order for a Low Air Loss Alternating Pressure Mattress. A review of the electronic medical record indicated that Resident #201's most recent weight dated 7/18/2024 was 124 pounds. On 8/1/2024 at 10:42 AM, Resident #201 was observed in bed. The air mattress control knob was set at 250 pounds. On 8/2/2024 at 6:52 AM, Resident #201 was observed in bed. The air mattress control knob was set at 250 pounds. On 8/5/2024 at 8:00 AM, Resident #201 was observed in bed. The air mattress control knob was set at 250 pounds. Certified Nursing Assistant #6 was interviewed on 8/5/2024 at 11:15 AM and stated that when they took care of Resident #94 and #201, they did not touch the air mattress control knob. Certified Nursing Assistant #6 stated the weight setting was the responsibility of the nurses. Certified Nursing Assistant #6 stated they were only responsible for checking if the air mattress was deflated or unplugged. Registered Nurse #11, the Medication Nurse, was interviewed on 8/5/2024 at 11:30 AM and stated they did not check the air mattress weight setting for Resident #94 and #201. Registered Nurse #11 stated that the Wound Care Coordinator was responsible for checking and monitoring the air mattresses. The Wound Care Coordinator was interviewed on 8/5/2024 at 11:51 AM and stated when the air mattress is first installed, they set up the air mattress control knob according to the resident's weight and then spot-check the air mattress weight calibration occasionally. The Wound Care Coordinator stated they did not remember the last time they checked Resident #94 and Resident #201's air mattresses. The Wound Care Coordinator stated they did not have any documentation of the air mattress monitoring. The Wound Care Physician was interviewed on 8/5/2024 at 3:54 PM and stated the facility was responsible for monitoring the air mattresses. The Wound Care Physician stated the weight setting on the air mattress should correspond with the resident's weight. The Wound Care Physician stated the correct weight setting was essential otherwise the air mattress would be either too hard or too soft and could affect wound healing. The Director of Nursing Service was interviewed on 8/7/2024 at 11:30 AM and stated the Wound Care Coordinator was responsible for monitoring the air mattress and that the air mattress weight setting should correspond with the resident's actual weight. The Director of Nursing Service stated the Wound Care Nurse should have monitored Resident #94 and Resident #201's air mattress weight setting during wound care rounds. 10 NYCRR 415.12(c)(1)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00339563) initiated on [DATE] and completed on [DATE], the facility did not ensure each resident transferred to the hospital and discharged from the facility had documentation in the medical record of the attempts made by the facility to meet the needs of the resident before the resident was discharged to the hospital. This was identified for one (Resident #413) of three residents reviewed for death and the facility did not ensure each resident had documentation from a Physician of the necessity to transfer or discharge the resident. This was identified for two (Resident #413 and #414) of three residents reviewed for death. Specifically, Resident #413 suffered a cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping) in the facility and attempts of cardiopulmonary resuscitation and the use of an automated external defibrillator were not documented in the resident's medical record. Additionally, Resident #413 and Resident #414 suffered a cardiac arrest and were transferred to the hospital. There was no discharge note written by the Physician for both residents. The finding is: The facility's policy titled Cardiopulmonary Resuscitation-Emergency Response Code Blue, dated ,d+[DATE] documented that the staff responding (to Code Blue) is responsible for documenting the interventions and outcome of the emergency response in the resident's medical record. The facility's policy titled Hospital Transfers, effective ,d+[DATE], documented that when nursing staff notices a change in the resident's condition indicating medical intervention, the charge nurse/nursing supervisor shall evaluate the resident and report their findings to the attending/covering physician. The Registered Nurse will document findings and actions in the medical record using the Situation, Background, Assessment, and Recommendation (SBAR) note or progress note. In addition, the Physician/Nurse Practitioner shall document the present medical condition in the space provided on the institutional transfer form. Registered Nurse/Nursing Supervisor shall document a transfer note in the Situation, Background, Assessment, and Recommendation (SBAR) form. Resident #413 was admitted to the facility with diagnoses including End Stage Renal Disease, Diabetes Mellitus, and Depression. The [DATE] Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A Comprehensive Care Plan titled Resident Does Not Have Advanced Directives (legal documents to make provisions for future health care decisions in the event the individual is unable to make such decisions for themselves) in place, initiated on [DATE] documented to educate the resident on advanced directives and give the resident an opportunity to enact an advanced directive. A Situation, Background, Assessment, and Recommendation (SBAR) note dated [DATE] at 2:15 PM, created by Registered Nurse #3, documented Resident #413 had a cardiac arrest and respiratory arrest (no breathing). The resident was unresponsive. The resident was a full code (cardiopulmonary resuscitation can be used). Nurse Practitioner #1 was notified with an order to call Emergency Medical Services (911) and transfer the resident to the hospital. The section titled Nursing Notes in the Situation, Background, Assessment, and Recommendation (SBAR) form was blank. There was no documentation in the medical record that cardiopulmonary resuscitation was initiated for Resident #413. Additionally, there was no documentation from the Physician regarding the resident's transfer/discharge or disposition after the resident was transferred to the hospital. Registered Nurse #3 was interviewed on [DATE] at 11:57 AM and stated they were no longer employed at the facility and did not recall Resident #413. Registered Nurse #3 stated if the resident was a full code, the facility staff would have initiated cardiopulmonary resuscitation and documented it in the resident's medical record. Assistant Director of Nursing #1, the Nurse Educator, was interviewed on [DATE] at 12:34 PM and stated there should absolutely be notes written detailing what actions were taken by facility staff during a full code. If staff initiated cardiopulmonary resuscitation and used an automatic external defibrillator, this should be documented. Licensed Practical Nurse #2, the medication nurse, was interviewed on [DATE] at 1:37 PM and stated on [DATE], they found Resident #413 unresponsive and called Code Blue; a lot of staff responded, and they (Licensed Practical Nurse #2) initiated the cardiopulmonary resuscitation. Staff also attempted to use the automatic external defibrillator but there was no shock advised. Cardiopulmonary resuscitation was continued until the emergency medical services arrived and then they took over. The emergency medical services transported the resident to the hospital. Licensed Practical Nurse #2 stated they did not write a progress note because the nursing supervisor usually writes the notes. The Registered Nurse is responsible for completing the Situation, Background, Assessment, and Recommendation (SBAR) form which should include all interventions that were applied before the resident's transfer to the hospital. If a resident is pronounced dead at the hospital, the nursing supervisor gets a call from the hospital and should then write a progress note to document the resident's disposition. Nurse Practitioner #1 was interviewed on [DATE] at 8:15 AM and stated they did not write a transfer/discharge note for Resident #413 because they (Nurse Practioner #1) were not there at the time the Emergency Response Code was called. Nurse Practitioner #1 stated they would not write a note if they were not present. Physician #3, the attending Physician, was interviewed on [DATE] at 10:30 AM and stated they did not write a discharge summary or note in Resident #413's medical record because they did not see the resident and were not involved with the Emergency Response Code. Physician #3 stated the emergency room called them and told them that the resident expired in the emergency room . If they were present during the Emergency Response Code, they would have written a note. Physician #3 stated that a discharge note is more important when a resident is being discharged to the community. The facility has a protocol for when a resident is being discharged home, I am not sure about a discharge to the hospital. The Director of Nursing Services was interviewed on [DATE] at 12:10 PM and stated they did not know if the facility protocol requires the doctor to write a note when a resident is transferred to the hospital. The Medical Director was interviewed on [DATE] at 8:30 AM and stated that doctors should write a note when a resident is transferred or discharged to the hospital. Any resident who gets discharged from the facility must have a discharge summary. Resident #414 was admitted with diagnoses including End Stage Renal Disease, Diabetes Mellitus, and Hypertension. The [DATE] Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A Comprehensive Care Plan titled Resident Does Not Have Advanced Directives (legal documents to make provisions for future health care decisions in the event the individual is unable to make such decisions for themselves) in Place, initiated [DATE] documented to educate the resident on advanced directives and give the resident an opportunity to enact an advanced directive. A nursing progress note for Resident #414 dated [DATE] at 9:55 AM documented the resident was found unresponsive to verbal and tactile stimuli, no pulse, and no respiratory movement. The resident was a full code. Code Blue was initiated at 8:40 AM and 911 was called. An automated external defibrillator was applied, and shock was advised one time. Emergency medical technicians arrived at the facility at approximately 8:51 AM. The resident left the facility via ambulance at 9:30 AM. A nursing progress note dated [DATE] at 10:56 AM documented writer called the hospital and spoke with a Physician who stated the resident arrived at the hospital in cardiac arrest and was pronounced dead at 9:52 AM. There was no documentation in Resident #414's medical record from the resident's physician regarding the resident's transfer/discharge. Physician #1, Resident #414's attending physician, was interviewed on [DATE] at 12:02 PM and stated they were away in February 2024 when Resident #414 expired. Physician #2 was covering their residents. Physician #1 stated there should be a Physician discharge note in place that includes the reason the resident went to the hospital and the outcome. The Director of Nursing Services was interviewed on [DATE] at 12:10 PM and stated they did not know if the facility protocol requires the doctor to write a note when a resident is transferred to the hospital. Physician #2 was interviewed on [DATE] at 12:36 PM and stated they usually write discharge summaries for residents who are under their care. Resident #414 was not their resident and perhaps Physician #1 missed documenting the discharge summary since they (Physician #1) were away. The Medical Director was interviewed on [DATE] at 8:30 AM and stated that doctors should write a note when a resident is transferred or discharged to the hospital. Any resident who gets discharged from the facility must have a discharge summary. 10 NYCRR 415.3(i)(1)(ii)(a)(b)

Based on record review and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that a person-centered care plan for each resident that includes measurable objectives and timeframes to meet each resident's medical and nursing needs was implemented as identified in the comprehensive assessment. This was identified for one (Resident #71) of five residents reviewed for Respiratory Care. Specifically, Resident #71 had a physician's order to drain fluids from the abdominal cavity on the 7:00 PM - 7:00 AM shift via a Peritoneal (abdominal) Pleurex catheter (a thin, flexible tube that is inserted into the abdominal cavity to drain fluid) due to the diagnosis of Ascitis (a condition where fluid builds up in the abdomen between the lining of the abdomen and the abdominal organs). A review of the resident's medical record from 7/1/2024 to 7/12/2024 and from 8/1/2024 to 8/3/2024 revealed no documented evidence that the abdominal fluid was drained as per the physician's orders for a total of 11 out of 15 opportunities. The finding is: The facility's policy for Peritoneal Drainage System- Pleurex Catheter dated 4/2023 documented to chart the resident's response to the procedure and the volume of Ascites fluid drained. Resident #71 was admitted with diagnoses that included Cirrhosis of the Liver and Ascites. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14, which indicated the resident had intact cognition. The resident had no behavioral problems and did not reject care. A Comprehensive Care Plan dated 4/7/2023 and last reviewed on 7/31/2024 documented alteration in gastrointestinal status related to the disease process. Interventions included to discuss with the resident, family, or caregivers any concerns, fears, or issues related to gastrointestinal distress. Drain Ascites fluid via peritoneal drain every 12 hours, no more than 500 milliliters of fluid each drain, elevate the head of the bed to semi-Fowler's (patient lies on their back with their head and upper body raised at a 30-45 degree angle on the bed) position as needed. A physician's order dated 6/28/2024 documented to drain of the Peritoneal (abdominal) Pleurex Catheter up to 500 milliliters of fluid every day for abdominal discomfort and distension. The Treatment Administration Record for July 2024 was reviewed on 8/7/2024 and revealed there was no documented evidence of the amount of fluid drained from the Peritoneal Pleurex Catheter on 7/1/2024, 7/2/2024,7/5/2024, 7/6/2024, 7/7/2024, 7/8/2024, 7/9/2024, and 7/11/2024. A review of the medical record revealed that Resident #71 went to the hospital on 7/26/2024 and returned on 7/31/2024. A Physician's order dated 8/1/2024 documented to drain Left Chest Pleurex Catheter up to 500 cubic centimeters daily in the evening for Pleurex Catheter. A Treatment Administration Record for August 2024 was reviewed on 8/7/2024 and revealed there was no documented evidence of the amount of fluid drained from the Pleurex Catheter from 8/1/2024 to 8/3/2024. Physician #2 was interviewed on 8/8/2024 at 11:37 PM and stated they have been caring for Resident #71 for the past three years. The resident has Ascites due to Cirrhosis of the Liver. Physician #2 stated that if too much fluid was drained from the Pleurex Catheter, the resident could develop Hypotension (low blood pressure). Registered Nurse #16, who was assigned to Resident #71 on 7/5/2024, 7/9/2024, and 7/11/2024, was interviewed on 8/8/2024 at 12:27 PM. Registered Nurse #16 stated they usually document the amount of fluid drained from the Pleurex Catheter on the Treatment Administration Record. Registered Nurse #16 stated they were supposed to document the amount of fluid drained from the Pleurex Catheter on the Treatment Administration Record. Registered Nurse #17, who was assigned to Resident #71 on 7/2/2024, 7/6/2024, 7/7/2024, 7/8/2024, and 8/3/2024, was interviewed on 8/8/2024 at 1:48 PM. Registered Nurse #17 stated Resident #71 had a Pleurex Catheter and they had drained no more than 500 cubic centimeters of fluid from the Pleurex Catheter daily during the 7:00 PM to 7:00 AM shift. Registered Nurse #17 stated they did not know why the drainage amount was not documented on the Treatment Administration Record on 7/2/2024, 7/6/2024, 7/7/2024, 7/8/2024, and 8/3/2024. The Director of Nursing Services was interviewed on 8/8/2024 at 1:52 PM and stated that the nurses must document the amount of fluid drained from the Pleurex Catheter on the Treatment Administration Record. 10 NYCRR 415.11(c)(1)

Based on Observation, Interview and record review during an abbreviated and partial extended survey the facility failed to ensure that each resident's right to accept or refuse medical treatment and formulate an advance directive was maintained in accordance with State Law. The Facility failed to establish and implement an effective system for communicating each Residents advance directive choices to the interdisciplinary team and follow Physician's order specific to advance directive. Specifically, one (Resident #1) of ten Residents reviewed for advance directives had a Physician order for [REDACTED].#1 was transferred to the hospital where he was pronounced dead. Additionally, nine (Residents #1, #2, #3, #4, #5,#6, #7, #8 and #10) of ten were not accurately identified by the various indicators used by the facility for a resident ' s advance directive status. This failure has the potential to falsely identify a resident's advance directives. Additionally two residents (Resident # 3 and # 4) were identified with no physician orders for DNR in the Residents' hard copy of medical record. This resulted in no known actual harm with the potential for widespread harm that is Immediate Jeopardy for 268 Residents' health and safety. Complaint Number: NY 044 The findings are: The Policy and Procedure titled, Do Not Resuscitate (DNR), dated ,[DATE] documented that Physician writes the order for DNR in the resident's medical record. The Licensed Nurse ensures the resident's identification wristband has a purple charm, place a purple dot on the medical record binder of the resident and on the room tag when there is an active DNR. The social worker maintains a current list of residents with DNR status and emails clinical department heads/administration. The Policy and Procedure titled Cardio [MEDICAL CONDITION] Resuscitation (CPR), dated ,[DATE] documented First CPR certified staff member is to remain with resident, conduct the primary evaluation, begin chest compression, if indicated and direct supporting staff to retrieve emergency equipment. There is no documented evidence of staff training regarding a procedure of what to do if resident's purple charm indicator is missing. During an observation on [DATE] at 10:00 AM to 11:00AM three residents (#5, #6 and #7) on Tower unit had all the DNR identifiers (purple charm, purple dot on the door name tag and advance directive paperwork) except the purple dot on the medical record binder. Two Residents (#8 and #10) had all DNR identifiers (purple charm, purple dot on medical record binder and advance directive paperwork) except purple dot on the door name tag. One Resident (#2) was listed on the advance directive list as full code despite a physician order for [REDACTED]. During a subsequent observation on [DATE] at 3:00PM two (#3 and #4) lacked documented evidence of a physician order for [REDACTED]. 1) Resident #1 was an [AGE] year old male admitted to the facility with the [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE] documented resident alert and oriented to self. The Medical Record Advance Directive section provided an Adult Patient without Capacity/Surrogate Decision DNR order or Withdrawal or Withholding of Other Life Sustaining Treatment order sheet dated [DATE] which documented directives that Resident #1 should not be resuscitated. The Medical Record Advance Directive section provided an Adult Patient without Capacity/Surrogate Decision DNR order or Withdrawal or Withholding of Other Life Sustaining Treatment documented a Surrogate's written decision consent to a DNR order. The Nursing Admission assessment dated [DATE] documented that Resident #1 had a DNR. The Admission physician order dated [DATE] documented Do Not Resuscitate and check placement of charm every shift for advance directive. The Medication Administration Record [REDACTED]. The Medical Record lacked documented evidence of Comprehensive Care Plan (CCP) for advance directives. Nursing Progress Note (NPN) (written by the Registered Nurse Supervisor (RNS#1) dated [DATE] at 4:33 AM documented that resident (Resident #1) found unresponsive, No pulse, breath sound, no blood pressure, lip cyanotic. Code blue initiated at 3:30 by nurse, CPR administered, 22 gauge intravenous line inserted to right forearm. ? normal saline wide open in progress, transferred to emergency room at 3:55 AM. NPN (written by Licensed Practical Nurse (LPN#1)) dated [DATE] at 5:42 AM documented resident (Resident #1) was found unresponsive at 3:30AM, resident full code, code blue called, nursing supervisor made aware, CPR administered, intravenous line started. Resident transferred to hospital at 3:55 AM. NPN (written by RNS#1) dated [DATE] documented resident expired at the hospital at 4:18AM. The Social Work Short Term Sub acute Admission assessment dated [DATE] documented advance directive as DNR for Resident # 1. The undated Summary of Investigation documented that the staff did not follow resident's plan of care by the charge nurse (LPN#1) and the Registered Nurse Supervisor (RNS#1). The facility reviewed policy on DNR and found it to be compliant with the regulations. During an interview with 11:00 PM - 7:00 AM Registered Nurse Supervisor (RNS#1) on [DATE] at 2:55 PM, RNS#1 stated that on [DATE] she responded to code blue approximately between 3:00AM and 3:30AM after she grabbed her supplies. When she entered the room she saw other staff members (RN#1, RN#2, RN#6, LPN#2 and LPN# 4) were all present in the room and were suctioning the resident and Ambuing. RN#2 was placing the defibrillator pads on the resident. RNS#1 stated that the purple dot on the spine of the chart and the DNR paperwork were missing from Resident #1's chart which indicated that he was a full code. She did not look for the charm on the Identification bracelet or the doctor's order as she was not the first one to respond to the code. RNS#1 stated that to determine the DNR status she would not trust the purple charm "having a purple charm does not mean anything, I go to the chart to look for the actual DNR paperwork and dot on the chart." She stated that there has never been an identifier (purple dot) on the door name tag or a list related to advance directive on the units. RNS#1 did not receive in-service specific to facility's DNR/CPR policy. RNS#1 stated that she got to the unit at 3:35AM and started the CPR at approximately 3:37AM including the cardiac compressions after receiving command from the defibrillator to initiate CPR. During a subsequent interview with RNS#1 on [DATE] at 12:45PM, RNS#1 stated that hospital DNR was not present in Resident#1's medical record under the advance directive section; she was not sure how long the hospital DNR was valid after residents get admitted to the facility. "If I do see a hospital DNR and no facility generated DNR, I would initiate a CPR as the hospital DNR should be clarified by the social worker." During an interview with 11:00 PM - 7:00 AM Registered Nurse (RN#1) on [DATE] at 9:38PM, RN#1 stated that at around 4:00AM she heard code blue and responded, she took the Automatic External Defibrillator (AED). Upon arrival to the unit the charge nurse (LPN#1) standing at the nursing station and stated to her that R#1 was "no DNR" and she did not see any purple dot on the chart. RN#1 stated that she assessed Resident # 1 and found him unresponsive, no palpable pulse. She looked for the identification bracelet and found it without a purple charm. The RN#1 stated that sometimes residents may take off the purple charm off their bracelets that is why after she looks for the charm "present or not she will still go to the chart to make sure patient is a DNR or not. "The RNS#1 denied initiating the CPR for Resident # 1. She did not know of Resident #1's advance directive status (DNR) until [DATE]. According to RN#1 the identifiers for the DNR were the purple charm on the identification bracelet, purple dot on the chart and the advance directive DNR paperwork in the chart. "The purple dot on the door name tag was never the identifier prior to the incident (with Resident #1)." RN#1 stated that the DNR paperwork was the primary and most reliable identifier for her to determine a resident's DNR status and if she found the primary identifier missing, she would call her supervisor to make the decision regarding resuscitating the resident as the supervisor is the only person to go to at night to make decisions. During an interview with 11:00 PM -7:00 AM Registered Nurse (RN#2) on [DATE] at 10:00AM, RN#2 stated that he responded to the code blue on the tower unit and was notified by the charge nurse (LPN#1) that Resident (Resident # 1) was a full code. When he entered that room he witnessed the nursing supervisor (RNS#1) inserting intravenous line and LPN#2 Ambuing Resident # 1. RNS#1 instructed RN#2 to initiate cardiac compressions as Resident was not a DNR. RN#2 did not find a purple charm on Identification bracelet. RN#2 stated that the primary identifier for the DNR is the DNR paperwork in the chart and if that is missing then the hospital paperwork should be checked especially for a newly admitted resident. The hospital DNR is valid for at least three days after admission to the facility. RN#2 stated that the purple dots sometimes fall off the chart that is why when a resident is found unresponsive without pulse, all the identifiers (DNR paper work in the chart, purple charm and the purple dot on the spine of the chart) must be checked prior to starting the CPR. During an interview with 7:00 AM-3:00 PM Registered Nurse (RN#4) on [DATE] at 11:00 AM, RN#4 stated that when she finds a resident unresponsive, the first thing she would look for is the advance directive DNR paperwork in the chart. She did not like the charm on the identification bracelet and the dots on the door and the chart as they may fall off or get lost in transition "my bible is the chart and the DNR paperwork; If the unresponsive resident had no charm on the identification bracelet it would not make me do the compressions just looking at the charm, I can sit there and put charms on any one I want, I need to see the actual DNR paperwork." RN#4 stated that if the DNR paperwork is missing from the chart she would go to the computer to check for the doctor's order "unfortunately it's a big lapse in time, but if I am not sure I would not start the CPR on someone until I find their advance directive status." RN#4 stated that if she found a resident unresponsive with no pulse in other clinical areas, she would call the unit and ask the staff on the unit of resident's advance directive status and have them bring the medical record to the area for her to see the actual DNR paper work "I can't base my assessment on someone else's words." RN#4 stated that she would not know what she would do if the DNR paperwork was missing from the medical record. During an interview with 11:00 PM -7:00 AM Licensed Practical Nurse (LPN#2) on [DATE], LPN#2 stated that the DNR paperwork should be checked to identify residents' advance directive status. "Personally the purple dots on the chart and the charms are the hill of beans they can fall off, I would never go by the charm." The DNR paperwork is the primary identifier, I would go out of the resident's room and check to make sure by looking in the medical record, call the supervisor and grab the oxygen tank and wait for the supervisor. "Usually the supervisor makes the call to initiate CPR; we never initiate CPR until the nursing supervisor is on the unit." LPN#2 stated that if the DNR paperwork is missing and the physician order is present "the MD (physician) order for DNR means nothing, we need to see the actual DNR paperwork." During an interview with Social Worker (SW#1) on [DATE] documented that she reviewed the advance directive with the surrogate who confirmed Resident #1's DNR status and his hospital DNR paperwork was in the advance directive section of his medical record. The nurse should have honored the hospital DNR which is a valid document and should be in effect until the facility generated DNR is in effect. SW#1 stated that the facility generated DNR was not initiated on the day of admission or the next day as the doctor was not in the facility. SW#1 affirmed that the purple charm was present on Resident #1 ' s identification bracelet During an interview with the Social Worker (SW#2) on [DATE] at 1:05 PM, SW#2 stated that she reviewed the medical record of Resident #1 to make sure that the advance directives were in place. SW#2 affirmed that all the DNR identifiers (the purple dot on the spine of the chart, the purple charm on the identification bracelet and the DNR paper work) were all in place for Resident # 1. SW # 2 stated that every one is responsible to make sure that the identifiers are in place once the DNR is initiated for any resident. The hospital DNR is accepted at the facility (SW#2 was unable to state for how long the hospital DNR is valid after admission to the facility). Social service department generated a list of all residents with advance directives and updated and distributed it weekly and as needed. During an interview with 7:00 AM-3:00 PM Licensed Practical Nurse (LPN#3) on [DATE] at 2:09 PM, LPN#3 stated that if she found a resident unresponsive she would check for the identification bracelet for a purple charm and if she did not see the purple charm she would go out of the room to check the Resident's chart to confirm with the actual DNR paper and then go back to the room to initiate CPR. LPN#3 stated that even when the physician order for [REDACTED]. LPN# 3 was unable to state what she would do if she encountered an unresponsive resident without the identification bracelet. LPN#3 was not aware of the advance directive list in the other clinical areas other than on the units. During an interview with the 7:00 AM - 3:00 PM Registered Nurse (RN#3) on [DATE] at 2:33 PM, RN#3 stated that the primary identifier for DNR is the purple charm on the identification bracelet. RN#3 stated that even if the purple charm is present or not she would still go out and check the door for the purple dot and then go to the chart to check the actual DNR paperwork for a resident who is found without pulse and respiration. If the DNR paperwork is not present in the chart she would call code blue and then go back to the room to start the CPR. RN#3 stated that if the unresponsive resident was found without the identification bracelet she would call the supervisor and then call code blue to find out who the resident is, once the resident is identified then she would know what to do with the resident. During an interview with 7:00 AM-3:00 PM Registered Nurse Supervisor (RNS#2) on [DATE] at 3:10PM, RNS#2 stated that when a resident is found unresponsive without a purple charm "call the unit they will tell you the advance directive status." When identification bracelet is missing on an unresponsive resident call code blue, get the person ready for CPR by placing oxygen, laying them flat and in the mean time some one would call the unit to ascertain the DNR/CPR status. During an interview with 7:00 AM-3:00 PM Registered Nurse (RN#5) on [DATE] at 3:07PM, RN#5 stated that she would check for the purple charm on the bracelet, purple dot on the door and on the medical record and the advance directive paperwork on an unresponsive person to ascertain the DNR/CPR status prior to performing any life saving actions "I would not start CPR, I would find out the DNR status by checking all the identifiers first." RN#5 stated that she would run to the desk to call for help if no one was in the hallway During an interview with 11:00 PM -7:00 AM Licensed Practical Nurse (LPN#4) on [DATE] at 4:30PM, LPN#4 stated that if she found a resident without pulse and respiration, she would check for the purple charm on the identification bracelet and would come out of the room to check the chart for DNR/CPR status, call for help while checking the advance directive status; if resident is a full code she would go back in to the room and initiate cardiac compressions. During an interview with 11:00 PM -7:00 AM Licensed Practical Nurse (LPN#1) on [DATE] at 9:40 AM, LPN#1 stated that a Certified Nursing Assistant (CNA) reported to her that Resident # 1 did not look right. Upon going in the room she found Resident # 1 unresponsive with no pulse. LPN#1 told the CNA to stay with Resident #1 while she came out of the room and called the code blue over the phone. Resident # 1 did not have a purple charm on his bracelet. LPN#1 stated that RNS#1 came up within three to five minutes and took Resident # 1's chart from her in to the resident s room and instructed to start the CPR. LPN#1 stated that she looked for the DNR paperwork but could not find it in the advance directive section. She did not check for the physician orders as she could not locate the advance directive paperwork. Hospital DNR is only valid for 48 hours after admission, if the facility generated DNR is not initiated after48 hours, resident would be resuscitated despite presence of hospital DNR. LPN#1 stated that she would check for the purple charm on the identification bracelet and if no charm is identified she would then check the chart for the advance directive paperwork to identify an unresponsive resident's advance directive status. If the advance directive paperwork is missing, then a code blue is called. During an interview with Registered Nurse In-service Coordinator (ISC) on [DATE] at 2:03 PM, the ISC stated that she was not aware of any advance directive list. When a resident is found unresponsive she expected the staff to start CPR until they visually see the DNR paperwork. If the DNR paperwork is present CPR can be stopped. "Generally I don't go by the purple charm on the bracelet, it's just a helper, if the staff can't find the DNR paperwork the staff should continue CPR even though resident has a purple charm; resident may have rescinded it." During an interview with 3:00 PM-11:00 PM Licensed Practical Nurse (LPN#5) on [DATE] at 4:40 PM, LPN#5 stated that she did not necessarily go by the purple charm on the identification band " anything can change and staff might forget to take charm off." LPN # 5 stated that she would always check the medical record for the actual DNR paperwork. During an interview with 11:00 PM-7:00 AM Registered Nurse (RN#6) on [DATE] at 11:30 AM, RN#6 stated that she would not rely on the purple charm or the dots on the door or the chart, "if I don't see the actual DNR paperwork and there is a purple charm present on the identification bracelet, I would start CPR on the resident and would only stop when I visually see the DNR paperwork." RN#6 was unable to state what would she do if there was no DNR paperwork but the Physician order was present for an unresponsive resident. During an interview with the Director of Nursing (DON) on [DATE] at 12:31PM, the DON stated that the purple charm is very hard to fall off the identification bracelet but the purple dot may fall off the chart. When the staff assesses resident as unresponsive she expects them to identify the advance directive status and start CPR immediately if the purple charm is not identified on the identification bracelet. The physician order is acceptable to identify a residents' DNR status and nurses are expected to look for the orders primarily in the chart. During an interview with The Medical Director (MD) on [DATE] at 1:30 PM, the MD stated that he did not recall reviewing CPR/DNR policy as nothing specific came up related to advance directive. The hospital DNR should be valid and honored until the resident or the designated representatives rescinds it. The MD stated that the staff should have followed the doctor's order for DNR. During an interview with the Primary Care Physician (PCP) on [DATE] at 9:15 AM, the PCP stated that Resident (Resident # 1) had an order for [REDACTED]. a class one offense." During an interview with the Administrator on [DATE] at 9:57 AM, the Administrator stated that he started an investigation on [DATE] when he noticed that Resident #1 was resuscitated; when he checked the electronic medical record he found resident to have a DNR order. The Administrator expected staffs to follow Resident #1's wishes for his advance directive. 415.3(e)(1)(ii)

Based on staff interviews and record review during an abbreviated and partial extended survey it was determined that the administration failed to ensure that there was a system in place to ensure that each resident's right to accept or refuse medical treatment and formulate an advance directive was maintained in accordance with State Law. Specifically, the Administration failed to ensure that policies and procedures for identifying advance directives were implemented; failed to identify system failures to establish mechanisms for accurately documenting and communicating each resident's advance directive choices to the interdisciplinary team. The facility failed to have staff trianed with regards to a procedure of what to do if a DNR identifier was missing. This resulted in no actual harm with potential for widespread harm that is immediate jeopardy for 268 residents' health and safety. Complaint Number: NY 044 Cross References: F155- Advance Directives F520- Quality Assessment and Assurance The findings are: The Policy and Procedure titled, Do Not Resuscitate (DNR), dated ,[DATE] documented that Physician writes the order for DNR in the resident's medical record. The Licensed Nurse ensures the resident's identification wristband has a purple charm, place a purple dot on the medical record binder of the resident and on the room tag when there is an active DNR. The social worker maintains a current list of residents with DNR status and emails clinical department heads/administration. The Policy and Procedure titled Cardio [MEDICAL CONDITION] Resuscitation (CPR), dated ,[DATE] documented First CPR certified staff member is to remain with resident, conduct the primary evaluation, begin chest compression, if indicated and direct supporting staff to retrieve emergency equipment. There is no documented evidence of staff training regarding a procedure of what to do if resident's purple charm indicator is missing. The undated Summary of Investigation documented that the staff did not follow resident's plan of care by the charge nurse (LPN#1) and the Registered Nurse Supervisor (RNS#1). The facility reviewed policy on DNR and found it to be compliant with the regulations. During an interview with 11:00 PM - 7:00 AM Registered Nurse Supervisor (RNS#1) on [DATE] at 2:55 PM, RNS#1 stated that on [DATE] she responded to code blue approximately between 3:00AM and 3:30AM after she grabbed her supplies. When she entered the room she saw other staff members (RN#1, RN#2, RN#6, LPN#2 and LPN# 4) were all present in the room and were suctioning the resident and Ambuing. RN#2 was placing the defibrillator pads on the resident. RNS#1 stated that the purple dot on the spine of the chart and the DNR paperwork were missing from Resident #1's chart which indicated that he was a full code. She did not look for the charm on the Identification bracelet or the doctor's order as she was not the first one to respond to the code. RNS#1 stated that to determine the DNR status she would not trust the purple charm "having a purple charm does not mean anything, I go to the chart to look for the actual DNR paperwork and dot on the chart." She stated that there has never been an identifier (purple dot) on the door name tag or a list related to advance directive on the units. RNS#1 did not receive in-service specific to facility's DNR/CPR policy. RNS#1 stated that she got to the unit at 3:35AM and started the CPR at approximately 3:37AM including the cardiac compressions after receiving command from the defibrillator to initiate CPR. During a subsequent interview with RNS#1 on [DATE] at 12:45PM, RNS#1 stated that hospital DNR was not present in Resident#1's medical record under the advance directive section; she was not sure how long the hospital DNR was valid after residents get admitted to the facility. "If I do see a hospital DNR and no facility generated DNR, I would initiate a CPR as the hospital DNR should be clarified by the social worker." During an interview with 11:00 PM -7:00 AM Licensed Practical Nurse (LPN#1) on [DATE] at 9:40 AM, LPN#1 stated that a Certified Nursing Assistant (CNA) reported to her that Resident # 1 did not look right. Upon going in the room she found Resident # 1 unresponsive with no pulse. LPN#1 told the CNA to stay with Resident # 1 while she came out of the room and called the code blue over the phone. Resident # 1 did not have a purple charm on his bracelet. LPN#1 stated that RNS#1 came up within three to five minutes and took Resident # 1's chart from her in to the resident s room and instructed to start the CPR. LPN#1 stated that she looked for the DNR paperwork but could not find it in the advance directive section. She did not check for the physician orders [REDACTED]. Hospital DNR is only valid for 48 hours after admission, if the facility generated DNR is not initiated after48 hours, resident would be resuscitated despite presence of hospital DNR. During an interview with Registered Nurse In-service Coordinator (ISC) on [DATE] at 2:03 PM, the ISC stated that she was not aware of any advance directive list. When a resident is found unresponsive she expected the staff to start CPR until they visually see the DNR paperwork. If the DNR paperwork is present CPR can be stopped. "Generally I don't go by the purple charm on the bracelet, it's just a helper, if the staff can't find the DNR paperwork the staff should continue CPR even though resident has a purple charm; resident may have rescinded it." During an interview with the Director of Nursing (DON) on [DATE] at 12:31 PM, the DON stated that the purple charm is very hard to fall off the identification bracelet but the purple dot may fall off the chart. When the staff assesses resident as unresponsive she expects them to identify the advance directive status and start CPR immediately if the purple charm is not identified on the identification bracelet. The physician order [REDACTED]. During an interview with The Medical Director (MD) on [DATE] at 1:30 PM, the MD stated that he did not recall reviewing CPR/DNR policy as nothing specific came up related to advance directive. The hospital DNR should be valid and honored until the resident or the designated representatives rescinds it. The MD stated that the staff should have followed the doctor's order for DNR. During an interview with the Primary Care Physician (PCP) on [DATE] at 9:15 AM, the PCP stated that Resident (Resident # 1) had an order for [REDACTED]. a class one offense." During an interview with the Administrator on [DATE] at 9:57 AM, the Administrator stated that he started an investigation on [DATE] when he noticed that Resident #1 was resuscitated; when he checked the electronic medical record he found resident to have a DNR order. The Administrator expected staffs to follow Resident #1's wishes for his advance directive. 415.26

Based on record review and staff interviews conducted during an abbreviated and partial extended survey, the facility failed to provide a quality assessment program that readily identified each resident's right to accept or refuse medical treatment and formulate an advance directive in accordance with State Law. Specifically, the Quality Assessment and Assurance (QAA) Committee failed to review and evaluate the sequence of events preceding Resident # 1's death on [DATE] to identify system failures and determine the root cause. This resulted in no actual harm with the potential for widespread harm that is Immediate Jeopardy for 268 residents' health and safety. Complaint Number: NY 044 Cross References: F155 - Advance Directives F490 - Administration The Findings are: The Policy and Procedure titled, Do Not Resuscitate (DNR), dated ,[DATE] documented that Physician writes the order for DNR in the resident's medical record. The Licensed Nurse ensures the resident's identification wristband has a purple charm, place a purple dot on the medical record binder of the resident and on the room tag when there is an active DNR. The social worker maintains a current list of residents with DNR status and emails clinical department heads/administration. The Policy and Procedure titled Cardio [MEDICAL CONDITION] Resuscitation (CPR), dated ,[DATE] documented First CPR certified staff member is to remain with resident, conduct the primary evaluation, begin chest compression, if indicated and direct supporting staff to retrieve emergency equipment. There is no documented evidence of staff training regarding a procedure of what to do if resident's purple charm indicator is missing. The undated Summary of Investigation documented that the staff did not follow resident's plan of care by the charge nurse (LPN#1) and the Registered Nurse Supervisor (RNS#1). The facility reviewed policy on DNR and found it to be compliant with the regulations. During an interview with 11:00 PM - 7:00 AM Registered Nurse Supervisor (RNS#1) on [DATE] at 2:55 PM, RNS#1 stated that on [DATE] she responded to code blue approximately between 3:00AM and 3:30AM after she grabbed her supplies. When she entered the room she saw other staff members (RN#1, RN#2, RN#6, LPN#2 and LPN# 4) were all present in the room and were suctioning the resident and Ambuing. RN#2 was placing the defibrillator pads on the resident. RNS#1 stated that the purple dot on the spine of the chart and the DNR paperwork were missing from Resident #1's chart which indicated that he was a full code. She did not look for the charm on the Identification bracelet or the doctor's order as she was not the first one to respond to the code. RNS#1 stated that to determine the DNR status she would not trust the purple charm "having a purple charm does not mean anything, I go to the chart to look for the actual DNR paperwork and dot on the chart." She stated that there has never been an identifier (purple dot) on the door name tag or a list related to advance directive on the units. RNS#1 did not receive in-service specific to facility's DNR/CPR policy. RNS#1 stated that she got to the unit at 3:35AM and started the CPR at approximately 3:37AM including the cardiac compressions after receiving command from the defibrillator to initiate CPR. During a subsequent interview with RNS#1 on [DATE] at 12:45PM, RNS#1 stated that hospital DNR was not present in Resident#1's medical record under the advance directive section; she was not sure how long the hospital DNR was valid after residents get admitted to the facility. "If I do see a hospital DNR and no facility generated DNR, I would initiate a CPR as the hospital DNR should be clarified by the social worker." During an interview with 11:00 PM -7:00 AM Licensed Practical Nurse (LPN#1) on [DATE] at 9:40 AM, LPN#1 stated that a Certified Nursing Assistant (CNA) reported to her that Resident # 1 did not look right. Upon going in the room she found Resident # 1 unresponsive with no pulse. LPN#1 told the CNA to stay with Resident #1 while she came out of the room and called the code blue over the phone. Resident # 1 did not have a purple charm on his bracelet. LPN#1 stated that RNS#1 came up within three to five minutes and took Resident # 1's chart from her in to the resident s room and instructed to start the CPR. LPN#1 stated that she looked for the DNR paperwork but could not find it in the advance directive section. She did not check for the physician orders [REDACTED]. Hospital DNR is only valid for 48 hours after admission, if the facility generated DNR is not initiated after48 hours, resident would be resuscitated despite presence of hospital DNR. During an interview with Registered Nurse In-service Coordinator (ISC) on [DATE] at 2:03 PM, the ISC stated that she was not aware of any advance directive list. When a resident is found unresponsive she expected the staff to start CPR until they visually see the DNR paperwork. If the DNR paperwork is present CPR can be stopped. "Generally I don't go by the purple charm on the bracelet, it's just a helper, if the staff can't find the DNR paperwork the staff should continue CPR even though resident has a purple charm; resident may have rescinded it." During an interview with the Director of Nursing (DON) on [DATE] at 12:31 PM, the DON stated that the purple charm is very hard to fall off the identification bracelet but the purple dot may fall off the chart. When the staff assesses resident as unresponsive she expects them to identify the advance directive status and start CPR immediately if the purple charm is not identified on the identification bracelet. The physician order [REDACTED]. During an interview with The Medical Director (MD) on [DATE] at 1:30 PM, the MD stated that he did not recall reviewing CPR/DNR policy as nothing specific came up related to advance directive. The hospital DNR should be valid and honored until the resident or the designated representatives rescinds it. The MD stated that the staff should have followed the doctor's order for DNR. During an interview with the Primary Care Physician (PCP) on [DATE] at 9:15 AM, the PCP stated that Resident (Resident # 1) had an order for [REDACTED]. a class one offense." During an interview with the Administrator on [DATE] at 9:57 AM, the Administrator stated that he started an investigation on [DATE] when he noticed that Resident #1 was resuscitated; when he checked the electronic medical record he found resident to have a DNR order. The Administrator expected staffs to follow Resident #1's wishes for his advance directive. 415.27(a-c)